Culturally Tailored Intervention Improves Mental Health Symptoms in Latino Immigrants with Dual Diagnosis
Key findings
- The Integrated Intervention for Dual Problems and Early Action (IIDEA) manual is designed to treat co-occurring mental health and substance use disorder symptoms among Latinos
- In a binational randomized trial, therapists successfully initiated treatment with 77% of 172 participants assigned to the IIDEA group who had not been seeking behavioral health care
- More than half of participants in the IIDEA group completed treatment
- IIDEA had no effect on primary alcohol and drug outcomes, compared with enhanced usual care, but it was effective with regard to mental health outcomes
- In exploratory analyses in the subgroup of participants with moderate to severe baseline symptoms, IIDEA showed significant treatment effects on overall substance use and drug use, as well as mental health
Less than half of people with co-occurring mental health and substance use disorder symptoms get behavioral health treatment. This happens for a variety of reasons, but the problem is worse among Latino immigrants, who fear deportation, face discrimination and language barriers and have high rates of uninsurance.
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Margarita Alegría, PhD, chief of the Disparities Research Unit at Massachusetts General Hospital, and colleagues have created Integrated Intervention for Dual Problems and Early Action (IIDEA), a therapy that addresses both mental health, and drug and alcohol misuse symptoms. In JAMA Network Open, they report that the therapy improved mental health symptoms in a heterogeneous population of Latinos, as well as certain substance use outcomes in the subgroup of participants with moderate to severe baseline symptoms.
The Study Design
Participants were recruited between September 2, 2014, and February 2, 2017, from 17 primary care clinics or emergency departments and 24 Latino-serving community sites in Boston, USA, Madrid, Spain, and Barcelona, Spain. They were randomized to the IIDEA treatment (n=172) or to enhanced usual care (n=169).
Treatment consisted of 10 to 12 sessions of the IIDEA intervention, which was adapted for diverse Latino patients. Each session lasts 45 to 75 minutes. Trained clinicians at the sites delivered the treatment for three to six months in person or by telephone.
Patients in the control group met with their primary care physician as usual, if they were in care. A care manager at the sites contacted them five times in six months to assess their symptoms, ensure safety and make referrals if necessary.
Research assistants blind to study randomization assessed the outcomes two, four, six and 12 months after baseline. Participants received $30 or €25 for each assessment, increasing to $50 or €30 for the six-and 12-month assessments.
The Intervention
The IIDEA integrates cognitive behavioral therapy (CBT), motivational interviewing, mindfulness practice and cognitive restructuring. The substance use component includes strategies for reducing cravings, preventing relapse, strengthening coping skills and preventing sexually transmitted infections. In the trial, IIDEA treatment was conducted in English or Spanish and was offered at home to participants with childcare or illness constraints.
The Study Population
Key inclusion criteria included:
- Age 18 to 70
- No imminent suicidal ideation
- No specialty behavioral health care provided in the previous three months or scheduled in the upcoming month
Overall, 341 Latinos enrolled with an average age of 34, of whom 91% were born outside the United States or Spain. Participants originated from 17 countries besides the United States or Spain and had lived in their host country from <1 year to >30 years.
Principal Findings
Of the 172 individuals enrolled in IIDEA, 51.7% attended more than six sessions, 25.6% attended one to five sessions and 22.7% did not initiate treatment. Altogether, 77% completed the 12-month follow-up and 75% completed at least three follow-up assessments.
The primary outcome measures were changes in the drug and alcohol components of the Addiction Severity Index Lite and a urine drug test. At the six-month follow-up, no statistically significant treatment effects were found on these measures.
However, at the six-month follow up, the IIDEA group showed significantly reduced scores on the Patient Health Questionnaire–9 (for depression), the Posttraumatic Stress Disorder Checklist, the Hopkins Symptom Checklist–20 (for overall mental health) and a composite measure, compared with the control group.
Further Analyses
Exploratory analyses showed that the treatment effects of IIDEA on overall substance use and the urine test results at six months were significantly larger for participants with moderate to severe baseline symptoms than those with mild symptoms. Reduction in mental health symptoms was also greater among participants with moderate to severe baseline symptoms.
Attendance at more than four sessions was associated with significantly higher effect sizes for reducing alcohol misuse and depressive symptoms.
Site of Care
Most patients in the IIDEA group received the treatment in person (74%), and they were more likely to experience improvement than those treated by telephone. The researchers suspect it was difficult for patients treated by telephone to concentrate on mindfulness exercises and cognitive restructuring. Moreover, they believe at least one in-person visit may be necessary to reduce cultural mistrust and establish rapport.
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