article review

Research Article

Culturally Adapted Psychotherapeutic Interventions for Latino Depression and Anxiety: A Meta-Analysis

Abbie Nelson1 , Esther Ayers1, Fei Sun1, and Anao Zhang2

Abstract Objectives: Culturally adapted psychotherapeutic interventions have been developed to treat Latino depression and anxiety. Evidence is lacking regarding the overall effectiveness and generalizability of these adapted interventions. This study conducted a systematic review and meta-analysis of psychotherapeutic interventions for Latino depression or anxiety. Method: A search of nine electronic databases and manual review of reference lists were conducted. Thirteen studies of randomized controlled trials were eligible and included for meta-analysis using robust variance estimation in meta-regression. Results: An overall small treatment effect that is statistically significant was identified for Latino depression or anxiety of d¼ 0.334, 95% confidence interval [0.049, 0.619], p < .05. Discussion and Implications: More research is needed to determine the effectiveness of culturally adapted psychotherapeutic interventions for Latino depression or anxiety.

Keywords Latino, psychotherapeutic interventions, Latino depression or anxiety, systematic review, meta-analysis

Anxiety and depression, affecting all demographics across the

life span, are the two most common mental health disorders for

the population in the United States, with anxiety disorders

estimated at 28.8% (Kessler et al., 2005) and depression esti-

mated at 17% (Centers for Disease Control and Prevention

[CDC], 2018). An estimated 7.1% of children and teenagers

(CDC, 2019) and 21.7% of adults (Kessler et al., 2005) in the

United States have an anxiety disorder in their lifetime. One in

six Americans, approximately 17%, will experience depression

in their life span (CDC, 2019). The estimates of overall pre-

valence rates of depression among Latinos were higher than the

national average of 17% at a rate of 27% determined by a cross-

sectional analysis of 15,864 men and women aged 18–74 years

in the population-based Hispanic Community Health Study/

Study of Latinos (Wassertheil-Smoller et al., 2014). In this

study, a shortened Center for Epidemiological Studies Depres-

sion Scale was used to assess depression (Wassertheil-Smoller

et al., 2014). Alegria et al. (2008), found a rate of anxiety

disorders for U.S.-born Latinos 18.9% compared to foreign-

born Latino immigrants at a lower rate of 15.2% using data

from the National Latino and Asian American Study and the

National Comorbidity Survey Replication (Kessler & Merikan-

gas, 2004). Although numbers vary depending on the study and

method, it is still clear Latinos are experiencing anxiety and

depression. We used Latino to refer to Hispanic and Latino

population studied in this research. The term “Hispanic”

emerged in the middle to late 1970s and was used by the Cen-

sus Bureau in the 1980s to describe people with varying

backgrounds but share a common language and cultural heri-

tage (Del Olmo, 2001 as cited by Delgado, 2007). The term

Latino emerged in the early 1990s and it is not uncommon to

see the terms Hispanic and Latino used interchangeably (Del-

gado, 2007).

The Latino population in the United States was 56.5 million

in 2015 accounting for 17.6% of the total population, and it is

expected to grow to 29% of the population by 2050 (Pew

Research, 2015).The high prevalence of both depression and

anxiety among Latinos and the limited number of culturally

adaptive interventions and research of efficacy create the need

for research to identify if culturally adaptive interventions are

effective in addressing depression and/or anxiety among Lati-

nos. Without effective treatment for Hispanics with anxiety and

depression, the negative societal effects will compound as the

percentage of the population grows likely leading to more eco-

nomic, health, and familial costs to individuals and society.

This study reports findings of a systematic review and meta-

analysis of culturally adapted psychotherapeutic interventions

for treating Latino depression or anxiety. The purpose of this

1 School of Social Work, Michigan State University, East Lansing, MI, USA 2 School of Social Work, University of Michigan, Ann Arbor, MI, USA

Corresponding Author:

Abbie Nelson, School of Social Work, Michigan State University, 655 Audi-

torium Rd #254, East Lansing, MI 48824, USA.

Email: [email protected]

Research on Social Work Practice 2020, Vol. 30(4) 368-381 ª The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1049731519899991 journals.sagepub.com/home/rsw

study is to evaluate whether culturally adapted psychothera-

peutic interventions are effective for treating Latino depression

or anxiety. Studies included had interventions for treating

depression or anxiety because depression and anxiety are

highly comorbid, and both outcomes are often reported simul-

taneously in clinical trials.

Compared with non-Latino Whites, Latinos with similar

mental health needs are using mental health services less due

to cultural, structural, and economic factors (Cabassa et al.,

2006). Other barriers to receiving the care they need are lack

of Latino health-care professionals, low socioeconomic levels,

higher rates of uninsured, and societal and individual preju-

dices and discrimination (Ruiz, 2002). If mental illness is left

untreated, it negatively impacts daily functioning causing poor

concentration (Aisenberg et al., 2012), lack of energy (Alegria

et al., 2008), can result in a poorer response to future treat-

ments, and a higher risk the mental illness will become chronic

(Ghio et al., 2013).

Despite the critical need for services, research continues to

identify mental health service gaps among Latinos and suggests

that the use of nonculturally sensitive interventions may not be

effective for Latino populations. The use of culturally adapted

interventions may be a solution for encouraging adherence and

retention to mental health services for Latinos.

Cultural match theory states individuals benefit from inter-

ventions that align more closely with their cultural character-

istics (La Roche et al., 2011). La Roche et al. tested this theory

with the Latino population and found patients were more likely

to adhere to a culturally competent relaxation intervention that

aligned with their cultural values of allocentrism, a term used to

describe a personality trait in which a person focuses their

attention on others’ actions more than themselves. Specifically,

for depression, a culturally adapted behavioral activation tech-

nique showed preliminary success in Latino engagement and

continued investment in services (Kanter et al., 2010). In recent

years as the importance of culturally competent treatment mod-

alities emerged, conceptual models and frameworks for imple-

menting cultural adaptations have been created and

implemented with the realization of the complexity of this

process. Bernal et al. (2009) highlighted the different views

of treatments, one view stating universal treatments should

be able to apply to all people, while others called for a com-

pletely separate approach to interventions depending on the

culture (Comas-Diaz, 2006). As a middle ground between the

above approaches, culturally adapted evidence-based treat-

ments show positive results with diverse populations such as

Latinos and Asian Americans. However, efficacy is inconclu-

sive due to the various ways of measuring cultural adaptations.

For behavioral health interventions, there has been enough

literature published on steps to take to culturally adapt inter-

ventions that five common stages have emerged that behavioral

health researchers and practitioners can use when determining

when and how to implement adaptations (Barrera et al., 2013).

All of the above frameworks give great guidance on how to

identify the need and implement cultural adaptations. A com-

prehensive review article (Jani et al., 2009) looking at the effect

of cultural adaptations of interventions used in the areas of

health, mental health, and substance abuse with Latinos found

that most of the 23 studies included showed positive outcomes

after implementing a culturally adapted intervention. The

groundwork has been laid, but more research is needed to

synthesize the evidence and examine the effect size of cultu-

rally adapted interventions on client outcomes.

Limited systematic reviews attempted to conclude the effec-

tiveness of the statistical significance compared to treatment.

One systematic review study (Pineros-Leano et al., 2017)

examined 11 randomized controlled trial (RCT) and non-

RCT studies to determine the effectiveness of cognitive beha-

vioral therapy (CBT) with immigrant Latinos and described the

various cultural adaptations. Pineros-Leano et al. concluded

that the CBT interventions resulted in decreased depression

symptoms. They described the cultural adaptations used in the

various studies such as environmental and cognitive adapta-

tions but were not able to measure how effective these were.

Another systematic review of 36 RCT and non-RCT studies

focused on depression treatment among Latino adults (Collado

et al., 2016). Thirty-five of the studies incorporated cultural

modifications to the interventions, with the most common

adaptation being the provision of therapy in Spanish. CBT

delivered in client’s homes or via teletherapy showed signifi-

cant reductions in depression compared to control participants.

Individual outcomes had the best results when using interper-

sonal treatment for 16 sessions. The study called for a more

thorough evaluation of treatment moderators relevant to Lati-

nos, including language preference, acculturation, and subse-

quent case management given the heterogeneity of the

population. With the results of the above studies, it remains

unclear how effective cultural adaption is for this population

and what components are responsible for this effect if there is a

significant one.

Even fewer meta-analyses examined the effect of culturally

adapted interventions, without a focus solely on Latinos. A

meta-analysis by Escobar and Gorey (2018) sought to deter-

mine whether culturally adapted cognitive behavioral interven-

tions (CBIs) have a different effectiveness than those without

adaptation. They determined the effect to be significant at post-

intervention period, d ¼ 0.41, 95% confidence interval (CI)

[0.30, 0.52], and at 6- to 12-month follow-up with d ¼ 0.44,

95% CI [0.30, 0.58] when compared to interventions that were

not adapted or were only adapted on “surface structure,” which

involved matching the intervention to observable characteris-

tics of the population (e.g., language) but did not include

deeper cultural aspects. The authors suggested the continued

need for research due to small sample sizes and the RCTs being

more randomized pilot trials that lacked blinding. Another

meta-analysis (Van Loon et al., 2013) looked at the effective-

ness of culturally adapted depression and anxiety treatments for

ethnic minorities in Western countries and found a significant

pooled effect size of 1.06, 95% CI [0.51, 1.62], p < .001. They

contributed the effectiveness to the adaptations on cultural val-

ues and beliefs related to the healing process. Of the nine

studies used for Van Loon et al.’s review, only three focused

Nelson et al. 369

specifically on the Latino population showing the knowledge

gap of the effectiveness specifically for Latinos.

As evidenced by the above literature, no meta-analyses have

focused on culturally adapted interventions using RCTs to treat

anxiety or depression among Latinos. While culturally adapted

intervention research for Latinos tends to grow, research is

needed to determine whether and how culturally adapted inter-

ventions are working and which conditions among Latinos

yield the most effectiveness. In addition, conclusions taken

from previous studies that lacked the rigor of RCTs may be

producing biased results. Therefore, this study will add to the

growing knowledge base in an important way.

Method

Following the Cochrane Collaboration Guidelines (Higgins &

Green, 2011), this study used various search strategies to obtain

relevant literature published between 1900 and February 2019.

The strategies included searching nine electronic databases,

grey literature, and reference lists in related systematic reviews.

The nine electronic databases were CINAHL Plus with Full

Text, Family & Society Studies Worldwide, Gender Studies

Database, Social Sciences Full Text (H.W. Wilson), Education

Resources Information Center, Academic Search Complete,

Health Source: Nursing/Academic Edition, Psychology and

Behavioral Sciences Collection under EBSCOhost, and Sco-

pus. These databases were included as they covered a wide

range of journals related to mental health and the topic of

interest to this review. The initial eight databases were searched

using the search terms to identify culturally adapted

(“culturally adapted” or “culturally competent” or “culturally

sensitive”) AND Latino population (latin*) AND therapy

(therap*) AND depression (depress*). Choosing only peer-

reviewed articles with these terms yielded only 35 results. The

search was then expanded by using the search terms to identify

culturally adapted (cultur*) AND Latino population (latin*)

AND therapy (therap*) AND (depress*) OR anxiety (anx*),

which yielded 170 results. The same broader terms were then

used in Scopus, which added 126 results. After input from the

reviewer, we did post hoc analyses using the term Hispanic and

resulted in an additional four studies.

Inclusion and Exclusion Criteria

To be eligible for inclusion, a study needed to be (1) an RCT

that took place in the United States and (2) examining the

effects of psychotherapeutic intervention on depression and/

or anxiety of Latinos. Study participants could be of any age

as long as they were Latino. Psychotherapeutic interventions

are broadly defined in this review to include therapeutic tech-

niques or strategies used by therapists and psychosocial inter-

ventions implemented by community health practitioners with

the intent to improve mental health symptoms. Community

health practitioners are persons with knowledge about the com-

munity they work in and are providing support, services, or

psychosocial interventions with the desire to create positive

change in the community. Community health workers such

as promotoras referring to community health workers in

Spanish-speaking communities are also included in this cate-

gory (Office of Minority Health & Health Equity, 2019). Lati-

nos were operationalized as a person of any age belonging or

relating to a culture from Latin America or other countries that

speak Spanish/and or English and define themselves as Latinx.

Culturally adapted was defined as any item of the intervention

modified to be sensitive to the culture of individuals who are

receiving the treatment that takes into account their values,

language, rituals, social networks, background, and “lived

experience of the participants” (Marsiglia & Booth, 2015).

Culturally adapted interventions for Latinos may include but

are not limited to including the following features: program

delivered in Spanish, use of Latino community health workers

“promotora,” and addressing mental health beliefs and norms

specific to Latino community. A study was included if it used

measure(s) of depression and/or anxiety as either primary or

secondary outcomes. For example, a study that examined the

effect of a culturally sensitive cognitive behavioral group inter-

vention for Latino Alzheimer’s caregivers and measured neu-

ropsychiatric symptoms as well as depression would be

included. Studies were only accepted if published in English.

A study would be excluded if (1) Latinos were not a part of the

intervention, (2) did not have a randomly assigned control/

comparison group, (3) did not contain measure(s) of depression

and/or anxiety, (4) did not report necessary statistical informa-

tion for effect size calculations, (5) did not include a cultural

adaptation to the intervention, and (6) was conducted in another

country.

Screening and Data Extraction

Two doctoral-level students and one postdoctoral fellow parti-

cipated in eligibility screening, and the two doctoral students

completed the data extraction procedures. Using Covidence

online software (https://www.covidence.org/home), title and

abstract of each study was screened by each doctoral student

independently and blinded to each other’s decisions. The third

independent screener (postdoc fellow) resolved the conflicts.

During full-text screening, the two doctoral students indepen-

dently reviewed the full texts and discussed any differences.

The independent reviewer was consulted on the articles that the

students could not find a consensus. A manual review was

conducted of the reference lists of systematic reviews related

to interventions for Latinos for depression or anxiety to identify

any missed studies from the search for inclusion. A coding

sheet for data extraction was developed and then used to guide

coding of all included studies.

Coding domains (available upon reasonable request from

the first author) consisted of participant and provider charac-

teristics, intervention characteristics, research design, and

effect size data. Participant characteristics included age, gen-

der, marital status, socioeconomic status, and Latino subgroup.

Provider characteristics included profession, educational back-

ground, clinical experience, and whether they received

370 Research on Social Work Practice 30(4)

supervision and training. Intervention characteristics included

an intervention’s type (e.g., therapeutic vs. supportive), dosage

(minutes per session, number of sessions, and duration in

weeks), format (e.g., individual, group), delivery methods

(e.g., in-person, technology-assisted), and delivery setting

(e.g., home, community-based mental health service).

Research design included the nature of the control group, diag-

nostic tools, and outcome measure(s). Since all studies

included were RCTs, the nature of the comparison group was

coded as treatment as usual or waitlist control.

Interscreener and Interrater Agreement

Satisfactory interscreener reliability was observed with 79% for title/abstract and 85% for full-text screening. Interrater

reliability was calculated using a percent agreement model

by dividing the number of agreements over all possible extrac-

table data points. The two researchers reached a satisfactory

interrater agreement of 87% for data extraction. All disagree-

ments were resolved by discussion and consensus.

Data Analysis

Data extraction was conducted in Microsoft Excel and ana-

lyzed using R software (version 1.1.463) in four stages: (1)

conducting descriptive statistics of participants, providers,

intervention characteristics, and research design; (2) calculat-

ing small sample–corrected effect size estimates; (3) synthesiz-

ing effect size estimates across studies; and (4) moderator

analysis using meta-regression.

Effect Size Calculation

All of the depression and anxiety outcomes reported in the

studies for this analysis were continuous outcomes. There-

fore, their effect size estimates were calculated using Hedges’

g effect size (Cooper et al., 2009). Hedges’ g represents stan-

dardized mean differences when different measures were used

across studies. The g value was further adjusted using

Hedges’ small sample size correction (Hedges, 1981) to

obtain an unbiased estimate. This estimate is noted as “d” in

this review.

Effect Size Synthesis and Moderator Analysis

An overall treatment effect size estimate and moderator anal-

yses were conducted using robust variance estimation (RVE) in

meta-regression, a method that has been supported by both

methodological and previous empirical studies (Hedges et al.,

2010; Tanner-Smith & Tipton, 2014; Zhang et al., 2019). Sev-

eral studies included in this review reported multiple effect

sizes, which introduced statistical dependence into the resulting

effect sizes. Comparing with other statistical procedures that

handle within-study dependence, such as generalized least

squares estimation (Olkin & Gleser, 2009) or multilevel

meta-analysis modeling (Van den Noortgate et al., 2013), RVE

fits better because RVE makes no assumptions about effect size

sampling distributions and can estimate the covariance struc-

ture of the dependent effect sizes without statistical information

needed in other methods. Methodological studies recom-

mended an ideal sample size of five effect sizes per study and

40 studies for RVE to generate reasonably accurate results

(Hedges et al., 2010; Tipton, 2015). Because existing studies

meeting the inclusion criteria of this study is less than 40, we

used small sample size adjustment when running the meta-

regression with RVE (Tipton, 2015).

Having identified variability among effect size estimates,

we conducted moderator analyses to examine factors that influ-

ence effect size. Moderator analysis is able to indicate the

statistical differences between different subgroups. Since it

does not determine if the effect size of each subgroup is statis-

tically significant, an analysis of treatment effect among sub-

groups is conducted alongside moderator analysis to improve

the results of clinical significance.

Publication Bias and Risk of Bias

Publication bias refers to the nonrepresentativeness of articles

published among all the research done in an area. This happens

when studies with nonsignificant results are less likely to be

published, which affects the bias of effect sizes. This review

used Vevea and Woods’ (2005) weight function model to sta-

tistically assess the possibility of publication bias, and a funnel

plot of the effect size estimates graphed against their standard

errors was used to visually depict the bias. Risk of bias was

assessed in light of the evaluation criteria specified in the

Cochrane Handbook for Systematic Reviews of Intervention

(Higgins & Green, 2011).

Results

Search Results

The Preferred Reporting Items for Systematic Reviews and

Meta-Analyses (PRISMA) diagram in Figure 1 shows the

results of a detailed literature search and the results from the

selection process. A total of 331 references were uploaded to

Covidence for screening, 98 duplicates were removed leaving

233 for title and abstract screening. Of the 233 articles, only 26

articles met inclusion criteria for full-text screening. Full-text

review further excluded 16 due to research design leaving 10

studies for data extraction. A manual review was conducted of

the reference lists of systematic reviews related to interventions

for Latinos for depression or anxiety, and 8 more studies were

identified for potential inclusion but then 3 were excluded due

to research design leaving 15 studies for data extraction. The

five studies that had been found had been missed in the original

search due to not including search terms of Hispanic and sub-

groups such as Mexican. During data extraction, one study was

further excluded due to missing a control group and another as

the intervention measured was not psychotherapeutic, resulting

in final 13 studies selected in the meta-analysis.

Nelson et al. 371

Study Characteristics

Table 1 presents study characteristics of all 13 studies, with a

total sample size of N ¼ 1,532 participants included in this

review. Nine studies (64%) examined depression as the pri-

mary outcome and one study examined anxiety as the primary

outcome. The remaining three studies examined both anxiety

and depression outcomes. Participants were an average of 41

years old. Three studies did not provide relationship status,

but of the 10 that reported about half were partnered (47%),

and 83.7% were female. All 13 studies used randomized con-

trol design. Most of the studies (85%) used therapeutic inter-

ventions, therapeutic and supportive (38.4%), two studies

(22.2%) used supportive only, and one study used mixed

interventions. Four studies (30.7%) used active treatment con-

trol groups, only one used waitlist as a control group, and

eight studies (61.5%) used treatment as usual. A large variety

of Latino subgroups were identified including Mexican

American, Puerto Rican, Dominican Republic, Columbian,

Guatemalan, Central and South American, and two identify-

ing the population as only Latino and not breaking them into

subgroups. Not all studies commented on socioeconomic sta-

tus, but six articles reported income ranging from US$10,000

to US$50,000 average annual income of participants; two

articles denoted employment status only with no income

denoted.

Seven studies (54%) used individual intervention, four

(44.4%) used a group intervention, and two used both

individual and family interventions. Most studies (85%) used

in-person interventions, one study used technology-assisted

interventions, and one study used a telephonic method. Five

interventions (n ¼ 5, 38.4%) were delivered at community-

based mental health centers, and two were at outpatient

clinics (15.3%).

Thirteen studies reported an average of 12 sessions for the

intervention, ranging from 5 to 24 sessions. Ten studies

reported an average of 65 min per session, ranging from 15

to 120 min. Of the three remaining studies, in one, participants

got to choose how many minutes they engaged with the inter-

vention and results were not provided; the remaining two stud-

ies’ information on minutes was not included. All studies

together reported an average of 11.6 weeks of intervention

duration, ranging from 4 to 24 weeks across different

interventions.

Interventions were implemented by mental health profes-

sionals in 69.2% of the studies and three (23%) used parapro-

fessionals only with one using paraprofessional and medical

personal and one of the studies that used mental health profes-

sionals also used medical personnel. Seven of the studies had

providers with master’s degrees or higher implementing the

intervention (54%). Providers were given training before and

Records identified through

Database search (N=331)

Records after duplicates

removed (N=233)

Title and abstract screening

(N=233) 207 studies irrelevant

Full-text articles assessed

(N=26) 16 studies ineligible design

Articles for data extraction

first round (N=10)

Articles for data extraction

second round (N=15)

Articles included in final

analysis (N=13)

Records identified through

manual search (N=8) 3 studies ineligible design

1 study missing control

group

1 study non-therapeutic

intervention

Figure 1. PRISMA diagram of search flow.

372 Research on Social Work Practice 30(4)

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w eb

si te

w it h

in fo

rm at

io n

o n

h ea

lt h

to p ic

s an

d p h ys

ic al

ac ti vi

ty .

C E S-

D C

E S-

D N

R

G o n ye

a et

al .

(2 0 1 6 )

T ¼

3 3 , C ¼

3 4

8 4 .4

% M

ex ic

an ,

D o m

in ic

an ,

P u er

to R

ic an

, an

d C

o lu

m b ia

n

5 5

ye ar

s o ld

, 9 2 .7

fe m

al e,

4 0 .3

% m

ar ri

ed

W LC

B ili

n gu

al M

as te

rs So

ci al

W o rk

er u se

d cu

lt u ra

lly se

n si

ti ve

fr am

ew o rk

th at

w as

co n si

st en

t o f va

lu es

, b el

ie fs

, an

d liv

ed ex

p er

ie n ce

s in

al l p h as

es o f th

e re

se ar

ch p ro

je ct

1 2

w ee

ks , 9 0 -m

in se

ss io

n s

p er

th e

p ar

ti ci

p an

ts re

q u es

t al

l se

ss io

n s

w er

e d o n e

in Sp

an is

h . T

h e

tr ea

tm en

t gr

o u p

re ce

iv ed

C B

T in

te rv

en ti o n . T

h e

co n tr

o l gr

o u p

re ce

iv ed

p sy

ch o ed

u ca

ti o n

se rv

ic es

b y

te le

p h o n e.

Se rv

ic es

re ce

iv ed

at a

co m

m u n it y-

b as

ed m

en ta

l h ea

lt h

se tt

in g.

C E S-

D m

ea su

re d

b y

a Sp

an is

h ve

rs io

n .

ST A

I- S

m ea

su re

d b y

a Sp

an is

h ve

rs io

n

C E S-

D , ST

A I-

S T

-4 d id

n o t

co m

p le

te , C

-6 d id

n o t

co m

p le

te

(c on

tin ue

d)

373

T a b

le 1 .

(c o n ti n u ed

)

A u th

o r

Sa m

p le

La ti n X

Su b gr

o u p

D em

o gr

ap h ic

C o n tr

o l

P ro

vi d er

In te

rv en

ti o n

C h ar

ac te

ri st

ic s

In cl

u si

o n

C ri

te ri

a O

u tc

o m

e M

ea su

re s

A tt

ri ti o n

R at

es

Si m

o n i et

al .

(2 0 1 3 )

T ¼

2 0 , C ¼

2 0

M ex

ic an

A m

er ic

an 4 6

ye ar

s o ld

, 7 2 .5

% m

al e,

2 7 .5

% fe

m al

e, 6 5

si n gl

e an

d 3 5

m ar

ri ed

T A

U Fi

ve b ili

n gu

al – b ic

u lt u ra

l La

ti n o

gr ad

u at

e st

u d en

ts in

p sy

ch o lo

gy . T

w o

h ad

m as

te r’

s d eg

re es

an d

tw o

en ro

lle d

in an

M A

p ro

gr am

in cl

in ic

al p sy

ch o lo

gy th

at u se

d cu

lt u ra

lly ad

ap te

d C

B T

. T

h e

in te

rv en

ti o n

w as

d o n e

at a

co m

m u n it y

cl in

ic .

1 6

w ee

ks , 5 0 -m

in se

ss io

n s.

T h e

in d iv

id u al

C B

T tr

ea tm

en t

w as

fo r

ad h er

en ce

an d

d ep

re ss

io n

w it h

an al

ar m

ed p ill

b o x

co m

p ar

ed to

u su

al ca

re .

In te

rv en

ti o n

w as

d o n e

in E n gl

is h

an d

Sp an

is h .

B D

I, M

A D

R S

B D

I, M

A D

R S

2 0 %

lo st

to fo

llo w

- u p

Le et

al .

(2 0 1 1 )

T ¼

9 4 , C ¼

9 2

C en

tr al

A m

er ic

an an

d So

u th

A m

er ic

an

2 5

ye ar

s o ld

, 1 0 0 %

fe m

al e,

3 5 .9

% si

n gl

e, an

d 6 4 .9

% m

ar ri

ed

T A

U T

w o

p o st

b ac

h el

o r’

s b ili

n gu

al b ic

u lt u ra

l re

se ar

ch st

af f co

n d u ct

C B

T p sy

ch o ed

u ca

ti o n al

gr o u p

se ss

io n s.

A cu

lt u ra

l ad

ap ta

ti o n

w as

u ti liz

ed .

C o n d u ct

ed in

a co

m m

u n it y-

b as

ed h ea

lt h

ce n te

r an

d a

h o sp

it al

cl in

ic

8 w

ee ks

, 1 2 0 -m

in se

ss io

n s.

T h e

C B

T co

u rs

e w

as ta

u gh

t in

Sp an

is h .

C E S-

D , B

D I-

II ,

an d

M D

E C

E S-

D , B

D I-

II , an

d M

D E

3 0 %

lo st

to fo

llo w

- u p

G al

la gh

er -

T h o m

p so

n et

al .

(2 0 0 8 )

T ¼

4 7 , C ¼

4 2

H is

p an

ic /L

at in

a 5 2

ye ar

s o ld

, 1 0 0 %

fe m

al e,

7 7 .5

% si

n gl

e, an

d 1 8 %

m ar

ri ed

A T

C In

te rv

en ti o n s

w er

e co

n d u ct

ed b y

p o st

d o ct

o ra

l fe

llo w

s o r

ad va

n ce

d gr

ad u at

e st

u d en

ts in

p sy

ch o lo

gy o r

re la

te d

fie ld

s th

at u se

d b ili

n gu

al an

d b ic

u lt u ra

l fr

am ew

o rk

s. Sm

al l

gr o u p s

o cc

u rr

ed at

a co

m m

u n it y

ce n te

r.

1 6

w ee

ks , 1 2 0

m in

C B

T sm

al l gr

o u p

co m

p ar

ed to

m in

im al

te le

p h o n e-

b as

ed gr

o u p

C E SD

C E SD

1 6 %

, w

it h

n o

si gn

ifi ca

n t

d iff

er en

ce s

b y

co n d it io

n o r

b y

et h n ic

it y

B ed

o ya

et al

. (2

0 1 4 )

T ¼

6 3 , C ¼

5 5

La ti n o /H

is p an

ic 4 2

ye ar

s o ld

, 6 9 %

fe m

al e,

4 2 %

m ar

ri ed

,a n d

5 8 %

u n m

ar ri

ed

T A

U In

te rv

en ti o n s

w er

e co

n d u ct

ed b y

cl in

ic ia

n s

th at

w er

e su

p er

vi se

d w

ee kl

y.

Fi rs

t vi

si t

w as

9 0

m in

an d

se co

n d

vi si

t w

as 4 5

m in

co n d u ct

ed in

Sp an

is h

D SM

-I V

P H

Q -2

lo st

1 5 %

in 6

m o n th

s

E ll

et al

. (2

0 1 7 )

T ¼

1 7 8 , C ¼

1 7 0

La ti n o , M

ex ic

an 6 8 %

, an

d C

en tr

al A

m er

ic an

1 6 %

5 7

ye ar

s o ld

, 8 5 %

fe m

al e,

d id

n o t

co m

p le

te h ig

h sc

h o o l 7 9 %

T A

U Se

ss io

n s

b y

p ro

m o to

ra th

at w

as tr

ai n ed

an d

su p er

vi se

d

T re

ce iv

ed 6

w ee

kl y

p sy

ch o ed

u ca

ti o n al

se ss

io n s

fo llo

w ed

b y

th re

e b o o st

er se

ss io

n s

co m

p ar

ed to

u su

al cl

in ic

ca re

to ev

al u at

e d ep

re ss

io n

an d

se lf-

ca re

m an

ag em

en t

fo r

d ia

b et

es an

d h ea

rt d is

ea se

p at

ie n ts

P H

Q -9

P H

Q -9

St u d y

at tr

it io

n at

1 2

m o n th

s w

as 3 0 %

(A H

H 3 1 %

vs . U

C 2 8 %

, p ¼

.5 1 )

1 0 4

p at

ie n ts

lo st

to fo

llo w

-u p

(c on

tin ue

d)

374

T a b

le 1 .

(c o n ti n u ed

)

A u th

o r

Sa m

p le

La ti n X

Su b gr

o u p

D em

o gr

ap h ic

C o n tr

o l

P ro

vi d er

In te

rv en

ti o n

C h ar

ac te

ri st

ic s

In cl

u si

o n

C ri

te ri

a O

u tc

o m

e M

ea su

re s

A tt

ri ti o n

R at

es

B ee

b er

et al

. (2

0 1 0 )

T ¼

3 4 , C ¼

3 7

La ti n a

m o th

er s,

M ex

ic an

9 2 %

2 6

m ea

n ag

e, le

ss th

an 1 0

ye ar

s o f

ed u ca

ti o n , 8 4 %

w it h

p ar

tn er

, p re

fe rr

ed Sp

an is

h

T A

U C

u lt u ra

lly ta

ilo re

d in

te rv

en ti o n

d el

iv er

ed b y

m as

te r’

s le

ve l p sy

ch ia

tr ic

n u rs

es an

d p ro

je ct

tr ai

n ed

Sp an

is h

la n gu

ag e

in te

rp re

te rs

T re

ce iv

ed 1 1

in h o m

e p sy

ch o th

er ap

y in

te rv

en ti o n

in te

rs p er

se d

w it h

fiv e

sh o rt

b o o st

er vi

si ts

w it h

o n ly

in te

rp re

te r,

1 6

co n ta

ct s,

m o th

er s

co m

p le

te d

q u es

ti o n n ai

re s

an d

4 5 -m

in vi

d eo

ta p in

g o f

in te

ra ct

io n

w it h

ch ild

C E S-

D C

E S-

D 1 3 %

K an

te r

et al

. (2

0 1 5 )

T ¼

2 1 , C ¼

2 2

M ex

ic an

, P u er

to R

ic o , an

d o th

er

3 8

ye ar

s o ld

, 7 9 %

fe m

al e,

an d

5 3 .5

% m

ar ri

ed

T A

U E x is

ti n g

M H

p ra

ct it io

n er

s w

er e

T A

U o n e

o f th

e fo

u r

h ad

cl in

ic al

p ra

ct ic

e lic

en su

re w

h ile

o n e

w as

o b ta

in in

g lic

en su

re

1 2

w ee

ks o f se

ss io

n ,w

ee kl

y fo

r 5 0

m in

D SM

-I V

H am

ilt o n

R at

in g

Sc al

e fo

r d ep

re ss

io n

(H R

SD )

P o st

tr ea

tm en

t 3 4 .9

% ,f

o llo

w -u

p 4 1 .9

%

Fe ld

m an

et al

. (2

0 1 6 )

T ¼

1 6 , C ¼

1 6

La ti n o , P u er

to R

ic an

8 3 %

4 3

ye ar

s o ld

, 9 4 %

fe m

al e,

m ar

ri ed

2 3 %

, 2 7 %

h ig

h sc

h o o l ed

u ca

ti o n

o r

le ss

, an

d 5 0 %

in co

m e

le ss

th an

1 6 K

A T

C C

lin ic

al p sy

ch o lo

gy p o st

d o ct

o ra

l fe

llo w

an d

ad va

n ce

d gr

ad u at

e st

u d en

ts , gi

ve n

tr ai

n in

g an

d su

p er

vi si

o n

T -C

B P T

co m

p ar

ed to

m u si

c an

d re

la x at

io n

th er

ap y,

8 w

ee kl

y se

ss io

n s

D SM

-I V

cr it er

ia fo

r P D

, P D

SS >

8

P D

SS 0 %

at 3 -m

o n th

fo llo

w -u

p

N ot

e. M

ea su

re m

en t

sc al

es ¼

A D

IS -C

:A n x ie

ty D

is o rd

er s

In te

rv ie

w Sc

h ed

u le

— C

h ild

Sy m

p to

m C

o u n t;

A D

IS -C

/P ¼

A n x ie

ty D

is o rd

er s

In te

rv ie

w Sc

h ed

u le

fo r

D SM

-I V

— C

h ild

an d

P ar

en t

V er

si o n s;

A D

IS -C

SR ¼

A n x ie

ty D

is o rd

er s

In te

rv ie

w Sc

h ed

u le

— C

lin ic

ia n ’s

Se ve

ri ty

R at

in g;

A D

IS -P ¼

A n x ie

ty D

is o rd

er s

In te

rv ie

w Sc

h ed

u le

— P ar

en t

Sy m

p to

m C

o u n t

ab o u t

th e

C h ild

; B D

I ¼

B ec

k D

ep re

ss io

n In

ve n to

ry ; C

B T ¼

co gn

it iv

e b eh

av io

ra l

th er

ap y;

C D

I ¼

C h ild

re n ’s

D ep

re ss

io n

In ve

n to

ry ; C

E S-

D ¼

C en

te r

fo r

E p id

em io

lo gi

ca l St

u d ie

s D

ep re

ss io

n Sc

al e;

D SM

-V ¼

D ia

gn os

tic an

d St

at is tic

al M

an ua

l of

M en

ta lD

is or

de rs

, fif

th ed

iti on

. C

B P T ¼

co gn

it iv

e b eh

av io

r p sy

ch o p h ys

io lo

gi ca

lt h er

ap y;

(F A

C T

)- B re

as t ¼

Fu n ct

io n al

A ss

es sm

en t

o fC

an ce

r T

h er

ap y;

M A

D R

S: M

o n tg

o m

er y–

A sb

er g

D ep

re ss

io n

R at

in g

Sc al

e; M

D E ¼

M aj

o r

D ep

re ss

iv e

Sc re

en er

/m o o d

sc re

en er

;R C

M A

S ¼

R ev

is ed

C h ild

re n ’s

M an

ife st

A n x ie

ty Sc

al e;

S- B D

I ¼

Sp an

is h -L

an gu

ag e

B ec

k D

ep re

ss io

n In

ve n to

ry ;S

T A

I- S ¼

St at

e A

n x ie

ty In

ve n to

ry -S

ta te

; P D

SS ¼

P an

ic D

is o rd

er Se

ve ri

ty Sc

al e.

T ¼

tr ea

tm en

t gr

o u p

sa m

p le

si ze

;C ¼

co n tr

o l

gr o u p

sa m

p le

si ze

; N

R ¼

n o t

re p o rt

ed ; T

A U ¼

tr ea

tm en

t- as

-u su

al (a

s d ef

in ed

in th

e te

x t)

; W

LC ¼

W ai

tl is

t co

n tr

o l;

A T

C ¼

ac ti ve

tr ea

tm en

t co

n tr

o l;

LC SW ¼

Li ce

n se

d C

lin ic

al So

ci al

W o rk

er s.

375

supervision while implementing the interventions in 12 studies,

and one did not provide this information.

Publication Bias and Risk of Bias

Publication bias was assessed using funnel plot (Figure 2) by

plotting observed effect size estimates by their standard errors.

The distribution of effect size estimates was reasonably sym-

metric with many of the values falling within the funnel, which

supported the absence of publication bias. Vevea and Woods’

(2005) sensitivity analysis further supported this conclusion

with the observed effect size (solid vertical line) overlapping

with a theoretical effect size (solid vertical line on center) for

the funnel to be theoretically symmetric.

Table 2 presents the results of assessing risk of bias. Overall,

studies reported low risk of bias in random sequence generation

(13/13), allocation concealment (11/13), selective reporting (9/

13), and blinding of personnel and participants (9/13). Studies,

however, reported high risk of bias in handling incomplete

outcome data (8/13) and blinding of outcome data (5/13).

Meta-Analytic Results

The overall treatment effect was estimated using an intercept

only meta-regression analysis with RVE and small sample size

adjustment. The 13 RCTs contained 44 effect sizes. An overall

minor treatment effect that is statistically significant was iden-

tified for Latino depression or anxiety, d ¼ 0.334, 95% CI

[0.049, 0.619], p < .05. On average, participants receiving cul-

turally adjusted psychosocial services reported 0.334 standard

deviations (SDs) higher than participants in the comparison/

control group.

Moderator and Subgroup Analysis

Table 3 presents the results of the moderator and subgroup

analyses. Age, gender, comparison group type, number of

sessions, minutes per session, and duration of weeks of inter-

vention, and profession of provider did not show any signif-

icant moderated treatment effect. Marital status significantly

moderated treatment effect, b ¼ 0.002, 95% CI [�0.020,

0.025], p ¼ .025. For participants who are not married, treat-

ment effect was 0.002 SDs higher on average than those who

were married. In addition, subgroup analysis of depression

and anxiety did not result in any significant outcomes among

subgroups. Univariate meta-regression indicated that outcome

type (depression ¼ 1 and anxiety ¼ 2) did not significantly

moderate the treatment effect, b ¼ 0.955, 95% CI [�0.347,

2.258], p ¼ .101, indicating the difference in effect size

between depressive and anxiety outcomes was not statistically

significant. There were no subgroup effects with only one

moderated effect for those that were not married, b ¼ 0.002,

95% CI [�0.020, 0.025], p ¼ .025.

Discussion and Applications to Practice

The population of the United States is evolving to have a higher

concentration of Latinos, with lifetime estimates for anxiety,

Figure 2. Publication bias assessing using funnel plot and sensitivity analysis.

Table 2. Cochrane Collaboration’s Tool for Assessing Risk of Bias.

Study RSG AC BPP BOD IOD SR

Pina et al. (2012) þ þ � ? þ þ Feldman et al. (2016) þ ? þ ? � ? Hinton et al. (2011) þ � ? � þ ? Ashing and Rosales (2014) þ þ þ þ ? ? Marcus et al. (2016) þ þ � ? ? þ Gonyea et al. (2016) þ þ � ? þ þ Simoni et al. (2013) þ þ þ ? ? ? Gallagher-Thompson et al. (2008) þ þ þ þ ? þ Kanter et al. (2010) þ þ þ þ þ þ Beeber et al. (2010) þ þ þ ? þ þ Bedoya et al. (2014) þ þ þ þ þ þ Ell et al. (2017) þ þ þ ? þ þ Le et al. (2011) þ þ þ þ þ þ Total number of “þ”s 13 11 9 5 8 9

Note. RSG ¼ random sequence generation; AC ¼ allocation concealment; BPP ¼ blinding of participants and personnel; BOD ¼ blinding of outcome data; IOD ¼ incomplete outcome data; SR ¼ selective reporting. “þ” ¼ low risk of bias; “�” ¼ high risk of bias; and “?” ¼ unclear risk of bias.

376 Research on Social Work Practice 30(4)

depression, and substance use disorders among Latinos in the

United States at a prevalence of 28.1% for men and 30.2% for

women (Alegria et al., 2008). The National Association for

Mental Health documents common factors that impede Latinos

from seeking mental health services, including cultural nega-

tive stigma, language barriers, lack of bilingual staff to help

meet their needs, and lack of health insurance.

These high rates of depression and anxiety and barriers to

service have led researchers and practitioners to develop and

implement culturally adapted interventions to meet the diverse

needs. However, there is limited research on the efficacy of

culturally adapted interventions for Latino anxiety and depres-

sion. Thus, this study conducted a systematic review and meta-

analysis of culturally adapted psychotherapeutic interventions

for treating Latino depression and/or anxiety.

Overall, this study identified an overall minor treatment

effect that is statistically significant of culturally adapted psy-

chotherapeutic interventions for Latino depression and/or anxi-

ety. There was not a significantly higher effect on those

interventions treating anxiety over depression. Although our

results offer promising evidence of the effectiveness of cultu-

rally adapted intervention for Latino depression and anxiety,

the minor significance indicates these results should be taken as

preliminary and support the need for continued research to

support the claim. Here, we can relate to Hernandez Robles

et al.’s (2018) and Valdez et al.’s (2018) findings that appeared

to be close to our results although our significance was higher

before we offer alternative explanations below. These two

systematic reviews focusing on culturally adapted intervention

for substance use rather than for anxiety and depression among

Latinos showed small or no effects. Hernandez Robles et al.’s

study found an effect size, d ¼ 0.06 (p ¼ .01), very small and

not clinically important but did increase at a follow-up time

point. They suggest that there may be secondary positive out-

comes to culturally adapted interventions and that more

research is needed to determine what makes these adaptations

effective and with which subgroups of Latino populations.

Similar to these nonclinically significant findings, the other

systematic review (Valdez et al., 2018) analyzed the effective-

ness of gender and cultural adaptations for alcohol and sub-

stance abuse interventions for Latino males and reported

nonsignificant results. The studies reviewed by Valdez et al.

had some mixed results showing positive results for secondary

outcomes and some suggesting the culturally adapted interven-

tions may outperform other treatments but were unable to

determine if these results were related to the intervention, out-

comes, or issues with methodology.

The result of a larger effect size across the studies for cul-

turally adapted interventions for those that were not married

may be explained by those that are married may be more likely

to seek help from their family first or informal means before

seeking treatment outside the family. Previous research sug-

gests that Latinos that have family support are more likely to

seek informal or religious means for mental health care (Villa-

toro et al., 2014). Therefore, when they seek help, their cases

may be more severe, and therefore, the effectiveness of the

Table 3. Overall Treatment Effect and Single-Predictor Meta-Regression Analysis.a,b

Characteristics/Moderators Estimate t (df) K/N 95% CI p

Overall treatment effect 0.334 2.57 (11.5) 13/43 [0.049, 0.619] <.05 Outcome type (ref: depression, b0) �0.657 �1.87 (6.29) 13/43 [�1.507, 0.192] .108 Anxiety (b1) 0.955 2.37 (2.91) 13/43 [�0.347, 2.258] .101 Age (b0) 1.720 2.22 (1.6) 13/43 [�2.544, 5.983] .187

(b1) �0.033 �1.90 (2.9) 13/43 [�0.088, 0.023] .156 % Female (b0) 2.773 1.91 (1.76) 13/43 [�4.365, 9.911] .213

(b1) �0.0312 �1.72 (2.61) 13/43 [�0.081, 0.027] .197 % Married (b0) 0.067 0.180 (4.40) 9/26 [�0.925, 1.058] .865

(b1) 0.002 0.311 (3.27) 9/26 [�0.020, 0.025] .025 Control group (ref: active control, b0) 2.033 2.11 (4.28) 13/43 [�0.579, 4.645] .098 Nonactive controlc (b1) �0.944 �1.93 (6.84) 13/43 [�2.108, 0.219] .096 Minutes per session (b0) 0.966 1.47 (3.76) 9/35 [�0.907, 2.840] .220

(b1) �0.006 �1.05 (2.72) 9/35 [�0.024, 0.013] .378 Number of sessions (b0) �0.2424 �0.329 (2.80) 9/32 [�2.683, �0.182] .765

(b1) 0.0784 0.892 (3.44) 9/32 [�0.182, 0.339] .431 Duration (b0) 0.392 0.746 (5.55) 13/43 [�0.920, 1.705] .508

(b1) 0.018 0.441 (5.55) 13/43 [�0.082, 0.117] .911 Intervention provider (ref: mental health, b0) 0.950 1.66 (6.05) 13/43 [�0.446, 2.347] .147

Nonmental health providers (b1) �0.198 �1.28 (4.20) 13/43 [�0.621, 0.225] .268

Note. K ¼ number of studies; N ¼ number of effect sizes; df ¼ degrees of freedom; CI ¼ confidence interval. b0 should be interpreted as the intercept in a regression model, that is the value of the reference group or when the moderator value equals to zero, and b1 should be interpreted as the regression coefficient that is for each unit increases in the moderator or when the moderator equals to one, what is the associated increase in the dependent variable—effect size aIf df < 4, a lower p value (p < .01) should be used for statistical inference. bAlthough presented in the same table, predictors were entered one-by-one individually to the model. cNonactive control included (treatment-as-usual and supportive intervention). *p < .05. **p < .01. ***p < .001.

Nelson et al. 377

culturally adapted intervention may not be as detected. More

research would be needed to confirm this explanation or look

into other differences and potential varying needs between

these different groups.

This conclusion cautions firm interpretations from these

results for several reasons. First, given the limited number of

studies included, we may lack sufficient power to identify an

overall greater significant effect size. The results of this study

mirrored those from the only other meta-analysis identified that

looked at culturally adapted interventions for Latinos (Escobar

& Gorey, 2018) that found culturally adapted CBIs were more

effective than CBIs without adaptation. The other study was

able to show a higher significant effect because the study had a

larger sample size and included non-RCTs. In light of these

differences, more studies with a rigorous RCT design are war-

ranted before reaching a definitive conclusion. Although it was

necessary to have two outcome measures (i.e., measures of

anxiety, depression) and a variety of different subgroups of the

Latino population included due to the limited number of studies

involving these populations, interpretations of our findings

need to be cautious about the confounds due to such broad

inclusion criteria.

Second, this study did not have sufficient information of the

specific cultural adaptations of each study to be able to deter-

mine if certain kinds of cultural adaptations could have led to a

higher significance in effect. More research is needed to deter-

mine culturally adapted components of interventions that may

have an effect. Additional studies are needed to build upon

these results and control for different variances in cultural

adaptation. It may be that only a minor effect was found for

cultural adaptations that are not grounded in the population, but

more research would be needed to clarify this point. Cabassa

and Baumann (2013) have suggested the need to combine cul-

tural adaption models with implementation science in order to

better understand not only how the adaptations may be affect-

ing the microlevel of the client and practitioner but also to draw

from the ecological perspective of implementation research to

understand the context surrounding the intervention and how

the context and adaptation interplay with one another. Future

research could help expand these concepts by looking at not

only the aspects of the interventions on a microlevel that are

having an impact but also how the changes are interplaying

with the organizational cultural and context surrounding the

implementation of the cultural adaptation.

It is also necessary to conduct studies measuring the differ-

ence between effects in different Latino subgroups, as they

have different levels of mental health concerns, cultures, and

background that could affect the effect of interventions. For

example, Wassertheil-Smoller and colleagues (2014) found

that overall, the prevalence of depression was 27% for the

Hispanic population, ranging from 22.3% for Mexican back-

ground to 38% for Puerto Ricans. These statistics highlight the

risk of placing such a heterogenous population into one

research category. Further interpretation caution is needed as

this study only measured interventions that utilized depression

and/or anxiety as an outcome. However, culturally adapted

interventions for Latinos have been used to treat various other

outcomes, and more studies are needed to see whether the

intervention effect varies depending on the outcome measure.

Additionally, mental health service providers reported signifi-

cant challenges in providing evidence-based interventions that

incorporate effective cultural adaptation to reach optimal treat-

ment outcome (Antoniades et al., 2014). The challenges the

practitioners face on the ground level may affect the fidelity

of implementing the intervention, which in turn affects the

effect. As researchers and practitioners continue to determine

the best ways to serve the needs of Latinos, our findings shed

important light on the importance of determining how to make

culturally adapted interventions more effective for the Latino

population.

This systematic review and meta-analysis revealed some lim-

itations. To begin, it is important to note that there is a chance

this review did not cover all of the studies. While the studies

gathered by the Cochrane Library offered the basis for this meta-

analysis, there is likely to be studies missing from both the

Cochrane Library and the nine electronic databases. In turn,

missing studies may affect the power of identifying a significant

effect. In addition, data screening and extraction of data were run

by two separate screeners/coders, which functioned indepen-

dently of each other. Due to this factor, it is vital to note that

human error will occur. Although it was necessary to have two

outcome measures (i.e., measures of anxiety, depression) and a

variety of different subgroups of the Latino population included

due to the limited number of studies involving these populations,

such broad inclusion criteria may introduce confounds in terms

of maturity, instrumentation, and differential levels of accultura-

tion may result in confounding variables. Last, this study was

limited by its small sample size. Thus, the minor significance

may simply be due to low statistical power.

This study represents the only meta-analysis to our knowl-

edge that examined the effectiveness of culturally adapted

interventions (not limited to a certain modality) for Latino

depression or anxiety. Despite the limitations, this research has

concluded that current research can support that culturally

adapted psychotherapeutic intervention has a minor significant

effect on depression or anxiety. More evidence is needed

regarding the effect of culturally adapted psychotherapeutic

interventions for Latino anxiety or depression, particularly

related to what are the effective or ineffective aspects of these

treatments, but social workers and those working with Latinos

can use these results to have some confidence that cultural

adaptions while working with diverse populations is having

some effect. As the Latino population continues to rise, it is

imperative that social workers, counselors, and other helping

professionals determine the most effective and approachable

interventions to serve this population, so that they are open to

receive services and feel comfortable to return to healing

environments.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

378 Research on Social Work Practice 30(4)

Funding

The authors received no financial support for the research, authorship,

and/or publication of this article.

ORCID iD

Abbie Nelson https://orcid.org/0000-0001-9963-1248

Anao Zhang https://orcid.org/0000-0002-3199-1113

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