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Intervention Summary

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Cultural Adaptation of Cognitive Behavioral Therapy (CBT) for Puerto Rican Youth

Cultural Adaptation of Cognitive Behavioral Therapy (CBT) for Puerto Rican Youth is a short-term intervention for Puerto Rican adolescents aged 13-17 years who are primarily Spanish speaking and have severe symptoms of depression. The intervention focuses on improving an adolescent's cognitions, behaviors, and relationships, with the goals of shortening the time that the adolescent feels depressed, reducing his or her depressive feelings, increasing the adolescent's sense of control over his or her life, and teaching the adolescent how to prevent the onset of depression.

The intervention was adapted from a cognitive behavioral model, considering cultural, developmental, and socioeconomic factors. The adaptation was informed by a framework for ecological validity (i.e., familiarity between the adolescent's experiences of his or her ethnocultural and linguistic context and the cultural properties of the treatment) and culturally sensitive criteria (i.e., language, persons, metaphors, content, concepts, goals, methods, context).

The intervention is delivered by a trained therapist in either an individual or group format. It consists of 12 weekly, 1-hour sessions and includes an option for 4 additional sessions. The 12 sessions are divided into three modules:

  • Thoughts Module (sessions 1-4), which describes how thoughts influence mood
  • Activities Module (sessions 5-8), which describes how activities influence mood
  • Interpersonal Module (sessions 9-12), which describes how interactions with other people affect mood

After the 12 sessions have been completed, the therapist reviews each adolescent's progress and decides whether the additional sessions are necessary and, if so, what those sessions will entail.

To deliver the intervention, a therapist must have at least a master's degree and also must have completed an 18-hour training, which includes video observations, role-plays, and readings. Therapists also receive an hour of weekly supervision during the course of the 12-week treatment.

In studies reviewed for this summary, Puerto Rican adolescents identified as having symptoms of depression received the intervention after being referred by local schools, clinics, and mental health professionals.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: December 2010
1: Symptoms of depression
2: Internalizing symptoms
3: Externalizing symptoms
4: Self-concept
Outcome Categories Mental health
Social functioning
Ages 13-17 (Adolescent)
Genders Male
Female
Races/Ethnicities Hispanic or Latino
Settings Outpatient
Other community settings
Geographic Locations Urban
Implementation History This intervention was first implemented in 1992 at the University of Puerto Rico, Río Piedras Campus. Since then, 198 Puerto Rican adolescents have received this intervention.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: December 2010

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Rosselló, J., & Bernal, G. (1999). The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of Consulting and Clinical Psychology, 67(5), 734-745.  Pub Med icon

Study 2

Rosselló, J., Bernal, G., & Rivera-Medina, C. (2008). Individual and group CBT and IPT for Puerto Rican adolescents with depressive symptoms. Cultural Diversity and Ethnic Minority Psychology, 14(3), 234-245.  Pub Med icon

Supplementary Materials

Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23(1), 67-82.  Pub Med icon

Rivera-Medina, C. L., Bernal, G., Rosselló, J., & Cumba-Aviles, E. (2010). A study of the predictive validity of the Children's Depression Inventory for major depression disorder in Puerto Rican adolescents. Hispanic Journal of Behavioral Sciences, 32(2), 232-258.

Rosselló, J., & Bernal, G. (1996). Adaptation of cognitive-behavioral and interpersonal treatments for depressed Puerto Rican adolescents. In E. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders (pp. 157-185). Washington, DC: American Psychological Association Press.

Outcomes

Outcome 1: Symptoms of depression
Description of Measures Symptoms of depression were assessed using the Children's Depression Inventory (CDI), which was translated into Spanish and culturally adapted while maintaining semantic, content, technical, and conceptual equivalence to the original instrument. The CDI is a 27-item, self-report scale suitable for use with school-aged children and adolescents. The CDI measures a wide range of depressive symptoms, including disturbances in mood and capacity to enjoy activities, self-evaluations, and interpersonal behavior. For each item, the adolescent describes his or her feelings during the past 2 weeks, using a scale ranging from 0 (absence of the symptom) to 2 (severe symptom).
Key Findings In one study, adolescents were randomly assigned to one of three study conditions: CBT, individual psychotherapy (IPT), or a wait-list control. From pre- to posttest, participants who received CBT and those who received IPT had a reduction in symptoms of depression compared with participants in the control group (p = .015 and p = .002, respectively). The result for CBT had a small effect size (Cohen's d = 0.43), and the result for IPT had a medium effect size (Cohen's d = 0.73). From pre- to posttest and at 3-month follow-up, there were no significant differences in symptoms of depression between participants in the CBT and IPT groups. Participants in the control group were not included in the analyses of data from the 3-month follow-up because they were eligible to receive therapy.

In another study, adolescents were randomly assigned to one of four study conditions: the individual or group format of CBT or the individual or group format of IPT. From pre- to posttest, there were no significant differences in symptoms of depression between participants in the individual and group formats of CBT and between participants in the individual and group formats of IPT. However, from pre- to posttest, participants in both CBT formats had a reduction in symptoms of depression compared with participants in both IPT formats (p = .016).
Studies Measuring Outcome Study 1, Study 2
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 2: Internalizing symptoms
Description of Measures Internalizing symptoms were assessed using the Child Behavior Checklist (CBCL). The CBCL is a self-report instrument that measures the social abilities and behavioral problems of children and adolescents through two broad groupings of symptoms: internalizing problems (e.g., being withdrawn, having somatic complaints, feeling anxious/depressed) and externalizing problems (e.g., exhibiting delinquent and aggressive behaviors). Research staff administered the CBCL in Spanish.
Key Findings Adolescents were randomly assigned to one of four study conditions: the individual or group format of CBT or the individual or group format of IPT. From pre- to posttest, there were no significant differences in internalizing symptoms between participants in the individual and group formats of CBT and between participants in the individual and group formats of IPT. However, from pre- to posttest, participants in both CBT formats had a reduction in internalizing symptoms compared with participants in both IPT formats (p = .037).
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 3.9 (0.0-4.0 scale)
Outcome 3: Externalizing symptoms
Description of Measures Externalizing symptoms were assessed using the CBCL, a self-report instrument that measures the social abilities and behavioral problems of children and adolescents through two broad groupings of symptoms: internalizing problems (e.g., being withdrawn, having somatic complaints, feeling anxious/depressed) and externalizing problems (e.g., exhibiting delinquent and aggressive behaviors). Research staff administered the CBCL in Spanish.
Key Findings Adolescents were randomly assigned to one of four study conditions: the individual or group format of CBT or the individual or group format of IPT. From pre- to posttest, there were no significant differences in externalizing symptoms between participants in the individual and group formats of CBT and between participants in the individual and group formats of IPT. However, from pre- to posttest, participants in both CBT formats had a reduction in externalizing symptoms compared with participants in both IPT formats (p = .035).
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 3.9 (0.0-4.0 scale)
Outcome 4: Self-concept
Description of Measures Self-concept was assessed using the Piers-Harris Children's Self-Concept Scale (PHCSCS), an 80-item, self-report instrument. The adolescent responds with "yes" or "no" to each item regarding what he or she likes or dislikes about himself or herself. Research staff administered the PHCSCS in Spanish.
Key Findings Adolescents were randomly assigned to one of four study conditions: the individual or group format of CBT or the individual or group format of IPT. From pre- to posttest, there were no significant differences in self-concept between participants in the individual and group formats of CBT and between participants in the individual and group formats of IPT. However, from pre- to posttest, participants in both CBT formats had an improvement in self-concept compared with participants in both IPT formats (p = .006).
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 3.8 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent) 54% Female
46% Male
100% Hispanic or Latino
Study 2 13-17 (Adolescent) 55% Female
45% Male
100% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Symptoms of depression 3.8 3.8 3.9 3.3 3.3 3.6 3.6
2: Internalizing symptoms 4.0 4.0 4.0 3.9 3.6 3.9 3.9
3: Externalizing symptoms 4.0 4.0 4.0 3.9 3.6 3.9 3.9
4: Self-concept 4.0 3.5 4.0 3.9 3.6 3.9 3.8

Study Strengths

The instruments used to measure change in key outcomes were well researched and had good to excellent psychometric properties. Both studies used multiple methods (e.g., treatment manuals, clinical adherence measure, training, videotaped sessions, weekly supervision) in an effort to ensure intervention fidelity. One study had very low attrition and included an intent-to-treat approach, which conservatively included all participants in the change analyses. Both studies randomly assigned adolescents to treatment conditions and used appropriate statistical analyses.

Study Weaknesses

One study had high noncompletion rates as well as high attrition at the 3-month follow-up. In the other study, the difference in treatment fidelity levels across the IPT and CBT treatment conditions (78.2% and 88.2%, respectively) is a confounding variable; that is, the difference in fidelity findings also may have contributed to differences in the outcome findings. Both studies had relatively small sample sizes.

Readiness for Dissemination
Review Date: December 2010

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Clinical Adherence Measure

Program Web site, http://ipsi.uprrp.edu/recursos.html

Rosselló, J., & Bernal, G. (2007). Treatment manual for cognitive behavioral therapy for depression: Group format (therapist's manual)--Adaptation for Puerto Rican adolescents. San Juan: University Center for Psychological Services and Research, University of Puerto Rico, Río Piedras.

Rosselló, J., & Bernal, G. (2007). Treatment manual for cognitive behavioral therapy for depression: Individual format (therapist's manual)--Adaptation for Puerto Rican adolescents. San Juan: University Center for Psychological Services and Research, University of Puerto Rico, Río Piedras.

Rosselló, J., & Bernal, G. (2007). Treatment manual for cognitive behavioral therapy for depression: Participant's manual--Adaptation for Puerto Rican adolescents. San Juan: University Center for Psychological Services and Research, University of Puerto Rico, Río Piedras.

Training PowerPoint slides:

  • Activities Module
  • Case One
  • Case Two
  • CBT Theory
  • Challenge in CBT
  • Interpersonal Module
  • Management of Suicide Risk
  • Thought Module

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
2.8 2.3 1.8 2.3

Dissemination Strengths

The therapist's manuals are concise and provide detailed instructions on delivering the intervention. The participant's manual is appropriately tailored to the target population. The training content is thorough, including discussion of cultural competence, potential treatment obstacles, and family engagement. The training uses case presentations, lecture, role-playing, and supervised casework to build clinician proficiency in the intervention. Several outcome measurement tools and a clinical adherence measure are identified as resources to support quality assurance.

Dissemination Weaknesses

The group-format therapist's manual includes much of the same content as the individual-format manual, with few exercises and specific strategies for engaging group members with the content of the sessions. Training options are limited for clinicians seeking implementation guidance. Written materials and the training content provide little guidance for identifying intervention participants; administering outcome measurement tools and interpreting data; assessing and ensuring fidelity to the model; and understanding the requirements and purpose of clinical supervision, as well as using it as part of quality assurance. Implementers must acquire outcome measurement tools from outside sources. The adherence tool does not include quality indicators to support the measurement of clinician skill at delivering intervention components.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Therapist's manual (group or individual format) Free Yes
Participant's manual Free Yes
2-month, off-site clinician training seminar in Puerto Rico (includes implementation and quality assurance materials) $400 per participant No
3-day, on-site training (includes implementation and quality assurance materials) $3,500 per site, plus trainer travel expenses No
Phone and email technical assistance Free No
Ongoing consultation Varies depending on site needs and location No
Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Jungbluth, N. J., & Shirk, S. R. (2009). Therapist strategies for building involvement in cognitive-behavioral therapy for adolescent depression. Journal of Consulting and Clinical Psychology, 77(6), 1179-1184.  Pub Med icon

* Rosselló, J., Bernal, G., & Rivera-Medina, C. (2008). Individual and group CBT and IPT for Puerto Rican adolescents with depressive symptoms. Cultural Diversity and Ethnic Minority Psychology, 14(3), 234-245.  Pub Med icon

Shirk, S. R., Kaplinski, H., & Gudmundsen, G. (2009). School-based cognitive-behavioral therapy for adolescent depression: A benchmarking study. Journal of Emotional and Behavioral Disorders, 17(2), 106-117.

Contact Information

To learn more about implementation, contact:
Yovanska Duarté-Vélez, Ph.D.
(787) 764-0000 ext 7186
ymduarte@ipsi.uprrp.edu

To learn more about research, contact:
Guillermo Bernal, Ph.D.
(787) 764-0000 ext 4177
gbernal@ipsi.uprrp.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.