Review Of Efficacy Research

Empirical validation of treatment approaches is determined based on outcome studies of efficacy and effectiveness. Efficacy studies are based on randomized controlled trials that adhere to strict guidelines for determining identified outcomes related to specific treatment modalities provided by trained experts. Efficacy studies answer the question of whether or not a specific treatment works for a specific disorder. For example, the National Institute of Mental Health Treatment of Depression Collaborative Research Program (NIMH TDCRP) documented the relative efficacy of CT and interpersonal therapy (IPT) in comparison to antidepressant medication (Elkin et al., 1989). In this study, both CT and IPT were found to be effective for reducing symptoms of unipolar depression (Depression Guideline Panel, 1993); however, too few ethnic/minority patients were included in the randomized sample, and differential outcomes by ethnicity were not analyzed. In general, with the few exceptions reviewed in the following section, efficacy studies of CT and CBT have not included enough ethnic/ minority individuals to permit analyses of outcomes for African American and Latino populations.

Effectiveness studies differ from efficacy studies in that they apply empirically validated (efficacious) treatments to settings outside controlled laboratory conditions. Therefore, these studies can be important in determining treatment outcomes for diverse groups, because effectiveness re search can answer the question of whether a treatment is efficacious in a particular setting or for a particular population. In addition, effectiveness research expands the evaluation of treatment outcomes beyond alleviation of disorder symptoms by including issues such as the feasibility, acceptability, length or cost of treatment, or the degree to which a specific treatment is adequate for the setting or population. We review the available data from available efficacy and effectiveness studies of CT and CBT for depression in African Americans and Latinos, as well as data from studies using cognitive-based interventions for the prevention of depression.

Despite increased research attention paid to the efficacy of treatments for depression since the NIMH Collaborative Study in the 1980s, no available efficacy studies have examined CT or CBT for depression across ethnic groups. This is unfortunate, because empirically validated treatment approaches are increasingly valued in clinical settings and medical insurance policy guidelines. However, there is promising evidence for the utility of cognitive approaches with ethnic/minority patients based on different kinds of studies in the literature. In addition to a few studies with small comparative samples, that tested differences in CT outcome between ethnic/minority and white patients, a handful of within-group studies have tested outcomes for African Americans or Latinos. Also, some studies have examined CT outcomes with specialized populations (e.g., HIV patients with depressive symptoms), and others have tested outcomes of treatment with enhancements to psychotherapy for ethnic/minority patients. These studies have begun to establish the efficacy of cognitive approaches for ethnic/ minority patients, particularly those studies with specific adaptations to service delivery and attention to cultural issues.

An early, randomized controlled trial compared group CT therapy and group behavioral therapy (BT) for depression in a small sample of Puerto Rican women (Comas-Díaz, 1981). The 25 participants were randomized to three treatment conditions (CT, BT, and control) and outcomes were determined by self-report and clinical and behavioral ratings. The intervention was conducted over 4 weeks and included five, 1.5-hour treatment sessions. Both therapy groups showed a reduction in depressive symptoms in comparison to the control group, and there were no significant differences between CT and BT groups. At a 5-week follow-up, however, participants in the BT group showed slightly improved outcomes in comparison to the CT group. A nonrandomized study of 175 low-income and minority medical patients, including mostly African Americans and Latinos, showed moderate reductions in depressive symptoms after individual and group treatment with a manualized CBT intervention (Organista, Muñoz, & Gonzalez,

1994). There were no differences in treatment outcome among African American, Latino, and European American patients, although ethnic/ minority patients were more likely to terminate treatment prematurely (a finding similar to that of Sue et al., 1994).

More recent studies with specific groups have shown mixed results for CT and CBT treatment for ethnic/minority patients. It is difficult, though, to draw conclusions due to the inability to analyze differential outcomes in small samples and the ability of results to generalize beyond special populations. For example, an exploratory randomized study of CBT versus supportive psychotherapy versus combination treatment (medication and supportive psychotherapy) was conducted with 101 HIV-positive patients experiencing depressive symptoms (Markowitz, Speilman, Sullivan, & Fishman, 2000). African Americans receiving CBT reported significantly poorer outcomes in comparison to Latino and European American patients. The findings, however, are based on the four African American patients in the CBT condition, out of a total of 18 African Americans in the study sample. Alternatively, in a small exploratory study of depressed, low-income African American women, Kohn et al. (2002) found that participants in a group therapy intervention of culturally adapted CBT reported greater decreases in depressive symptomatology after 16 weeks of treatment in comparison to demographically matched women participating in a nonadapted CBT group.

In an effort to engage and to maintain depressed ethnic/minority patients in therapy and improve functioning, Miranda, Azocar, Organista, Dwyer, and Arean (2003a) examined the impact of including clinical case management as a supplement to standard CBT. The supplemental intervention was intended to work toward resolving environmental stressors (e.g., housing, employment, recreation, relationships) that contribute to distress. Patients receiving case management attended more CBT sessions and were less likely than those without the supplemental intervention to drop out of the intervention. There were no differences in treatment response to CBT between African American and Latino patients. African American patients (41% of the sample) with supplemental case management surprisingly reported more depressive symptoms and worse functioning than those treated with CBT alone. Also, there was no impact of the supplemented therapy on the posttreatment functioning of African American patients, in contrast with Latino patients. African Americans receiving CBT alone showed greater improvement than African Americans receiving supplemental case management with CBT. Though these findings seemingly downplay the importance of environmental stressors for African American treatment outcomes, the researchers explained that the unexpected findings may have resulted from unintended differences in case management delivery. Specifically, posttreatment review of the data revealed that Latino patients received more home visits than African American patients. Greater number of home visits suggests that Latino patients may have received more case management and/or more personalized case management that could have resulted in better treatment outcomes.

Another outcome study provided enhancements to treatment by fulfilling basic needs to promote participation in treatment for depression with African American women and Latina immigrants (Miranda et al., 2003b). The purpose of the study was to assess the impact of appropriate care (i.e., paroxetine or bupropion antidepressant medication, or CBT vs. control) on depressed minority women by reducing accessibility barriers. Enhancements consisted of pretreatment education meetings about depression and treatment, cultural adaptations to guideline-based medication and CBT, intensive outreach and routine follow-up, reimbursement for child care and transportation costs, flexible scheduling, language modifications, and culturally sensitive professionals. Cumulatively, these accommodations helped circumvent barriers and ensured accessibility of appropriate care to a population at risk for receiving inadequate community care. Whereas medication treatment produced superior 6-month outcomes over CBT, patients receiving either type of appropriate care reported improved functioning and significant decreases in depressive symptoms in comparison to the control condition. There were no posttreatment differences in depressive symptoms between African American and Latina patients. Miranda and colleagues (2003c) have noted that minor accommodations, including translated materials for patients, culturally relevant training materials for service providers, and use of ethnic/minority treatment experts, yield particularly large clinical benefits for ethnically diverse patients. Thus, practical modifications and enhancements of traditional CBT delivery appear to benefit depressed ethnic/minority patients by increasing the utilization of appropriate care.

In addition to treating depression effectively, CT approaches have been found to be effective in reducing the risk of major depression. To our knowledge, however, only one preventive intervention trial of CBT with ethnic/minority adults has been conducted. Muñoz, Ying, and Bernal (1995) conducted a randomized controlled trial of a manualized CBT group intervention with 150 low-income, predominantly minority adults at risk for depressive disorder based on symptom levels (but not yet meeting criteria for diagnosis) in a primary care setting. Results indicated that the intervention significantly reduced depressive symptoms in the CBT group com pared to the control group. Group CBT has also been found to be effective in reducing risk for depression among low-income urban Latinos who have just migrated to the United States (Arce & Torres-Matrullo, 1982). The groups provided patients support for processing ways to communicate their emotions and approaching their conflicts within a new culture, therefore reducing risk for depression and other disorders. In general, however, more research is needed to understand the potential of CT for reducing risk and preventing the onset of depression.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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