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«The Mediating Effect of Acculturation on the Effectiveness of Culturally Adapted Cognitive Behavioral Therapy with Mexican Americans Suffering From ...»

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The term Mexican American is used throughout the dissertation to refer to individuals who were born in Mexico and immigrated to the United States or who were born in the United States and are of Mexican descent. At times the terms Hispanic or Latino are used as they appear in the literature reviewed. Whenever possible, data is presented that is specific to Mexican Americans. When statistics are presented for Hispanics or Latinos in general, it is with the understanding that 64% of Hispanics or Latinos are Mexican Americans (American Community Survey, 2007). When describing the acculturation process, the U.S. mainstream culture is the host society into which Mexican Americans are acculturating. The Mexican American and U.S. mainstream cultures tend to be at polar extremes of one another regarding some cultural characteristics. Some of the predominant cultural characteristics for Mexican Americans are collectivism, present-orientedness, and placing emphasis on relationships, while some of the predominant cultural characteristics for the U.S. mainstream culture are individualism, future-orientedness, and placing greater emphasis on tasks (LaFayette de Mente, 1996; Poonam, 2002; Triandis, 1988).

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This dissertation investigates whether acculturation level has an impact on how well people of Mexican descent respond to mental health treatment. The main objective of this dissertation is to examine whether acculturation needs to be considered when culturally adapting interventions for Mexican Americans. The purpose of this study is to further understand what factors can help address the issue of treatment disparities for Mexican Americans.

When examining the issue of disparities, there are several distinctions that should be made. First, the definition of differences, disparity, and discrimination should be considered. Differences involve differences in utilization rates based on a particular set of factors such as because a particular group may be younger or healthier than the rest of the population. Disparity results from provider practice patterns, uninsurance rates, and other health care factors. The Institute of Medicine (2002) defines disparity as “a difference in treatment provided to members of different ethnic groups that is not justified by the underlying health conditions of treatment preferences of patients” (pg.

32). Discrimination results when a provider supplies less to a member of an ethnic minority (McGuire, Alegria, Cook, Wells & Zaslavsky, 2006). Disparities can be discussed broadly when examining the magnitude of variation across all groups.

Disparities can also be defined narrowly when examining how different a specific group is from the overall population (Pearcy & Keppel, 2002). Service disparities, involve issues of prevalence, access, availability, and uninsurance rates. Treatment disparities

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(McGuire et al., 2006; U.S. Department of Health and Human Services, 2001). This dissertation focuses on how culturally adapting an evidence-based practice can bridge the gap in treatment disparities for Mexican Americans by increasing the effectiveness of mental health treatment for this population.

This section of the chapter presents information on the prevalence of depression for Mexican Americans and for the general population. Then, the effects and costs of depression are examined. The chapter concludes with a discussion of current mental health practices and how these have lead to disparities for Mexican Americans.

The prevalence of depression among Mexican Americans is estimated to range from 13% to 30% (Mendes de Leon & Markides, 1988; Moscicki, Locke, Rae & Boyd, 1989; Vernon & Roberts, 1982). These rates differ from the point prevalence of 5% to 9% and a lifetime prevalence of 17% to 20% in the general U.S. population (Kessler et al., 2005; Oquendo, Lizardi, Greenwald, Weissman & Mann, 2004; Sansone, & Sansone, 1996; Sharp, 2005). One study found lifetime prevalence of 28.4% and past-year prevalence of 14.4% for Mexican Americans (Alegria et al., 2007). Nevertheless, the prevalence of depression in the Mexican American population has not been widely studied (Sue & Chu, 2003). Most of the available literature reflects data gathered from studies on elderly Mexican Americans (Chiriboga, Yuri, Banks, & Giyeon, 2007; Cuellar, Bastida, & Braccio, 2004; Gonzalez, Haan, & Hinton, 2001; Schneider, 2004).

Studies on racial and ethnic disparities in the prevalence of depression yield

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past six months in a sample of 4,745 adults who were part of a large statewide survey conducted in Colorado. The sample consisted of 84.2% Caucasians and 10% Hispanics, predominantly Mexican Americans. Riolo, Nguyen, Greden, & King (2005) conducted an analysis of data from the National Health and Nutrition Examination Survey III and found that Whites had a higher prevalence of major depression than African Americans and Mexican Americans. On the other hand, an analysis of secondary data from the 1996 Health and Retirement Survey (HRS) conducted by Dunlop and her colleagues (2003) found that African Americans and Mexican Americans had a higher incidence of major depression than Whites. It is possible that the difference in these two studies may be explained by the fact that the second study looked at older Mexican Americans ages 54 to 65 while the first study sampled participants ages 15 to 40 years of age.





In addition to differences in prevalence across racial and ethnic groups, evidence points to within group differences. Empirical studies have looked at prevalence of psychiatric disorders and utilization rates for Mexican Americans according to nativity.

The results of these studies generally point to a higher prevalence for U.S.-Born Mexicans Americans (Burnam, Telles, Hough, & Escobar, 1987; Escobar, Waitzkin, Silver, Gara & Holmar, 1998; Golding & Burnam, 1990; Vega, et al., 1998) than their foreign-born counterparts. Length in the United States also seems to play a role. Vega, Kolody, Aguilar-Gaxiola, & Catalano (1999) found a higher prevalence of depression for immigrant Mexican Americans who lived in the United States for more than 13 years.

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Mexican Americans respond to treatment for depression.

EFFECTS AND COSTS OF DEPRESSION

Depression impacts the individual through decreased quality of life, increased morbidity and mortality and through the stigma associated with mental illness (Brody, 2003). Depression was ranked first and said to contribute to 10.7% of the total years lived with disability from all causes in the Global Burden of Disease Study (Murray & Lopez, 1996). Several studies found that patients have higher levels of functioning and satisfaction in daily activities, role functioning, and social relationships when their depressive symptoms are less severe (Huppert, Weiss, Lim, Pratt & Smith, 2001;

Koivumaa-Honkanen et al., 1996; Kuehner, 2002; Saarijarvi, Salminen, Toikka, & Raitsalo, 2002). In addition, depression often occurs with other psychiatric conditions such as anxiety and substance abuse disorders. Depression is also associated with many physical conditions at significant rates. Documented rates of depression in patients with myocardial infarction range from 20-40%, in patients with diabetes mellitus from 14-18% and in patients with end-stage renal disease from 5-22% (Goldman, Nielsen, Hunter, & Champion, 1999).

Mortality rates for patients who have depression in addition to medical conditions are excessive (Kimmel et al., 2000). Depression may be a barrier to treatment compliance since it is characterized by anhedonia, the diminished interest in almost all activities most of the day, nearly every day (Wang & Watnick, 2004). Harman, Edlund, Forney and

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symptoms, poorer rates of adherence to treatment, poorer outcomes for the chronic conditions, and higher mortality rates.

Furthermore, the stigma related to having a mental illness is a significant concern.

Self-stigma or the internalization of stigma by people with mental illness has been shown to have deleterious effects on a person’s self-esteem (Davidson, 1992 & Estroff, 1989) and on the self-esteem of their families (Wahl & Harmon, 1989; Wahl, 1999).

Considering the issue of stigma is very important when exploring mental health treatment issues for minorities because stigma has been identified as one of the reasons minorities are hesitant to seek treatment for mental health issues (Snowden, Masland, Ma, & Ciemens, 2006).

In addition, the costs to society related to treatment of depression and loss of productivity were estimated to reach $81.5 billion in the year 2000 (Greenberg et al., 2003). Depression leads to higher healthcare utilization, is the leading cause of absenteeism and is a contributing factor to reduced productivity at work (Donohue & Pincus, 2007). Major depressive disorder was associated with 27.2 lost workdays per ill worker per year in a study conducted by the Comorbidity Survey Replication (Kessler et al., 2006). Data specific to costs of depression for Mexican Americans was not found in the literature.

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The supplement to the 1999 Surgeon General’s report titled Mental Health:

Culture, Race, and Ethnicity, addresses the issue of mental health treatment disparities for minorities, including Mexican Americans and the larger Hispanic population (U.S.

Department of Health and Human Services, 2001). This comprehensive, report explores the complexity of the impact of culture on attitudes about seeking mental health services, who seeks treatment and what types of services they seek. Two important implications emphasized in this report were that using traditional and mainstream mental health practices have resulted in disparities (Sue, 2003) and that untreated mental illness results in ethnic minority communities suffering more than White communities (U.S.

Department of Health and Human Services, 2001). Four major disparities in mental

health treatment are identified in the Supplement:

• Minorities have less access to, and availability of, mental health services.

• Minorities are less likely to receive needed mental health services.

• Minorities in treatment often receive a poorer quality of mental health care.

• Minorities are underrepresented in mental health research.

Despite the vast amount of research that is being conducted for evidence-based practices, there is very little research conducted on how evidence-based practices fare for minorities. The U.S. Surgeon General’s Supplement (2001) reported that few clinical trials included analyses for minority groups. The authors urged that clinical practice guidelines and program standards be subjected to rigorous empirical study (Sue, 2003).

Similarly, in a review of empirical literature, Miranda et al. (1996) indicated that very few treatment efficacy studies were conducted with ethnic minorities and that only one study included a Spanish-speaking sample (Chambless et al., 1996). In addition, a

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any inclusion of nonwhites (Braslow et al., 2005).

Several authors have pointed out that findings in research for one population do not always apply culturally to other populations (Hall, 2001; Sue, 2003). Bernal and Sharron del Rio (2001) argue that most empirically supported therapies are evaluated by using samples of primarily White, middle-class, English-speaking females. The authors challenge the double standard that treatments found to be effective for the majority are used with minorities.

This study examines if culturally adapted practices have different outcomes for two groups of Mexican Americans as a way to address treatment disparities. The manner in which treatment disparities affect Mexican Americans and Hispanics more generally is discussed in detail in the literature review. In part, these treatment disparities result from the lack of attention to cultural aspects of mental health interventions and the lack of minority participation in mental health research. Culturally adapting interventions for Mexican American is one way to address these disparities. Moreover, current mental health interventions do not meet the needs of Mexican Americans because they do not take into account the process of acculturation. Mexican Americans are a very heterogeneous group and therefore, any attempt to culturally adapt interventions should consider acculturation.

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health services for Mexican Americans, including utilization, access and barriers.

Dropout rates, lack of specialty mental health care and the use of primary care settings for mental health services emerge in the literature as relevant treatment issues. In addition, financial issues and the large number of uninsured Mexican Americans complicate access to services. Finally, language and cultural issues, as well as, other barriers that are identified in the literature are presented.

The second part of this literature review focuses on cultural adaptation as a way to address mental health treatment issues for Mexican Americans. The terms cultural competence, evidence-based practices, and cultural adaption are defined. Several authors’ arguments for the need for culturally adapted interventions are then presented. A review of previous culturally adapted interventions concludes this section.

The final section of this chapter presents studies using acculturation as a variable in examining the mental health of Mexican Americans. Some studies use place of birth as a proxy for acculturation, while other studies use an acculturation scale. A review of literature on acculturation and mental health for Mexican Americans leads to an understanding of how complex this topic is and that the study of this phenomenon is still in its infancy.

TREATMENT ISSUES

Several treatment issues related to mental health services for Mexican Americans have been the subject of empirical analysis. Research studies support the existence of disparities in mental health treatment utilization for Hispanics in general. For example,

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