A Critical Review of Culturally Sensitive Treatments for Depression:Recommendations for Intervention and Research

Zornitsa Kalibatseva and Frederick T. L. LeongMichigan State University

Recent meta-analyses and reviews have showed that culturally adapted mental health interventions aremore effective for racial and ethnic minorities than traditional unadapted psychotherapy. Despite theadvances in providing culturally sensitive mental health services, disparities among racial and ethnicminorities still exist. As a body of literature on culturally sensitive treatments accumulates, there is a needto examine what makes a treatment for specific presenting problems culturally sensitive. This articlepresents a critical review of existing culturally sensitive treatments for depression because it is one of themost common and debilitating mental disorders. In particular, we examined what treatment modalitieswere used, what types of adaptations were implemented, and what populations were targeted. Theconceptual framework this review uses to categorize existing culturally sensitive treatments includes atop-down, a bottom-up, or an integrative approach. The review reveals that the majority of culturallysensitive treatments for depression employed an evidence-based bottom-up approach, which involvedgeneral and practical adaptations, such as translating materials or infusing specific cultural values. Moststudies used cognitive–behavioral strategies and included Latinos and African Americans. Recommen-dations and future directions in interventions and research are discussed to decrease mental health caredisparities among ethnic minorities.

Keywords: culturally sensitive treatment, culturally adapted treatment, depression, racial/ethnicminorities, adaptation, therapy

Depression is among the most debilitating disorders and largestcontributors to the world’s global burden of disease (World HealthOrganization [WHO], 2008). Therefore, it has been of paramountimportance to find effective psychosocial treatments for depres-sion and examine what treatments work for whom (Norcross &Wampold, 2011). Previous reviews of psychosocial treatmentswith ethnic minorities (Huey & Polo, 2008; Miranda et al., 2005)and meta-analyses (Benish, Quintana, & Wampold, 2011; Griner& Smith, 2006; Smith et al., 2011) have examined the overalleffectiveness of cultural adaptations in various treatments targetingmultiple disorders. In particular, cultural adaptations appear to bemore effective than no treatment (d � 0.58), treatment as usual(d � 0.22) or unadapted psychotherapy (d � 0.32; Benish et al.,2011; Huey & Polo, 2008) and show moderately strong benefitfrom pre- to post- intervention (d � 0.45; Griner & Smith, 2006).As depression is one of the most prevalent and incapacitatingmental disorders and mental health professionals strive to provideadequate depression treatment to all patients, it is important toexamine in depth the culturally sensitive treatments for depressionin the United States.

Since the existing evidence-based treatments (EBTs) in theUnited States are infused with Western norms, researchers need to

determine whether such treatments are equally effective for otherpopulations (e.g., ethnic minorities or nationals of other countries)or whether new culturally sensitive treatments are necessary (Ber-nal & Domenech Rodríguez, 2012; Gone, 2009). In the last de-cade, several studies explored the development and implementa-tion of culturally sensitive treatments (CSTs) for depression fordifferent ethnic groups. However, this growing body of literaturehas not been reviewed and analyzed. The goal of this article is toprovide a critical review of the literature on culturally sensitivetreatments for depression and to establish what makes a depressiontreatment culturally sensitive, how effective such treatments are,and what populations CSTs targeted. Conceptually, this reviewexamines the existing culturally sensitive treatments using a top-down approach or surface adaptations, a bottom-up approach ordeep adaptations, and an integrative approach or a combination oftop-down and bottom-up approaches. In the final section, we offerrecommendations for future research and implementation of CSTsfor depression with the goal to reduce mental health disparitiesamong culturally diverse groups.

CSTs entail “the tailoring of psychotherapy to specific culturalcontexts” (Hall, 2001, p. 502). Bernal and Domenech Rodríguez(2012) examined cultural adaptations within the framework ofevidence-based practice. The authors discussed the relationshipbetween psychotherapy and culture, which can range from “invis-ible” or “absent” to “inseparable” or “intertwined” (Bernal &Domenech Rodríguez, 2012, p. 4). Multiple terms have been usedto describe the variability and gradation in the relationship be-tween culture and psychotherapy, such as “culturally adapted,anchored, appropriate, centered, competent, congruent, informed,relevant, responsive, and sensitive” (p. 4). For example, the term

Zornitsa Kalibatseva and Frederick T. L. Leong, Department of Psy-chology, Michigan State University.

Correspondence concerning this article should be addressed to ZornitsaKalibatseva at the Department of Psychology, 127B Psychology Building,Michigan State University, East Lansing, MI 48824-1116. E-mail:kalibats@msu.edu

Psychological Services © 2014 American Psychological Association2014, Vol. 11, No. 4, 433–450 1541-1559/14/$12.00 DOI: 10.1037/a0036047

433

culturally embedded implies the strongest relationship such thatpsychotherapy is considered an integral part of the context,whereas culturally adapted suggests systematic changes to theprotocol of an existing treatment in order to make features of thetreatment relevant to the culture of the target population. Morespecifically, cultural adaptation is “any modification to anevidence-based treatment that involves changes in the approach toservice delivery, in the nature of therapeutic relationship, or incomponents of the treatment itself to accommodate the culturalbeliefs, attitudes, and behaviors of the target population” (Whaley& Davis, 2007, pp. 570–571). The term culturally sensitive is usedin this review to indicate varying degrees of integration of culturein psychotherapy, which may range from culturally embeddedpsychotherapy to one or two specific cultural adaptations, such aschanging the language or hiring bicultural staff.

Culture, Race, Ethnicity, and Disparities in ServiceUtilization Among Ethnic Minorities

In the last two decades, there has been an increased awarenessof the influence of culture on psychopathology and psychotherapy(Leach & Aten, 2010; López & Guarnaccia, 2000). Workingdefinitions of race, ethnicity, and culture are provided below asthese concepts are often used interchangeably (Betancourt & Lo-pez, 1993). Race refers to similar observable physical character-istics, such as skin color, hair type and color, eye color, and facialfeatures. It often implies biological variation as the physiognomicfeatures specific to one race are associated with populations withinisolated geographic locations (Betancourt & Lopez, 1993). Ethnic-ity usually refers to groups that share characteristics, such asnationality, language, history, traditions, race, and/or culture. Typ-ically, ethnic characteristics occur simultaneously with race andculture, which may contribute to the common interchangeable useof these terms.

Culture refers to “highly variable systems of meanings, whichare learned and shared by a people or an identifiable segment of apopulation” (p. 630; Betancourt & Lopez, 1993; Rohner, 1984).Psychologically relevant elements that constitute culture represent“social norms, roles, beliefs, and values” (Betancourt & Lopez; p.630) and may include topics, such as familial roles, gender roles,communication styles, affective styles, values of authority or per-sonal control, individualism, collectivism, and spirituality amongothers (Betancourt & Lopez). These culturally relevant elementsmay influence how people report and conceptualize their experi-ence of distress, determine if they seek and/or stay in treatment aswell as their treatment outcome (U.S. Department of Health andHuman Services [DHHS], 2001).

Data from the Collaborative Psychiatric Epidemiology Surveysrevealed that lifetime prevalence rates of depression among U.S.racial and ethnic groups varied. Approximately 13.5% of Hispan-ics, 11.4% of Native Americans, 10.8% of non-Hispanic Blacks,17.9% of non-Hispanic Whites, and 9.1% of Asian Americans metcriteria for major depressive episode (Beals et al., 2005; Breslau etal., 2006; Takeuchi, Hong, Gile, & Alegría, 2007). Researchershave found significant disparities in depression treatment amongethnic minorities in the United States despite the similar or lowerprevalence rates of depression compared to non-Hispanic Whites(Alegría et al., 2008; Harman, Edlund, & Fortney, 2004). In anationally representative sample, Alegría et al. (2008) identified

significant ethnic differences in utilization of mental health ser-vices among people diagnosed with past-year depressive disorder,with 63.7% of Latinos, 68.7% of Asians, and 58.8% of non-Hispanic Blacks, compared with 40.2% of non-Hispanic Whites,failing to access services. Moreover, there were disparities in thelikelihood of both having access to and receiving adequate care fordepression for Asian Americans and non-Hispanic Blacks in con-trast to non-Hispanic Whites. These findings are consistent withthe disparities in service utilization reported in the supplement tothe U.S. Surgeon General Report Mental health: Culture, race,and ethnicity (U.S. DHHS, 2001). The supplement provided anoverview of the limited mental health research with ethnic minor-ities and described the lack of information as a “critical disparity”(p. 159, U.S. DHHS, 2001).

Evidence-Based Treatments and Culturally SensitiveTreatments

The recognition of mental health service utilization disparitiesand the scarcity of research on psychological treatments withethnic and racial minority populations necessitated the carefulexamination of all available information in this field. Two majorreviews of psychosocial treatments with ethnic minority youth andadults (Huey & Polo, 2008; Miranda et al., 2005) concentrated onanswering the question of whether or not EBTs that have beenpredominantly tested with White middle-class English-speakingclients can generalize to ethnic minorities. Evidence-based treat-ments (EBTs) refer to “the interventions or techniques (e.g.,cognitive–behavioral therapy for depression, exposure therapy foranxiety) that have produced therapeutic change in controlled tri-als” (Kazdin, 2008, p. 147). Since the majority of “possibly effi-cacious” EBTs have been developed and tested primarily withWhite, middle-class, English-speaking women, mental health pro-fessionals have questioned their efficacy with ethnic minorities(Bernal & Scharrón-del-Río, 2001; Miranda et al., 2005).

Based on a limited number of EBT studies the earlier reviewconcluded that cognitive–behavioral therapy (CBT) and interper-sonal therapy (IPT) are effective for African Americans and Lati-nos (Miranda et al., 2005). In the second review, Huey and Polo(2008) focused on the effectiveness of evidence-based treatmentsfor ethnic minority youth and found that based on Chambless andHollon’s (1998) criteria there were no “well-established” treat-ments. Yet, the review suggested that there were some “probablyefficacious” and “possibly efficacious” treatments for anxiety-related problems, attention-deficit/hyperactivity disorder, depres-sion, conduct problems, substance abuse problems, and trauma-related syndromes.

Both review papers concluded that the existing EBTs that havebeen tested with ethnic minorities showed promising results. How-ever, these reviews included both traditional EBTs and culturallysensitive or adapted EBTs with ethnic minorities (e.g., Kohn,Oden, Muñoz, Robinson, & Leavitt, 2002; Rossello & Bernal,1999). Combining both types of treatments in reviews or analysesmay be problematic because it would be difficult to determine ifthe treatment outcome is associated with the traditional treatmentor the culturally sensitive elements.

In the last decade, a growing number of CST studies adaptedEBTs (e.g., Kohn et al., 2002) or developed treatments for specificpopulations with the help of focus groups (e.g., Stacciarini, 2008).

434 KALIBATSEVA AND LEONG

At the same time, a prominent debate in the field of CSTs has beenwhether EBTs should be adapted or not (Atkinson, Bui, & Mori,2001; La Roche & Christopher, 2008). Some researchers believethat EBTs should be used in their original form to preserve theirfidelity, others find a middle ground by proposing cultural adap-tations to existing treatments, and yet others believe that culturecannot be artificially added and culturally sensitive treatmentsshould be generated from specific cultural groups (La Roche &Christopher, 2008).

In an attempt to categorize the existing culturally sensitivetreatments, Cardemil (2008) offered an organizing framework forCSTs that listed three perspectives with their respective advan-tages and limitations. The first perspective states that CST is theproduct of culturally sensitive therapists. The second perspectiveviews CSTs as culturally adapted EBTs. The last perspectiveproposes that CSTs make culture the central focus and mainprinciple in developing the treatment and such approaches areusually described as culturally centered (Bernal & DomenechRodríguez, 2012). Thus, according to the second and third per-spectives, CSTs can encompass cultural adaptations of existingtreatments as well as newly developed treatments for specificgroups of color (Hall & Yee, 2013).

Various researchers have questioned whether it is possible tohave evidence-based treatments that are also culturally sensitive(Atkinson, et al., 2001; Bernal & Scharron-del-Rio, 2001; Hall,2001; La Roche & Christopher, 2008). Therefore, an importantquestion that remains is whether culturally diverse groups wouldbenefit more from culturally sensitive interventions than fromunadapted EBTs.

In support of this idea, Griner and Smith (2006) examined thebenefit of evidence-based culturally adapted mental health inter-ventions. A meta-analysis of 76 studies found an average treatmenteffect size (d � .45) from pre- to postintervention, which indicateda moderately strong benefit of culturally adapted interventions. Inaddition, Griner and Smith found that treatments for groups ofsame-race participants were four times more effective (d � .49)than treatments for groups of mixed-race participants (d � .12).This finding suggests that cultural adaptations for specific groupsmay be more beneficial than general multicultural adaptations.Another important finding was that effect sizes of culturallyadapted treatments increased when participants were older andwhen there was a higher percentage of Hispanic participants. Theauthors attributed the greater benefits of cultural adaptations forthese populations to the impact of acculturation suggesting thatolder populations may be less acculturated than younger popula-tions and some Hispanic populations that do not speak Englishmay be less acculturated. In addition, when the therapist spoke theparticipants’ native language (if not English), the treatment effectwas larger (d � .49) than when the therapist did not speak theparticipants’ native language (d � .21). A logical next step is toreview the nature of the cultural adaptations and test if theycontribute to the already existing treatments.

Smith, Domenech Rodríguez, and Bernal (2011) reviewed ex-isting definitions and means for culturally adapting psychotherapyand provided clinical examples of adapted “traditional” Westerntreatments. The authors conducted a meta-analysis that included8,620 participants from 65 studies and concluded that the cultur-ally adapted treatments had a moderate effect (d � .46). In addi-tion, Smith et al. (2011) suggested that the most effective treat-

ments were those with greater numbers of cultural adaptations.However, none of the existing reviews has primarily focused onthe specific adaptations or elements that would make a treatmentculturally sensitive for a particular disorder.

Cultural Adaptations: Frameworks and Models

Domenech Rodríguez and Bernal (2012) traced the beginning ofcultural adaptation models within positivist approaches to therapy,which emphasize “systematic observation and scientific discov-ery” (p. 23). The authors provided a thorough review of 11 broadframeworks or models for cultural adaptation. Several of theseframeworks were used for culturally sensitive depression treat-ments.

The Multidimensional Model for Understanding Culturally Re-sponsive Psychotherapies (Koss-Chioino & Vargas, 1992) pro-posed two dimensions of psychotherapy: culture and structure. Thedimension of culture included cultural content and cultural contextand the dimension of structure consisted of process and form.Kohn et al. (2002) used a framework that resembled this one toculturally adapt a CBT for African American women.

Another framework that has been used in a number of culturallysensitive treatments is the Ecological Validity Framework (EVF;Bernal, Bonilla, & Bellido, 1995). It consists of eight areas of anintervention that may be culturally adapted. Language refers toculturally relevant oral and written forms of communication (e.g.,translation, specific jargon). The persons dimension captures theclient-therapist dyad dynamics (e.g., ethnic match). Metaphorsinclude expressing ideas in culturally relevant visual and verbalforms (e.g., role models, sayings). Content refers to attending tothe client’s values, traditions, and interpersonal styles (e.g.,familismo, simpatia). The concepts about the treatment, the treat-ment goals, and the treatment methods also need to be consistentwith the cultural values and expectations of the client. Finally, thecontext is taken into consideration in the assessment and interven-tion (e.g., acculturation, country of origin, family constitution,etc.). At least three studies used the EVF (Nicolas, Arntz, Hirsch,& Schmiedigen, 2009; Rossello & Bernal, 1999; Rossello, Bernal,& Rivera-Medina, 2008) to adapt existing cognitive–behavioraland interpersonal treatments for depression for Haitian and PuertoRican adolescents.

Theoretically, this review examines the existing culturally sen-sitive treatments using a top-down, a bottom-up, or an integrativeapproach. In this case, top-down refers to cultural adaptations to anestablished treatment to make it sounds and look more compatibleto the population of interest (e.g., translate materials to the lan-guage of the client, train staff to be warmer in interpersonalinteractions). These types of adaptations may be similar to Resni-cow et al.’s (2002) “surface adaptations.” Alternatively, bottom-uprefers to “deep adaptations” that consider contextual factors influ-encing behavior (e.g., historical, political, and sociocultural con-texts) and often involve collaboration with the potential recipientsof the treatment in the form of focus groups or qualitative research.An integrative approach refers to the use of both top-down andbottom-up adaptations and may include the use of a specificcultural adaptation framework. Although Hwang (2006, 2009)proposed a framework titled Integrating Top-Down andBottom-Up Approach in Adapting Psychotherapy, the use of theterms “top-down” and “bottom-up” in this review does not include

435CULTURALLY SENSITIVE DEPRESSION TREATMENTS

all of the elements that Hwang listed. Additionally, this reviewutilizes Leong’s Cultural Accommodations Model (CAM; Leong& Lee, 2006) to discuss the findings and formulate future recom-mendations for research and practice.

The primary goal of this article is to review the body of litera-ture on culturally sensitive treatments for depression and answerseveral questions that are important for the understanding andevaluation of these treatments and relevant to addressing existingdisparities:

1) What makes a treatment for depression culturally sensi-tive?

2) What types of existing treatments for depression havebeen adapted and/or tested (e.g., theoretical background;individual/family/group) and what are the outcomes?

3) What types of clients are these treatments targeting (e.g.,age, SES, ethnicity/race)?

4) What possible recommendations for future research canbe made?

Literature Review Method

Peer-reviewed articles examining culturally sensitive depressiontreatments were identified using the PsycInfo database in Decem-ber 2012. Keywords and subject terms included depression, de-pressed, treatment, therapy, psychotherapy in conjunction withadaptation, culturally adapted, culturally sensitive, multicultural,culture, ethnicity, race, and ethnic minority. In addition, publishedmeta-analyses (Benish et al., 2011; Griner & Smith, 2006; Huey &Polo, 2008; Smith et al., 2011) and review articles (Horrell, 2008;Miranda et al., 2005) of psychosocial treatments with ethnic mi-norities or nonmainstream populations were reviewed and relevantstudies were drawn. The first author (ZK) conducted the literaturesearch and reviewed the search results. Articles included in thisreview 1) focused on culturally sensitive treatments for depression,2) mentioned at least one element in the treatment related to theclients’ culture, and 3) described the cultural adaptation or frame-work used in the treatment. Culturally sensitive prevention pro-grams for depression were excluded. We identified 16 studies ofculturally sensitive treatments for depression based on these inclu-sion/exclusion criteria presented in Table 1.

Results

Elements of Culturally Sensitive Treatments forDepression

Some of the studies adapted specific elements using a top-downapproach (e.g., Dai et al., 1999), whereas others used frameworksand/or bottom-up and integrative approaches to create new treat-ments (e.g., Nicolas et al., 2009; Stacciarini, 2008). Frequenttop-down adaptations included hiring bilingual and bicultural pro-viders, offering all materials in the language of the group (e.g.,Spanish, Mandarin), and adapting the materials and exercises to beculturally appropriate. All studies that included Spanish-speakingpopulations emphasized the importance of cultural values, such as

respeto and simpatia, and instructed the staff to be warmer andmore personalized in their interactions with Spanish-speaking pa-tients (Kanter et al., 2010; Miranda, Azocar et al., 2003).

The Ecological Validity Model (Bernal et al., 1995) guided thecultural adaptations in a few of the culturally sensitive treatmentsfor depression reviewed in this paper (Nicolas et al., 2009; Ros-sello & Bernal, 1999; Rossello et al., 2008). Thus, these treatmentsincluded systematic adaptations in the eight broad areas listed inBernal et al. (1995). The structure/process and content adaptationsthat Kohn et al. (2002) described resembled the terminology fromKoss-Chioino and Vargas’ (1992) framework.

Some of the bottom-up approaches included generating focusgroups with stakeholders (Stacciarini, 2008), interviews with pro-viders who work with the population of interest (Naeem et al.,2011), and development of partnerships with the community (Ni-colas et al., 2009). Often the qualitative data generated from thesebottom-up approaches would be later integrated with preexistingelements of the treatment (e.g., treatment modules). However,some researchers could choose to reinvent the entire treatment bycreating new treatment modules based on the collected qualitativeinformation.

Whereas some studies provided rationale for the cultural adap-tations they made, others simply described them. For example,Nicolas et al. (2009) described elaborately every step of the cul-tural adaptation process and the reasoning behind it. Some of thesuggested changes that emerged from the focus groups (i.e.,bottom-up approach) included: integration of other theories be-sides CBT theory that explained the etiology of depression (i.e.,integrative approach); the inclusion of metaphors, language, andexamples that are relevant to the life of Haitian adolescents; and theunfamiliarity with some of the homework assignments and activ-ities, such as active listening. Based on the feedback, Nicolas andcolleagues proceeded to make a second wave of adaptations. Suchmultistage adaptations of treatments show the reasoning behindevery action and are important in creating an ecologically validintervention that integrates the community’s opinions. Nicolas etal. only provided a description of their detailed adaptation processbut did not have data available to show how the culturally adaptedtreatment was received by the target group.

Characteristics of Culturally SensitiveTreatments for Depression

Thirteen of the 16 culturally sensitive treatments for depressionreviewed in this article were cognitive–behavioral in nature. Twostudies provided case management (Miranda, Azocar et al., 2003;Yeung et al., 2010) and one (Ngo et al., 2009) tested a qualityimprovement intervention in a primary care setting. A couple ofstudies (Chavez-Korell et al., 2012; Kanter et al., 2010) usedbehavioral activation which is similar to the behavioral componentof CBT. Two studies adapted problem solving therapy (Chavez-Korrel et al.; Chu et al., 2012) for older adults, which is also basedon a CBT framework. Only two of the 16 studies (Rossello &Bernal, 1999; Rossello et al., 2008) tested individual and groupinterpersonal therapy (IPT). There were no differences between theindividual IPT and CBT outcomes, as it has been previously found(Elkin et al., 1989). However, the Group CBT yielded betterresults than the Group IPT (Rossello et al., 2008).

436 KALIBATSEVA AND LEONG

Tab

le1

Cul

tura

lly

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reat

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epre

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rtic

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raph

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cond

ition

(#of

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ions

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tion)

Cul

tura

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veel

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tsD

ropp

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tR

eten

tion

Eff

ect

size

Out

com

e

Cha

vez-

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ell

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012)

186

Lat

ino

elde

rs8–

12-s

essi

onin

divi

dual

PST

and

BA

1)M

akin

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etr

eatm

ent

feas

ible

for

aco

mm

unity

setti

ngto

impr

ove

Lat

ino

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acce

ss,

rete

ntio

n,an

dou

tcom

es;

2)A

dapt

ing/

tran

slat

ing

all

mat

eria

lsan

dco

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ting

all

serv

ices

inSp

anis

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Ada

ptin

gm

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popu

latio

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wor

nolit

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the

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437CULTURALLY SENSITIVE DEPRESSION TREATMENTS

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Spec

ial

atte

ntio

ngi

ven

tofa

mil

ism

o(e

.g.,

clie

nt’s

impr

ovem

ent

will

cont

ribu

teto

fam

ily’s

impr

ovem

ent

infa

mily

func

tioni

ng);

Prov

ided

inpr

imar

yca

re;

Paid

spec

ial

atte

ntio

nto

som

atic

com

plai

nts

and

how

toad

dres

sth

emw

ithth

erap

eutic

tech

niqu

es(e

.g.,

rela

xatio

n,sl

eep

hygi

ene)

4(2

7%)

11(7

3%)

d�

2.71

(pos

ttrea

tmen

t);

d�

2.53

(fol

low

-up)

Part

icip

ants

repo

rted

asi

gnif

ican

tre

duct

ion

inde

pres

sion

sym

ptom

s(5

7%)

atpo

sttr

eatm

ent

and

reta

ined

the

impr

ovem

ent

atth

e6-

mon

thfo

llow

-up

(54%

redu

ctio

nfr

omba

selin

e).

438 KALIBATSEVA AND LEONG

Tab

le1

(con

tinu

ed)

Stud

yPa

rtic

ipan

tsD

emog

raph

ics

Tre

atm

ent

cond

ition

(#of

sess

ions

and

dura

tion)

Cul

tura

llyse

nsiti

veel

emen

tsD

ropp

edou

tR

eten

tion

Eff

ect

size

Out

com

e

Kan

ter

etal

.(2

010)

10L

atin

aw

omen

inth

eU

.S.

12-s

essi

onin

divi

dual

BA

Incl

usio

nof

free

,lo

w-c

ost,

and

cultu

rally

sens

itive

activ

atio

nta

rget

s(e

.g.,

wal

king

,at

tend

ing

com

mun

ityac

tiviti

es,

such

aslo

cal

fest

ival

san

dre

crea

tiona

lgr

oups

,go

ing

toch

urch

,bo

rrow

ing

fitn

ess

DV

Ds

from

the

libra

ry,

goin

gto

the

park

);In

corp

orat

ion

ofL

atin

o-sp

ecif

icva

lues

and

belie

fs(f

amil

ism

o,pe

rson

alis

mo,

mar

iani

smo,

and

mac

hism

o)an

dat

tent

ion

toth

eir

effe

cton

activ

atio

n;A

dditi

onof

spec

ific

stra

tegi

esto

addr

ess

trea

tmen

ten

gage

men

tan

dre

tent

ion

inth

efi

rst

sess

ion;

Invi

tatio

nto

incl

ude

fam

ilym

embe

rsin

the

trea

tmen

t;Fa

mily

,so

cial

,an

dco

mm

unity

reso

urce

sut

ilize

dto

the

exte

ntpo

ssib

le.

Tra

nsla

ted

mat

eria

ls;

Bili

ngua

lan

dbi

cultu

ral

staf

f

4(4

0%)

6(6

0%)

d�

1.67

for

com

plet

ers;

d�

1.07

for

inte

nt-t

o-tr

eat

60%

ofpa

rtic

ipan

tsac

hiev

edre

mis

sion

atth

een

dof

trea

tmen

t

(tab

leco

ntin

ues)

439CULTURALLY SENSITIVE DEPRESSION TREATMENTS

Tab

le1

(con

tinu

ed)

Stud

yPa

rtic

ipan

tsD

emog

raph

ics

Tre

atm

ent

cond

ition

(#of

sess

ions

and

dura

tion)

Cul

tura

llyse

nsiti

veel

emen

tsD

ropp

edou

tR

eten

tion

Eff

ect

size

Out

com

e

Koh

net

al.

(200

2)10

Afr

ican

Am

eric

anlo

w-i

ncom

ew

omen

16-s

essi

ongr

oup

CB

TSt

ruct

ure/

proc

ess

adap

tatio

ns:

only

Afr

ican

Am

eric

anw

omen

;cl

osed

grou

pto

faci

litat

eco

hesi

on;

expe

rien

tial

med

itativ

eex

erci

ses

atth

ebe

ginn

ing

ofea

chse

ssio

nan

da

term

inat

ion

ritu

al;

chan

ges

inth

ela

ngua

ge.

Con

tent

adap

tatio

ns(f

our

mod

ules

):de

cons

truc

ting

the

“Bla

cksu

perw

oman

”m

yth;

expl

orin

gsp

iritu

ality

and

relig

iosi

ty;

rein

forc

ing

impo

rtan

ceof

fam

ily;

disc

ussi

ngA

fric

anA

mer

ican

fem

ale

iden

tity

and

empo

wer

men

t

2(2

0%)

8(8

0%)

N/A

Whe

nco

mpa

red

with

dem

ogra

phic

ally

mat

ched

wom

en,

the

decr

ease

ofde

pres

sive

sym

ptom

sin

the

cultu

rally

adap

ted

grou

pw

astw

ice

larg

erth

anth

atin

the

regu

lar

CB

Tgr

oup

(-12

.6vs

.-5

.9po

ints

onth

eB

DI)

.

Mir

anda

,A

zoca

r,et

al.

(200

3)19

9 (ran

dom

ized

)A

fric

anA

mer

ican

,L

atin

olo

win

com

ePC

Ps

12-s

essi

ongr

oup

CB

Tvs

CB

T�

case

man

agem

ent

Bili

ngua

lan

dbi

cultu

ral

prov

ider

s;M

ater

ials

inSp

anis

h,T

rain

ing

staf

fto

show

resp

eto

and

sim

pati

a;W

arm

erin

tera

ctio

ns;

Low

erre

adin

gle

vel;

Plea

sant

activ

ities

free

23(3

0%)

ofSp

anis

h-sp

eaki

ngpa

tient

s:16

(40%

)of

CB

Tal

one

and

6(1

7%)

ofC

BT

�D

CM

;44

(36%

)of

Eng

lish-

spea

king

patie

nts:

27(4

4%)

ofC

BT

alon

ean

d17

(28%

)of

CB

T�

DC

M

70%

ofSp

anis

h-sp

eaki

ngpa

tient

s;64

%of

Eng

lish-

spea

king

patie

nts

N/A

The

Span

ish-

and

Eng

lish-

spea

king

patie

nts

resp

onde

deq

ually

wel

lto

cogn

itive

-beh

avio

ral

ther

apy

alon

e.Fe

wer

depr

essi

vesy

mpt

oms

notic

edon

lyfo

rSp

anis

hsp

eaki

ngcl

ient

sin

CB

T�

case

man

agem

ent.

440 KALIBATSEVA AND LEONG

Tab

le1

(con

tinu

ed)

Stud

yPa

rtic

ipan

tsD

emog

raph

ics

Tre

atm

ent

cond

ition

(#of

sess

ions

and

dura

tion)

Cul

tura

llyse

nsiti

veel

emen

tsD

ropp

edou

tR

eten

tion

Eff

ect

size

Out

com

e

Mir

anda

,C

hung

,et

al.

(200

3)26

7 (ran

dom

ized

)A

fric

anA

mer

ican

(n�

117)

,L

atin

o(n

�13

4)lo

win

com

ew

omen

8-se

ssio

nC

BT

Bili

ngua

lpr

ovid

ers;

Man

ual

and

mat

eria

lsin

Span

ish;

Span

ish-

spea

king

staf

f;Ps

ycho

ther

apis

tsan

dnu

rse

prac

titio

ners

expe

rien

ced

and

com

mitt

edto

wor

king

with

low

-inc

ome

min

oriti

es

N/A

48(5

3%)

rece

ived

4or

mor

eC

BT

sess

ions

N/A

The

psyc

hoth

erap

yin

terv

entio

nw

asno

tsu

peri

orto

com

mun

ityre

ferr

alin

decr

easi

ngde

pres

sive

sym

ptom

s(p

�.3

2)or

impr

ovin

gro

lefu

nctio

ning

(p�

.58)

,bu

tdi

dre

sult

inim

prov

edso

cial

func

tioni

ng(p

�.0

6).

Nae

emet

al.

(201

1)34

(ran

dom

ized

)Pa

kist

ani

adul

ts9-

sess

ion

indi

vidu

alC

BT

�an

tidep

ress

ant

(n�

17)

and

cont

rol

(n�

17)

Use

dqu

alita

tive

data

from

clin

ical

psyc

holo

gist

sab

out

thei

rex

peri

ence

prov

idin

gC

BT

tode

pres

sed

patie

nts

and

barr

iers

inth

erap

y;C

olle

cted

info

rmat

ion

abou

tsy

mpt

oms,

refe

rral

beha

vior

,at

trib

utio

nst

yles

,an

dac

cept

abili

tyof

ther

apy

from

9de

pres

sed

patie

nts;

Nex

t,co

nduc

ted

focu

sgr

oups

with

colle

gest

uden

tsus

ing

the

“nam

eth

etit

le”

tech

niqu

eto

obta

ineq

uiva

lent

idio

mat

icph

rase

sw

ithou

ttr

ansl

atin

gth

ete

rmin

olog

yin

Urd

ufi

rst;

The

rapi

sts

focu

sed

onph

ysic

alsy

mpt

oms;

Urd

ueq

uiva

lent

sof

CB

Tja

rgon

;A

ppro

pria

teho

mew

ork;

Atte

ndan

ceof

afa

mily

mem

ber;

Folk

stor

ies

and

exam

ples

ofth

elif

eof

Prop

het

Muh

amm

adan

dQ

uran

used

3(1

8%)

atte

nded

few

erth

an6

14(8

2%)

d�

.60

Ina

RC

T,

the

auth

ors

com

pare

da

9-se

ssio

nC

BT

�an

tidep

ress

ants

(n�

17)

and

antid

epre

ssan

ts�

usua

lca

re(n

�17

)an

dob

serv

edsi

gnif

ican

tim

prov

emen

tin

depr

essi

ve,

anxi

ety,

and

som

atic

sym

ptom

sam

ong

patie

nts

who

rece

ived

CB

T.

(tab

leco

ntin

ues)

441CULTURALLY SENSITIVE DEPRESSION TREATMENTS

Tab

le1

(con

tinu

ed)

Stud

yPa

rtic

ipan

tsD

emog

raph

ics

Tre

atm

ent

cond

ition

(#of

sess

ions

and

dura

tion)

Cul

tura

llyse

nsiti

veel

emen

tsD

ropp

edou

tR

eten

tion

Eff

ect

size

Out

com

e

Ngo

etal

.(2

009)

325

Afr

ican

Am

eric

an(n

�59

),L

atin

o(n

�22

4)an

dW

hite

(n�

42)

low

-inc

ome

adol

esce

nts

Qua

lity

impr

ovem

ent

inte

rven

tion

(inc

lude

dC

BT

orca

rem

anag

emen

t)

Tra

inin

gst

aff

oncu

ltura

lse

nsiti

vity

issu

es;

Tai

lori

ngex

ampl

esto

fit

the

cultu

ral

cont

ext

ofea

chyo

uth

and

fam

ily;

Bili

ngua

lca

sem

anag

ers;

Atte

ndin

gto

cultu

ral

issu

es(e

.g.,

auth

ority

ofel

ders

,si

mpa

tia)

N/A

N/A

N/A

The

auth

ors

conc

lude

dth

atB

lack

yout

hin

QII

expe

rien

ced

sign

ific

ant

redu

ctio

nin

depr

essi

onsy

mpt

oms

and

use

ofm

enta

lhe

alth

serv

ices

at6-

mon

thFU

and

Lat

ino

yout

hre

port

edgr

eate

rsa

tisfa

ctio

nw

ithQ

IIth

anus

ual

care

.N

icol

aset

al.

(200

9)N

/AH

aitia

nA

mer

ican

adol

esce

nts

16tw

o-ho

urse

ssio

nsin

grou

psof

5–10

part

icip

ants

;G

roup

CB

T(d

evel

opm

ent)

Use

dco

mm

unity

focu

sgr

oups

tode

velo

ptr

eatm

ent

base

don

the

ecol

ogic

alva

lidity

mod

el(B

erna

let

al.,

1995

);T

hecu

ltura

lad

apta

tion

proc

ess

ofA

CD

Cin

clud

edth

ecr

eatio

nof

anad

viso

rybo

ard,

deve

lopi

ngpa

rtne

rshi

pw

ithth

eco

mm

unity

,tr

aini

ngth

efo

cus

grou

ple

ader

s,co

nduc

ting

focu

sgr

oup

sess

ions

with

Hai

tian

adol

esce

nts,

and

inte

grat

ion

ofth

efo

cus

grou

pda

tato

mod

ify

the

trea

tmen

t;N

otte

sted

N/A

N/A

N/A

N/A

442 KALIBATSEVA AND LEONG

Tab

le1

(con

tinu

ed)

Stud

yPa

rtic

ipan

tsD

emog

raph

ics

Tre

atm

ent

cond

ition

(#of

sess

ions

and

dura

tion)

Cul

tura

llyse

nsiti

veel

emen

tsD

ropp

edou

tR

eten

tion

Eff

ect

size

Out

com

e

Ros

sello

&B

erna

l(1

999)

71(r

ando

miz

ed)

Puer

toR

ican

adol

esce

nts,

54%

fem

ale

CB

T(n

�25

),IP

T(n

�23

)or

wai

tlist

(n�

23);

12on

e-ho

urin

divi

dual

sess

ions

(CB

T,

IPT

)

Bas

edon

ecol

ogic

alva

lidity

and

cultu

ral

sens

itivi

tym

odel

(Ber

nal

etal

.,19

95);

Tra

nsla

ted

inst

rum

ents

;A

dapt

edtr

eatm

ent

man

uals

tobo

thde

velo

pmen

tal

and

cultu

ral

sens

itive

crite

ria;

Inte

grat

edan

dem

phas

ized

idea

sim

port

ant

inPu

erto

Ric

ancu

lture

such

asfa

mil

ism

o,si

mpa

tia,

resp

eto,

pare

ntal

auth

ority

,pr

esen

ttim

eor

ient

atio

n,an

dso

cioe

cono

mic

cont

ext;

Too

kin

toco

nsid

erat

ion

cultu

ral

aspe

cts

ofth

etr

eatm

ents

that

cons

ider

the

“int

erpe

rson

al”

aspe

cts

ofth

eL

atin

ocu

lture

.

Con

trol

5(2

2%),

IPT

4(1

7%)

and

CB

T4

(16%

)

68%

ofIP

Tan

d52

%of

CB

Tpa

rtic

ipan

tsco

mpl

eted

trea

tmen

t

(d�

.73

for

IPT

and

d�

.43

for

CB

T)

Part

icip

ants

inth

eC

BT

(n�

25)

and

IPT

(n�

23)

grou

psh

owed

asi

gnif

ican

tde

crea

sein

depr

essi

vesy

mpt

oms

com

pare

dto

the

wai

tlist

grou

pw

ithm

oder

ate

effe

ctsi

zes

(d�

.73

for

IPT

and

d�

.43

for

CB

T). (tab

leco

ntin

ues)

443CULTURALLY SENSITIVE DEPRESSION TREATMENTS

Tab

le1

(con

tinu

ed)

Stud

yPa

rtic

ipan

tsD

emog

raph

ics

Tre

atm

ent

cond

ition

(#of

sess

ions

and

dura

tion)

Cul

tura

llyse

nsiti

veel

emen

tsD

ropp

edou

tR

eten

tion

Eff

ect

size

Out

com

e

Ros

sello

etal

.(2

008)

112 (r

ando

miz

ed)

Puer

toR

ican

adol

esce

nts

inPu

erto

Ric

o

12-s

essi

onin

divi

dual

CB

T(n

�23

),gr

oup

CB

T(n

�29

),in

divi

dual

IPT

(n�

31),

orgr

oup

IPT

(n�

29)

Bas

edon

ecol

ogic

alva

lidity

and

cultu

ral

sens

itivi

tym

odel

(Ber

nal

etal

.,19

95);

Sam

eas

Ros

sello

&B

erna

l(1

999)

;A

dapt

edgr

oup

man

uals

usin

gth

ecu

ltura

lad

apta

tion

mod

el

1(4

.3%

;in

divi

dual

CB

T),

1(3

.4%

;gr

oup

CB

T),

3(9

.6%

;in

divi

dual

IPT

),an

d1

(3.4

%;

grou

pIP

T)

95.7

%(C

BT

indi

vidu

al);

96.6

%(C

BT

grou

p);

90.4

%(I

PTin

divi

dual

);96

.6%

(IPT

grou

p)

Indi

vidu

alvs

.G

roup

was

d�

.18,

indi

vidu

alth

erap

ybe

tter

by54

%th

angr

oup

ther

apy;

CB

Tvs

.IP

Td

�.4

3,pa

tient

sin

CB

T67

%be

tter

than

IPT

Bot

hIP

Tan

dC

BT

inth

eir

indi

vidu

alan

dgr

oup

form

atpe

rfor

med

wel

l.H

owev

er,

CB

T(c

ombi

ned

grou

pan

din

divi

dual

)re

sulte

din

sign

ific

antly

grea

ter

decr

ease

sin

depr

essi

vesy

mpt

oms,

chan

ges

inse

lf-c

once

pt,

and

redu

ctio

nin

inte

rnal

izin

gan

dex

tern

aliz

ing

beha

vior

sin

com

pari

son

toIP

T(c

ombi

ned

grou

pan

din

divi

dual

).St

acci

arin

i(2

008)

16Pu

erto

Ric

anw

omen

inth

eU

.S.

Com

mun

ity-

base

dgr

oup

inte

rven

tion

(dev

elop

men

t)

Focu

sgr

oups

yiel

ded

the

follo

win

gca

tego

ries

:fa

mily

and

com

mun

ityva

lues

,m

ainl

and/

non-

mai

nlan

dcu

ltura

lva

rian

ces,

com

mun

icat

ion

styl

e,re

ligio

n,ed

ucat

ion

and

occu

patio

nal

vari

ance

s,he

alth

belie

fs,

Puer

toR

ican

trad

ition

s,em

otio

ns,

and

copi

ngsk

ills.

N/A

N/A

N/A

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444 KALIBATSEVA AND LEONG

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445CULTURALLY SENSITIVE DEPRESSION TREATMENTS

Seven of the adapted treatments were offered in a group format.Only one of the studies (Kohn et al., 2002) indicated that the groupwas closed after the start of the group, although it appeared thatother group treatments worked similarly (Dai et al., 1999; Rosselloet al., 2008) but it was not clear if the closed group format wouldbe preserved in a nonresearch setting. Depending on the format ofthe treatment (individual or group), the duration varied between 8and 16 sessions (between 60 and 120 minutes per session). Over-all, dropout rates for CSTs were low (ranged from 0% to 40%),which resulted in relatively high retention rates (from 60% to100%) for the culturally sensitive treatment conditions.

The majority of the reviewed CSTs for depression revealedmedium to large effect sizes for pretreatment to posttreatment (d �2.71 post treatment in Interian et al., 2008; d � 1.67 for completersin Kanter et al., 2010). Two studies compared a CST condition toa control condition and also found evidence for medium effectsizes in favor of the CST (d � .73 for CBT and d � .43 for IPTvs. control in Rossello & Bernal, 1999; d � .76 for adapted CBTvs. control in Wong, 2008) Another study found that culturallyadapted CBT in combination with antidepressants yielded betterresults than antidepressants only (d � .60; Naeem et al., 2011).Finally, Rossello et al. compared group and individual CBT andgroup and individual IPT and discovered that individual treatmentsperformed slightly better than group treatments (d � .18) andculturally adapted CBT performed better than culturally adaptedIPT (d � .43).

Participant Characteristics

The participants in five of the reviewed studies were low-income individuals, and there was a wide range of age groups.Three studies (Kohn et al., 2002; Miranda, Chung et al., 2003;Stacciarini, 2008) focused on therapy for depressed women only.Even studies that did not plan on limiting the recruitment towomen enrolled predominantly female participants (93%; Interianet al., 2008; 100%; Kanter et al., 2010). Three of the reviewedstudies developed culturally sensitive treatments for older adultsand four concentrated on adolescents.

In terms of ethnicity and race, Hispanics and African Americanswere most studied; three studies assessed a culturally adapteddepression treatment for Asian Americans (Chu et al., 2012; Dai etal., 1999; Yeung et al., 2010), and we located no study thatexamined a CST for depression for Native Americans. Two inter-national studies examined culturally adapted depression treatmentsin Hong Kong and Pakistan. In addition, the treatments wereprovided in a number of settings varying from primary care (In-terian et al., 2008) to outpatient hospital clinics (Miranda, Azocaret al., 2003). Generally, the existing culturally sensitive treatmentswere diverse in serving different age groups and targeting popu-lations at risk for depression.

All of the reviewed studies that provided data found significantdecreases in depressive symptomatology posttreatment. However,none of the studies examining these culturally sensitive treatmentshas empirically assessed directly the specific role of the adapta-tions. Kohn et al. (2002) used a comparison group of demograph-ically matched participants to compare the reduction in depressivesymptoms among African American women in the culturallyadapted CBT and the traditional CBT and found that the decreaseof symptoms was doubled in the culturally adapted CBT group.

Chavez-Korell et al. (2012) reported that IMPACT had been usedin its unadapted form with Latino elders in the past and was foundas effective as it was for the overall population. Apart from thesestudies, there is little evidence to support that the cultural adapta-tions are the main mechanism responsible for the favorable out-comes. Nonetheless, all studies had relatively high retention (over60%) and high social and ecological validity.

Discussion

We identified 16 studies that met inclusion criteria for culturallysensitive treatments for depression. The studies widely varied inthe description and assessment of cultural adaptations. The major-ity of the reviewed CSTs were behavioral or cognitive–behavioralin nature. This finding may not be surprising since CBT is con-sidered an EBT for depression (Chambless et al., 1998). In addi-tion, Domenech Rodríguez and Bernal (2012) pointed out thatwithin a pragmatist paradigm, cultural adaptation models werepredominantly developed to work with behavioral and cognitive–behavioral interventions.

Several of the CSTs for depression were in a group formant.Group therapies may be advantageous because they are morecost-effective, provide care for more people, and encourage closerelationships and support among group members. However, thegroup format may be troublesome for people whose cultural valuesrelate to stigma of mental disorders and may be especially unpop-ular in small communities, where people may know each other.Alternatively, a few studies used culturally adapted treatments inan individual therapy format (Interian et al., 2008; Kanter et al.,2010; Rossello & Bernal, 1999). It may be easier to make culturaladaptations in the process of individual therapy given that mostculturally competent therapists are likely to do some adaptationsalready. However, if such adaptations in individual therapy weremade but not documented, it may be difficult to assess theireffectiveness.

At the same time, Muñoz and Mendelson (2005) suggested thatchanges in existing interventions for depression should inviteethnic minority involvement in development, include cultural val-ues particular to the ethnic group, incorporate spirituality andreligion if relevant, take into account the clients’ acculturationlevel, address race, prejudice, and discrimination, and offer strat-egies to empower the clients. The inclusion of community mem-bers in the process of adapting or developing a treatment is ofutmost importance if the researcher wants to attract and retainparticipants. However, only three of the reviewed studies hadinvited community members to assist them in the adaptation (Chuet al., 2012; Nicolas et al., 2009; Stacciarini, 2008).

A number of the CSTs for depression targeted ethnic minorityand low SES women. In general, low SES and being a female maybe considered two of the risk factors for depression (Piccinelli &Wilkinson, 2000; Simonds, 2001). Therefore, these demographiccharacteristics may be overrepresented within the ethnic minoritygroups that have received culturally sensitive treatments for de-pression.

Additionally, the studies that provided data about dropout andretention rates presented a positive outlook with retention ratesconsistently above 60% and typically much higher. These numberslook promising considering that more than 65% of clients termi-nate psychotherapy before the 10th session and most clients attend

446 KALIBATSEVA AND LEONG

fewer than 6 sessions (Barrett et al., 2008). Moreover, the studiesthat provided effect sizes also suggested that clients’ depressivesymptoms significantly improve from pre to post treatment andcompared to a control group.

Recommendations for Intervention

Our recommendations for intervention from this review can beframed within the Cultural Accommodation Model (CAM) ofpsychotherapy (Leong & Lee, 2006), which involves three steps:“(a) identifying the cultural gaps or cultural blind-spots in anexisting theory that restricts the cultural validity of the theory, (b)selecting current culturally specific concepts and models fromcross-cultural and ethnic minority psychology to fill in the culturalgaps and accommodate the theory to racial and ethnic minoritiesand culturally diverse populations, and (c) testing the culturallyaccommodated theory to determine if it has incremental validityabove and beyond the culturally unaccommodated theory” (Leong& Serafica, 2001; p. 185).

As a proposed model of cross-cultural psychotherapy, a keycomponent of the Cultural Accommodation Model is to examinethe cultural validity of our models of psychotherapy and to identifyculture-specific elements that would fill the gaps of existing mod-els and enrich their utility and effectiveness with culturally diverseclientele (Leong & Kalibatseva, 2011). Furthermore, the CAMrecognizes the importance of using the person-environment inter-action models rather than focusing only on the person and ignoringthe cultural context variables in the lives of these culturally diverseindividuals (Leong & Kalibatseva, 2011). As a result, culturallydiverse clients who experience psychotherapy as congruent withtheir culture may be more likely to stay in treatment and benefitfrom it.

How should we evaluate the cultural validity of our models andwhat culture-specific elements should be selected? Relying on theindividual preferences of psychotherapists (or researchers) cannotbe justified. Instead, Leong and Lee (2006) proposed that inapplying the CAM, the Evidence-Based Practice (EPB) approachcould be utilized to both evaluate our existing models and to selectculture-specific variables to research which can then be applied inclinical practice. This review followed the recommendations of theCAM to identify cultural adaptations that have been successful indepression treatments. Yet, it is important to acknowledge that it isdifficult to compare the cultural adaptations across studies andgeneralize what adaptations work best.

The studies of culturally sensitive treatment for depressionreviewed in this article therefore examine the research evidence toguide the cultural accommodation process in providing treatmentto culturally diverse depressed patients. This review has identifiedculture-specific elements in treatment that have proven to increasethe effectiveness of our interventions. In this review specific todepression, we found that accommodating for language is critical.The effectiveness of bilingual therapists was found across multiplestudies. It is therefore recommended that therapists carefully eval-uate the language ability and needs of their depressed patients bothbefore initiating and during the treatment process. Moreover, thecultural adaptations to most treatments indicated that simple trans-lation may not be enough to make a treatment culturally sensitive.Thus, this recommendation expands beyond translation of materi-als and incorporates verbal and visual forms of communication

(e.g., metaphors, role models) that make the treatment consistentwith the cultural context of the client.

Similar to Leong and Lee (2006), this review also found thatculture-specific values related to interpersonal relationships, fam-ily, and spirituality can play a significant role when providingtherapy to culturally diverse patients. Specifically, our reviewfound that treatments which carefully accommodated for thesedifferences in cultural specific values resulted in better outcomes.For example, culture-specific interpersonal values included res-peto, familismo, and simpatia among Latino patients and religionand spirituality among African American patients. In addition,adaptations that increase the interaction of clients with health careprofessionals, such as care management may also yield betterretention and treatment outcomes. Culturally appropriate assess-ment, exploration of the client’s illness beliefs, and de-stigmatization of depression as an illness also most likely posi-tively contribute to recruitment, retention, and positive treatmentoutcome (Interian et al., 2008). Although very few CSTs in thisreview directly discussed this issue, the concept of depression, thesymptoms that typically are most bothersome, and the stigmaassociated with depression may be grounded within a culturalcontext that needs to be carefully explored. To illustrate this,neurasthenia, a popular cultural syndrome, captures a construct,which may be similar to depression among Asians. Neurasthenia(literally “lack of nerve strength”) is characterized by mental orphysical fatigue, and two of seven symptoms: dizziness, pain in themuscles, tension headaches, inability to relax, irritability, sleepdisturbance, and dyspepsia. It still remains a popular diagnosis inChina, in particular, and scholars have argued that it is commonlyused because of its acceptance as a medical diagnosis that conveysdistress without the stigma of a psychiatric diagnosis (Schwartz,2002).

Finally, the treatment approaches that were used were mostlyproblem-focused and direct. This finding is consistent with argu-ments that culturally diverse individuals may struggle with open-ended and nondirective therapy (Leong, Lee, & Kalibatseva, inpress). Moreover, establishing a warm and trusting relationshipand discussing assumptions about hierarchy and engagement of theclient in therapy were important elements in most of the culturallysensitive treatments for depression. To summarize, health careproviders are strongly encouraged to consider the importance oflanguage beyond translation, the integration of culturally salientvalues, beliefs, and traditions, and the understanding of etiology,symptom presentation, and stigma associated with depressionwhen providing CSTs for depression.

Recommendations for Research

Culturally adapted treatments for depression appear effective insymptom reduction and ethnic minority clients may be more likelyto seek and stay in treatment if they consider the issues discussedin therapy relevant to their culture. An important next step in thisfield is to compare a culturally adapted depression treatment and adepression treatment in its original form in order to find out if andhow much the cultural adaptations contribute to the favorableoutcomes. Future research that examines cultural adaptations asspecific mechanisms for change would contribute to our under-standing of the active and important ingredients of therapy thatproduce beneficial outcomes (Kazdin, 2007).

447CULTURALLY SENSITIVE DEPRESSION TREATMENTS

Based on this review, there are two likely directions for thefuture of CSTs: researchers will continue to adapt existing treat-ments by changing the process and content based on theory andprevious research or they will rely more on using frameworks andcommunity focus groups that will inform them of what to includein the treatment. Both directions seem promising as long as theadaptations are made based on sound reasoning and evidence. Theutilization of focus groups to inform and guide the adaptationprocess may be particularly helpful when treating specific popu-lations that have not received much attention in previous research.No matter which direction researchers choose, it is important todocument every cultural adaptation and the logic behind it. Sim-ilarly, Cardemil (2010) argued that researchers need to investigatethe social validity/acceptability, the efficacy, and the mechanismsof action associated with the cultural adaptations as well aschanges in symptoms and levels of engagement among partici-pants.

Other recommendations focus on the types of demographicgroups that need to be targeted in the future. First, this review didnot find any prior culturally sensitive treatment for depression withNative Americans. Gone and Alcántara’s (2007) review of theliterature on effective mental health interventions for AmericanIndians and Alaska Natives indicated that there were two preven-tive studies of depression. Yet, the lack of research on depressiontreatments with Native Americans needs to be addressed. In addi-tion, there was a general lack of males recruited in most of thereviewed treatments. The lower number of males may be explainedby the higher likelihood of women to suffer from depression(Simonds, 2001). However, researchers have also found that menand, in particular, ethnic minority men may be less likely to seekhelp for depression due to existing stigma in the society andcompliance to masculinity norms (Vogel, Heimerdinger-Edwards,Hammer, & Hubbard, 2011).

Another recommendation for research on culturally sensitivetreatment would be to explore within-group differences. For ex-ample, the DSM–IV–TR and DSM-5 have identified cultural iden-tity as a central moderator when diagnosing and treating persons ofcolor. More research is needed to delineate how these culturallysensitive treatments may need to be modified for clients withvarious levels of cultural identity. For example, cultural adapta-tions of CBT for Mexican Americans should not assume thatMexican Americans are a monolithic group. Instead, acculturationmay mediate the effect of a CST, such that Mexican Americandepressed clients with high or low levels of acculturation mayreact differently to a cultural adapted model of CBT (Villalobos,2009).

Lastly, few of the cultural adaptations addressed the concept ofdepression and what it means to be depressed in one’s culture. Inother words, the core components of the treatments that treatsymptom reduction were mostly kept intact and many of theperipheral elements were adapted (e.g., Chu et al., 2012). Hence,most cultural adaptations seem to be focused on the perspective ofcross-cultural psychotherapy rather than cross-cultural psychopa-thology. Since culture may influence the etiology, symptom ex-pression, diagnosis, and treatment of depression (e.g., Kleinman &Good, 1985), it may be valuable to explore how one’s culturalbackground may impact the way one thinks about what depressionis and how to cure it. Therefore, an ethnographic assessment asproposed in one of the studies (Interian et al., 2008) may be an

important element to include in future culturally sensitive treat-ments for depression. Lastly, depression is a multidimensionalconstruct and it may help to incorporate this idea in culturaladaptations of depression treatments (Kalibatseva & Leong, 2011).Focusing on the interpersonal and cognitive aspects of depressionhas been very effective but there are also somatic, affective, andexistential aspects of depression that may be important to addressin culturally sensitive treatments.

Based on our critical review of the literature, we have offered aseries of recommendations that we hope will guide future researchon culturally sensitive treatments for depression. In addition tofilling the gaps identified in this set of recommendations, we alsoencourage a greater amount of attention to culturally sensitivemeasurement of depression in order to advance the field. As ourassessment of treatment outcome relies on culturally sensitiveassessment, the authors see these two areas as closely related.

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Received February 22, 2013Revision received December 18, 2013

Accepted January 8, 2014 �

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