Psychotherapy for Major Depressive Disorder in Latinos

Alan Podawiltz, DO, MS, FAPA

Texas College of Osteopathic Medicine, and the Department of Psychiatry and Behavioral Health, University of North Texas Health Science Center, Fort Worth

Larry Culpepper, MD, MPH

Department of Family Medicine, Boston University School of Medicine, Boston, Massachusetts

Hispanic or Latino refers to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. In this activity, the terms Hispanic and Latino are used interchangeably.

The APA guidelines1 for the treatment of MDD recommend psychotherapy either alone or in conjunction with pharmaceutical approaches for acute mild-to-moderate MDD, and in conjunction with pharmaceutical treatment for moderate-to-severe MDD (AV 1). Although IPT and CBT have been scientifically validated as effective psychotherapies for patients with MDD,1–4 limited research exists regarding their effectiveness.2 However, studies5,6 have found that Hispanics prefer counseling to medical treatment for depression. One study6 found that, of the 121 depressed Hispanic patients interviewed about their perception of primary care treatments for depression, 88% said their depression would be helped by counseling or psychotherapy.

Interpersonal Psychotherapy

Clearly psychotherapy can be adapted for various cultures. Markowitz et al2 adapted IPT for Hispanic patients by focusing on relationship issues that are central to Latino cultures. They also incorporated cultural roles such as maternity, spirituality, and acculturation into the therapy to enable greater patient understanding of interpersonal problems and to allow “gradual, modeled expression of emotion while preserving equanimity.”2(p220) Other adaptations included using cultural idioms, de-emphasizing the medical nature of depression in favor of an interpersonal relationship focus, and decoding the meaning of interpersonal relationships within the patient’s cultural context. In reviewing cases conducted over 3 years, the researchers2 found that patients supported and welcomed the psychotherapy and appreciated the quick results. The time-limited therapy, however, was sometimes viewed as a sign of abandonment, and many patients struggled with appearing for regular appointments on time; termination was also difficult.

Cognitive-Behavioral Therapy

Miranda et al7 showed that 8 to 12 weeks of group CBT could be effective in a low-income Latino population. Patients were more likely to complete the minimum 8 sessions if they also received case management and were less likely to exhibit depressive symptoms at 6 months follow-up than those who received CBT only (AV 2). Cultural adaptations for CBT included providing all materials in English and Spanish, and training therapists to show respecto (obedience to authority, particularly parental authority) and simpatia (a need to be polite that discourages criticism and assertiveness) to patients, as well as “allowing for warmer, more personalized interactions” than are typically provided with this type of therapy.7(p220)

More

3-Stage Model of Psychotherapy

La Roche8 developed a 3-stage model of psychotherapy for Hispanics that recognizes the concepts of familialism (familismo or strong attachments, reciprocity, and loyalty to extended family members), respecto, and allocentrism (a tendency to define oneself in relation to others), which is anathema to the Western values of individualism and autonomy. These concepts are all core values within Latino communities. La Roche’s stages are:

  1. Address the patient’s chief complaint (depression) and reduce the symptoms. During this stage, the primary goal is to assess and remove any risk to the patient or to others. Then, the patient and therapist set therapeutic goals focused on symptom reduction.

  2. Understand the patient’s narrative. In eliciting the narrative, the therapist should recognize that questions about patients’ families are likely to lead to a more detailed discussion than questions about the patients themselves. However, patients may be reluctant to share negative family information. Understanding and acknowledging the patient’s spiritual, socioeconomic, and cultural background is also important in making sense of the narrative. In addition, acknowledging and addressing somatic symptoms, which often occur in Latino patients with MDD, is necessary.

  3. Foster empowerment. Empowerment occurs as patients “understand themselves and identify community stressors and resources.” In this third stage, the therapist should achieve an increased understanding and validation of the patient’s experiences in different cultural and social contexts.

Conclusion

Although some forms of psychotherapy may be effective with or without medication for the treatment of MDD, minimal research exists on their effects in Hispanic populations. However, both IPT and CBT may be modified to reflect cultural issues. Barriers to psychotherapy for Latinos include economic problems, lack of time, and physical health problems.6 Modifications include maintaining a focus on family, understanding the cultural importance attached to respect, and being aware of cultural tendencies toward allocentrism rather than individualism.

Abbreviations

APA=American Psychiatric Association
BDI=Beck Depression Inventory
CBT=cognitive-behavioral therapy
IPT=interpersonal therapy
MDD=major depressive disorder

References

  1. American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 2nd ed. Am J Psychiatry. 2000;157(suppl 4):1–45.
  2. Markowitz JC, Patel SR, Balan IC, et al. Toward an adaptation of interpersonal psychotherapy for Hispanic patients with DSM-IV major depressive disorder. J Clin Psychiatry. 2009;70(2):214–222.
  3. Elkin I, Shea MT, Watkins JT, et al. National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Arch Gen Psychiatry. 1989;46(11):971–982.
  4. Cuijpers P, van Straten A, van Oppen P, et al. Are psychological and pharmacologic interventions equally effective in the treatment of adult depressive disorders? a meta-analysis of comparative studies. J Clin Psychiatry. 2008;69(11):1675–1685.
  5. Cooper LA, Gonzales JJ, Gallo JJ, et al. The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. Med Care. 2003;41(4):479–489.
  6. Karasz A, Watkins L. Conceptual models of treatment in depressed Hispanic patients. Ann Fam Med. 2006;4(6):527–533.
  7. Miranda J, Azocar F, Organista KC, et al. Treatment of depression among impoverished primary care patients from ethnic minority groups. Psychiatr Serv. 2003;54(2):219–225.
  8. La Roche MJ. Psychotherapeutic considerations in treating Latinos. Harv Rev Psychiatry. 2002;10(2):115–122.
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