Telephone Cognitive Behavioral Therapy for Rural Latinos: A Randomized Pilot Study Gino Aisenberg, PhD UW School of Social Work Megan Dwight Johnson, MD MPH RAND Corporation Daniela Golinelli,, PhD RAND Corporation Mary O Brien, O MSW Yakima Valley Farm Workers Clinic Evette J. Ludman, PhD Group Health Research Institute
Disparities in Depression Care Among Latinos with diagnosable MH condition: Fewer than 1 in 5 contact a general health provider (<1 in 10 among recent immigrants) Fewer than 1 in 11 contact a mental health specialist (<1 in 20 among recent immigrants) Even when primary care providers diagnose depression and recommend treatment: Latinos (OR=0.42) are less likely than whites to report taking an antidepressant Latinos are less likely than whites to obtain specialty MH services (OR=0.50) (Miranda & Cooper, 2004) Men, recent immigrants and those with limited English proficiency are particularly unlikely to receive appropriate care for depression. (Young et al., 2001, Vega et al., 1999, Sentell et al., 2007, Brach et al., 2005)
Psychotherapy for Latinos Latinos are more likely to prefer psychotherapy over antidepressants for treatment of depression (Dwight-Johnson et al., 2004) Latinos benefit from evidence based, culturally sensitive, manualized therapies (Miranda et al., 2005) Adding case management can increase treatment adherence to manualized CBT (Miranda et al., 2003)
Barriers to Depression Treatment Family, work, acculturative, economic, and migration-related related stress, poor housing conditions, and competing life priorities (Magana et al., 2003; Hovey et al., 2000; Miranda et al., 1996) Psychotherapy is rarely available in primary care settings where Latinos are most likely to seek care For rural Latinos: lack of bilingual and bicultural mental health providers and lack of specialty mental health, geographic isolation, lack of transportation, and language/cultural barriers
Aims 1. Examine the effectiveness of an adapted telephone based cognitive behavioral therapy intervention among rural Latino primary care patients compared to enhanced usual care. 2. Describe intervention implementation. 3. Identify the need for further manual adaptation.
Study site Yakima Valley Farm Workers Clinic (YVFWC), Walla Walla Family Medical Center site Private, not for profit Serves low-income predominantly Latino patients, including patients from Oregon Wide range of integrated primary care services No on-site psychotherapeutic intervention available No licensed, bilingual practitioner available in region to provide psychotherapy
Intervention Structured 8-session 8 CBT Provided by trained MSWs In Spanish or English Optional initial in person session Weekly telephone group supervision Feedback to PCPs Registry to track patient progress Secure digital recordings of sessions for supervision Case management Assistance with making appt with primary care physician for medication if desired Active follow-up and intervention with community resources Provided by trained BSW level person
Socio-cultural cultural Adaptation Original manual developed by Gregory Simon and Evette Ludman (Group Health Research Institute) Translation of manual into Spanish Nueva Vista Revision of manual to include vignettes reflective of local rural experiences Use of trained bilingual, bicultural personnel First session in person if patient preferred
Enhanced usual care Educational pamphlet Referral to PCP Medication management if provided by PCP
Outcomes Blinded telephone assessments at 6 weeks, 3 months, 6 months post screening Hopkins Symptom Checklist (SCL-20) depression scale Patient Health Questionnaire (PHQ-9) Patient rated improvement Patient rated satisfaction Qualitative exit interviews at 6 months
Recruitment flow chart 869 Latino pts. screened 14% (N=119) study eligible 84% (101) enroll and complete baseline assessments Randomization N=51 CBT+CM N=50 usual care
Demographics Intervention Usual Care Female 39 (78.0%) 40 (78.4%) Male 11 (22.0%) 11 (21.6%) Latino 45 (90.0%) 47 (92.2%) Nativity --US born 0 (0%) 4 (7.8%) --Mexico 47 (94.0%) 45 (88.2%) --Other 3 (6.0%) 2 (3.9%)
More Demographics Intervention Usual Care Education <6 yrs, 15 (30.0%) 15 (29.4%) >6 and <11 yrs 24 (48.0%) 26 (51.0%) HS graduate 7 (14.0%) 7 (13.7%) Some college 4 (8.0%) 5 (9.8%) Married 32 (64.0%) 32 (62.7%)
Work Status and Income Intervention Usual Care Employed 26 (52.0%) 24 (47.1%) Migrant worker 7 (14.0%) 3 (5.9%) Seasonal worker 15 (30.0%) 17 (33.3%) Income <=$5000 2 (4.2%) 6 (11.8%) $5001-$15,000 $15,000 23 (47.9%) 13 (25.5%) $15,001-$25,000 $25,000 16 (33.3%) 15 (29.4%) >=$25,000 7 (14.6%) 10 (19.6%)
Baseline SCL Month 3 SCL Month 6 SCL Baseline PHQ-9 1.8 (0.8) 1.8 (0.8) 1.8 (0.8) 0.24 0.813 1.1 (0.8) 0.9 (0.7) 1.3 (0.8) 2.26 0.027* 1.0 (1.0) 0.8 (0.7) 1.2 (1.1) 1.85 0.068 17.2( 3.6) 16.7 (3.7) 17.7 (3.3) 1.40 0.163 Month 3 PHQ-9 8.9 (6.4) 7.3 (5.4) 10.4 (6.9) 2.09 0.040* Month 6 PHQ-9 7.7 (7.4) 5.4 (6.3) 10.0 (8.0) 2.67 0.009*
PHQ-9 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Wave PHQ-9 6 8 10 12 14 16 18
Month 3 SCL reduction >50%, N(%) 30 (42.3%) 19 (54.3%) 11 (30.6%) 4.096 0.043* 043* Month 6 SCL reduction >50%, N(%) 42 (57.5%) 26 (66.7%) 16 (47.1%) 2.858 0.0910 Month 3 PHQ-9 9 reduction >50%, N(%) 37 (55.2%) 19 (59.4%) 18 (51.4%) 0.427 0.514 Month 6 PHQ-9 9 reduction >50%, N(%) 46 (65.7%) 30 (78.9%) 16 (50.0%) 5.874 0.015* 0
Qualitative exit interviews suggested further adaptations More guidance about involving family members to support behavioral activation More specific role of therapist in facilitating medication for those with more severe depression
Lessons learned: Implementation Important therapist qualities: Interpersonal warmth important to establish trust and rapport comfort with manual adherence comfort with tracking of outcomes comfort and proficiency with basic computer technology
Lessons learned: Training Role playing each session by phone in pairs: --increased familiarity with material -- encouraged mutual support Address cultural factors and not presume cultural competency even if Latino Need for training in: Basics of depression and its treatment Clinical assessment Use of tracking sheet and digital recorders
Lessons learned: Implementation Importance of sustained communication with PCPs Case Management valued by patients, PCPs, and study team Pts experience multiple stressors patience and extensive outreach and follow-up is crucial Be responsive to gender matching concerns Address patient concerns about confidentiality in small rural communities
Conclusions Telephone CBT appears effective in reducing depressive symptoms among rural low income Latino primary care patients. Telephone delivery was acceptable to patients and feasible in rural primary care strong rapport and trust established. Low income Latinos in rural areas have many competing priorities. Extensive outreach is essential and more practical with telephone interventions that is responsive to their context.