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Census figures indicate that the Latino population grew from 35 million in 2001 to 52 million in 2011, making it the largest ethnic minority group in the United States (U.S. Census Bureau News, 2012). This increase does not include the undocumented Latino immigrant population, which is estimated to be about 9 million people (Passel & Cohn, 2012), or the 3.7 million Puerto Ricans who live on the island of Puerto Rico, a U.S. territory. By 2050, the U.S. Census Bureau projects that 29% of the nation’s population will be of Latino heritage (Taylor & Cohn, 2012). Mexicans are the largest subgroup, accounting for about 65% of the U.S. Latino population, followed by Puerto Ricans (9%) and Cubans (4%). Also, Latinos in the United States include individuals with ancestries from Central America (8%), South America (6%), and the Dominican Republic (3%; Lopez & Dockterman, 2011). Individuals of Latino heritage represent 21 Spanish-speaking countries, each with unique sociopolitical and historical contexts, religious and cultural traditions, Spanish

http://dx.doi.org/10.1037/14668-014 Psychological Testing of Hispanics, Second Edition: Clinical, Cultural, and Intellectual Issues, K. F. Geisinger (Editor) Copyright © 2015 by the American Psychological Association. All rights reserved.

LATINOS AND DEPRESSION: MEASUREMENT ISSUES

AND ASSESSMENT

AZARA L. SANTIAGO-RIVERA, GREGORY BENSON-FLóREZ, MARIA MAGDALENA SANTOS, AND MARISELA LOPEZ

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language dialect(s), indigenous roots, and foods. Likewise, their diversity is reflected in the blending of indigenous people (e.g., Mayan, Aztec, Inca) and Spaniards from Spain for some groups, whereas other Latino groups are a mix of African or Asian and Spanish ancestries (Acosta-Belén & Sjostrom, 1988).

UNDERSTANDING DEPRESSION IN THE LATINO CONTEXT

The Latino population’s projected growth, prevalence of depression, course of illness, and service utilization rates underscore the need to assess and measure depression accurately among members of this diverse demographic group. Earlier studies examining depression rate estimates based on aggregated data revealed that Latinos reported lower rates of lifetime mood disorders com- pared with non-Latino Whites (Kessler et al., 2005). However, Latinos with a history of mood disorders were at greater risk of persistent course of illness, almost twice that of non-Latino Whites after controlling for socioeconomic status (Breslau, Kendler, Su, Gaxiola-Aguilar, & Kessler, 2005).

More recent investigations, accounting for the diversity within the population, have examined depression rates by subgroup. In particular, the National Latino and Asian American Study (NLAAS; Alegría et al., 2004) results indicated differential rates of depression by subgroup, with Mexicans showing the lowest rates and Puerto Ricans the highest (Alegría, Mulvaney- Day, et al., 2007). Consistent with NLAAS results, previous findings showed high prevalence rates among Puerto Ricans when compared with other Latino subgroups (Moscicki, Rae, Regier, & Locke, 1987). Cuban-origin individu- als, as a group, have shown lower levels of depression symptomatology than other Latino subgroups (Narrow, Rae, Moscicki, Locke, & Regier, 1990). Although data are limited, there is evidence suggesting higher prevalence rates among Latinos of Central and South American origin compared with Mexican Americans (Hovey, 2000a, 2000b), but lower rates compared with Puerto Ricans (Alegría, Mulvaney-Day, et al., 2007). In sum, the findings of higher rates of depression for Puerto Ricans and Central and South Americans indicate that the burden of depression and other potentially related health problems is significant.

Acculturation has been widely studied to explain how Latinos adjust and adapt to a new host country. Some research based on aggregate data or on Latino samples representing various subgroups has suggested that increased psychological distress and mental health problems are associated with higher levels of acculturation, a phenomenon known as the immigrant paradox (Alegría, Shrout, et al., 2007). Specifically, native-born Mexican Americans who are more acculturated to the American way of life demonstrate higher lifetime prevalence of major depression and dysthymia compared with foreign-born

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Mexicans who have recently arrived in the United States (Burnam, Hough, Karno, Escobar, & Telles, 1987). This finding suggests that nativity may serve as a protective factor for foreign-born Mexicans, whereas acculturation has potentially negative effects on mental health (Grant et al., 2004). However, the immigrant paradox has not been observed across all Latino subgroups, including those experiencing psychiatric disorders (Alegría, Shrout, et al., 2007). Although differences in depression rates have been observed in indi- viduals of Mexican origin, based on nativity (i.e., U.S. vs. foreign born), the same pattern has not been observed among Puerto Ricans. Likewise, the rap- idly growing proportion of U.S.-born Mexicans, expected to account for most population growth in the years to come, may lead to a significance increase in the rates of depression.

MEASUREMENT ISSUES IN THE ASSESSMENT OF DEPRESSION

One of the major challenges often faced by clinicians is finding the appropriate measure to assess depression accurately. First and foremost, it is difficult to establish measurement equivalence because of cultural differ- ences in the meaning and expression of symptoms. This perspective is evi- dent in the culture-bound syndromes described in the Diagnostic and Statistical Manual of Mental Disorders (fourth ed.; American Psychiatric Association, 1994) that are specific to Latinos, such as ataque de nervios [nervous attack or breakdown] and nervios [nervousness], susto [fright], espanto [sudden fright], and perdida del alma [loss of the soul], and whose symptoms may be a manifes- tation of distress among Mexicans, Puerto Ricans, Central Americans, and South Americans (Aguilar-Gaxiola, Kramer, Resendez, & Magaña, 2008). Likewise, there is sufficient evidence suggesting that Latinos tend to somati- cize mental health problems, reporting more physical symptoms of distress than European Americans (Canino & Alegría, 2009).

Despite these challenges, efforts to investigate measurement equivalence have yielded interesting results. For example, Crockett, Randall, Shen, Russell, and Driscoll (2005) investigated within- and across-ethnic-group equivalence of the Center for Epidemiologic Studies Depression Scale (CES–D; Radloff, 1977) in a sample of Mexican, Cuban, Puerto Rican, and Anglo American adolescents. They found that the four factor domains (i.e., positive affect, nega- tive affect, somatic, and interpersonal) were similar for the Mexican and Anglo American adolescents, but not for the Puerto Rican and Cuban adolescents. For Cuban adolescents, five different factors emerged that could not be mean- ingfully interpreted by the investigators.

Second, research has suggested possible gender differences in the expression of depression symptoms. For example, Posner, Stewart, Marín,

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and Pérez-Stable (2001) found that the original four-factor structure of the CES–D proposed by Radloff (1977; i.e., depressive affect, positive affect, somatic, and interpersonal domains) was a good fit to the data for the women and, more important, when controlling for acculturation and age, but not for the men in the sample.

Third, it is widely acknowledged that most psychological assessment tools have been developed using middle class, highly educated, and White European samples. The lack of Latino representation in studies designed to develop such measures has led to a lack of culture-specific norms, raising con- cerns about their appropriateness (Butcher, Cabiya, Lucio, & Garrido, 2007).

Finally, there has been a growing interest in Spanish-language measures because of the significant number of monolingual Spanish-speaking Latinos in the United States. Recent surveys show that 30% to 35% of Latinos are not fluent in English (e.g., Taylor & Cohn, 2012). The lack of Spanish-language psychological assessments has been problematic in accurately diagnosing and treating depression. In an attempt to address this concern, more attention has been given to the translation from English to Spanish of well-established measures of depression such as the Beck Depression Inventory—II (A. T. Beck, Steer, & Brown, 1996), CES–D (Radloff, 1977), and the Geriatric Depression Scale (Yesavage et al., 1982) and in investigating the psychomet- ric properties of the translated version (e.g., Penley, Weibe, & Nwosu, 2003). It is important to note that having a translated version of a commonly used English-language depression inventory may seem better than not having one; however, simply translating the measure does not make it viable. It is essential to determine that the English and Spanish versions of a particu- lar measure are equivalent in content, reliability, and validity (Fernandez, Boccaccini, & Noland, 2007).

ASSESSMENTS

The focus of this section is to describe a number of commonly used assessment instruments for depression screening for which the psychometric properties have been examined. However, this listing of measurement tools is not exhaustive due to the chapter page limitations. The measures described are those used to assess depression in Latino adults who reside in the United States.1

1For a more detailed review of assessments for both adults and children, please refer to Aguilar-Gaxiola and Gullotta, 2008.

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Beck Depression Inventory—II

The Beck Depression Inventory (BDI; A. T. Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) is one of the most widely used and well-established self-report measures of depression symptoms in nonclinical and clinical samples. There is an extensive body of research indicating that it has sound psychometric properties. The BDI–II (A. T. Beck et al., 1996) is a revised version of the BDI consisting of 21 items assessing a variety of symptoms occurring in the 2 weeks prior to assessment and that correspond more closely to major depressive disorder (Penley et al., 2003). On a scale from 0 to 3 (0 = no depressive symptom and 3 = severe depressive symptom), participants rate the 21 items, with higher scores indicating more depression symptoms. The total score indicates the level of depression as minimal (1–13), mild (14–19), moderate (20–28), or severe (29–63). According to Wiebe and Penley (2005), the BDI–II was translated into Spanish by a diverse group of psychologists, but normative data are virtually nonexistent.

Results of earlier studies provide considerable support for the use of the English version of the BDI among older Mexican Americans. The internal consistency coefficient was .80 for this group (Gatewood-Colwell, Kaczmarek, & Ames, 1989); .98 for a community sample of diverse bilingual Latinos from Mexico, South and Central America, Cuba, and Puerto Rico (Novy, Stanley, Averill, & Daza, 2001); and .82 for a college student sample (Contreras, Fernandez, Malcarne, Ingram, & Vaccarino, 2004). More recently, Gloria, Castellanos, Kanagui-Muñoz, and Rico (2012) conducted a comparison study of the BDI–II, CES–D, and Self-Rating Depression Scale (SDS; Zung, 1965) to explore the internal consistency, as well as the construct and convergent validity of these measures. For purposes of this discussion, they found that the BDI–II yielded an internal consistency coefficient of .88 and was significantly correlated with the CES–D (.75) and the SDS (.61).

Several studies have examined the English and Spanish versions of the BDI–II, adding another level of complexity to the internal consistency and factor structure of the scale. Specifically, Novy et al. (2001) used an elaborate translation and adaptation process for the BDI–II and other measures and found that the correlation between the Spanish and English versions was .94 in a bilingual community sample. More recently, Wiebe and Penley (2005) examined the internal reliability and factorial validity of both language ver- sions of the BDI–II and found the following: (a) the English version yielded a reliability coefficient of .89, (b) the Spanish version yielded a coefficient of .91, (c) respectable test–retest reliability coefficients for the English and Spanish versions were obtained (.73 and .86, respectively), and (d) confir- matory factor analysis for each version resulted in a good fit with A. T. Beck and colleagues’ (1996) model. Essentially, this study showed strong support

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for the language equivalence of the English and Spanish versions in a college student sample.

The psychometric properties of the Spanish version of the BDI–II with Latinos residing in the United States has also received some attention in recent years. Penley and colleagues (2003) recognized, like many others, the need to develop reliable Spanish translations of measures to accurately assess depression symptoms in those who are either Spanish dominant or Spanish monolinguals. In their study, they examined the Spanish BDI–II in a sample of Mexican Americans undergoing hemodialysis for end-stage renal disease and found good internal consistency (.92) and a less than ideal factor structure that, according to the researchers, still provided “an adequate fit to the Spanish BDI–II patient data” (p. 574). Furthermore, when comparing the English and Spanish versions of the BDI–II, they found no statistical difference between the English and Spanish total scores, suggesting equivalency. However, the authors recommended interpreting these results with caution because of the small sample size in the comparison of the two measures (n = 23). Nonetheless, their study was one of the first to examine the equivalence of the Spanish and English BDI–II and showed promising results.

Likewise, Bonilla, Bernal, Santos, and Santos (2004) revised, pilot tested, and conducted a study with a Puerto Rican college student sample (on the island of Puerto Rico) and found that their Spanish version of the BDI (BDI–S) demonstrated high internal consistency (.88) and a factor structure that, according to the authors, is comparable with the domains identified by other studies (e.g., sadness, hopelessness, somatic, negative thoughts) and consistent with how depression has been conceptualized. In sum, these stud- ies have clearly demonstrated that the Spanish version of the BDI, either the BDI–S developed by Bonilla et al. (2004) or the Spanish version of the BDI–II (e.g., Penley et al., 2003), is a reliable screening tool that can be used with a diverse Latino population.

Center for Epidemiologic Studies Depression Scale

The CES–D was originally developed to assess somatic and affective symptoms of depression in adult community samples. It is a 20-item, self- report, paper-and-pencil measure that assesses depression symptoms and mood during the past week. The responses to each item are: 0 (less than one day), 1 (one to two days), 2 (three to four days), and 3 (five to seven days). The items include symptoms such as depressed mood, feelings of guilt and worthlessness, feelings of helplessness, loss of appetite, and sleep disturbance (Gloria et al., 2012). Although the CES–D is widely used, studies have shown differences in mean scores and prevalence rates among various ethnic and racial groups (e.g., Kim, Chiriboga, & Jang, 2009). Moreover, a recent meta-analytic study

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by Kim, DeCoster, Huang, and Chiriboga (2011) examined the factor struc- ture of the CES–D using confirmatory factor analyses and found support for the original four-factor structure in African Americans, American Indians, Latinos, and Whites, but not in Asians. Using exploratory factor analysis, they discovered that the four original factors were present in all five ethnic and racial groups; however, they found that for Latinos the structure was actually different in that the item loadings of depressed affect and somatic symptoms “switched between the two factors” (p. 388).

The Spanish version has shown adequate internal consistency, with alphas ranging from .88 to .90 (Piedra & Byoun, 2012). A meta-analysis investigating the practicality of the measure in primary care settings showed that the 20- and 10-item versions of the measure are valid for depression screening (Reuland et al., 2009). Another study found the CES–D to be an accurate measure of depression symptoms in a sample of 303 middle- aged Spanish-speaking Puerto Ricans living in the northeastern United States (Robison, Gruman, Gaztambide, & Blank, 2002). As stated earlier, Posner et al. (2001) gathered data from three studies of urban Latinos and found gender differences, concluding that the measure was not a good fit for Latino men.

With respect to Latino subgroup differences, Crockett and colleagues (2005) found equivalent factor structures for Anglo and Mexican Americans but not for Puerto Rican and Cuban youth. The authors attributed these results to potential cultural differences in the expression of depression symp- tomatology. Another study using a short version of the CES–D found it to be an accurate measure of depression symptoms for Mexican American farm workers (Grzywacz et al., 2010).

Patient Health Questionnaire—9

The Patient Health Questionnaire—9 (PHQ–9; Spitzer, Kroenke, & Williams, 1999) is a nine-item self-report measure that assesses depres- sion and is mainly used in primary care settings. The PHQ is a version of the Primary Care Evaluation of Mental Disorders (Kroenke & Spitzer, 2002). Respondents indicate the degree to which nine symptoms are pres- ent (depressed mood, difficulties sleeping, changes in appetite, suicidality, difficulties concentrating, anhedonia, worthlessness or guilt, agitation, and fatigue; Merz, Malcarne, Roesch, Riley, & Sadler, 2011) and are experienced during the 2 weeks prior to assessment using a 4-point scale from 0 (not at all) to 3 (nearly every day). Scores range from 0 to 27, with higher scores indicting more depression symptoms. Scores ranging from 5 to 9 are considered mild, 10 to 14 moderate, 15 to 19 moderately severe, and 20 to 27 severe (Kroenke & Spitzer, 2002). Alpha reliability coefficients ranging from .86 to .89 and

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good criterion validity were found using the clinical diagnostic interview (Spitzer, Williams, Kroenke, Hornyak, & McMurray, 2000).

More than 3 decades of research and practice have determined that the PHQ–9 is a valid and reliable measure of depression among racial and ethnic populations, including Latinos (Huang, Chung, Kroenke, Delucchi, & Spitzer, 2006). In a study examining the internal consistency of the PHQ–9 with a mostly female mixed Spanish- and English-speaking sample, researchers found a coefficient alpha of .80, demonstrating good reliability (Huang et al., 2006). This measure has been translated into many languages, including Spanish, making it popular for use with different ethnic and cul- tural groups.

Although research is limited, a few studies have examined the appro- priateness of the PHQ–9 for Spanish-speaking Latinas. Merz et al. (2011) assessed the structural validity of the English and Spanish versions of the PHQ–9 with a community sample of English- and Spanish-speaking Latinas. In this mixed sample of primarily Mexican descent, the internal consistency of the English and Spanish versions showed coefficient alphas of .84 and .85, respectively. Exploratory factor analysis determined that the PHQ–9 had good structural validity. In addition, the PHQ–9 has been found to be an adequate measure of depression in Latina college students (Granillo, 2012). Although these studies show promising results, future studies using the PHQ–9 should include men and a more heterogeneous sample.

ASSESSMENTS IN CRITICAL NEED AREAS

Latinas and Postpartum Depression

There is considerable concern that postpartum depression is on the rise, and yet, according to Le, Perry, and Ortiz (2010), as much as “50% of post- partum cases go undetected and untreated” (p. 249). There has been a grow- ing interest in validating measures for Latinas residing in the United States and in South America because of their high risk of developing postpartum depression (e.g., Affonso, De, Horowitz, & Mayberry, 2000; Kuo et al., 2004). One of the measures receiving attention in recent years is the Postpartum Depression Screening Scale Spanish version (PDSS; C. T. Beck & Gable, 2005), a 35-item self-report measure that assesses symptoms of postpartum depression and consists of seven dimensions: sleeping and eating distur- bances, anxiety and insecurity, emotional lability, cognitive impairment, loss of self, guilt and shame, and thought of hurting oneself. In addition, a shorter seven-item version exists, consisting of one item from each of the dimensions. Respondents indicate the level of agreement with each item using a 5-point

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scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating depression. The total score can range from 7 to 175 on the full ver- sion and 7 to 35 on the short version; 59 or less is considered normal adjust- ment, 60 to 79 indicates minor symptoms of postpartum depression, and 80 or greater indicates major postpartum depression. The English version of the PPSD has adequate reliability and validity, yielding an internal consis- tency coefficient of .98 for the total scores, and content validity ranging from .80 to .91 (C. T. Beck & Gable, 2002).

C. T. Beck and Gable (2003) studied the Spanish version of the PPDS (PPDS–S) in a diverse sample of primarily Latinas of Puerto Rican and Mexican heritage and found a reliability coefficient of .95 for the total scores, with a range of .76 to .90 for the seven dimensions. Likewise, C. T. Beck and Gable (2005) reported strong reliability coefficients for Mexicans (.95), Puerto Ricans, (.96), and Central and South Americans (.95). Interestingly, they reported a cutoff score of 60 for both minor and major postpartum depression, meaning that the Spanish version was unable to differentiate these two levels. In a more recent study Le and colleagues (2010) examined the psychometric properties of the short and long forms of the PPDS–S in a sample of women, mostly from different countries in Central America, in particular, El Salvador and Mexico, and found good internal consistency across the three subgroups (.97). They also found that the short seven-item version did not perform as well but was still within what those researchers considered acceptable ranges (i.e., .85 for women from El Salvador, .77 for Mexican women, .83 for women from other Central American countries). The overall coefficient for the short version was .83. In essence, the PPDS, both the English and the Spanish versions, shows adequate usefulness.

Older Latino Adults

The interest in accurately assessing depression in older adults is gaining momentum because the population of individuals age 65 and older is grow- ing quickly (U.S. Census Bureau, 2010), and as a group, a significant per- centage of older adults experience depression (Chavez-Korell et al., 2012). Although the body of research is limited, several studies have shown that older Latino adults may be at greater risk of depression (e.g., Falcón & Tucker, 2000). More recently, Diefenbach, Disch, Robison, Baez, and Coman (2009) reported higher prevalence of major depressive disorder and anxiety among Puerto Ricans compared with African Americans age 60 and older living in an urban setting. One of the challenges in assessing depression in older adults is that it is often difficult to differentiate the symptoms of depression from those associated with the natural aging process, such as deterioration of cognitive functioning, as well as changes in physical heath and activity

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(Fernández-San Martín et al., 2002). Nonetheless, it is important to assess and treat depression in older adults.

The Geriatric Depression Scale (GDS; Yesavage et al., 1982) is a popu- lar measure used to assess depression symptoms in older adults. There is a 30-item and 15-item version of the GDS. Respondents are asked to answer yes or no to a series of questions about how they felt during the past week. The 15-item version has received considerable attention and has been translated and validated in Spanish. The GDS–15 scores range from 0 to 15, with 0 to 4 considered normal, 5 to 8 mild depression, 9 to 11 moderate depression, and 12 to 15 severe depression. Validation studies have shown that the GDS is 91% to 100% sensitive and 72% to 82% specific (e.g., Scogin & Shah, 2006).

In a recent meta-analysis comparing the diagnostic accuracy of both the GDS 15- and 30-item measures in a primary care setting, the 15-item scale was 81% sensitive and a 78% specific for the presence of depression, whereas the 30-item measure was 77% sensitive and 65% specific (Mitchell, Bird, Rizzo, & Meader, 2010). The results are mixed for the Spanish version of the GDS. In a review of the literature on the diagnostic accuracy of measures of depression in the Spanish language, Reuland et al. (2009) found sensitivities ranging from 76% to 89% and specificities ranging from 64% to 98%, suggest- ing that there is support for the GDS’s utility.

FUTURE DIRECTIONS

On the basis of the literature review, we make a number of suggestions for further work with respect to the reliability and validity of measures of depression. First, future studies should expand the sample to include other subgroups that have been largely ignored. A good example is Le et al.’s (2010) study that examined the psychometric properties of the PDSS–S with a sam- ple of mothers predominantly from El Salvador. In particular, they pointed out that many of these women experienced significant trauma due to the politi- cal unrest in their country of origin. Equally important, they recommended conducting interviews with participants from the different subgroups when validating measures to see how the items on the measure are understood.

Second, there is a small but significant body of work on the validation of measures in Spanish, primarily from Spain. Examples of such efforts are (a) a brief version of the CES–D (CES–D–7) administered to a community sample of adults, ages 18 to 80, living in a metropolitan area (Herrero & Garcia, 2007); (b) the Hospital Anxiety and Depression Scale administered to a sample of patients with various chronic diseases, including a control group of students and community participants (Quintana et al., 2003); and (c) the GDS administered to a sample of older adults 64 and older treated

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in a primary care setting (Fernández-San Martín et al., 2002). Considering the strong support for the translated versions, perhaps future studies should focus on comparing U.S. Latinos with those from other Spanish-speaking countries to determine the reliability and validity of the scores emerging from the measure.

Third, a significant number of studies did not consider levels of accul- turative stress in determining the utility of a particular measure, which is surprising given the extensive research on the psychological impact of acculturation and acculturative stress (e.g., Hovey, 2000a, 2000b; Wiebe & Penley, 2005). As such, it is recommended that a measure of accultura- tion and acculturative stress be included when examining the psychometric properties of any measure that assesses depression.

Fourth, measurement equivalency continues to be a challenge. For instance, there is a need to address gender differences reported in the litera- ture suggesting that some measures may not be appropriate to use with males (Posner et al., 2001; Rivera-Medina, Caraballo, Rodríguez-Cordero, Bernal, & Dávila-Marrero, 2010). Measurement equivalency includes conducting comparative studies within and across Latino subgroups, as well as compar- ing English and Spanish versions of the same measure (e.g., Crockett et al., 2005). Although this is a complex process, it is necessary to address this issue to accurately screen, diagnose, and treat individuals.

Fifth, we found that few studies described the steps taken to translate a measure or the method(s) used. Considering that there are regional vari- ants of the Spanish language (i.e., various Spanish dialects) that can result in using different words to describe psychological phenomena, it is impera- tive that translation processes address this issue. Novy and colleagues (2001) provided a thorough description of various steps taken to translate measures that only had English versions, as well as measures that had Spanish versions. For instance, one of the steps involved a review of the measures by a group of bilingual individuals from various Latino subgroups (Mexico, Central America, and South America). Their elaborate method addressed not only the need to establish cultural equivalence of translated measures but also word or phrase equivalence. Thus, future attempts to establish measurement equivalency should incorporate similar translation approaches.

Sixth, more attention should be given to how language choice influ- ences the reporting of symptoms. Research has suggested that the sever- ity of symptoms is greater when assessment of bilinguals is conducted in Spanish compared with English (e.g., Guttfreund, 1990). Therefore, the severity of symptoms may be reported differently depending on the lan- guage being used.

Finally, computer-assisted methods of screening for depression may be a viable alternative. Some of the advantages noted are that it (a) increases

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the accuracy and ease with which the test is administered and reduces possible human error and (b) may be more cost-effective by streamlining the screening process (González, 2008). For example, research has shown that a computerized Spanish version of the BDI–II has good reliability and validity (González & Shriver, 2004). Likewise, computer-assisted meth- ods developed by Gerardo González (2008), such as the Voice-Interactive Depression Assessment System, and the earlier work by Ricardo Muñoz and colleagues (e.g., Muñoz, McQuaid, González, Dimas, & Rosales, 1999) using voice recognition, demonstrate sound psychometric properties.

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Aguilar-Gaxiola, S. A., & Gullotta, T. P. (Eds.). (2008). Depression in Latinos: Assessment, treatment, and prevention. New York, NY: Springer.

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