Treatment engagement and response to CBT among Latinos with anxiety disorders in primary care

Effectiveness-implementation hybrid trial of Spanish language, digital cognitive-behavioral therapy (dCBT) intervention for depression and anxiety - protocol for the SUPERA (SUpport from PEeRs to expand Access) study

BACKGROUND

Limited English Proficiency (LEP) Latinxs experience a longer duration of untreated depression and anxiety. LEP Latinxs have difficulty accessing mental healthcare due to insufficient Spanish-speaking behavioral/mental health clinicians to meet demand. These under-resourced healthcare systems are less likely to be the site for the implementation of innovations. Digital interventions can provide an effective option for overcoming these barriers; yet, when digital evidence-based treatments are available, uptake and engagement is often low. This manuscript presents the protocol for the SUPERA (SUpport from PEeRs to expand Access) study which will evaluate the implementation of an evidence-based, Spanish language, digital cognitive-behavioral therapy (dCBT) intervention (i.e., SilverCloud) in safety-net primary care clinics for LEP Latinx patients with depression or anxiety.

METHODS

We will conduct an effectiveness-implementation hybrid trial (Type 2) design comparing engagement and clinical outcomes in two modalities of dCBT delivery (peer-supported vs. unsupported). We will also compare provider-level outreach (using a clinic patient registry) versus inreach (traditional provider referral) to compare rates of initiation, completion, and cost. Participants will be 426 LEP Latinx adults ≥18 years of age, PHQ-9 ≥ 10 or GAD-7 ≥ 8, with access to the internet via smartphone, and not currently receiving individual psychotherapy. We will collect baseline, post-intervention (8 weeks), and follow up (3 months) data.

CONCLUSION

The long-term goal of this research is to aid in the implementation of digital mental health interventions that can be sustainably implemented in low-resourced settings, while reducing the reliance on professionals, overcoming workforce deficits, and increasing relevance for diverse populations.

A randomized controlled trial on using predictive algorithm to adapt level of psychological care for community college students: STAND triaging and adapting to level of care study protocol

BACKGROUND

There is growing interest in using personalized mental health care to treat disorders like depression and anxiety to improve treatment engagement and efficacy. This randomized controlled trial will compare a traditional symptom severity decision-making algorithm to a novel multivariate decision-making algorithm for triage to and adaptation of mental health care. The stratified levels of care include a self-guided online wellness program, coach-guided online cognitive behavioral therapy, and clinician-delivered psychotherapy with or without pharmacotherapy. The novel multivariate algorithm will be comprised of baseline (for triage and adaptation) and time-varying variables (for adaptation) in four areas: social determinants of mental health, early adversity and life stressors, predisposing, enabling, and need influences on health service use, and comprehensive mental health status. The overarching goal is to evaluate whether the multivariate algorithm improves adherence to treatment, symptoms, and functioning above and beyond the symptom-based algorithm.

METHODS/DESIGN

This trial will recruit a total of 1000 participants over the course of 5 years in the greater Los Angeles Metropolitan Area. Participants will be recruited from a highly diverse sample of community college students. For the symptom severity approach, initial triaging to level of care will be based on symptom severity, whereas for the multivariate approach, the triaging will be based on a comprehensive set of baseline measures. After the initial triaging, level of care will be adapted throughout the duration of the treatment, utilizing either symptom severity or multivariate statistical approaches. Participants will complete computerized assessments and self-report questionnaires at baseline and up to 40 weeks. The multivariate decision-making algorithm will be updated annually to improve predictive outcomes.

DISCUSSION

Results will provide a comparison on the traditional symptom severity decision-making and the novel multivariate decision-making with respect to treatment adherence, symptom improvement, and functional recovery. Moreover, the developed multivariate decision-making algorithms may be used as a template in other community college settings. Ultimately, findings will inform the practice of level of care triage and adaptation in psychological treatments, as well as the use of personalized mental health care broadly.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05591937, submitted August 2022, published October 2022.

Mediators of Ethnic Differences in Dropout Rates From a Randomized Controlled Treatment Trial Among Latinx and Non-Latinx White Primary Care Patients With Anxiety Disorders

ABSTRACT

Disparities in treatment engagement and adherence based on ethnicity have been widely recognized but are inadequately understood. Few studies have examined treatment dropout among Latinx and non-Latinx White (NLW) individuals. Using Andersen's Behavioral Model of Health Service Use (A behavioral model of families' use of health services. 1968; J Health Soc Behav. 1995; 36:1-10) as a framework, we examine whether pretreatment variables (categorized as predisposing, enabling, and need factors) mediate the relationship between ethnicity and premature dropout in a sample of Latinx and NLW primary care patients with anxiety disorders who participated in a randomized controlled trial (RCT) of cognitive behavioral therapy. Data from a total of 353 primary care patients were examined; 96 Latinx and 257 NLW patients participated. Results indicated that Latinx patients dropped out of treatment more often than NLW patients, resulting in roughly 58% of Latinx patients failing to complete treatment compared with 42% of NLW, and approximately 29% of Latinx patients dropping out before engaging in modules related to cognitive restructuring or exposure, relative to 11% of NLW patients. Mediation analyses suggest that social support and somatization partially explained the relationship between ethnicity and treatment dropout, highlighting the importance of these variables in understanding treatment disparities.

Anxiety symptoms and puberty interactively predict lower cingulum microstructure in preadolescent Latina girls

Preadolescence is a period of increased vulnerability for anxiety, especially among Latina girls. Reduced microstructure (fractional anisotropy; FA) of white matter tracts between limbic and prefrontal regions may underlie regulatory impairments in anxiety. However, developmental research on the association between anxiety and white matter microstructure is mixed, possibly due to interactive influences with puberty. In a sample of 39 Latina girls (8-13 years), we tested whether pubertal stage moderated the association between parent- and child-reported anxiety symptoms and FA in the cingulum and uncinate fasciculus. Parent- but not child-reported anxiety symptoms predicted lower cingulum FA, and this effect was moderated by pubertal stage, such that this association was only significant for prepubertal girls. Neither anxiety nor pubertal stage predicted uncinate fasciculus FA. These findings suggest that anxiety is associated with disruptions in girls' cingulum white matter microstructure and that this relationship undergoes maturational changes during puberty.

The influence of ethnic-racial identity and discrimination on mental health treatment attitudes among college students

Objective: While understanding racial/ethnic disparities in mental health services use is a growing priority in colleges and universities, little is known the attitudes that may contribute to these disparities. Methods: This study investigates the relationship between clinic diversity, ethnic-racial identity, discrimination, and treatment attitudes. College students n = 250 (Asian 21%, Black 11%, Latinx 23%, and White 45%) participated in an online experimental task rating hypothetical clinic websites that varied by clinician diversity and completed a series of self-report questionnaires. Results: Clinician diversity did not influence treatment attitudes, but discrimination and ethnic-racial identity were significantly related to treatment attitudes. Additionally, the relationship between public regard and treatment attitudes was moderated by race/ethnicity. Conclusions: By focusing on treatment attitudes rather than behaviors, this study addresses potential areas of intervention to address racial/ethnic disparities in college mental health.

Knowledge about Treatment (KaT) in Mental Health Services

This study developed and psychometrically evaluated a brief measure of mental health treatment knowledge (N = 726). Scores from Knowledge about Treatment (KaT) demonstrated a unidimensional measure with good model fit, internal consistency reliability, convergent and predictive validity, test-retest reliability, and measurement invariance across gender, ethnicity, education, and poverty status.

Toxic Metal -Mediated Neurodegradation: A Focus on Glutathione and GST Gene Variants

Increasing pieces of evidence have supported those chemicals from industrial, agricultural wastes and organoleptic activities play important role in the development of neurological disorders. The frequency of neurological disorders is increased to a much extent in recent years with the advancements in science and technology. Google Scholar, PubMed, and Scopus databases were selected to search the relevant information by using keywords including "Heavy metals", "Neurotoxicity", "Glutathione", "Glutathione AND Neurodegenerative disorders" etc. Heavy metals are particularly recognized as a major resource of toxicities during the stage of early pregnancy where a fetus gets exposed to them from maternal activities and circulation. As infants have a weak immune system and cannot respond to the specific challenge as faced by the body during mercury, zinc, iron, and cadmium exposure. Daily diet and drinking habits in addition to industrial activities also form a major field of study under investigation. This study aims to investigate the role of these metals in the accumulation of pollutants in the brain, liver, and kidneys hence leading to serious consequences. Moreover, their prevalence in teenagers that are under the age of ten years is being observed that leads them to learn, writing, and intellectual abilities. Males are more affected due to their hormonal differences. The role of the GST gene in the development of cognitive conditions and its phenotypes has been discussed thoroughly in this review. The mutations of GST lead to the accumulation of peroxides and superoxides which exacerbate oxidative damage to cells. Binding of toxic metals to GSH genes and the role of glutathione transferase genes is was demonstrated in this review.

Digital Mental Health Services: Moving From Promise to Results

The papers in this special issue make a compelling case for the value of digital mental health services (DMHS; including technology-based interventions, assessments, and prevention programs) to help address some of the currently unmet needs in mental health care. At the same time, the papers highlight the work that needs to be accomplished for DMHS to fulfill their promise. We review the papers' contributions in terms of (a) the imperative to increase access to evidence-informed, high-quality care, especially for underserved populations, both in the United States and globally; (b) ways to use DMHS to improve the ways that clinical care is provided to make treatment provision more effective and efficient; and (c) the current state of the research on DMHS for emotional disorders. We then consider lessons learned and recommendations to move the field forward, such as increasing (and making transparent) the research base on DMHS, adopting regulatory standards for DMHS, attending carefully to training issues for DMHS and best practices for dissemination and implementation, designing specifically for digital platforms, and being intentional about efforts to reduce disparities regarding who benefits from DMHS.

Ethnic differences in behavioral and physiological indicators of sensitivity to threat

The clinical presentation of anxiety may differ between Hispanics/Latinx (H/L) and non-H/L, although findings on ethnic differences in self-reported anxiety symptoms have been mixed. Fewer studies have focused on ethnic differences in quick and relatively automatic laboratory-assessed indicators of anxiety symptoms, which have the potential to be more objective indicators than self-report. Therefore, the present study examined ethnic differences in two laboratory-assessed indicators of threat sensitivity (an important transdiagnostic mechanism of anxiety): attentional bias to threat and electromyography startle reactivity to threat. White H/L (n = 117) and White non-H/L (n = 168) adults who were matched on demographics and lifetime psychopathology (including anxiety) completed a dot-probe task to assess attentional bias to threat and the No-Predictable-Unpredictable threat (NPU) task to assess startle reactivity to threat. Results indicated that H/L displayed less Slow OrientationRB (β = -0.27, p = 0.032, R2β∗ = 0.02), and increased Slow DisengagementRB (β = 0.31, p = 0.016, R2β∗ = 0.02) compared to non-H/L. H/L exhibited blunted overall startle compared to non-H/L (β = -0.30, p = 0.014, R2β∗ = 0.02), but groups did not differ in startle reactivity to either predictable or unpredictable threat. In summary, H/L and non-H/L may differ in their experience and presentation of anxiety symptoms and such differences may vary across indicators of sensitivity to threat.

Tele-mental health intervention for caregivers of children on home ventilation: A randomized control trial

AIM

This study aims to evaluate a Tele-P cognitive behavioural intervention (CBT) to promote the emotional functioning (i.e. reduce anxiety, depression and social isolation) and improve the quality of life (QoL) of caregivers of children who are ventilator dependent at home.

BACKGROUND

There is an urgent need for support of parents with technology-dependent children. Research shows that the parents of children whose chronic illness require assisted-technology experience significant emotional stress, potential gaps in social isolation, and social isolation leading to lower quaility of life, unhealthy family functioning, and negative psychological consequences.

RESULTS

Participation in a Tele-P intervention significantly reduced caregivers' anxiety, depression and fatigue, and reduction was sustained in a 4 week follow-up period. There was no significant change in social isolation.

CONCLUSION

Findings demonstrate preliminary efficacy of an innovative Tele-P intervention on outcomes of anxiety, depression and fatigue in an at-risk group of caregivers. Although the intervention did not improve self-reported social isolation, using technology in combination with established psychological support is an efficient way to better equip our mental health intervention systems to serve vulnerable populations.

Randomized pilot trial of cognitive-behavioral therapy and acceptance-based behavioral therapy in the treatment of Spanish-speaking Latino primary care patients with generalized anxiety disorder

The evidence base supporting the usefulness of traditional cognitive-behavioral therapy (CBT) and newer acceptance-based CBT treatments for generalized anxiety disorder (GAD) has grown over the past decades. GAD is prevalent among several Latino subgroups, particularly Puerto Ricans. However, there remains uncertainty regarding the appropriateness of these interventions for Spanish-speaking Latinos since they have been routinely excluded in both efficacy and effectiveness studies. As an initial step to bridge this gap, this pilot study examined the potential efficacy of two CBT interventions for GAD, traditional CBT and acceptance-based behavioral therapy (ABBT), in a sample of Spanish-speaking Latinos. Ninety primary care patients with GAD were randomly assigned to receive CBT (n=30), ABBT (n=30), or treatment as usual (TAU) (n=30). Excessive worry, the core feature of GAD, was assessed with the Penn State Worry Questionnaire (PSWQ), which is considered the gold standard measure of GAD-related worry. At follow-up, PSWQ scores for participants in the CBT and ABBT groups were statistically lower than those of the TAU group and statistically comparable to each other. CBT and ABBT reduced worry level to a greater degree than usual care by follow-up. Our findings provide preliminary, yet crucial data, which support the potential of both interventions targeting GAD symptoms among Spanish-speaking Latino primary care patients.

Development of a cognitive bias modification intervention for anxiety disorders in primary care

OBJECTIVES

There is a great need for low-intensity, scalable treatments in primary care, where most anxious patients first present for treatment. We describe Stage IA treatment development and a Stage IB feasibility trial of cognitive bias modification (CBM) for transdiagnostic anxiety in primary care.

METHODS

The online intervention, Mental Habits, comprised eight sessions of a personalized CBM targeting attention and interpretation biases. Coaches assisted patients in using the website, monitored progress via a dashboard, and shared information with primary care providers. We evaluated Mental Habits in an open trial (N = 14) and a randomized controlled trial (RCT) (N = 40) in primary care patients with anxiety disorders.

RESULTS

We compared results to a priori benchmarks of clinically meaningful outcomes. In the open trial, Mental Habits met feasibility, acceptability, and efficacy benchmarks. In the pilot RCT, there was greater dropout at one study site which ultimately closed. In the intent-to-treat analyses, Mental Habits met the benchmark for self-report, but not the interview measure of anxiety. Symptom Tracking did not meet the benchmark for self-report or interview measures of anxiety. In per-protocol analyses, Mental Habits exceeded the benchmark for both self-report and interview measures, whereas Symptom Tracking met the benchmark for self-report. Interpretation bias improved in the Mental Habits group, but not in Symptom Tracking. No effects were observed for attention bias.

CONCLUSION

The online CBM intervention demonstrated good acceptability and, when delivered at a stable primary care clinic, preliminary effectiveness in primary care. A larger RCT is warranted to test effectiveness.

PRACTITIONER POINTS

A personalized, transdiagnostic Cognitive Bias Modification (CBM) intervention for anxiety in primary care is acceptable to primary care patients with social anxiety disorder, generalized anxiety disorder, and/or panic disorder /agoraphobia. With training and supervision from licensed mental health clinicians, bachelor's-level coaches can assist primary care patients to self-administer CBM. Offering a low-intensity, self-directed anxiety intervention in primary care can greatly expand the reach of anxiety treatment, with minimal need for additional resources. Interpretation bias may be an important clinical target for primary care patients with anxiety.

Cultural adaptations of cognitive behavioural therapy for Latin American patients: unexpected findings from a systematic review

The current literature extensively recommends making cultural adaptations to psychological therapies, in order to address the differences in values, beliefs and attitudes that patients from different ethnic groups might hold. Although this approach has shown positive outcomes in some settings, it is not well established yet whether such adaptations are needed for all therapies and in all cultures. Therefore, the main aim of this study was to systematically review the literature regarding culturally adapted and ‘conventional’ cognitive behavioural therapy (CBT) for Latin American patients, within Latin American and non-Latin American countries. Sixty empirical studies regarding the effectiveness of culturally adapted and conventional CBT were included in this review. The included studies were carried out in Latin American and non-Latin American countries. The information from all studies was synthesized and assessed, including intervention effect sizes, patient retention rates, methodological quality of the papers, and the type of cultural adaptation made to the therapy. There were no differences between the sets of studies in terms of effectiveness, retention rates, methodological quality, or proportion of statistically significant interventions. Most of the cultural adaptations were peripheral or unspecified. The evidence to date indicates that both conventional and culturally adapted CBT offer the same benefits for Latin American patients in terms of effectiveness and retention rates. Rather than focusing on cultural adaptations, clinicians are encouraged to improve the way they deliver CBT through training and supervision.

Key learning aims

(1)

Two Trajectories of Depressive Symptom Reduction Throughout Behavioral Activation Teletherapy Among Underserved, Ethnically Diverse, Primary Care Patients: A VitalSign6 Report

While prior research has investigated trajectories of depressive symptom change throughout psychotherapy, such work has not been conducted exclusively among underserved patients receiving brief Behavioral Activation (BA) teletherapy, intervention modifications that should reduce barriers to therapy initiation and engagement. The current project used cluster analysis to determine discrete groups of symptom change among patients receiving an 8-session BA teletherapy intervention, and analyzed whether demographic and clinical characteristics were associated with group membership. Data from 105 patients referred from charity primary care clinics and receiving at least two therapy sessions were analyzed. Patients were predominantly female and Latina. The 9-item Patient Health Questionnaire (PHQ-9) was the outcome. Two categories were determined: a larger group (N = 61) demonstrating initially less severe symptoms and experiencing a gradual recovery, and a smaller group beginning with more severe symptoms, and experiencing a steeper recovery. In both groups, a majority of participants experienced at least a 5-point drop in depressive symptoms, while in the latter group, a majority of patients achieved depressive symptom remission (PHQ-9 < 5). Monolingual Spanish speakers were more likely to be in the former group, but no other demographic or clinical characteristics were associated with group membership. In both groups, a majority of the symptom reduction occurred by sessions 4-6. Therefore, two categories of depressive symptom change, slow responders and rapid responders, occur among patients receiving a brief BA teletherapy intervention. No demographic differences aside from primary language, nor any clinical characteristics, distinguish group membership, suggesting similar patterns of symptom reduction among a primarily underserved sample.

Who Benefits Most from Adding Technology to Depression Treatment and How? An Analysis of Engagement with a Texting Adjunct for Psychotherapy

Introduction: Cognitive behavioral therapy (CBT) is an established treatment for depression, but its success is often impeded by low attendance. Supportive text messages assessing participants' mood in between sessions might increase attendance to in-clinic CBT, although it is not fully understood who benefits most from these interventions and how. This study examined (1) user groups showing different profiles of study engagement and (2) associations between increased response rates to mood texts and psychotherapy attendance. Methods: We included 73 participants who attended Group CBT (GCBT) in a primary care clinic and participated in a supportive automated text-messaging intervention. Using unsupervised machine learning, we identified and characterized subgroups with similar combinations of total texting responsiveness and total GCBT attendance. We used mixed-effects models to explore the association between increased previous week response rate and subsequent week in-clinic GCBT attendance and, conversely, response rate following attendance. Results: Participants could be divided into four clusters of overall study engagement, showing distinct profiles in age and prior texting knowledge. The response rate to texts in the week before GCBT was not associated with GCBT attendance, although the relationship was moderated by age; there was a positive relationship for younger, but not older, participants. Attending GCBT was, however, associated with higher response rate the week after an attended session. Conclusion: User groups of study engagement differ in texting knowledge and age. Younger participants might benefit more from supportive texting interventions when their purpose is to increase psychotherapy attendance. Our results have implications for tailoring digital interventions to user groups and for understanding therapeutic effects of these interventions.

Predictors of Adherence to Treatment in Behavioral Health Therapy for Latino Immigrants: The Importance of Trust

A complex array of barriers to care influence patients' adherence to behavioral healthcare services. Understanding barriers to care is critical to ensure sufficient dosage of treatment. This study assessed the influence of perceived barriers on Latino migrants' prospective adherence to treatment for co-occurring mental health and substance use disorders as part of a clinical trial. Eligible participants (18-70 years-old) were recruited from community-based settings and classified according to their intervention session attendance. Baseline assessments included socio-demographic factors, clinical characteristics (i.e., depression, anxiety, post-traumatic stress disorder, substance use), psychosocial and cultural factors (i.e., ethnic identity, health literacy, discrimination), and perceived attitudinal and structural barriers to care. Treatment involved 10-sessions of cognitive-behavioral therapy, psychoeducation, and mindfulness (Integrated Intervention for Dual problems and Early Action) and emphasized participant's engagement in treatment. We used multinomial logistic regression models to examine the association between barriers to care reported at baseline, sociodemographic characteristics, psychosocial and cultural factors, clinical factors, and treatment adherence. Mistrust in previous behavioral health treatment(s) was the reported barrier significantly associated with completion of the program after adjusting for clinical, psychosocial, and cultural factors, with those expressing mistrust in previous treatment(s) showing higher rates of completion compared to those who did not report this barrier. Evidence-based and culturally-tailored interventions provided by ethnically matched providers may overcome cultural mistrust and increase adherence to behavioral health care among Latino immigrants.

Cognitive behavioral therapy for primary care depression and anxiety: a secondary meta-analytic review using robust variance estimation in meta-regression

Cognitive-behavioral therapy (CBT) is well supported for treating depressive and anxiety disorders. Trials of CBT for anxiety and depression in primary care have increased over the past decade, yet only one meta-analysis, published in 2015, examined this topic and the scope of that review is relatively narrow. This study conducted a systematic review and meta-analysis of primary care based CBT for depression and anxiety. A search of seven electronic databases, six professional websites, and reference lists from articles meeting inclusion criteria was conducted for studies published between 1900 and November 2018. Fifty-seven eligible studies (including 10,701 participants; 221 effect sizes) of randomized controlled trials were eligible and included for meta-analysis using robust variance estimation in meta-regression. Outcome indicators were depression and anxiety measures. An overall significant treatment effect, d = 0.400, 95% CI (0.235, 0.566), p < 0.001, of CBT for depression and anxiety disorders in primary care was identified. Subgroup analyses indicated significant treatment effect for: (1) depressive (d = 0.425, p < 0.001) and anxiety (d = 0.393, p < 0.01) outcomes, (2) studies conducted inside primary care (d = 0.412, p < 0.001), (3) studies using individual-based CBT (d = 0.412, p < 0.001), (4) studies without primary care physician involvement (d = 0.395, p < 0.001), and (5) studies using both tele-health (d = 0.563, p < 0.001) and in-person CBT (d = 0.363, p < 0.001). The percentage of White participants, treatment composition (CBT only versus CBT + other approaches), and treatment duration were significant moderators. Implications for clinical practice are discussed based on both moderator and subgroup analysis results.

Evaluation of the Integrated Intervention for Dual Problems and Early Action Among Latino Immigrants With Co-occurring Mental Health and Substance Misuse Symptoms: A Randomized Clinical Trial

IMPORTANCE

Immigrants are at an increased risk for co-occurring mental health and substance misuse symptoms; however, effective treatments are lacking.

OBJECTIVE

To evaluate the effectiveness of the Integrated Intervention for Dual Problems and Early Action (IIDEA) program compared with enhanced usual care.

DESIGN, SETTING, AND PARTICIPANTS

This effectiveness randomized clinical trial was conducted from September 2, 2014, to February 2, 2017, in 17 clinics or emergency departments and 24 community sites in Boston, Massachusetts, as well as in Madrid and Barcelona, Spain. Equal randomization (1:1) in 2-person blocks was used, assigning participants to either the IIDEA treatment group (n = 172) or the enhanced usual care control group (n = 169). Intent-to-treat analyses assessed effectiveness, and post hoc analyses examined whether results varied by symptom severity or treatment dose. Eligible participants were between 18 and 70 years of age, self-identified as Latino, screened positive for co-occurring symptoms, and were not receiving specialty behavioral health services.

INTERVENTIONS

Participants were randomized to a 10-session IIDEA treatment or to enhanced usual care.

MAIN OUTCOMES AND MEASURES

Primary outcomes were changes in alcohol and drug misuse and results of a urine test for drug metabolites but not for alcohol misuse. Secondary outcomes were symptoms of depression, generalized anxiety, posttraumatic stress disorder, and overall mental health.

RESULTS

In total, 341 participants were randomized to either the IIDEA treatment group (n = 172; 94 [54.7%] female, mean [SD] age, 33.5 [11.6] years) or the enhanced usual care control group (n = 169; 80 [47.3%] female, mean [SD] age, 34.3 [11.8] years). No statistically significant effects of IIDEA were found for primary drug and alcohol outcomes (ASI Lite-drug score: β = -0.02 [SE, 0.69; P = .88; Cohen d, 0.00; 95% CI, -0.17 to 0.17]; ASI Lite-alcohol score: β = -0.01 [SE, 1.19; P = .66; Cohen d, 0.00; 95% CI, -0.12 to 0.12]; urine drug test result: β = -0.36 [SE, 0.43; P = .50; OR, 0.70; 95% CI, 0.30-1.61]), but statistically significant effects were observed for secondary mental health outcomes. The IIDEA treatment was effective in reducing depressive symptoms per the Public Health Questionnaire-9 score (β = -1.14; SE, 0.47; P = .02; Cohen d, 0.20 [95% CI, 0.04-0.36]), posttraumatic stress disorder symptoms per the Posttraumatic Stress Disorder Checklist-5 score (β = -3.23; SE, 1.59; P = .04; Cohen d, 0.25 [95% CI, 0.01-0.37]), and overall mental health symptoms per the Hopkins Symptom Checklist-20 (β = -0.20; SE, 0.07; P = .01; Cohen d, 0.25 [95% CI, 0.08-0.42]) and composite mental health (β = -3.70; SE, 1.75; P = .04; Cohen d, 0.19 [95% CI, 0.01-0.36]) scores at the 6-month follow-up. Exploratory analyses suggested that 6-month treatment effects occurred for patients whose drug misuse was moderate to severe at the baseline assessment. Among patients with moderate to severe substance misuse, IIDEA substantially reduced substance use per the urine test results (odds ratio, 0.25 [95% CI, 0.09-0.67]; P = .01). Treatment dose showed small to large effect sizes by outcome.

CONCLUSIONS AND RELEVANCE

The IIDEA treatment did not change drug misuse but did improve secondary mental health and substance misuse outcomes for a heterogeneous population with moderate to severe symptoms; this finding provides a path for treating Latino immigrants with co-occurring mental health and substance misuse symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02038855.

Telemental health training and delivery in primary care: A case report of interdisciplinary treatment

Telehealth can overcome access and availability barriers that often impede receiving needed mental health services. This case report describes an interdisciplinary approach to treatment for an individual with chronic physical health conditions and comorbid mental health concerns, which resulted in high utilization (and associated costs) of preventable emergency services. The report describes clinical case progression on anxiety symptoms and emergency service utilization while concurrently highlighting telehealth-specific practice implications, especially as they pertain to training settings.

Mindful attention moderating the effect of experiential avoidance in terms of mental health among Latinos in a federally qualified health center

The present study examined the moderating role of mindful attention in the relation between experiential avoidance and anxious arousal, social anxiety, depressive symptoms, and the number of mood and anxiety disorders among a sample of Latinos seeking health services at a primary care facility. Participants included 326 adult Latinos (M_age = 39.79 years, SD = 11.27; 88.9% female; 98.2% used Spanish as their first language). Results provided empirical evidence of an interaction between mindful attention and experiential avoidance for anxious arousal, social anxiety, depressive symptoms, and the number of mood and anxiety disorders in the studied sample. Specifically, among Latinos with lower (vs higher) levels of mindfulness, greater experiential avoidance was related to greater anxiety/depressive symptoms and number of mood and anxiety disorders. Together, these data provide novel empirical evidence of the clinically relevant interplay between mindful attention and experiential avoidance regarding a relatively wide array of negative emotional symptoms and disorders among Latino primary care patients. Limitations of the study include a largely female sample and cross-sectional data.

Cultural influences on mental health symptoms in a primary care sample of Latinx patients

The present study examines how both between group (i.e., ethnic group membership) and within group cultural factors (i.e., nativity status, age of immigration, and perceived discrimination) may contribute to anxiety and related symptoms in Latinx with anxiety disorders. Baseline data were examined from patients who participated in one of the largest intervention studies for adults with anxiety disorders in primary care settings; 196 Latinx and 568 NLW (non-Latinx White) patients participated. Proportions of anxiety disorders were similar between Latinx and NLWs; however, Latinx, on average, had a greater number of anxiety disorders than NLWs. Levels of anxiety and depression symptom severity, anxiety sensitivity, and mental functional impairment were similar between the ethnic groups. Latinx expressed greater somatization and physical functional impairment than NLWs. Among Latinx, perceived discrimination, but not other cultural variables, was predictive of mental health symptoms while controlling for age, gender, education, and poverty. Overall, these findings suggest more similarities than differences in types and levels of anxiety and anxiety-related impairment, with some important exceptions, including greater levels of somatization and physical functional impairment among Latinx patients. Further, perceived discrimination may be an important factor to consider when examining risk for greater symptom burden among Latinx with anxiety.

Implementing Group CBT for Depression Among Latinos in a Primary Care Clinic

Depression in low-income Latino populations can be treated using group cognitive behavioral therapy (GCBT). However, effective delivery of GCBT for depression in primary care settings is often impeded by high dropout rates and poor homework adherence. In this study, we describe the structure, processes, and outcomes (including attendance, homework completion, and symptom measures) of GCBT for Spanish-speaking Latino patients with depression in an urban public sector primary care setting. For this study, 96 Latino patients in a primary care clinic participated in at least 1 session of GCBT. Although depressive symptoms among these patients, as measured by the PHQ-9, significantly decreased during treatment, attendance and homework completion were limited. Even with a strategy in place to allow patients to continue in treatment after missing several sessions, 23% of patients dropped out of therapy following their initial session, and approximately half of all patients completed less than 50% (or 8) therapy sessions. Homework was only completed 23% of the time it was checked. Greater session attendance prospectively predicted lower depressive symptoms over time. We discuss potential strategies to increase engagement, treatment effects, and symptom reduction for depression in primary care settings.

Homework in Cognitive Behavioral Therapy: A Systematic Review of Adherence Assessment in Anxiety and Depression (2011-2016)

Treatment adherence has posed a substantial challenge not only for patients but also for the health profession for many decades. The last 5 years has witnessed significant attention toward adherence with cognitive behavioral therapy (CBT) homework for anxiety and depressive disorders, and adherence assessment methods have diversified. However, there remains a large component of the adherence process not assessed in CBT, with patient effort, engagement, and the known role for treatment appraisals and beliefs necessitating the pursuit of improved adherence assessment methods.

A Transmedia Storytelling Intervention With Interactive Elements to Benefit Latinas' Mental Health: Feasibility, Acceptability, and Efficacy

BACKGROUND

Latinos report higher rates of depression and anxiety than US whites but are less likely to receive care. Transmedia storytelling interventions accessible on the Internet via smartphones, tablets, and computers hold promise for reducing reluctance to explore or get help for symptoms because they are private, convenient, and can reach large numbers of people, including Latinas with mental health needs.

OBJECTIVE

The purpose of this study was to examine the feasibility, acceptability, and preliminary efficacy of a mental health transmedia intervention for Latinas with elevated symptoms of depression, anxiety, or both.

METHODS

A total of 28 symptomatic English-speaking Latina women aged 21 to 48 years participated in a 6-week study using a within-group design. All aspects of the study were completed via telephone or Internet. Participants used their personal devices to engage the Web-based transmedia intervention (in English) that included story-based videos, a data-informed psychotherapeutic video, an interactive video sequence, and a blog written from the point of view of one of the characters with links to mental health resources. Perceived confidence to get help and perceived importance for seeking immediate help were both measured using single-item questions. Participants completed surveys at baseline (via telephone) and 1 and 6 weeks after media engagement that measured various factors, including depression (Patient Health Questionnaire; PHQ-9 and PHQ-8) and anxiety (Generalized Anxiety Disorder scale; GAD-7). A telephone interview was conducted within 72 hours of media engagement. Action taken or intentions to get help (single-item question) and talking about the videos with others (single-item question) were measured 1 and 6 weeks after media engagement. Repeated measures analysis of variance was used to assess change in depression (PHQ-8) and anxiety (GAD-7) before transmedia engagement and 1 and 6 weeks after. Spearman correlations evaluated the association of confidence and importance of getting help with action taken, anxiety, and depression.

RESULTS

All 28 Latinas (English speakers) who engaged with the transmedia remained in the 6-week study. Within 1 week of transmedia engagement, 39% of women took action to get help, and 82% discussed the media with others. Symptoms of depression (F2,54=9.0, P<.001) and anxiety (F2,54=18.7, P<.001) significantly reduced across time. Higher levels of confidence were significantly associated with actions taken at 1 (P=.005) and 6 weeks (P=.04), and higher levels of importance were significantly associated with actions taken at 1 (P=.009) and 6 weeks (P=.003). Higher levels of confidence were associated with lower levels of depression (P=.04) and anxiety (P=.01) at 6 weeks.

CONCLUSIONS

Preliminary findings indicate a culturally tailored mental health transmedia intervention is a feasible approach that holds promise for engaging large numbers of symptomatic English-speaking Latina women to begin the process of seeking help, as well as decreasing symptoms of anxiety and depression.

Vida Calma: CBT for Anxiety with a Spanish-Speaking Hispanic Adult

BACKGROUND

Hispanic adults aged 55 years and older are the fastest growing ethnic minority group in the United States facing significant mental health disparities. Barriers in accessing care have been attributed to low income, poor education, language barriers, and stigma. Cultural adaptations to existing evidence-based treatments have been encouraged to improve access. However, little is known about mental health treatments translated from English to Spanish targeting anxiety among this Hispanic age group. Objctive: This case study offers an example of how an established, manualized, cognitive-behavioral treatment for adults 55 years and older with generalized anxiety disorder (known as "Calmer Life") was translated to Spanish ("Vida Calma") and delivered to a monolingual, Hispanic 55-year-old woman.

RESULTS

Pre- and post-treatment measures showed improvements in symptoms of anxiety, depression, and life satisfaction.

CONCLUSION

Findings suggest Vida Calma is a feasible treatment to use with a 55-year-old Spanish-speaking adult woman.

CLINICAL IMPLICATIONS

Vida Calma, a Spanish language version of Calmer Life, was acceptable and feasible to deliver with a 55-year-old participant with GAD. Treatment outcomes demonstrate that Vida Calma improved the participant's anxiety, depression, and life satisfaction.

The role of negative affect in the relation between subjective social status and mental health among economically disadvantaged Latinos in primary care

Purpose

The purpose of this paper is to examine the explanatory role of negative affect in the relation between subjective social status and anxiety/depressive disorders, suicidality symptoms, and disruption in life domains (i.e. disability; work/school, social life, and family life/home responsibilities) among Latinos seeking health services at a primary healthcare facility.

Design/methodology/approach

An experiment was designed using participants including 205 adult Latinos (Mage=39.2; SD=11.4) with annual incomes of less than $30,000. The sample was mostly female (85.9 percent) with a majority (98.5 percent) indicating Spanish as their first language.

Findings

Results indicated that subjective social status was indirectly related to the mental health variables through negative affect. Notably, these observed effects were evident above and beyond the variance accounted for by gender, age, marital status, educational status, employment status, and number of years in the USA.

Research limitations/implications

The present findings suggest that there is merit in focusing further scientific attention on the interplay between subjective social status and negative affect to better understand and possibly intervene to reduce anxiety/depressive vulnerability and disability among Latinos in primary care settings.

Originality/value

The current study sheds light on the relationship between social status and negative affect in the Latino population. Elucidating mental health in a minority population such as the Latino population provides insight into the mental health needs among minorities that have yet to be addressed.

Psychological treatment of comorbid asthma and panic disorder in Latino adults: Results from a randomized controlled trial

Confusion between panic and asthma symptoms can result in serious self-management errors. A cognitive behavior psychophysiological therapy (CBPT) intervention was culturally adapted for Latinos consisting of CBT for panic disorder (PD), asthma education, differentiation between panic and asthma symptoms, and heart rate variability biofeedback. An RCT compared CBPT to music and relaxation therapy (MRT), which included listening to relaxing music and paced breathing at resting respiration rates. Fifty-three Latino (primarily Puerto Rican) adults with asthma and PD were randomly assigned to CBPT or MRT for 8 weekly sessions. Both groups showed improvements in PD severity, asthma control, and several other anxiety and asthma outcome measures from baseline to post-treatment and 3-month follow-up. CBPT showed an advantage over MRT for improvement in adherence to inhaled corticosteroids. Improvements in PD severity were mediated by anxiety sensitivity in CBPT and by depression in MRT, although earlier levels of these mediators did not predict subsequent improvements. Attrition was high (40%) in both groups, albeit comparable to CBT studies targeting anxiety in Latinos. Additional strategies are needed to improve retention in this high-risk population. Both CBPT and MRT may be efficacious interventions for comorbid asthma-PD, and CBPT may offer additional benefits for improving medication adherence.

Synergistic effects of pain intensity and anxiety sensitivity in relation to anxiety and depressive symptoms and disorders among economically disadvantaged latinos in a community-based primary care setting

The present investigation examined the interactive effects of anxiety sensitivity and pain intensity in relation to anxious arousal, social anxiety, and depressive symptoms and disorders among 203 Latino adults with an annual income of less than $30,000 (84.4% female; M_age=38.9, SD=11.3 and 98.6% used Spanish as their first language) who attended a community-based primary healthcare clinic. As expected, the interaction between anxiety sensitivity and pain intensity was significantly related to increased anxious arousal, social anxiety, and depressive symptoms as well as number of depressive/anxiety disorder diagnoses. The form of the significant interactions indicated that participants reporting co-occurring higher levels of anxiety sensitivity and pain intensity evinced the greatest levels of anxious arousal, social anxiety, and depressive symptoms as well as higher levels of depressive and anxiety disorders. These data provide novel empirical evidence suggesting that there is clinically-relevant interplay between anxiety sensitivity and pain intensity in regard to a relatively wide array of anxiety and depressive variables among Latinos in a primary care medical setting.

Interactive effect of negative affectivity and anxiety sensitivity in terms of mental health among Latinos in primary care

From a public health perspective, primary care medical settings represent a strategic location to address mental health disapirty among Latinos. Yet, there is little empirical work that addresses affective vulnerability processes for mental health problems in such settings. To help address this gap in knowledge, the present investigation examined an interactive model of negative affectivity (tendency to experience negative mood states) and anxiety sensitivity (fear of the negative consequences of aversive sensations) among a Latino sample in primary care in terms of a relatively wide range of anxiety/depression indices. Participants included 390 Latino adults (Mage=38.7, SD=11.3; 86.9% female; 95.6% reported Spanish as first language) from a primary care health clinic. Primary dependent measures included depressive, suicidal, social anxiety, and anxious arousal symptoms, number of mood and anxiety disorders, and disability. Consistent with prediction, the interaction between negative affectivity and anxiety sensitivity was significantly related to suicidal, social anxiety, and anxious arousal symptoms, as well as number of mood/anxiety diagnoses and disability among the primary care Latino sample. The form of the interactions indicated a synergistic effect, such that the greatest levels of each outcome were found among those with high negative affectivity and high anxiety sensitivity. There was a trending interaction for depressive symptoms. Overall, these data provide novel empirical evidence suggesting that there is a clinically-relevant interplay between anxiety sensitivity and negative affectivity in regard to the expression of anxiety and depressive symptoms among a Latino primary care sample.

Pain severity and emotion dysregulation among Latinos in a community health care setting: relations to mental health

BACKGROUND

Although pain severity is often related to poorer mental health and is one of the most common presenting complaints in community health care settings, there is little understanding of the pain experience in relation to anxiety/depressive symptoms and disorders among Latino populations in medical contexts.

METHOD

To address this gap, the current study explored an interactive model of pain severity and emotion dysregulation in relation to anxiety/depressive symptoms and psychopathology among 274 Latinos who attended a community-based primary health care clinic [86.9% female; Mage=39.3 (SD=11.2); 96.0% indicated Spanish as their first language].

RESULTS

Results indicated a statistically significant interaction between pain severity and emotion dysregulation for suicidal symptoms, social anxiety symptoms and number of mood/anxiety disorders, such that more severe pain and greater levels of emotion dysregulation related to poorer mental health. Both pain severity and emotion dysregulation were significant predictors of depressive symptoms, but only pain severity was a significant predictor of anxious arousal symptoms.

CONCLUSIONS

These novel findings suggest a clinically significant interplay between pain severity and emotion dysregulation among Latinos in. The results are discussed in relation to the need for new screening and intervention tactics that address interrelations between pain severity and emotional dysregulation among Latinos seeking treatment in community health-care-based settings.

An Update on the Status of Sponsored Research in Counseling Psychology

Prior research has indicated that relative to other specialty areas in psychology, counseling psychology researchers are less likely to engage in research activities sponsored by external funding agencies. The primary purposes of this article were to address external funding in the counseling psychology profession and to compare the rates of articles published in the premier counseling psychology research journal ( Journal of Counseling Psychology [ JCP]) that reported external funding to other specialty areas’ premier research journals. Between 2007 and 2011, articles in JCP were less likely than those in other journals to report external funding and less likely to report research designs associated with external sponsorship. Post hoc analyses indicated that articles in a leading vocational research journal also had relatively low rates of external funding, and counseling psychology faculty members were less likely than peers in other programs to report external funding. The implications of these findings for the field are discussed.

A mental health intervention strategy for low-income, trauma-exposed Latina immigrants in primary care: A preliminary study

Latinos in the United States face significant mental health disparities related to access to care, quality of care, and outcomes. Prior research suggests that Latinos prefer to receive care for common mental health problems (e.g., depression and anxiety disorders) in primary care settings, suggesting a need for evidence-based mental health services designed for delivery in these settings. This study sought to develop and preliminarily evaluate a mental health intervention for trauma-exposed Latina immigrants with depression and/or posttraumatic stress disorder (PTSD) for primary care clinics that serve the uninsured. The intervention was designed to be simultaneously responsive to patients' preferences for individual psychotherapy and to the needs of safety-net primary care clinics for efficient services and to address the social isolation that is common to the Latina immigrant experience. The resulting intervention, developed on the basis of findings from the research team's formative research, incorporated individual and group sessions and combined evidence-based interventions to reduce depression and PTSD symptoms, increase group readiness, and improve perceived social support. Low-income Latina immigrant women (N = 28), who screened positive for depression and/or PTSD participated in an open pilot trial of the intervention at a community primary care clinic. Results indicated that the intervention was feasible, acceptable, and safe. A randomized controlled trial of the intervention is warranted. (PsycINFO Database Record

Anxiety sensitivity and mindful attention in terms of anxiety and depressive symptoms and disorders among Latinos in primary care

The present investigation examined the interactive effects of anxiety sensitivity and mindful attention in relation to anxiety and depressive symptoms and psychopathology among 145 adult Latinos (85.5% female; Mage=39.9, SD=10.8 and 98.6% used Spanish as their first language) who attended a community-based primary healthcare clinic. As expected, the interaction between anxiety sensitivity and mindful attention was significantly related to number of mood and anxiety disorders, social anxiety, and depressive symptoms. No significant interaction, however, was evident for panic (anxious arousal) symptoms. The form of the significant interaction indicated that Latinos reporting co-occurring higher levels of anxiety sensitivity and lower levels of mindful attention evinced the greatest levels of anxiety/depressive psychopathology, social anxiety, and depressive symptoms. These data provide novel empirical evidence suggesting that there is clinically-relevant interplay between anxiety sensitivity and mindful attention in regard to a relatively wide array of anxiety and depressive variables among Latinos in a primary care medical setting.

Anxiety sensitivity and subjective social status in relation to anxiety and depressive symptoms and disorders among Latinos in primary care

The present investigation examined the interactive effects of anxiety sensitivity and subjective social status in relation to anxiety and depressive symptoms and psychopathology among 143 Latinos (85.7% female; Mage=39.0, SD=10.9; 97.2% used Spanish as their first language) who attended a community-based primary healthcare clinic. Results indicated that the interaction between anxiety sensitivity and subjective social status was significantly associated with number of mood and anxiety disorders, panic, social anxiety, and depressive symptoms. The form of the significant interactions indicated that individuals reporting co-occurring higher levels of anxiety sensitivity and lower levels of subjective social status evidenced the greatest levels of psychopathology and panic, social anxiety, and depressive symptoms. The present findings suggest that there is merit in focusing further scientific attention on the interplay between anxiety sensitivity and subjective social status in regard to understanding, and thus, better intervening to reduce anxiety/depressive vulnerability among Latinos in primary care.

Quality of life and marital adjustment after cognitive behavioural therapy and behavioural marital therapy in couples with anxiety disorders

BACKGROUND

Anxiety disorders may affect nearly one in four persons and may cause significant impairment of interpersonal relationships including marital relationships. The effect of the disorder on the spouse and the impact of including the spouse in therapy are not well studied.

AIM

To determine if Cognitive Behavioural Therapy (CBT) improves the quality of life of participants with anxiety disorders and if marital adjustment of couples with anxiety disorders can be improved with Behavioural Marital Therapy (BMT), relative to standard care of pharmacotherapy and psychoeducation.

METHODS

An open label randomised controlled trial. Participants were randomly assigned to CBT+BMT or standard of care. Final assessments were carried out at 3.5 months after baseline. Quality of life was assessed using the WHOQOL-Bref instrument and Marital adjustment was measured using a marital quality scale. Chi-square test, student's t-test and Analysis of Variance (ANOVA) and Effect sizes with Cohen's d were used to compare differences between groups.

RESULTS

Clinically meaningful effect sizes for the CBT+ BMT intervention were evident for the marital adjustment scores among participants (d=0.63) and their spouses (d=1.29), and for the psychological (d=0.84), social (d=0.72) and environmental (d=0.52) domains of the WHOQOL of participants and psychological (d=0.86), social (d=0.32) and environmental domains (d=1.01) of the WHOQOL of spouses of participants.

CONCLUSION

CBT for the partner with anxiety disorder and BMT for couples with anxiety disorders and marital discord and involvement of the spouse in the therapy will be a useful addition to the management of a couple where one partner has an anxiety disorder.