Leopoldo J. Cabassa

Measuring Acculturation: Where We Are and Where We Need to Go

Acculturation measures intend to capture the psychological, behavioral, and attitudinal changes that occur when individuals and groups from different cultures come into continuous contact with each other. This article examines the most prominent theoretical models and assumptions that drive acculturation measures. Examples of Hispanic acculturation measures are used to illustrate how these theoretical foundations are applied in empirical measures. Particular emphasis is given to discussing the strengths and limitations of two bidimensional measures, the Bidimensional Acculturation Scale for Hispanics (BAS) and the Acculturation Rating Scale for Mexican Americans-Revised (ARSMA-II). Recommendations for improving these measures are presented. Moving beyond proxy measures, improving the operationalization of acculturation indicators, and incorporating theoretical models, as well as contextual variables, are the key recommendations presented for improving measures of acculturation.

Latino Adults' Access to Mental Health Care: A Review of Epidemiological Studies

Since the early 1980s, epidemiological studies using state-of-the-art methodologies have documented the unmet mental health needs of Latinos adults in the U.S. and Puerto Rico. This paper reviews 16 articles based on seven epidemiological studies, examines studies methodologies, and summarizes findings about how Latino adults access mental health services. Studies consistently report that, compared to non-Latino Whites, Latinos underutilize mental health services, are less likely to receive guideline congruent care, and rely more often on primary care for services. Structural, economic, psychiatric, and cultural factors influence Latinos’ service access. In spite of the valuable information these studies provide, methodological limitations (e.g., reliance on cross-sectional designs, scarcity of mixed Latino group samples) constrict knowledge about Latinos access to mental health services. Areas for future research and development needed to improve Latinos’ access and quality of mental health care are discussed.

It's Like Being in a Labyrinth: Hispanic Immigrants' Perceptions of Depression and Attitudes Toward Treatments

This study aimed to describe Hispanic immigrants’ perceptions of depression and attitudes toward treatments and to examine how demographics, acculturation, clinical factors, and past service use were associated with their perceptions and attitudes. A convenience sample of 95 Hispanic immigrant patients was presented a vignette depicting an individual with major depression. Structured interviews that included standardized instruments and open-ended questions were used to query patients about their views of depression and its treatments. Findings showed that Hispanic immigrants perceived depression as a serious condition caused by interpersonal and social factors. Consistent with existing literature, most patients endorsed positive attitudes toward depression treatments yet reported apprehensions toward antidepressants. Demographic factors, acculturation, depressive symptoms, and past mental health service use were related to patients’ views of depression and attitudes toward care. This study emphasizes the need to incorporate Hispanic immigrants’ perceptions and attitudes into depression treatments.

Depression and Diabetes among Low-Income Hispanics: Design Elements of a Socio-Culturally Adapted Collaborative Care Model Randomized Controlled Trial:

Objective: This article describes design elements of the Multifaceted Depression and Diabetes Program (MDDP) randomized clinical trial. The MDDP trial hypothesizes that a socioculturally adapted collaborative care depression management intervention will reduce depressive symptoms and improve patient adherence to diabetes self-care regimens, glycemic control, and quality-of-life. In addition, baseline data of 387 low-income, 96% Hispanic, enrolled patients with major depression and diabetes are examined to identify study population characteristics consistent with trial design adaptations. Methods: The PHQ-9 depression scale was used to identify patients meeting criteria for major depressive disorder (1 cardinal depression symptom + a PHQ-9 score of > 10) from two community safety net clinics. Design elements included sociocultural adaptations in recruitment and efforts to reduce attrition and collaborative depression care management. Results: Of 1,803 diabetes patients screened, 30.2% met criteria for major depressive disorder. Of 387 patients enrolled in the clinical trial, 98% had Type 2 diabetes, and 83% had glycated hemoglobin (HbA1c) levels ≥ 7%. Study recruitment rates and baseline data analyses identified socioeconomic and clinical factors that support trial design and intervention adaptations. Depression severity was significantly associated with diabetes complications, medical comorbidity, greater anxiety, dysthymia, financial worries, social stress, and poorer quality-of-life. Conclusion: Low-income Hispanic patients with diabetes experience high prevalence of depressive disorder and depression severity is associated with socioeconomic stressors and clinical severity. Improving depression care management among Hispanic patients in public sector clinics should include intervention components that address self-care of diabetes and socioeconomic stressors.

Latino Immigrant Men's Perceptions of Depression and Attitudes Toward Help Seeking

Perceptions of depression, attitudes toward depression treatments, help-seeking preferences, and perceived barriers to care were examined in a sample of 56 Latino immigrant men recruited from a primary health care clinic. Each participant was presented a vignette depicting an individual with major depression. Men described the vignette as a debilitating condition caused by social stressors that would improve with time. Men preferred counseling over medications and reported misconceptions about antidepressants. Faith in God and seeking help from family members were seen as important help-seeking strategies. Structural and financial barriers were prevalent among this sample of men. Implications for improving depression care for Latino immigrant men are discussed.

Capacity-to-Consent in Psychiatric Research: Development and Preliminary Testing of a Screening Tool

Objective: Assuring research participants’capacity to provide informed consent has become increasingly important in health and mental health research, and each study faces unique capacity-assessment challenges, possibly requiring its own screening tool. This article describes the development and preliminary testing of a capacity-to-consent tool constructed for a study of psychiatric diagnosing in a community clinic. Method: A 10-item screening device based on four legal standards for demonstrating capacity (understanding, appreciation, reasoning, and voluntarism) was created and tested with 68 adult patients entering the study. Results: Only five participants (7%) failed the screen, 61 (93%) passed. No participants who passed at entry were later found in psychiatric evaluations to lack capacity. Conclusion: The tool was effective in identifying persons who could not demonstrate consent capacity, thereby protecting prospective participants.

Measuring Latinos’ Perceptions of Depression: A Confirmatory Factor Analysis of the Illness Perception Questionnaire

This study examined the psychometric properties of the Revised Illness Perception Questionnaire adapted for a clinical sample of low-income Latinos suffering from depression. Participants (N = 339) were recruited from public primary care centers. Their average age was 49.73 years and the majority was foreign born females of either Mexican or Central American descent. Confirmatory factor analysis was used to test the factor structure of this measure. Construct and discriminant validity and internal consistency were evaluated. After the elimination of three items because of low factor loadings (< .40) and the specification of seven error covariances, a revised model composed of 24 items had adequate goodness-of-fit indices and factor loadings, supporting construct validity. Each of the subscales reported satisfactory internal consistency. Intercorrelations between the 5 illness perception factors provided initial support for the discriminant validity of these factors in the context of depression. The establishment of the psychometric properties of this adapted measure will pave the way for future studies examining the role illness perceptions play in the help seeking and management of depression among Latinos.

Sustainability of collaborative care interventions in primary care settings

• Summary: We assessed patient and provider barriers and facilitators to sustainability of a collaborative depression care model for depression treatment in predominantly Hispanic diabetes patients in safety net care clinics. • Findings: Semi-structured interviews and focus groups were conducted with patients and providers at two community clinics participating in a randomized controlled effectiveness trial of the Multi-faceted Depression and Diabetes Program (MDDP), a socioculturally adapted collaborative care model. Analysis identified eight themes grouped into three categories: barriers, facilitators, and recommendations for program sustainability. Barriers included patient concerns about use of medication and provider concerns about use of psychotherapy, increased workload for clinic staff, delay in receiving outcomes data, and lack of resources to sustain the program. Facilitators included patient benefits such as improved clinical outcomes, quality of care received, access, and satisfaction; provider benefits such as increased awareness and reduced anxiety; and clinic benefits in the form of reduced costs of care. Recommendations included changes in communication patterns among providers, specific changes in procedures, changes in resources, and changes in clinic organizational culture. • Applications: Sustainable adoption of collaborative depression care for underserved populations in safety net care systems by organizational decision-makers and providers requires: stable funding and qualified staff; technologies to facilitate provider access to easily applied treatment guidelines, information exchange between primary care physicians and depression care providers, and routine monitoring of patient depression symptoms and treatment adherence and satisfaction; and treatment consistent with patient preferences.

A Systematic Review of Depression Treatments in Primary Care for Latino Adults

Objective: A systematic literature review of randomized clinical trials (RCTs) assessing depression treatments in primary care for Latinos is conducted. The authors rate the methodological quality of studies, examine cultural and linguistic adaptations, summarize clinical outcomes and cost-effectiveness findings, and draw conclusions for improving depression care among this diverse population. Method: Electronic bibliographic databases, Web sites, and manual searches are used to identify nine peer-reviewed articles covering four RCTs. Results: Across trials, collaborative care models were more effective than usual care in reducing depression and improving functioning and accessibility to guideline-congruent care. Conclusion: The use of evidence-based treatments in primary care seems to be an effective and cost-effective strategy to reduce mental health care disparities among Latinos served in primary care.

Clinician-Patient Ethnicity in Psychiatric Diagnosis: A Pilot Study with Hispanics

Abstract Language and ethnicity are parts of the interpersonal process that converge during psychiatric diagnosis, affecting diagnostic accuracy and concordance among clinicians. In this feasibility study, the authors videotaped two Hispanic psychiatrists conducting typical diagnostic interviews with first-time Hispanic patients (N = 10) in a community mental health clinic. Then, two non-Hispanic psychiatrists viewed the videotapes with translator assistance. All psychiatrists rendered DSM-IV diagnoses on the patients they interviewed or whose tapes they watched. On Axis I, psychiatrists did not differ, diagnosing mostly mood disorders. On Axis II, non-Hispanic psychiatrists diagnosed personality disorders more often. On Axis IV, Hispanic psychiatrists identified more psychosocial stressors, especially family-related ones. On Axis V, Hispanic psychiatrists rated patients more functionally impaired. Although limited, the findings raise several interesting questions that can be useful to clinicians and researchers diagnosing patients from their own or a different culture. Are Axis I diagnoses less subject to cultural biases than Axis II personality disorders? Does cultural proximity between patient and clinician add sensitivity to psychosocial stressors while holding patients to higher functional standards?