Clinical Psychology Review 38 (2015) 65–78

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Clinical Psychology Review

Healthcare interventions for depression in low socioeconomic status populations: A systematic review and meta-analysis Antonio Rojas-García a, Isabel Ruiz-Perez b,c,⁎, Miguel Rodríguez-Barranco b, Daniela C. Gonçalves Bradley d, Guadalupe Pastor-Moreno b, Ignacio Ricci-Cabello e a

Department of Applied Health Research, University College London, UK Andalusian School of Public Health, Granada, Spain CIBER en Epidemiologia y Salud Pública (CIBERESP), Spain d Nuffield Department of Population Health, University of Oxford, UK e Nuffield Department of Primary Care Health Sciences, University of Oxford, UK b c

H I G H L I G H T S • • • • •

17 interventions were identified to treat DD in low-SES populations. There was a significant reduction in overall depressive symptoms at short-term. The overall effect slightly decreased at long-term. The effectiveness can be maximized through cultural training for providers. Booster sessions seem to reduce depressive symptoms at long-term.

a r t i c l e

i n f o

Article history: Received 31 July 2014 Received in revised form 15 February 2015 Accepted 3 March 2015 Available online 10 March 2015 Keywords: Depressive disorders Low socioeconomic status Effectiveness of interventions Culturally adapted interventions

a b s t r a c t The prevalence and impact of depressive disorders in developed countries are associated with certain population characteristics, including socioeconomic status. The aim of this systematic review and meta-analysis was to identify, characterize and analyze the short- and long-term effectiveness of healthcare interventions for depressive disorders in low socioeconomic status populations. The main biomedical databases were searched and fifteen articles assessing seventeen interventions were included in the review. Most interventions were implemented in the US (n = 11) and culturally adapted (n = 11). We conducted two meta-analyses for assessing both the short- (n = 11) and long-term effectiveness (n = 12) of interventions. There was a statistically significant reduction in overall depressive symptoms (−0.58, 95% CI [−0.74, −0.41]) at short-term (up to three months after the intervention), especially for combined and psychotherapeutic interventions. The overall effect slightly decreased at long-term (−0.42, 95% CI [−0.63, −0.21]). Those interventions including culturally specific training for providers and booster sessions seemed to be more effective in reducing depressive disorders at short and long term, respectively. In conclusion, healthcare interventions are effective in decreasing clinically significant depressive disorders in low socioeconomic status populations. Future interventions should take into account the key characteristics identified in this review. © 2015 Elsevier Ltd. All rights reserved.

Contents 1. 2.

Introduction . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . 2.1. Information sources and search strategy 2.2. Study selection . . . . . . . . . . . 2.2.1. Inclusion criteria . . . . . . 2.2.2. Exclusion criteria . . . . . . 2.2.3. Assessment of eligibility . . . 2.3. Assessment of risk of bias . . . . . .

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⁎ Corresponding author at: Andalusian School of Public Health, Campus Universitario de Cartuja s/n, Granada 18080, Spain. Tel.: +34 958027510. E-mail address: [email protected] (I. Ruiz-Perez).

http://dx.doi.org/10.1016/j.cpr.2015.03.001 0272-7358/© 2015 Elsevier Ltd. All rights reserved.

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2.4. Data extraction and synthesis of results . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . 3.1. Identification of articles . . . . . . . . . . . . 3.2. Study characteristics . . . . . . . . . . . . . . 3.3. Assessment of risk of bias . . . . . . . . . . . 3.4. Intervention characteristics . . . . . . . . . . 3.4.1. Components of the interventions . . . . 3.4.2. Cultural adaptations . . . . . . . . . . 3.5. Effectiveness of the interventions . . . . . . . . 3.5.1. Short-term effectiveness . . . . . . . . 3.5.2. Long-term effectiveness . . . . . . . . 3.5.3. Studies not included in the meta-analysis 4. Discussion . . . . . . . . . . . . . . . . . . . . . Role of funding source . . . . . . . . . . . . . . . . . . . Contributors . . . . . . . . . . . . . . . . . . . . . . . Conflict of interests . . . . . . . . . . . . . . . . . . . . Acknowledgments . . . . . . . . . . . . . . . . . . . . Appendix A. Supplementary data . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . 3.

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1. Introduction It has been estimated that one in four people will have a mental disorder during their lifetime (World Health Organization, 2001). Mood disorders are one of the most common types of mental disorder (Alonso et al., 2004; Kessler, Wai, Demler, & Walters, 2005; King et al., 2008). In terms of their prevalence, it has been calculated that ranges from 6.6% to 11.9% (Baumeister & Härter, 2007), of which about three quarters are depressive disorders, which makes them a leading cause of disability worldwide (Ferrari et al., 2013; Kessler et al., 2003; Marcus, Yasamy, Ommeren, Chisholm, & Saxena, 2012; Moussavi et al., 2007). There is a considerable body of evidence suggesting that the prevalence and impact of depressive disorders in developed countries are associated with certain population characteristics, including socioeconomic status (SES) (Lorant et al., 2007; Missinne & Bracke, 2012; Ruiz-Perez, Ricci-Cabello, Plazaola-Castano, Montero-Pinar, & Escriba-Aguir, 2011; Wang et al., 2005). Socioeconomic inequality in depression is heterogeneous and varies according to the way mental health disorder is measured, to the definition and measurement of SES, and to contextual features such as region and time (Lorant et al., 2003). Previous work has indicated that having a low SES, as ascertained by the use of proxies such as education and income, increases not only the risk of onset of depressive disorders but also their persistence (Lorant et al., 2003). In this sense, inequalities in healthcare provision are at least partially responsible for the observed health disparities. When compared with the general population, those with low-SES are less likely to be diagnosed with depression and to either seek or to receive treatment (Alegria et al., 2008; Cabassa, Zayas, & Hansen, 2006; Chung et al., 2003; Gallo, Marino, Ford, & Anthony, 1995; Grote, Swartz, & Zuckoff, 2008; Pingitore, Snowden, Sansone, & Klinkman, 2001), further contributing to the maintenance or exacerbation of the disorder. However, the evidence regarding the effectiveness of interventions aimed at decreasing inequalities in mental health care is sparse and limited to specific population subgroups, for instance by focusing on women (Levy & O'Hara, 2010) or ethnic minorities (Beach et al., 2006). Levy and O'Hara (2010) studied psychotherapeutic interventions targeted at low income depressed women (USA, Mexico and Chile), offering a series of recommendations for clinical practice, including the need to adapt these interventions to the specific characteristics of the target population. Cabassa and Hansen (2007) conducted a systematic review of depression treatments for Latino adults in the primary care setting, observing that collaborative care models achieved the best results in reducing treatment inequalities, which was reiterated in a subsequent study including a low-SES population (Bao et al., 2011).

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Other studies have also assessed the effectiveness of culturally adapted interventions for ethnic minorities, finding that interventions that were adapted to the targeted group were more likely to be successful (Benish, Quintana, & Wampold, 2011; Griner & Smith, 2006). According to the authors, cultural adaptations to mental health interventions consist of identifying how the client's culture and context might interact with the intervention and then systematically integrating his or her values and worldviews into treatment which can be done by explicitly discussing the client's cultural values and beliefs, or by using the client's preferred language during treatment, among other strategies (Benish et al., 2011). Taken together, the existing literature indicates that low SES populations are more likely to develop and maintain depressive disorders (Lorant et al., 2003), while also being less likely to seek or receive treatment (Alegria et al., 2008). Previous work has also indicated that culturally adapted interventions might bridge the gap and increase the effectiveness of mental health interventions for populations from certain disadvantaged groups, such as ethnic and racial minorities (Benish et al., 2011; Griner & Smith, 2006). However, the evidence for interventions aimed at populations with low SES is scarcer and often entangled with other characteristics such as gender or ethnicity. The aim of this systematic review and meta-analysis was to identify, characterize and analyze the short- and long-term effectiveness of healthcare interventions for depressive disorders specifically targeted to low SES populations. 2. Methods The present study is part of a broader systematic review, which aimed to identify and analyze healthcare interventions to reduce social inequalities in depressive disorders. The review and its procedures were planned, conducted, and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009). 2.1. Information sources and search strategy Specific search strategies were designed for the databases Medline (Ovid), CINAHL, Embase, PsycINFO, Scopus, and Web of Knowledge. The strategy, which combined MeSH terms and keywords (available in Online Appendix 1), was initially designed for Medline and subsequently adapted for the other databases. Additional searches were also conducted using relevant keywords in different databases such as Cochrane Library, CRD Databases, metaRegister of Controlled Trials, EURONHEED, CEA Registry, and European Action Program for Health

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Inequities. Finally, various gray literature sources, as well as reviews in similar topics, were consulted (full details available in Online Appendix 2). All the searches were executed in April 2013 from inception and no language restriction was applied. A bibliographical database was created using Reference Manager Professional Edition V10, and used to store and manage the references. 2.2. Study selection We selected studies assessing the effectiveness of healthcare interventions to treat depressive disorders in socially disadvantaged populations. Specifically, the following criteria were applied.

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assessment, after which a new independent assessment was performed, in order to select the studies to include in this review. Disagreements were solved through discussion with a third reviewer. 2.3. Assessment of risk of bias The studies were assessed using “The Cochrane Collaboration's tool for assessing risk of bias” (Higgins et al., 2011). Different sources of potential bias including randomization, allocation, blinding, incomplete outcome data or selective reporting were classified into three categories (low risk of bias, high risk of bias or unclear risk of bias). Two reviewers independently performed the assessment of the methodological quality, and a third reviewer was consulted for solving any disagreements.

2.2.1. Inclusion criteria 2.4. Data extraction and synthesis of results 2.2.1.1. Participants. The participants were socially disadvantaged patients with depressive disorders. The participants were judged to be socially disadvantaged when at least two thirds of them were characterized as having low-income and/or low-educational levels and/or unemployed. Depressive disorders had to be determined either according to 1) the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 2000) and/or the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (World Health Organization, 1992) criteria for major or minor depression, or as ascertained by screening instruments for depressive disorders for which there is available empirical evidence supporting their psychometric properties in terms of reliability, validity and/or responsiveness (e.g., BDI or HDRS). 2.2.1.2. Setting. Studies taking place in the primary, secondary or tertiary care setting were included. 2.2.1.3. Interventions. The interventions were delivered via the healthcare system and target the patients (and not health professionals or health services organization). 2.2.1.4. Study designs. Controlled trials, including randomized controlled trials (RCT) and quasi-experimental (QE) studies with non-randomized comparison groups were the designs of the study. To be included, control groups had to receive usual care or enhanced usual care. 2.2.1.5. Outcome measures. The studies had to include at least one measure of depressive disorders, which had to be determined either according to the DSM/ICD-10 as ascertained by previously described screening instruments. 2.2.2. Exclusion criteria In order to reduce the heterogeneity among interventions we excluded those studies reporting on interventions that were not delivered in countries that are members of the OECD (Organization for Economic Co-operation and Development, 2013) at the time of the study identification stage (April–May 2013). Membership to the OECD was used as a proxy for the identification of economically developed countries. The rationale for excluding interventions conducted in low- and middleincome countries from the review was based on the fact that both health systems' resources and patients' characteristics and needs are substantially different than in wealthier countries. Therefore the type of interventions implemented and assessed in those countries and their impact on their patients are systematically different. We also excluded conference abstracts and dissertations. Studies were not excluded based on language or publication date. 2.2.3. Assessment of eligibility The titles and abstracts of the documents retrieved by the search were independently screened by two reviewers for ascertaining eligibility. Those fulfilling the inclusion criteria were selected for full text

A data extraction form was developed and used to collect relevant information from each article, including information about the methods and population characteristics, interventions, comparators, outcomes, timing, settings and study design. Results were summarized both qualitatively and quantitatively. The qualitative summary included a description of the features and main outcomes of the interventions. Where data was available, meta-analyses of the effect of the intervention on depressive symptoms were also conducted. If data was insufficient for including in the meta-analysis, the corresponding author of each study was contacted to request further information. Two meta-analyses were planned in order to estimate the effects of the interventions on reducing depressive symptoms both at shortterm (b3 months after the end of the intervention) and at long-term (3 months or more after the end of the intervention). Selection criteria for the meta-analyses included RCTs or QEs comparing the intervention with usual care (or enhanced usual care), reporting depressive symptoms in the control and experimental group before and after the completion of the intervention. According to these criteria, raw mean (±standard deviation, SD) scores of depressive symptoms were extracted and transformed into standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated for all eligible studies in the meta-analysis and combined using random-effects models. Heterogeneity was quantified by the I2 statistic, where I2 ≥ 50% was considered evidence of substantial heterogeneity (Higgins & Green, 2011). Sources of heterogeneity were investigated by a Galbraith chart. Publication bias was quantitatively assessed with Begg and Egger tests. Univariate and multivariate meta-regression analyses were also performed to assess the possible effects of characteristics deemed potentially relevant: sample characteristics (age, ethnicity/race, type of depressive disorder, sex), study characteristics (setting, type of comparison group, measurement tool), intervention characteristics (type of intervention, use of booster session, duration, and intervention delivery), and strategies to culturally tailor the interventions (cultural adaptation of the content, training to providers in delivering the intervention in a culturally appropriate manner, use of peer providers and the provision of extra services to facilitate adherence to the intervention). All analyses were conducted with Stata, version 11.2. Statistical significance was accepted when p b .05. 3. Results 3.1. Identification of articles Search results are summarized in the PRISMA flow diagram (Fig. 1). The initial search identified a total of 4091 citations, 1154 of which were duplicated. Title and abstract of the remaining 2937 citations were screened; as a result 580 citations were selected for further assessment. After examination of full text articles, 15 articles assessing 17 interventions were included, as two articles assessed two active arms each (Gater et al., 2010; Miranda et al., 2003).

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A. Rojas-García et al. / Clinical Psychology Review 38 (2015) 65–78

Fig. 1. PRISMA flowchart of the selection process.

3.2. Study characteristics The characteristics of the included studies are summarized in Table 1. All studies except one (Organista, Muñoz, & González, 1994) were published from 2002 onwards. Eleven studies were carried out in the US (Chong & Moreno, 2012; Ciechanowski et al., 2004; Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002; Dwight-Johnson et al., 2011; Grote et al., 2009; Interian, Lewis-Fernandez, Gara, & Escobar, 2013; Jarjoura et al., 2004; Kim et al., 2011; Miranda et al., 2003; O'Mahen, Himle, Fedock, Henshaw, & Flynn, 2013; Organista et al., 1994), and the remaining four were conducted in Chile (Araya et al., 2003; Rojas et al., 2007), United Kingdom (Gater et al., 2010), and South Korea (Jeong et al., 2013). A total of 2261 participants were included, ranging from 32 (Diamond et al., 2002) to 507 (Kim et al., 2011) participants per study. Nine studies also targeted participants from ethnic minority backgrounds (Chong & Moreno, 2012; Diamond et al., 2002; Dwight-Johnson et al., 2011; Gater et al., 2010; Grote et al., 2009; Interian et al., 2013; Miranda et al., 2003; O'Mahen et al., 2013; Organista et al., 1994), mainly Hispanic, Latino-American, and African-American populations. Most studies exclusively included participants diagnosed with MDD (Araya et al., 2003; Chong & Moreno, 2012; Diamond et al., 2002; Dwight-Johnson et al., 2011; Gater et al., 2010; Jarjoura et al., 2004; Kim et al., 2011; Miranda et al., 2003; O'Mahen et al., 2013; Organista et al., 1994; Rojas et al., 2007) although some of the studies also included participants with dysthymia or minor depression (Ciechanowski et al., 2004; Grote et al., 2009; Interian et al., 2013; Jeong et al., 2013). Depressive symptoms were the main outcome of the studies, being measured with different scales such as the Beck Depression Inventory (BDI), the Edinburgh Postnatal Depression Scale (EPSD), the Patient Health Questionnaire (PHQ-9), the Hopkins Symptom Checklist (SCL),

and the Hamilton Depression Rating Scale (HDRS). Some studies also included secondary outcomes such as those measured by the Short Form 36 Health Survey (SF-36) (Araya et al., 2003; Miranda et al., 2003; Rojas et al., 2007). All the studies were RCTs with the exception of a QE (Organista et al., 1994). Eleven studies compared the intervention with a usual care group (Araya et al., 2003; Chong & Moreno, 2012; Ciechanowski et al., 2004; Diamond et al., 2002; Interian et al., 2013; Jarjoura et al., 2004; Jeong et al., 2013; Kim et al., 2011; Miranda et al., 2003; Organista et al., 1994; Rojas et al., 2007) and four with an enhanced usual care group (Dwight-Johnson et al., 2011; Gater et al., 2010; Grote et al., 2009; O'Mahen et al., 2013). 3.3. Assessment of risk of bias Risk of bias is presented in Fig. 2. There was high or unclear risk of bias for blinding, allocation concealment and other biases, namely sources of bias as differences at baseline between intervention and comparison group, or potential risk of bias associated with study design. Two studies were found to be at a higher risk of bias (Diamond et al., 2002; Organista et al., 1994). 3.4. Intervention characteristics The features of the interventions are summarized in Table 2. Interventions were mainly based on psychotherapeutic strategies (Ciechanowski et al., 2004; Diamond et al., 2002; Dwight-Johnson et al., 2011; Gater et al., 2010; Grote et al., 2009; Miranda et al., 2003; O'Mahen et al., 2013; Organista et al., 1994), combined interventions (Araya et al., 2003; Gater et al., 2010; Rojas et al., 2007), and collaborative care management (Jarjoura et al., 2004; Jeong et al., 2013; Kim et al., 2011). The

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Table 1 Features of the studies and interventions.

Features of the studies Year of the study publication 1994 2002 2003 2004 2007 2009 2010 2011 2012 2013 Epidemiologic design Randomized controlled trial Quasi-experimental study Number of participants Comparison group Usual care Enhanced usual care Country in which the intervention was conducted US Chile South Korea UK Features and effectiveness of the interventions Setting Primary care Hospital/clinic Community health center Home Duration (weeks) Female vs. Male/female Female Male/female Target population Low-income Low-income ethnic minorities Type of psychotherapy Psychotherapy Combined Care management Counseling Types of cultural adaptations Cultural content No Yes Peer provider No Yes Training No Yes Extra services No Yes a b

N

%

15

100

1 1 2 2 1 1 1 2 1 3

6.67 6.67 13.33 13.33 6.67 6.67 6.67 13.33 6.67 20.00

14 1 2261

93.33 6.67 32–507a

12 3

80.00 20.00

11 2 1 1 17

73.33 13.33 6.67 6.67 100

8 7 1 1 14.69 (11.96)b

47.06 41.18 5.88 5.88 5–50a

8 9

47.06 52.94

6 11

35.29 64.71

8 4 2 2 11

47.06 23.53 11.76 11.76 100

0 11

0 100

4 7

36.36 63.64

2 9

18.18 81.82

7 4

63.64 36.36

Range (minimum–maximum). Mean and standard deviation.

mean duration of the interventions was 14.69 weeks (SD = 11.96), ranging from five (Interian et al., 2013) to 50 weeks (Kim et al., 2011). Eight interventions were individually delivered (Chong & Moreno, 2012; Ciechanowski et al., 2004; Dwight-Johnson et al., 2011; Grote et al., 2009; Interian et al., 2013; Jeong et al., 2013; Kim et al., 2011; O'Mahen et al., 2013), five were group delivered (Araya et al., 2003; Gater et al., 2010; Organista et al., 1994; Rojas et al., 2007), three combined either individual or group delivered interventions (Diamond et al., 2002; Miranda et al., 2003), and one did not report delivery format (Jarjoura et al., 2004). As for the setting, eight interventions were carried out in primary care settings (Araya et al., 2003; Chong & Moreno, 2012; Dwight-Johnson et al., 2011; Gater et al., 2010; Jarjoura et al., 2004; Kim et al., 2011; Rojas et al., 2007), seven in hospitals or specialized clinics (Diamond et al., 2002; Grote et al., 2009; Jeong et al., 2013; Miranda et al., 2003;

Fig. 2. Assessment of risk of bias.

O'Mahen et al., 2013; Organista et al., 1994), one at the participant's home (Ciechanowski et al., 2004), and one in a community health center (Interian et al., 2013). 3.4.1. Components of the interventions There was a considerable number of shared components across interventions, such as cognitive-behavioral (Araya et al., 2003; Ciechanowski et al., 2004; Dwight-Johnson et al., 2011; Jarjoura et al., 2004; Jeong et al., 2013; Miranda et al., 2003; O'Mahen et al., 2013; Rojas et al., 2007), interpersonal (Grote et al., 2009; O'Mahen et al., 2013) or psycho-educational modules (Araya et al., 2003; Gater et al., 2010; Kim et al., 2011; O'Mahen et al., 2013; Rojas et al., 2007), engagement sessions (Ciechanowski et al., 2004; Gater et al., 2010; Grote et al., 2009; Kim et al., 2011; Miranda et al., 2003; O'Mahen et al., 2013), or medication (Araya et al., 2003; Chong & Moreno, 2012; Interian et al., 2013; Jarjoura et al., 2004; Jeong et al., 2013; Miranda et al., 2003; Rojas et al., 2007). Moreover, four interventions used “booster” or reinforcement sessions once the intervention was finalized (Araya et al., 2003; Ciechanowski et al., 2004; Grote et al., 2009; Interian et al., 2013). 3.4.2. Cultural adaptations Furthermore, 11 interventions were culturally adapted to the target population (Araya et al., 2003; Chong & Moreno, 2012; Dwight-Johnson et al., 2011; Gater et al., 2010; Grote et al., 2009; Interian et al., 2013;

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Table 2 Characteristics of the studies. Authors/country

Araya et al. (2003) Chile

Chong and Moreno. (2012) USA

Diamond et al. (2002) USA

Dwight-Johnson et al. (2011) USA

Gater et al. (2010) UK

Target population

Intervention

Effectiveness on depressive outcomes (intervention vs. comparison group)

Components of study arms

Design/N/follow-up Inclusion criteria

Study population

Setting

Cultural adaptation

The stepped-care improvement program (combined) was a multicomponent program consisting of a structured psycho-educational group, systematic monitoring of clinical progress, and a structured pharmacotherapy program for patients with severe or persistent depression. Usual care. All services normally available in the primary-care clinic, including antidepressant medication or referral for specialty treatment. Problem-solving treatment (psychotherapy) is a skills enhancing behavioral depression treatment based on the assumption that problems of daily life cause and maintain depressive symptoms, and through systematically identifying and addressing these problems, patients can achieve decreased depressive symptoms. Usual care. No additional services, but letters sent to their regular physicians and social workers reported their depression diagnosis with recommendations to continue usual care. Telepsychiatry (counseling). The psychiatrist used the Macromedia Breeze Manager Web application to create a virtual meeting room. The psychiatrist and the patient sat in front of their respective computers and webcams to talk. If the psychiatrist needed to communicate with the project recruiter during or at the end of the session, the psychiatrist would communicate through the telephone. Usual care included having one of several in-house mental health specialists to whom the providers could refer patients if needed Attachment-based family therapy (psychotherapy). Repairing attachment and promoting autonomy are the overarching goals, achieved through five specific treatment tasks. Waiting list (usual care). These participants received weekly 15-minute telephone calls restricted to monitoring for potential clinical deterioration with a BDI.

RCT/240/3 and 6 months

Female primary-care patients aged 18–70 years with current major depressive illness.

Low-income women with MDD

Primary care

7 weeks/group/social Writing of manual and asking people to read and workers and nurses comment. Manual used and adapted information from other manuals

HDRS SF-36 GHQ-12

Difference in mean scores (HDRS) −8.89, p b 0.000 (3 months). OR = 5.52 95% CI [3.06, 9.95] (6 months)

RCT/167/3 and 6 months

Adults aged 60 years or older receiving services from senior service agencies or living in senior public housing with DSM-IV minor depression or dysthymia diagnostic criteria.

Low-income older adults (N60) with minor depression or dysthymia

Home

Not reported

19 weeks/individual/ therapists and social workers

HSCL-20 PHQ-9 HRQoL

Difference in mean scores (HSCL-20) −0.41 95% CI [−0.70, −0.29] p b 0.001 (6 months) −0.19 95% CI [−0.40, −0.02] p = 0.03 (12 months)

RCT/167/3 and 6 months

Adults of Hispanic ethnicity, willing to be randomly assigned, to participate in the program for 6 months, and to be followed up, and have a diagnosis of major depression disorder based on the MINI.

Low-income Hispanics with MDD.

Primary care

Language and cultural concerns. Organizational readiness, an important concept for adopting a new practice. Appreciating the importance of mental health treatment. Cost.

6 months (one session per month for 6 months)/ individual/ psychiatrists

PHQ-9 MINI ARSMA II SDS VSQ-9

Not significant

RCT/32/3 and 6 months

Patients included in the study had a DSM-III-R primary diagnosis of major depressive disorder, were between the ages of 13 and 17 years, and had a primary caretaker willing to participate in treatment. Adult primary care patients were eligible for the study if they self-identified as Latino; spoke English or Spanish; screened positive for probable MDD.

Low-income African-American adolescents

Hospital

Not reported

12 weeks/combined/ therapists

HDRS BDI STAIC ABFT BHS SRFF YSR

ES = 1.21, p = 0.005 (HDRS) (3 months) Not significant (6 months)

Low-income Latino living in rural areas

Primary care

Modified content, trained therapists and language adaptation.

8 weeks/individual/ therapists

PHQ-9 HSCL

Not significant (3 months) p = 0.003 (PHQ-9) (6 months)

British Pakistani women aged between 16 and 65

Low-income British Pakistani

Primary care

To ensure cultural sensitivity, participants

10 weeks/group/ psychiatrists,

HDRS SF-36

Not significant. (in any comparison)

CBT-telephone based (psychotherapy). Eight telephone sessions; each session focused on a chapter from a patient workbook that had been translated into the Spanish language for this study. Usual care. Providers were free to provide any usually available care for depression, including antidepressants or referral to outside services. Care was considered enhanced because patients were encouraged to talk with their primary care provider about depression treatment Social intervention (psychotherapy). The culturally sensitive social intervention was

RCT/101/6 weeks 3 and 6 months

RCT/123/3 and 9 months

Duration/intervention Measures Depressive outcomes delivery/providers

A. Rojas-García et al. / Clinical Psychology Review 38 (2015) 65–78

Ciechanowski et al. (2004) USA

Study design

Grote et al. (2009) USA

Jarjoura et al. (2004) USA

Jeong et al. (2013) South Korea

Kim et al. (2011) USA

AHRQ (Agency for Healthcare Research and Quality) guidelines (care management). a) Education about depression and antidepressant treatment; b) encourage behavioral therapy through an appointment to the local public mental health agency; c) reschedule an appointment in 4 weeks; f) ensure that the screening nurse sees the patient as well as provide the nurse with pertinent information. Usual care. Usual care patients were told by the screening nurse that they may have a problem with depression and that treatment is effective for depression. The patients then had the opportunity to discuss their depression symptoms with their resident at the visit. (Care management). The care manager worked with each patient in the intervention group particularly intensively at the initial session, providing additional information on the causes of depression and treatment options, the importance of taking antidepressants, and the potential adverse effects of antidepressants. Usual care. Telephone care management (care management). The intent of the care management program was to engage participants with moderate or greater symptoms of depression in both in-person psychotherapy and antidepressant pharmacotherapy. Usual care. Control group members were sent a letter informing them that they might be experiencing depression, recommending that they see a healthcare provider concerning their depression, and providing a toll-free telephone

years attending the practices and diagnostic assessment for MDD

women

RCT/53/3 and 6 months

Women aged 18 years or older, ten to 32 weeks gestation, cut-off score N12 on EPDS.

Low-income predominantly ethnic minority women

RCT/50/5 weeks and 6 months

Major depressive disorder within the last month or current dysthymia, self-identification as Latino; treatment plan that included antidepressants; and aged between 18 and 65 Clinic patients over 18 years of age were consecutively eligible for the study if they were currently enrolled in Medicaid or were without private health insurance and had low income.

RCT/66/6 and 12 months

were collected by taxi accompanied by a female transport facilitator. The groups took place in a culturally acceptable venue with provision of childcare facilities.

psychologists, and British Pakistani mental health workers

VSSS

Urban obstetrics and gynecology clinic

Ethnographic interview, culturally sensitive/experienced providers, culturally-relevant content/illustrations.

8 weeks/individual/ therapists

BDI EPDS BAI

ES = 0.33 (BDI) ES = 0.71 (EPDS) (3 months) ES = 0.47 (BDI) ES = 0.89 (EPDS) (6 months)

Low-income Latino

Community health center

An iterative cultural adaptation framework was used to understand Latino antidepressant adherence issues and reasons for non-adherence.

5 weeks/individual/ therapists

BDI

Not significant (5 weeks) Fishers Exact Test, p = 0.042 (5 months)

Low-income patients

Primary care

Not reported

Not reported/not reported/nurses and physicians

BDI-II SF-36

ES = 0.41 (over the 6- and 12-month follow-ups)

Low-income patients

Psychiatric clinic

Not reported

6 months/individual/ psychologists (care manager)

HDRS BHS GDS

Compared means p = 0.044 (GDS) (6 months)

Primary care

Not reported

12 months/individual/ care managers

QIDS-SR

Not significant

RCT/57/6 months

An age 60 years or older and a diagnosis of current depressive disorder according to the DSM. The subjects were all diagnosed for depression in the study process.

RCT/507/6 and 18 months

(1) were 18 to 64 years Low-income of age; (2) screened patients positive for depression according to the QIDS-SR; (3) had selected a particular managed care organization as their Medicaid behavioral healthcare provider; (4) were not currently in treatment and had not

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(continued on next page)

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Interian et al. (2013) USA

designed to address social difficulties, isolation and poor access to primary care. Antidepressant (usual care). Participants were specifically invited and offered treatment by their GP, who was trained in the treatment protocol and monitoring following National Institute for Health and Clinical Excellence. Social intervention plus antidepressants Interpersonal Therapy-Brief (Psychotherapy). 1) Engagement session. 2) IPT-Brief focused on: role transition, role dispute, grief and interpersonal deficits. 3) Maintenance IPT sessions. Enhanced usual care. Participants assigned to enhanced usual care were informed of their diagnoses, given written educational materials about depression, and were strongly encouraged to seek treatment at the behavioral health center. Motivational interview (counseling). Overall, it empathized with participants' concerns about antidepressant treatment, while also drawing out their motivation to overcome depressive symptoms. Usual care. Participants in this condition received usual care provided at the bilingual division of the Community Health Center.

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Table 2 (continued) Authors/country

Study design

Components of study arms

Target population

Design/N/follow-up Inclusion criteria

number to call for more information about appropriate Medicaid-covered care.

RCT/267/3 and 6 months

CBT (psychotherapy). The psychotherapy intervention consisted of 8 weekly sessions, either in group or individually, depending on feasibility of women attending group. Community services (usual care). Women assigned to community referral as usual were educated about depression and mental health treatments available in the community. Medication: Women were treated with paroxetine.

O'Mahen et al. (2013) USA

Modified CBT (psychotherapy).1) An initial RCT/55/3 months perinatal specific assessment; 2) CBT conceptualization tailored to the woman's individual treatment goals; 3) psychoeducation about perinatal depression and psychotherapy; and 4) engagement strategies to identify and alleviate potential psychological and practical barriers. Enhanced usual care. They continued to receive midwife/obstetrical care as normal CBT (psychotherapy). Group treatment QE/175/4 months consisted of three four-session cognitive-behavioral modules. Usual care (Dropouts). Clinic contacts on the part of patients who underutilized mental health services RCT/230/6 months Multifaceted intervention (combined). Psycho-educational group, medication as needed, systematic monitoring, better training for providers or usual care (need to take own initiative to access services) Usual care. All services normally available in the primary-care clinic, including antidepressant medication or referral for specialty treatment.

Organista et al. (1994) USA

Rojas et al. (2007) Chile

Effectiveness on depressive outcomes (intervention vs. comparison group)

Study population

Setting

Cultural adaptation

Duration/intervention Measures Depressive outcomes delivery/providers

Low-income young minority women

Clinic

8 weeks/combined/ nurse (medication), therapists (CBT)

HDRS SF-36

Pregnant women aged 18 or older, 24 or more weeks pregnant and diagnostic assessment for MDD.

Ethnic minority low-income pregnant women

Obstetrics clinic (prenatal care)

16 weeks/individual/ social workers and psychologists

BDI-II EPDS BADS

Low-income and minority, depressed medical outpatients

Low-income minorities

Hospital

Bilingual providers treated all Spanish speaking women. All written materials, including psychotherapy manuals, were available in Spanish. All providers had extensive experience with and commitment to treating low-income and minority patients Modified CBT for delivery to a racially diverse, primarily low income sample of clinically depressed perinatal women, specifically for treatment barriers that span psychological, practical, and logistical arenas. Not reported

16 weeks/group/ therapists

BDI

Not reported

EPDS scored ≥10. Mothers meeting criteria for major depression according to the diagnostic and statistical manual of mental disorders (DSM-IV) were eligible

Low-income mothers

Primary care clinics

8 weeks/group/ physicians, nurses and mental health workers.

EPDS SF-36

Adjusted difference −4.5, p b 0.0001 (3 months) Not significant (6 months)

participated in in-person treatment 3 or more times in the past year; and (5) had not been diagnosed with other mental disorders. Low-income young women who meet the criteria for MDD

Writing of manual and asking people to read and comment. Manual used and adapted information from other manuals

CBT vs. Usual care. Not significant (3 months) t = 2.60, p = 0.01 (6 months) Medication vs. Usual care. t = 3.39, p b 0.001 (3 months) t = 4.75, p b 0.001 (6 months) Repeat measures F (1, 32) = 6.27, p = 0 .02 (BDI) 16 weeks (post randomization) to 3 months

Note: ABFT: attachment-based family therapy; ARSMA II: Acculturation Rating Scale for Mexican Americans-II; BAI: Beck Anxiety Inventory; BDI: Beck Depression Inventory; BHS: Beck Hopelessness Scale; CBT: cognitive-behavioral therapy; EPDS: Edinburgh Postnatal Depression Scale; ES: effect size; GDS: Geriatric Depression Scale; GHQ-12: General Health Questionnaire-12; HDRS: Hamilton Rating Scale for Depression; HRQoL: health-related quality of life; HSCL: Hopkins Symptoms Checklist; MDD: major depressive disorder; MINI: Mini International Neuropsychiatric Interview; PHQ-9: Patient-Health Questionnaire-9; QE: Quasi-experimental; QIDS-SR: Quick Inventory of Depressive Symptomatology — Self-report; RCT: randomized controlled trial; SDS: Sheehan's Disability Scale; SF-36: Short Form (36) Health Survey; SRFF: The Self-Report of Family Functioning; STAIC: State-Trait Anxiety Inventory for Children; VSSS: Verona Service Satisfaction Scale; VSQ-9: Visit-Specific Satisfaction Instrument; YSR: youth self-report.

A. Rojas-García et al. / Clinical Psychology Review 38 (2015) 65–78

Miranda et al. (2003) USA

Intervention

A. Rojas-García et al. / Clinical Psychology Review 38 (2015) 65–78

Miranda et al., 2003; O'Mahen et al., 2013; Rojas et al., 2007). These adaptations consisted in modifying the content of the interventions, adapting the language, and facilitating access to the intervention. In this respect, the providers/therapists were ethnically matched to the target population (Chong & Moreno, 2012; Dwight-Johnson et al., 2011; Gater et al., 2010; Miranda et al., 2003) or received cultural specific training (Araya et al., 2003; Dwight-Johnson et al., 2011; Gater et al., 2010; Grote et al., 2009; Miranda et al., 2003; O'Mahen et al., 2013; Rojas et al., 2007). Language was also adapted when required (Chong & Moreno, 2012; Dwight-Johnson et al., 2011; Gater et al., 2010; Interian et al., 2013; Miranda et al., 2003) or extra services as transportation facilities or childcare were provided in order to facilitate the intervention (Araya et al., 2003; Gater et al., 2010; Grote et al., 2009; Miranda et al., 2003). 3.5. Effectiveness of the interventions 3.5.1. Short-term effectiveness Initially 11 studies (Araya et al., 2003; Chong & Moreno, 2012; Ciechanowski et al., 2004; Diamond et al., 2002; Gater et al., 2010; Grote et al., 2009; Interian et al., 2013; Miranda et al., 2003; O'Mahen et al., 2013; Organista et al., 1994; Rojas et al., 2007) involving 13 interventions provided the necessary information to be included in the meta-analysis for short-term outcomes. However, two studies (Diamond et al., 2002; Organista et al., 1994) were excluded due to their high risk of bias. Thus nine studies reporting 11 interventions were included. A first meta-analysis was conducted to test whether there were differences between intervention and comparison groups at baseline level, showing statistical significance (SMD = 0.13, 95% CI [0.03, 0.24]) in favor of control groups. A second meta-analysis stratified by type of intervention was carried out to test the differences between

73

intervention and comparison groups at post-intervention. The heterogeneity among studies was moderate (I2 = 45.0%). By using the Galbraith chart we observed that no study strongly contributed to increase the heterogeneity. Hence, nine studies were included, reporting on 1223 participants (599 in the intervention and 624 in the comparison group). As ascertained by a random-effects model (Fig. 3), the combined effect of the intervention produced a significant reduction in the overall depressive symptoms of − 0.58 (95% CI [− 0.74, − 0.42]). There was no evidence of publication bias (p = 0.64 using Egger's test; p = 0.76 using Begg's test). Subgroup analysis revealed that psychotherapeutic and combined interventions produced the largest reductions (effect size = −0.66 and −0.68, respectively). Univariate and multivariate meta-regressions were performed to test which characteristics were associated with an increased likelihood of short-term effectiveness (Table 3). One characteristic seemed to be specifically related to the effect of the interventions, the type of target population, indicating that interventions that addressed ethnic minorities with low-SES were significantly less effective. The exception was the presence of training to providers: although no statistically significant differences were reached (p = 0.053), interventions including training to providers produced a more than two-fold higher impact than those that did not include it (SMD = −0.63 vs −0.25). Multivariate meta-regressions did not show any statistical significance. 3.5.2. Long-term effectiveness Ten studies (Araya et al., 2003; Chong & Moreno, 2012; Ciechanowski et al., 2004; Gater et al., 2010; Grote et al., 2009; Interian et al., 2013; Jeong et al., 2013; Kim et al., 2011; Miranda et al., 2003; Rojas et al., 2007) reporting data from 12 interventions provided the necessary information to be included in the meta-analysis for long-term outcomes. There were no baseline differences (SMD = 0.07, 95% CI [− 0.03,

Fig. 3. Forest plot intervention vs. comparison group at short-term.

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Table 3 Effect modifier variables at short-term.

All interventions Study characteristics Comparison Group Usual care Enhanced usual care Measures HRSD BDI PHQ-9 EPDS HSCL-20 Participants' characteristics Female vs. Male/female Male/female Female Type of depressive disorder Major depressive disorder Depressive disorders Type of disadvantaged population Low-income population Low-income ethnic minorities Mean age (change in SMD for each year of age) Intervention characteristics Setting Primary Care Hospital/Clinic Home Community health center Duration (change in SMD for an increase of one week of intervention) Type of intervention Psychotherapy Counseling Medication Multifaceted Intervention delivery Group Individual Combined CBT No Yes IPT No Yes Psycho-education No Yes Social Support No Yes Engagement session No Yes Medication No Yes Cultural adaptations Cultural content No Yes Peer provider No Yes Training No Yes Extra services No Yes

k

SMD

95% CI

Residual I2

11

−0.58⁎⁎⁎

−0.74, −0.41

45.00%

−0.57⁎⁎⁎ −0.62⁎⁎⁎

−0.76, −0.37 −0.95, −0.30

−0.56⁎⁎⁎ −0.68⁎⁎ −0.25 −0.62⁎ −0.81⁎⁎

−0.82, −0.30 −1.10, −0.25 −0.80, 0.31 −1.14, −0.10 −1.37, −0.25

−0.47⁎⁎ −0.63⁎⁎⁎

−0.78, −0.15 −0.82, −0.43

−0.53⁎⁎⁎ −0.75⁎⁎⁎

−0.72, −0.35 −1.10, −0.41

−0.78⁎⁎⁎ −0.46⁎⁎⁎ −0.00

−0.98, −0.58 −0.62, −0.29 −0.01, 0.01

−0.55⁎⁎⁎ −0.61⁎⁎⁎ −0.81⁎⁎ −0.25 −0.01

−0.80, −0.31 −0.93, −0.31 −1.35, −0.27 −0.96, 0.45 −0.01, 0.03

−0.66⁎⁎⁎ −0.25 −0.50⁎⁎⁎ −0.69⁎⁎⁎

−0.90, −0.42 −0.62, 0.12 −0.96, −0.04 −0.94, −0.43

−0.64⁎⁎⁎ −0.56⁎⁎⁎ −0.40

−0.91, −0.36 −0.82, −0.32 −0.94, 0.13

−0.46⁎⁎⁎ −0.69⁎⁎⁎

−0.68, −0.25 −0.89, −0.49

−0.55⁎⁎⁎ −0.91⁎⁎⁎

−0.71, −0.38 −1.39, −0.42

−0.54⁎⁎⁎ −0.64⁎⁎⁎

−0.76, −0.31 −0.88, −0.39

−0.61⁎⁎⁎ −0.54⁎⁎⁎

−0.83, −0.39 −0.80, −0.29

−0.56⁎⁎⁎ −0.59⁎⁎⁎

−0.83, −0.29 −0.82, −0.37

−0.61⁎⁎⁎ −0.57⁎⁎⁎

−0.93, −0.30 −0.77, −0.37

−0.81⁎⁎⁎ −0.56⁎⁎⁎

−1.31, −0.31 −0.73, −0.38

−0.67⁎⁎⁎ −0.56⁎⁎⁎

−0.92, −0.43 −0.73, −0.38

−0.25 −0.63⁎⁎⁎

−0.60, 0.09 −0.79, −0.46

−0.44⁎⁎ −0.63⁎⁎⁎

−0.72, −0.16 −0.85, −0.41

11 7 4 11 5 3 1 1 1 11 3 8 11 8 3 11 3 8 11 11 5 4 1 1 11 11 5 2 1 3 11 4 6 1 11 6 5 11 9 2 11 6 5 11 6 5 11 4 7 11 4 7 11 1 10 10 4 6 10 2 8 10 6 4

p-Value

50.46% Ref. .766 52.09% Ref. .641 .320 .841 .424 46.57% Ref. .400 44.75% Ref. .267 13.90% Ref. .013 48.23% 54.12% Ref. .755 .398 .430 44.34% 34.95% Ref. .069 .551 .877 50.08% Ref. .746 .452 33.65% Ref. .121 43.37% Ref. .166 45.57% Ref. .544 49.55% Ref. .688 50.43% Ref. .833 50.38% Ref. .830 45.58% Ref. .345 36.20% Ref. .228 27.27% Ref. .053 44.70% Ref. .345

Note: k = number of interventions; SMD = standardized mean difference; 95% CI = 95% confidence interval; Ref = reference category. BDI: Beck Depression Inventory; BHS: Beck Hopelessness Scale; CBT: cognitive-behavioral therapy; EPDS: Edinburgh Postnatal Depression Scale; ES: effect size; HDRS: Hamilton Rating Scale for Depression; HSCL: Hopkins Symptoms Checklist; I2 = variation in standardized mean difference attributable to heterogeneity; PHQ-9: Patient-Health Questionnaire-9. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

A. Rojas-García et al. / Clinical Psychology Review 38 (2015) 65–78

0.17]). A second meta-analysis was carried out to test the differences between intervention and comparison groups at follow-up of three months or more. The heterogeneity among studies was high (I2 = 74.8%), explaining a substantial part of the variability. Using the Galbraith chart, it was possible to identify that two studies (Araya et al., 2003; Grote et al., 2009) substantially contributed to increase the heterogeneity. However, those studies did not report evidence of high risk of bias and were thus included in the analysis. Therefore, 12 interventions were included, reporting on 1595 participants (804 in the intervention and 791 in the comparison group). As ascertained by a random-effects model, the combined effect of the intervention produced a significant reduction in the overall depressive symptoms of −0.42 (95% CI [−0.63, − 0.21]) (Fig. 4). However, only counseling and medication interventions showed a significant reduction of depressive symptoms of −0.41 (95% CI [−0.70, −0.12]) and −0.39 (95% CI [−0.74, −0.04]), respectively. There was no evidence of publication bias (p = 0.31 using Egger's test; p = 0.15 using Begg's test). Due to the high heterogeneity univariate meta-regressions were not carried out. Nevertheless, in order to check possible causes related to the high heterogeneity, it was planned to conduct a multivariate meta-regression including booster session and type of intervention. Results indicated a lower heterogeneity (residual I2 = 67.58%); however, only the presence of the booster session showed to be statistically significant (p b 0.014). 3.5.3. Studies not included in the meta-analysis Four studies presenting four interventions were excluded from metaanalysis for several reasons: unavailability of the data (Dwight-Johnson et al., 2011; Jarjoura et al., 2004), or high risk of bias (Diamond et al., 2002; Organista et al., 1994). Dwight-Johnson et al. (2011) tested a telephone-based culturally adapted CBT in rural low-income Latinos which showed great improvements in depressive symptoms in relation

75

to an enhanced usual care group, immediately after the end of intervention and at month six follow-up, but not at month three. Jarjoura et al. (2004) carried out an intervention which follows the Agency for Health Care Policy and Research (AHCPR) guidelines, showing improvements in depressive symptoms but not in quality of life and costs. Finally, Organista et al. (1994) only indicated differences between pre- and post-treatment and Diamond et al. (2002) found reductions of depressive symptoms in low-income African-American adolescents at 3 months but not at 6 months. 4. Discussion This systematic review identified 17 healthcare interventions aiming at ameliorating depressive disorders and reducing clinically significant depression symptoms in patients with low SES. The interventions were based on different approaches, namely psychotherapy and collaborative care, and most of them were culturally adapted to the target population. Our meta-analyses suggested that interventions reduced depressive symptoms both at short and long term. In addition we observed that the most effective interventions were those that included culturally specific training for providers/therapist and booster sessions. Previous systematic reviews have already assessed the effectiveness of interventions to treat or prevent depressive disorders. Nevertheless, they have addressed interventions targeted to the general population (Huntley, Araya, & Salisbury, 2012; Leis, Mendelson, Tandon, & Perry, 2009; Linde et al., 2015), or focused on specific types of depression (Sockol, Epperson, & Barber, 2011), or interventions (Chowdhary et al., 2013) or on specific disadvantaged populations (Levy & O'Hara, 2010; van der Waerden, Hoefnagels, & Hosman, 2011). In that sense, to the best of our knowledge, this is the first systematic review specifically focused on healthcare-led interventions to treat depressive disorders in socially disadvantaged populations, which constitutes one of

Fig. 4. Forest plot intervention vs. comparison group at long-term.

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the main strengths of this work. An additional strength is the exhaustive nature of the literature search. Six of the most relevant bibliographic databases for biomedical research were searched, using different search strategies tailored to each one, and keyword searches were performed in additional databases and biomedical literature portals. Specific gray literature portals were also consulted, and search was complemented by consulting other systematic reviews and original studies. In terms of limitations, we identified different types of treatments and pooled them together in our meta-analyses in order to estimate the overall effect of healthcare interventions specifically targeted to reduce depressive symptoms in patients with low SES. However, given the heterogeneity of interventions identified, the size of the overall effect obtained should to be carefully interpreted. Another possible limitation concerns publication bias, which could have overestimated the effectiveness of the interventions, although both Egger and Begg tests indicated that it was not present. The use of different questionnaires to test depressive symptoms might also have constrained the meta-analyses. However, most of the studies employed the BDI or HDRS to ascertain depressive symptoms. Finally, it might have been that the interventions were also impacting other outcomes such as quality of life. However, this data has not been consistently reported and was thus not included in the review. Our meta-analyses suggested that healthcare-led interventions produced a positive impact in reducing depressive disorders, with overall effect sizes of 0.58 and 0.42 for short and long term effect respectively. These effect sizes were statistically significant, and their magnitude can be interpreted as medium (Cohen, 1988). Our results are generally consistent with previous meta-analysis on interventions in depressed populations. Huntley et al. (2012) observed that group-based psychological therapies for depression in the primary care setting produced a reduction of 0.55. Effect size in the meta-analysis by van der Waerden et al. (2011) (focused on preventive interventions in low-SES women) was 0.31, whereas in the study by Sockol et al. (2011) (focused on perinatal depression) was 0.61. A recently meta-analysis comparing different types of psychological interventions delivered in primary care observed that effect sizes ranged from −0.14 to −0.56 (Linde et al., 2015). More than half of the interventions identified in our review were also addressed to participants from ethnic minority backgrounds. However, the results of our short-term meta-regression showed that interventions targeted to low-SES ethnic minorities were less effective than those addressed to low-SES populations who were not from ethnic minorities, which may suggest the need to further improve culturally adapted interventions to ethnic minorities. It could also be that the different levels of cultural adaptation employed by the studies included in this review, which range from language to using a culturally relevant framework for the intervention, have diluted its impact. Regarding the strategies to culturally adapt the interventions, it seems that culturally specific training for providers/therapists improves the effectiveness of the interventions, which might highlight the importance of providers' knowledge about patient's culture in order to enhance the results of the treatments. Additionally, specific cultural adaptation for a specific group is more effective than for a generic group, as indicated by Griner and Smith (2006), who found that interventions adapted for participants from the same race were four times more effective than interventions provided to participants of the mixed races. While the multiple components of complex interventions might create obstacles to specifically pinpointing which components are associated with an increased likelihood of success, previous work has indicated that it is always beneficial to culturally adapt mental health interventions and to take the participants' needs and unique challenges into account (Van Voorhees, Walters, Prochaska, & Quinn, 2007). In regard to therapeutic components of the interventions, several studies have supported the effectiveness of CBT, IPT, Problem Solving Therapy or Collaborative Care Management as effective treatments for depressive disorders (Bao et al., 2011; Cuijpers, Van Straten, Andersson,

& van Oppen, 2008; Driessen & Hollon, 2010; Hoifodt, Strom, Kolstrup, Eisemann, & Waterloo, 2011; Linde et al., 2015). In the present review, those interventions with higher short-term effectiveness were psychotherapies and combined interventions. Nevertheless, it is important to bear in mind that there was an overlap across interventions, including psychotherapeutic components or medication. Caution is thus required when trying to determine the effectiveness of different types of treatments (Cuijpers et al., 2008). Future interventions should focus on the combination of therapeutic/cultural components in order to enhance their implementation and effectiveness in healthcare settings. Therefore, further investigation is needed to clarify which factors are related to the improvement of the interventions, especially at long-term, even though the results suggest that low SES depressed population could benefit from culturally adapted interventions. In conclusion, this systematic review provides evidence about the effectiveness of healthcare-led interventions to intervene in depressive disorders and clinically significant depressive symptoms in low-SES populations, identifying also a number of features such as including multiple components, booster sessions or training to providers that, if included, could enhance their beneficial effects. Evidence generated here supports the use of these interventions to tackle the large and unfair social inequalities in mental health. Role of funding source Funding for this study was provided by the National Institute of Health Carlos III (Study PS09/00747). The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Contributors ARG and IRP designed the study. ARG and GP selected the articles and extracted relevant data. ARG and MRB conducted the statistical analysis. ARG, IRC, and DCG drafted the article. All authors provided input during the preparation of the manuscript, and approved the final version. Conflict of interests The authors declare that they have no conflict of interests. Acknowledgments The authors thank Victor Sarmiento (Andalusian Agency for Health Technology Assessment, Andalusia, Spain) for designing the bibliographic searches. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.cpr.2015.03.001. References Alegria, M., Chatterji, P., Wells, K., Cao, Z., Chen, C. N., Takeuchi, D., et al. (2008). Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatric Services, 59(11), 1264–1272. http://dx.doi.org/10.1176/appi.ps.59. 11.1264. Alonso, J., Angermeyer, M. C., Bernert, S., Bruffaerts, R., Brugha, T. S., Bryson, H., et al. (2004). Use of mental health services in Europe: Results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica, 109(Suppl. 420), 47–54. http://dx.doi.org/10.1111/j.1600-0047.2004. 00330.x. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed. text revision ed.). Washington, DC: Author. Araya, R., Rojas, G., Fritsch, R., Gaete, J., Rojas, M., Simon, G., et al. (2003). Treating depression in primary care in low-income women in Santiago, Chile: A randomised

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Healthcare interventions for depression in low socioeconomic status populations: A systematic review and meta-analysis.

The prevalence and impact of depressive disorders in developed countries are associated with certain population characteristics, including socioeconom...
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