The authors concluded that evidence-based treatments in primary care were effective and cost-effective for reducing mental health care disparities among Latinos. In view of methodological weaknesses in the review, in particular the questionable applicability of the included studies, the authors’ conclusions may not be reliable.

To evaluate the effectiveness of primary care treatments for depression in Latinos.

MEDLINE, PsycINFO, Social Science Abstracts and Cochrane Database of Systematic Reviews were searched. Relevant websites were also searched, including those of the National Institute of Mental Health, ClinicalTrial.gov and the Agency for Healthcare Research and Quality. Search terms were reported. The references of articles retrieved, relevant books and government reports were handsearched.

Randomised controlled trials (RCTs) conducted in primary care settings and that compared depression treatment(s) with usual care were eligible for inclusion, provided they reported treatment effectiveness or cost-effectiveness for Latino adults. Trials could be randomised by patient or by clinic.

Studies in the review were set in primary health clinics or recruited from health and welfare services in USA. Study populations were of mixed ethnicity and included 8% to 51% Latinos/Latinas (in one case older English-speaking Latinos only). All studies used guideline-based care. Guideline-based care comprised: manualised short-term psychological interventions (for example, individual or group cognitive-behavioural therapy or problem-solving therapy, delivered by trained clinical staff); standard pharmacological protocols; and/or education or monitoring within a quality improvement case management or collaborative-care framework. Interventions were compared with each other or with usual care or referral to community care. All studies made cultural and linguistic adaptations to treatment; most utilised bilingual and/or bicultural providers. Outcome measures included: depressive symptoms; rates of response, remission and major depression; social functioning; quality of life; employment status; and cost-effectiveness. Duration of follow-up varied from six to 57 months. Follow-up was conducted by mail and/or blinded telephone or personal interviews. The review included an RCT randomised at the group level as well as RCTs randomised at patient level.

The authors stated neither how papers were selected for the review nor how many reviewers performed the selection.

An adapted published quality rating scale was used to assess study validity (Miller 1995). Criteria covered 12 dimensions, which included: design; description of intervention, participant characteristics and dropouts; length and rate of follow-up; verification of participant self-report; blinding; analysis; and number of study sites. An additional study-specific criterion was whether there were explicit strategies to adapt interventions in line with Latino cultural and linguistic needs. Studies were allocated up to 17 points for quality.

The assessment was conducted by two independent reviewers. Disagreements were resolved by consensus.

Study findings were reported descriptively in the text.

The authors stated neither how data were extracted for the review nor how many reviewers performed the data extraction.

The studies were combined in a narrative synthesis.

Four RCTs (seven articles) were included in the review (n approximately 3,536, of whom about 750 were Latinos). Mean quality score was 14 out of 17 possible points (range 13 to 17). All studies reported details of patient characteristics and methodology, used valid outcomes measures, described drop-out rates and used suitable statistical procedures. Mean follow-up rate was 80% (range 73 to 83%).

Cognitive-behavioural therapy (CBT) and medication versus usual care: CBT and medication were both superior to usual care in improvements to depression-related clinical outcomes in study populations that included 31% to 51% Latinos (two RCTs). In both RCTs improved outcomes in the treatment groups (CBT or medication) persisted at 12 months compared with usual care.

CBT with or without case management among Latinos: One RCT reported that Spanish-speaking patients (n=77) who received CBT with case management had significantly less depressive symptoms and improved functioning at four and six months compared with those who received CBT alone (this result was not replicated among English-speakers).

Collaborative care and quality improvement in Latinos and African Americans: At 12 months, the collaborative care intervention was associated with significantly improved depression outcomes and higher response and remission rates than usual care (one RCT). Similarly, the quality improvement intervention was associated with significantly lower rates of probable depression than usual care, although employment rates did not improve significantly (one RCT). Among Latinos, those who received quality improvement were significantly more likely to receive appropriate depression care than controls (39% versus 26%, one RCT) and those who received collaborative care had a higher likelihood of using antidepressants and psychotherapy than controls (one RCT). At 57 months, the quality improvement intervention was associated with ongoing improvement in health outcomes and significantly lower rates of depression and unmet needs among Latinos and African Americans (a finding not replicated among non-Latino whites).

Latinos who received CBT in conjunction with a quality improvement initiative had significantly fewer depression-burden days than those who received usual care. Cost per quality-adjusted year (QALY) was US$6,100 or less. Quality improvement in conjunction with CBT was not cost-effective compared with usual care (one RCT).

A second RCT found that low-income minority women who received CBT or pharmacotherapy had significantly more depression-free days than women referred for community care. Cost per QALY for CBT and pharmacotherapy was $16,000 to $17,600, which was more cost-effective than community mental health care.

Evidence-based treatments in primary care were effective and cost-effective for reducing mental health care disparities among Latinos.

The objective of the review appeared to be an evaluation of the effectiveness of different primary care treatments for depression among Latinos. However, the review included comparisons between Latinos and non-Latinos, and also reported pooled outcomes for ethnic minorities with no separate analysis for Latinos. This reduced the applicability of the findings, as did the inclusion of a study that excluded Spanish speakers. Relevant sources were searched for studies, although it was unclear whether there were any restrictions to the search with respect to language or publication status. Steps were taken to minimise the risk of bias in validity assessment by having more than one reviewer make decisions independently, but it was unclear whether this also applied to study selection and data extraction. The decision to conduct narrative synthesis appeared appropriate given the heterogeneity between the studies, but the failure to tabulate results for each outcome measured and report any effect measures, confidence intervals and p values made it difficult to judge the clinical significance of the findings. It was unclear whether the poor reporting of results reflected deficiencies in the primary studies or in the review. In view of methodological weaknesses in the review, in particular the questionable applicability of the included studies, the authors’ conclusions may not be reliable.

Practice: The authors stated that depression treatment programmes for Latinos delivered in primary care using a collaborative care model were more effective than usual care. Treatment should be culturally adapted as appropriate for the population.

Research: The authors stated that further RCTs were needed on effective depression treatments for Latinos in primary care. These should report effect estimates and should include English and Spanish speakers from different socio-economic groups and acculturation levels. Studies should investigate case management, cultural and/or linguistic adaptations of treatments and how research evidence can best be applied in primary care.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.