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Cognitive Behavioral and Family Psychoeducational Therapies for Adolescent Inmates Experiencing Anxiety in a Narcotics Correctional Facility Madepan Mulia, Budi Anna Keliat, and Ice Yulia Wardani

Faculty of Nursing, Universitas Indonesia, Jalan Bahder Djohan Campus, Depok, Indonesia

ABSTRACT Illicit substance use is becoming a major global issue. In Indonesia, inmates imprisoned for illicit substance offences accounted for 40% of the total inmate population. This study aimed to identify the effects of cognitive behavioral and family psychoeducational therapies on inmates’ anxiety in the narco- tics correctional facility. Quasi-experimental pre-test–post-test with control group was employed in this study. Intervention Group 1 received a general nursing intervention whereas Intervention Group 2 received a combination of general nur- sing intervention with cognitive behavioral and family psy- choeducational therapies. This study involved 31 inmates for each group. Data were collected using the Hamilton Anxiety Rating Scale (HAM-A) and were analyzed using repeated ANOVA and independent t-tests. The study demonstrated that anxiety was significantly lower among those who received the combination of those three therapies compared to those who received general nursing intervention standalone (p < .005). This study suggested the implementation of both general nursing intervention and specialty therapies, particu- larly cognitive behavioral and family psychoeducational therapies, to address the anxiety problems experienced by adolescent inmates suffering from illicit substance dependence.

KEYWORDS Adolescent inmates; anxiety; cognitive behavioral therapy; family psychoeducational therapy

Introduction

Illicit substance use has been evolving worldwide. WHO estimated that 15 million people worldwide used narcotics, alcohols, psychotropic medicines, and other addictive substances. In Indonesia, the use of these illicit sub- stances is likewise increasing. The number of users increased considerably from 4.1 million in 2014 to 5.9 million in 2015. Shockingly, of the total users, nearly one quarter were students (22%) (Badan Narkotika Nasional Republik Indonesia, 2016). In addition, Directorate General of Corrections reported around 55,650 inmates were incarcerated for illicit substance offences and around 25,006 inmates were convicted for drug uses.

CONTACT Budi Anna Keliat [email protected] Faculty of Nursing, Universitas Indonesia, Jalan Bahder Djohan Campus, Depok 16424, Indonesia

COMPREHENSIVE CHILD AND ADOLESCENT NURSING 2017, VOL. 40, NO. S1, 152–160 https://doi.org/10.1080/24694193.2017.1386984

© 2017 Taylor & Francis

Substance use could cause negative consequences for individuals, families, and even society. Substance use may cause anxiety for individuals (Kaye, Vadivelu, & Dan Urman, 2015). Furthermore, it can contribute to financial problems in the family, resulting in feelings of insecurity, shame, and embarrassment, fear, and repulsion (Yosep & Dan Sutini, 2014). The nursing problem associated with substance use is, therefore, anxiety.

Anxiety is an emotional state and subjective personal experience charac- terized by the sense of unreasonable fear, uncertainty, powerlessness, isola- tion, and insecurity (Stuart, 2013). Factors contributing to anxiety include physical conditions and the ability to deal with the environment and to cope with stimuli, situations, and problems.

Nurses play an essential role in improving the health of individuals, family, and community, including those who suffered from substance use. Mental health nurses in particular, could contribute to delivering general and speci- alty therapies (psychosocial/psychotherapy). Psychotherapy or modality ther- apy is the appropriate nursing care to address the psychosocial problems of inmates and patients with substance use (Videbeck, 2008). The activities might include cognitive behavioral for adolescent inmates along with psy- choeducation therapies for their family.

Cognitive behavioral therapy is a cognitive reconstruction therapy that allows individuals to identify cognitive pattern, thoughts, or emotions asso- ciated with their behaviors. This type of therapy is proven to be effective in addressing syndromes including alcohol, marijuana, cocaine, and nicotine dependences, and in alleviating anxiety and depression in the community, in the urban and rural settings (Vallury, Jones, & Oosterbroek, 2015; Yosep & Dan Sutini, 2014).

An adequate support system is of fundamental importance for adolescent inmates. Adequate supports, including family, will improve inmates’ recovery from substance addiction (Ekasari & Dan Hafizhoh, 2009). Family plays a vital role to help inmates dealing with psychosocial issues by actively enga- ging in psychoeducation therapy. A study was conducted aiming to examine the effects of cognitive behavioral and family psychoeducational therapies on inmates’ anxiety. The study indicated that inmates’ anxiety significantly declined after they received family psychoeducational therapy (Nurbani, Keliat, Nasution, & Yusron, 2009).

Methods

A purposive sample of 62 respondents participated in this study, with the inclusion criteria of inmates aged 18–23 years old, had an anxiety score of above 1.0, imprisoned in a correctional facility, and resided in Bandar

COMPREHENSIVE CHILD AND ADOLESCENT NURSING 153

Lampung. The data were collected using random sample methods. This quantitative study employed quasi-experimental pre-test–post-test with con- trol group design. There were 31 respondents in each intervention group (Intervention Group 1 and Intervention Group 2). Intervention Group 1 received general nursing intervention, whereas Intervention Group 2 received both general and specialty nursing care (cognitive behavioral and family psychoeducational therapies).

The Hamilton Anxiety Rating Scale (HAM-A) was used in this study to measure the anxiety of adolescent inmates, comprising 14 items with the following 5 answer values: 4 = very severe, 3 = severe, 2 = moderate, 1 = mild, and 0 = no symptoms perceived. Anxiety was measured using Likert scale scores ranging from 0 to 56, with four main categories as follows: mild anxiety = 1–17; moderate anxiety = 18–24, severe anxiety = 25–30, and very severe anxiety ≥ 31. The instrument has been tested for validity and reliability with the r count value >.361 and Cronbach’s alpha = .896.

This study adhered to the ethical review standards. During the initial stage, we submitted the proposal to the Ethical Committee at the Faculty of Nursing of the University of Indonesia. We also requested a permission letter from the Faculty to perform validity and reliability tests. Then, when the official ethical approval and permission request letters were released, we proceeded to the regional office of the Ministry of Justice and Human Rights in South Sumatera Province and to the Correctional Facility Class III Palembang for validity and reliability tests of the research instrument.

Furthermore, we requested permission from the regional office of the Ministry of Justice and Human Rights in Lampung Province and the Correctional Facility Class II A Bandar Lampung for data collection. Prior to data collection, we trained research assistants for interrater reliability. In addition, written informed consent was given to all respondents of the study before the data collection.

This study comprised three main stages: pre-test, intervention, and post- test. The data collection was conducted over a period of 41 days with the following details: Pretest 1 for Intervention Group 1 was performed on the first day, whereas pre-test 1 for Intervention group 2 was performed on the 16th day. General nursing intervention pertaining to anxiety was subse- quently performed on the second day for Intervention Group 1 and on the 17th day for Intervention Group 2. Then, post-test 1 for Intervention Group 1 was started on the third day whereas post-test 1 for Intervention Group 2 was started on the 18th day.

Respondents from Intervention Group 1 had 12 days to independently practice the activities learned during the intervention stage. Then, post-test 2 was performed on the 15th day. Intervention Group 2, on the other hand, received three sessions of cognitive behavioral and family psychoeducation

154 M. MULIA ET AL.

therapies starting from the 18th day and post-test 2 was performed on the 30th day.

This study has been conducted conforming the ethical standards and has received the approval letter No. 51/UN2.F12.D/HKP.02.04/2017. In addition, expert validity and competence tests was conducted prior to the data collec- tion. Respondents were informed and reassured regarding their rights and ethical values of respect for human dignity, privacy and confidentiality, justice and inclusiveness, and balancing harms and benefits.

Result

The effects of general nursing intervention on adolescent inmates’ anxiety

The mean score of Intervention Group 1 post-intervention was 2.84 lower than at pre-intervention. Similarly, the mean score of Intervention Group 2 was 4.77 lower during post-intervention compared to pre-intervention. Anxiety level was relieved in both intervention groups, from moderate anxiety in the pre-intervention stage to mild anxiety in the post-intervention stage. Interestingly, the score of mean difference was relatively higher among Intervention Group 2. The analysis furthermore showed that the mean scores significantly differed between pre-intervention and post-intervention stages in both Intervention Group 1 and 2 (p < .05; see Table 1)

The effects of general nursing intervention with cognitive behavioral and family psychoeducation therapies on adolescent inmates’ anxiety

There was a significant decrease in the mean score of anxiety from 19.71 (moderate anxiety) in the pre-intervention stage to 14.94 (mild anxiety) at post-intervention for Intervention Group 1. The mean value of anxiety, then, decreased again to 8.19 at post-intervention 2. Further analysis showed a significant decrease of the anxiety score after the provision of general nursing intervention, and cognitive behavioral and family psychoeducational thera- pies (p < .005; see Table 2)

Table 1. The effects of general nursing intervention on adolescent inmates’ anxiety in the narcotics correctional facility, year 2017 (n = 62 inmates).

General Nursing Intervention

95% CI

Group Mean pre Mean post Mean diff. SD Min Max p value

Intervention 1 17.55 14.71 2.84 .314 8 24 .000 Intervention 2 19.71 14.94 4.77 .308 13 24 .000

COMPREHENSIVE CHILD AND ADOLESCENT NURSING 155

Differences of anxiety between adolescent inmates who received general nursing intervention with cognitive behavioral and family psychoeducation therapies and those who received only general nursing intervention

The results of this study showed that the mean score of anxiety was 3.26 lower among the members of Intervention Group 2 compared to those of Intervention Group 1. This finding, strikingly, revealed that the anxiety was significantly lower among inmates who received general nursing interven- tion, cognitive behavioral and family psychoeducation therapies (p < .05; see Table 3)

Discussion

General nursing intervention significantly reduced the mean score of anxiety by 2.84 in Intervention Group 1 and 4.77 in Intervention Group 2. This result underscored the substantial roles of general nursing intervention in alleviating anxiety (Bektas, 2008). This type of intervention aimed at helping inmates maintain their anxiety level remains at the lowest possible level. This intervention encompassed education regarding anxiety: its definition, signs and symptoms, causes, consequences, and ways to cope with it. This inter- vention also included exercises to demonstrate deep breathing, distraction, five-fingers hypnosis, and spiritual exercises (Bulecheck, Butcher, Dochterman & Wagner 2013).

General nursing intervention contained information with respect to anxi- ety. This information aimed to help the inmates recognize anxiety and cope with it. In addition, inmates learned techniques to reduce anxiety

Table 2. The effects of general nursing intervention with cognitive behavioral and family psychoeducation therapies on adolescent inmates’ anxiety in the narcotics correctional facility, year 2017 (n = 31 inmates).

General Nursing Intervention with Cognitive Behavioral and Family Psychoeducation Therapies

95% CI

Test Mean Mean Diff. SD Min Max p value

Pre 19.71 11.52 2.957 18.62 20.79 .000 Post 1 14.94 3.265 13.74 16.13 Post 2 8.19 2.056 7.44 8.95

Table 3. Differences of anxiety between adolescent inmates who received general nursing intervention with cognitive behavioral and family psychoeducation therapies and those who received only general nursing intervention, year 2017 (n = 62 inmates).

95% CI

Group Mean SD SE Mean diff. Min Max p value

Intervention 1 11.45 4.202 0.755 3.26 9.91 12.99 .000 Intervention 2 8.19 2.056 0.369 7.44 8.95

156 M. MULIA ET AL.

independently based on the schedule they made. This type of intervention was expected to lower inmates’ anxiety, evidenced by the decrease of the anxiety score after the post-test stage.

Deep breathing techniques were the first exercise techniques taught to the inmates in the general nursing intervention to reduce anxiety. In this tech- nique, inmates learned to demonstrate deep breathing, slow breathing (breath hold with maximum inspiration), and gradual exhalation, aiming at increasing lung ventilation and blood oxygenation. Deep breathing is an abdominal breathing technique done with slow, convenient, and rhythmic rates and eyes closed. This technique could increase alveoli ventilation, maintain gas exchanges, prevent lung atelectasis, enhance cough efficiency, and reduce physical and emotional stress through reduction in anxiety and pain intensity (Smeltzer & Bare, 2002). The next technique in the general nursing intervention was distraction. Inmates learned to divert their atten- tion from an experience that triggered their anxiety to pleasant things that could help them significantly relieve anxiety (Widianti, Mustikasari, & Dan Waluyo, 2011). Five-finger hypnosis is a technique to reduce anxiety ranging from mild to moderate (Widyanti & Dan Wardani, 2013).This technique can be done independently by imagining positive thoughts while touching each finger. For instance, inmates could imagine the time when their body felt healthy, when they had loving experiences, received sincere compliments or achievements, or when they were in the most wonderful place. Five-finger hypnosis allows individuals to ease their anxiety by having pleasant thoughts (Banon, Dalami, & Noorkasiani, 2014). Spiritual approach is another techni- que inmates learned in the general nursing intervention to reduce anxiety in the Narcotics’ Correctional facility (Faradisi, 2012). Dzikr as an Islamic spiritual practice could lower anxiety. It helps individuals feel relaxed and calm, and therefore could reduce the amygdala activities, relax tense muscles, and activate parasympatis nerves as a counter of sympathetic nerves (Stuart, 2013). Thus, Dzikr creates the feeling of calmness that contributes to the relaxation of sympathetic nerves.

Results of our study showed that cognitive behavioral and family psychoe- ducation therapies significantly alleviated anxiety, evidenced by the decrease in the mean score of anxiety by 6.75 after the intervention. This mean difference was greater, compared to that of the general nursing intervention (4.77). Accordingly, a mixture of general nursing intervention with cognitive behavioral and family psychoeducational therapies was significantly more effective in reducing anxiety than general nursing intervention alone.

Cognitive behavioral therapy aims to modify negative thoughts and beha- viors so that individuals may lessen their emotions and the negative con- sequences caused by those undesirable thoughts and behaviors (Epigee, 2009). Initially, most adolescent inmates expressed negative self-evaluation and were less capable of using their minds to control anxiety. However,

COMPREHENSIVE CHILD AND ADOLESCENT NURSING 157

during the therapy, inmates learned to explore new and positive alternative thoughts that would counter the anxiety coming from negative thoughts. This therapy was targeted to modify cognitive distortion and the way inmates think while responding to any event.

Cognitive behavioral therapy allows inmates to think logically about their conditions and view their conditions from different perspectives. They learned to identify situations that could trigger anxiety and learned to modify their negative perceptions to be more positive because that subsequently would impact positive behaviors, too. Some studies proved that cognitive behavioral therapy could effectively reduce anxiety (Hargiana, Keliat, & Mustikasari, 2015; McManus, Waite, & Dan Shafran, 2008; Vallury et al., 2015).

Family psychoeducational therapy was an approach that involved both inmates and their families. This therapy focused on addressing psycholo- gical problems. Inmates who had adequate family supports were more likely to constructively cope with their conditions (Lestari, Hamid, & Dan Mustikasari, 2011). Furthermore, family support significantly increased inmates’ willingness to recover from dependencies (Isnaini, Hariyono, & Dan Utami, 2011). Thus, family plays a substantial role in increasing inmates’ motivation and providing supports to the inmates to be free from addiction. This therapy had been proven to be effective in lowering anxiety (Lestari et al., 2011; Nurbani et al., 2009; Silitonga, Keliat, & Dan Wardani, 2013).

It can be concluded that the combination of general nursing intervention with cognitive behavioral and family psychoeducation therapies as a part of the specialty therapies could be the better intervention to reduce anxiety among adolescent inmates. Results of this study found significant decline in anxiety scores and levels after the general nursing intervention, cognitive behavioral and family psychoeducational therapies.

The results of this study demonstrated that inmates’ anxiety score dropped significantly after the general nursing intervention, cognitive behavioral and family psychoeducational therapies. Furthermore, it showed that anxiety was lower among those who received the combination of those three therapies compared to those who received general nursing intervention alone. This study suggested the implementation of both gen- eral nursing intervention and specialty therapies to address the anxiety problems experienced by adolescent inmates suffering from illicit sub- stance dependences. This study also indicated the crucial need of mental health nurse specialists in the Narcotics clinics at any correctional facil- ities. We also suggested the continuous professional development regard- ing cognitive behavioral and family psychoeducational therapies for nurses in the correctional facilities in order to alleviate anxiety problems among inmates in Indonesia.

158 M. MULIA ET AL.

Acknowledgments

Acknowledgements are given to the adolescent inmates who were willing to be research respondents.

Declaration of interest

The authors report no conflicts of interest.

Funding

The authors acknowledge the Directorate of Research and Community Services (DRPM) of Universitas Indonesia who supported the research funding.

References

Badan Narkotika Nasional Republik Indonesia. (2016). Press release Akhir Tahun 2016: Kerja Nyata Perangi Narkoba. Jakarta, Indonesia: BNN RI.

Banon, Dalami, & Noorkasiani. (2014, November). Efektivitas terapi hipnotis lima jari untuk menurunkan tingkat ansietas pasien hipertensi. Jurnal Keperawatan, 2(3), 24–33.

Bektas, D. K. K. (2008). Effect of health promotion education on presence of positive health behaviours, level of anxiety and self concept. Social Behaviour and Personality Journal, 35 (5), 681–690. doi:10.2224/sbp.2008.36.5.681

Bulecheck, G. M., Butcher, H. K., Dochterman, J. M., & Dan Wagner, C. M. (2013). Nursing intervention classification (NIC) (6th ed.). Singapore: Elsevier Inc.

Ekasari, A., & Dan Hafizhoh, N. (2009). Hubungan Antara adversity quotient dan dukungan sosial dengan intensi untuk pulih dari ketergantungan NAPZA pada penderita di wilayah bekasi Utara-Lembaga Kasih Indonesia. Jurnal Soul, 2(II), 108–135.

Epigee. (2009). Cognitive behaviour therapy (CBT) for post traumatic stress disorder. Retrieved from http://www.epigee.org/ptsd-cbt.html

Faradisi, F. (2012, September). Efektivitas terapi murotal dan terapi musik klasik terhadap penurunan tingkat kecemasan pasien pra operasi di pekalongan. Jurnal Ilmiah Kesehatan, V(2), 134–144.

Hargiana, G., Keliat, B. A., & Mustikasari, E. D. (2015). Pengaruh cognitive behavior therapy terhadap perubahan perilaku merokok, ketergantungan nikotin dan ansietas di masyarakat kecamatan cigombong (Thesis). Fakultas Ilmu Keperawatan, Universitas Indonesia, Depok, Indonesia.

Isnaini, Y., Hariyono, W., & Dan Utami, A. K. (2011). Hubungan antara dukungan keluarga dengan keinginan untuk sembuh pada penyalahguna NAPZA di lembaga pemasyarakatan wirogunan kota yogyakarta. Kesmas, 5(II), 186–194.

Kaye, A. D., Vadivelu, N., & Dan Urman, R. D. (2015). Substance abuse—Inpatient and outpatient management for every clinician. New York, NY: Springer. doi:10.1007/978-1- 4939-1951-2

Lestari, A., Hamid, S., & Dan Mustikasari, A. Y. (2011). Pengaruh terapi psikoedukasi keluarga terhadap pengetahuan dan tingkat ansietas keluarga dalam merawat anggota keluarga yang mengalami tbc paru di kota bandar lampung (Thesis). Fakultas Ilmu Keperawatan, Universitas Indonesia, Depok, Indonesia.

COMPREHENSIVE CHILD AND ADOLESCENT NURSING 159

McManus, F., Waite, P., & Dan Shafran, R. (2008). Cognitive behaviour therapy for low self esteem: A case example. St. Louis, MO: Elsevier.

Nurbani, Keliat, B. A., Nasution, & Yusron. (2009). Pengaruh psikoedukasi keluarga terhadap masalah psikososial ansietas dan beban keluarga (caregiver) dalam merawat pasien stroke di RSUPN dr. Cipto Mangunkusumo Jakarta (Thesis). Fakultas Ilmu Keperawatan, Universitas Indonesia, Depok, Indonesia.

Silitonga, R. O., Keliat, B. A., & Dan Wardani, I. C. (2013). Pengaruh acceptance and commitment therapy dan family psychoeducation terhadap kemampuan menerima dan berkomitmen serta mengatasi kondisi depresi dan ansietas pasien HIV/AIDS Di RS cipto mangunkusumo (Thesis). Fakultas Ilmu Keperawatan, Universitas Indonesia, Depok, Indonesia.

Smeltzer, S. C., & Bare, B. G. (2002). Keperawatan medikal bedah (8th edition, Vol. 1). Jakarta, Indonesia: EGC.

Stuart, G. W. (2013). Principles and practice of psychiatric nursing (10th ed.). St. Louis, MO: Mosby Elsevier.

Vallury, K. D., Jones, M., & Oosterbroek, C. (2015). Computerized cognitive behavior therapy for anxiety and depression in rural areas: A systematic review. Journal of Medical Internet Research, 17(6), e139. doi:10.2196/jmir.4145

Videbeck, S. L. (2008). Buku ajar keperawatan Jiwa. Jakarta, Indonesia: EGC. Widianti, E., Mustikasari, & Dan Waluyo, A. (2011). Pengaruh terapi logo dan terapi suportif

kelompok terhadap ansietas remaja di rumah tahanan dan lembaga pemasyarakatan wilayah provinsi jawa barat (Thesis) Fakultas Ilmu Keperawatan, Universitas Indonesia, Depok, Indonesia.

Widyanti, F., & Dan Wardani, I. Y. (2013). Pengaruh teknik lima jari terhadap tingkat kecemasan pasien pre operasi di RSUD dr. soedarso pontianak kalimantan barat (Thesis). Fakultas Ilmu Keperawatan, Universitas Indonesia, Depok, Indonesia.

Yosep, I., & Dan Sutini, T. (2014). Buku ajar keperawatan jiwa dan advance mental health nursing. Bandung, Indonesia: Refika Aditama.

160 M. MULIA ET AL.

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Sanchez et al. BMC Psychiatry (2021) 21:635 https://doi.org/10.1186/s12888-021-03641-0

R E S E A R C H A R T I C L E

Depression education fotonovela for engagement of Hispanic patients in treatment: a randomized clinical trial Katherine Sanchez1,2* , Brittany H. Eghaneyan3, Michael O. Killian4, Leopoldo J. Cabassa5 and Madhukar H. Trivedi2

Abstract Background: We report the primary outcomes from a randomized clinical trial testing a novel culturally-adapted patient education intervention to increase engagement of Hispanic patients in depression treatment. The Depres- sion Education Fotonovela (DEF), Secret Feelings, incorporates popular images, cultural norms, and vivid pictures embedded within a soap opera narrative to increase depression knowledge and dispel myths about treatment. We then assessed engagement in a integrated care treatment model in response to the education intervention and subsequent changes in depression symptoms in a large community-based clinic whose patient population is majority Hispanic.

Method: The sample included 150 adult Hispanic patients with a confirmed diagnosis of depression who were randomly assigned to either: [1] integrated care + fotonovela; or [2] integrated care + standard education. Differ- ences between treatment groups were examined as were changes in depression, anxiety, depression knowledge, and stigma scores over time and engagement in treatment.

Results: Results indicated that while depression scores significantly decreased over time for participants (F [2.811, 416.054] = 197.69, p < .001, η2 = .572), no differences between the two education groups were found (F [1, 148] = 0.70, p = .403, η2 = .005). At 12-month follow-up, 101 patients (80.8%) reported a 50% of greater reduction in depression scores from baseline.

Conclusions: We found little difference between the two education groups, suggesting that either may helpful for engaging Hispanic patients into care. Better tailoring of patient education, with the fotonovela or similarly adapted tools, will require more directly addressing the stigma associated with antidepressant medication.

Trial registration: The study was registered with www. clini caltr ials. gov: NCT02 702596, on 03/20/2016. Retrospec- tively registered.

Keywords: Depression, Education, Hispanics, Stigma, Integrated care, Fotonovela

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Background The prevalence of depression among the US Hispanic population is estimated to be 27% [1]. Response to treat- ment is slow, and relapse rates are high [2, 3]. Hispanic patients often voice fears about the addictive and harm- ful properties of antidepressants, worries about tak- ing too many pills, and the stigma attached to taking

Open Access

*Correspondence: [email protected] 2 Department of Psychiatry, UT Southwestern Medical Center, 6363 Forest Park Rd, Dallas, TX 75235, USA Full list of author information is available at the end of the article

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