Research and the Integration of Cultural Competence and EvidenceBased Practice

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Research and the Integration of Cultural
Competence and Evidence-Based Practice

• Charlotte Brown Ph.D.
• University of Pittsburgh School of Medicine
• 12/1/06

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Evidence-Based Practice

• Formulating the precise clinical question
• Defining the patients problem
• Defining the appropriate intervention
• Specifying the clinical outcome of interest
• Finding the evidence to answer the clinical
  question
• Evaluating the evidence for its validity and
  relevance
• (Geddes, 1996)

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Evidence-Based Practice

• Integrating the evidence with clinical expertise
  and patient values and applying the results to
  the clinical problem
• Evaluating the effectiveness of the
  intervention/clinicians performance

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Evidence Base for Mental Health Practice

• Enormous expansion in scientific base of mental
  health in past 20 years
• The extent to which mental health practice has
  become more evidence based is debatable
• Adoption of evidence-based approaches has been
  led in part by
• Growth in funding initiatives by National
  Institutes of Health
• Pharmaceutical Industry funding
• Professional Associations (American Psychological
  Association, American Psychiatric Association)

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Evidence Base for Mental Health Practice

• Also influenced by national changes in the
  structure, financing and provision of mental
  health services
• Strategies and tools developed to promote
  evidence-based practice involve strategies at
  multiple levels
• Patient/consumer
• Provider
• Practice/delivery system (e.g., HMO, public
  health clinic, private practitioner)
• Health plan
• Purchaser (e.g., employer who purchases health
  insurance, government for publicly-funded care)

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• Surgeon Generals Report on Mental Health (1999)
  emphasized the gap between opportunities offered
  by scientific advances and the realties of mental
  health practice
• Need for increased access
• Need for improvements to mental health services
• Especially for racial/ethnic minority persons

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Who is Represented by the Evidence?

• Minority Supplement to Surgeon Generals Report
  (2001)
• Limited science base on racial/ethnic minority
  mental health
• Clinical trials from 1986-1994 documented absence
  of racial/ethnic minority participants
• This has begun to change under impetus from NIMH
• e.g., grant applications must specify minority
  inclusion goals
• However, great variability in whether and how
  research questions and design address issues of
  culture

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Examples from Depression Research

• Relevant post-hoc analyses
• AA and White depressed primary care patients had
  similar symptomatic improvement in depressive
  symptoms in response to antidepressant medication
  or interpersonal psychotherapy (Brown et
  al.,1999)
• AA had poorer functional outcomes than Whites
• AA had poorer retention in pharmacotherapy
• AA had better retention in psychotherapy
• Although findings seem somewhat promising, it is
  possible that with cultural adaptations AA might
  have had better functional outcomes and better
  retention

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Examples from Depression Research

• Pooled analyses from paroxetine clinical trials
• Response and remission rates for patients with
  depression and comorbid anxiety disorders similar
  in Latino, AA, and Asian American and White
  patients (Roy-Byrne et al, 2005)

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Examples from Depression Research

• Depression treatment with CBT for Latino women
  (Comas-Diaz, 1981)
• Depression treatment with SSRIs for Mexican
  American women (Alonso et al, 1997)
• No control group
• Found improvement in depressive symptoms

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Examples from Depression Research

• CBT with case management augmentation for
  multi-racial/ethnic depressed, economically
  disadvantaged patients with depression (Miranda
  et al, 2003)
• No differences in response to CBT
• Case management augmentation effective for
  Spanish-speaking patients only
• Not for English-speaking Whites, Latinos, or AA

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Examples from Depression Research

• Multifacted, stepped care (psychoeducational
  group and medication management)treatment for
  depressed women in Santiago, Chile (Araya et al,
  2003)
• CBT and antidepressants for low-income
  racial/ethnic minority women (Miranda, et at,
  2003)
• Quality improvement intervention for depression
  in 46 primary care practices
• Educate clinicians
• Nurses to monitor patients
• Psychotherapists to provide CBT
• Probable depression at 6 9 months lower for AA
  and Latinos, but not for Whites

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Examples From Depression Research

• Secondary analysis of IMPACT study of treatment
  geriatric depression (Arean, 2005)
• Comparable responses to treatment for Whites, AA,
  Latinos

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• There is a small, but emerging literature
  suggesting that evidence-based interventions for
  depression are likely to be effective among
  racial/ethnic-minority groups
• Many studies made cultural adaptations to the
  intervention
• Made efforts to address barriers to care, and to
  enhance engagement in care

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Why is it Important to Integrate Cultural
Competence into Evidenced-Based Practice?

• Efficacy, Effectiveness, Dissemination of
  treatments
• We need effective models for training researchers
  to conceptualize, collaborate, and implement
  research studies in a culturally competent manner
• For Example
• Focus on disparities research
• Focus on community-based participatory research
• Emphasis on inclusion of racial/ethnic minorities
  in representative numbers

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Need for a Paradigm Shift to Foster Development
and Dissemination of Evidence-Based Treatment for
Racial/Ethnic Minorities

• Engaging diverse communities in a process of
  scientific inquiry
• More complex than the concept of recruitment
• Requires culturally sensitive approach
• Consideration of culture (customs, norms,
  language, style of communication)
• Investigators awareness of her/his own culture

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• Our work has to have value for research
  participants
• Collaboration is a critical element
• Commonly used models are often ethnocentric
• Comparative models vs. within group analyses
• Formative work is often necessary to generate
  appropriate questions/hypotheses

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When Do Researchers Need to Begin to Consider
Cultural Competence?

• Conceptualization
• Planning of treatment
• System
• Practitioner
• Patient level
• Engagement of Treatment Participants
• Delivery of Services
• Retention in Treatment

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• Community communication about research
  experience
• Provide feedback/training
• Find out about participants, referring
  practitioner/agencys research experience
• Incorporate these into future research
  implementation plans