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Insomnia study shows the way on adapting trials to better represent minorities

In April, the journal JAMA Psychiatry published a study that was reported to be the first of its kind – a randomised clinical trial that adapted an insomnia treatment programme for black women, which adjusted elements like visual content so that participants felt better represented, and included discussion of how the unique experiences of black women can contribute to their insomnia.

The researchers found that a culturally tailored programme was more effective at engaging participants, while still comparably improving their insomnia symptoms, than the untailored treatment.

While the study is new, writes Kasra Zarel in Undark, the research touched on a long-discussed topic in the field of mental health: how should therapists adapt their approaches for people of different cultures, including for racial and ethnic minority groups?

What is cultural adaptation?

Psychological research has historically skewed towards studying white people in Western societies, and practitioners shouldn’t assume that treatment and diagnosis tools designed for those populations will work for everyone. It’s important to make sure that underserved communities are not being left out from effective services. “Cultural adaptation” refers to preserving the essential components of evidence-based tools, while modifying certain aspects to increase engagement and relevance for the cultural group being served.

Various factors, including language barriers, setting, race, ethnicity, country of origin, treatment goals, education level, and religious beliefs must all be considered.

Does it work?

Evidence suggests that cultural adaptation is effective. Yet, despite growing interest and awareness, it remains unclear the extent to which therapists are practising cultural adaptation with their patients — and if they are, whether they’re doing so effectively.

The mental health field must make cultural adaptation a priority in both research and practice. Psychologists must build upon previous work to understand how best to adapt therapies, along with screening and diagnostic tools. They should also explore barriers to applying those therapies in clinical settings. Furthermore, there is a critical need for standardised frameworks so that culturally adapted interventions can be routinely and feasibly applied.

In the United States, the American Psychiatric Association’s (APA) main resource on the topic specifies some guidelines, but is nearly 10 years old, lacks a referral to standardised tools and approaches to use for implementation, and it is unclear whether and how these are incorporated in practice. And while the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a resource that mental health professionals use to guide diagnoses, includes a Cultural Formulation Interview — questions that professionals use to make cultural assessments related to diagnosis and treatment — experts believe it is not used as much as it can be and still needs to be refined.

Better guidance from organisations such as the APA would help practitioners and organisations become better trained and able to adapt therapies for different cultures.

Some institutions have embraced working and conducting research in culturally sensitive ways — and more should. Organisations like Unicef and the World Health Organization are among those that have recognised the relationship between culture and health.

For instance, Unicef has developed cultural adaptations of screening tools to improve global measurements of adolescent mental health through the Measurement of Mental Health Among Adolescents at the Population Level (MMAP) initiative, a project on which
I’ve been fortunate to collaborate. Even though mental health conditions are among the leading causes of disability worldwide, data on psychological conditions are limited in low- and middle-income countries, and few instruments are validated in these settings.

“You may completely misdiagnose the patient if you don’t understand the cultural variations,” said Shervin Shahnavaz, a clinical psychologist and psychotherapist at the Centre for Psychiatry Research and Centre for Education & Research at the Karolinska Institute.

How should psychology adapt?

It isn’t always obvious when a treatment or diagnostic tool needs to be adapted. Sometimes the need for adapting screening or treatment is clear, for instance, in the case of internally displaced people by the Boko Haram insurgency in Nigeria or refugees in humanitarian settings coming from unique, traumatic situations, who may face language barriers and have different cultural expressions and understandings of mental and psychological health.

Other times, the cultural disparities may be less obvious. For example, the insomnia study looked at an American population, but the treatment was adapted for black women because they have been historically underrepresented in research, display high rates of sleep problems, and have been previously shown to be less likely to initiate and continue treatment.

According to Eric Zhou, lead author of the study and an assistant professor of paediatrics at Harvard Medical School, while the study didn’t look at the exact reasons for the increased engagement, one main factor could be the treatment experience. Because the culturally adapted treatment used materials featuring black women, it better reflected the study’s participants and may have made the programme more relevant for them.

It might be the case that methods don’t need to adapt all that much — for instance, cognitive behavioural therapy, or CBT, which was used in the insomnia study, is known to be a flexible protocol according to Iony Ezawa, an assistant professor of psychology at the University of Southern California. Similarly, a validating approach, in which the therapist affirms that the patient’s experiences are understandable, could in fact be the most effective treatment for certain groups. After all, the therapeutic relationship is one of the best predictors of treatment outcomes. But without further research and better guidance, clinicians may be left with guessing best methods.

Furthermore, a study published in May explored whether a patient’s race affected how therapists provided CBT, a common and evidence-based treatment for depression. Ezawa and colleague Daniel Strunk, a professor of psychology at the Ohio State University, reported that therapists in the study found it less appropriate to use cognitive techniques typically employed in CBT when working with black patients compared to wWhite patients.

While validation could be considered a form of adaptation, in that it’s culturally sensitive, it’s unclear if it is the most effective approach. As the study’s authors pointed out, “Whether such adaptations enhance or detract from the care of black patients is an important issue that merits future investigation.” The field of psychology needs such studies, along with better guidance on how best to apply culturally adapted treatments.

Until then, embracing the practice of patient-centered care, is critical. Therapists must continue to be mindful and respectful of cultural differences. Everyone, regardless of their background deserves equitable mental health care.

Kasra Zarei is a freelance science journalist whose work has appeared in Slate and other outlets. He is a Ph.D. and M.D. student in global mental health.

Study details

Effect of Culturally Tailored, Internet-Delivered Cognitive Behavioural Therapy for Insomnia in Black Women: A Randomised Clinical Trial

Eric S. Zhou, PhD1,2; Lee M. Ritterband, PhD3; Traci N. Bethea, PhD4; et al

Published in JAMA Psychiatry on 20 April 2022

Key Points

Question How can insomnia disorder be treated effectively in black women over the internet, and how can intervention engagement be increased?

Findings In this randomised clinical trial including 333 black women, participants receiving both a standard internet-delivered cognitive behavioural intervention for insomnia and a version tailored for black women reported significantly greater insomnia improvement compared with those receiving sleep education alone. Participants were more likely to complete the full intervention if they received the tailored program, with intervention completion associated with greater insomnia improvement.

Meaning In this study, known sleep health disparities facing Black women in the US were addressed with an evidence-based treatment, and engagement was increased using a culturally adapted intervention.

Abstract

Importance
Black women are at risk for insomnia disorder. Despite interest in addressing sleep health disparities, there is limited research investigating the efficacy of criterion-standard treatment (cognitive behavioural therapy for insomnia [CBT-I]) among this racial minority population.

Objective
To compare the efficacy of a standard version of an internet-delivered CBT-I program, a culturally tailored version, and a sleep education control at improving insomnia symptoms.

Design, Setting, and Participants
In this single-blind, 3-arm randomised clinical trial, participants in a national, longitudinal cohort (Black Women’s Health Study [BWHS]) were recruited between October 2019 and June 2020. BWHS participants with elevated insomnia symptoms were enrolled and randomised in the current study.

Interventions
Participants were randomised to receive (1) an automated internet-delivered treatment called Sleep Healthy Using the Internet (SHUTi); (2) a stakeholder-informed, tailored version of SHUTi for Black women (SHUTi-BWHS); or (3) patient education (PE) about sleep.

Main Outcomes and Measures
The primary outcome was insomnia severity (Insomnia Severity Index [ISI]). Index score ranged from 0 to 28 points, with those scoring less than 8 points considered to not have clinically significant insomnia symptoms and a score of 15 points or higher suggesting insomnia disorder. An ISI score reduction of more than 7 points was considered a clinically significant improvement in insomnia symptoms. The SHUTi-BWHS program was hypothesised to be more effective at significantly decreasing insomnia severity compared with the SHUTi program and PE.

Results
A total of 333 black women were included in this trial, and their mean (SD) age was 59.5 (8.0) years. Those randomised to receive either SHUTi or SHUTi-BWHS reported significantly greater reductions in ISI score at 6-month follow-up (SHUTi: −10.0 points; 95% CI, −11.2 to −8.7; SHUTi-BWHS: −9.3 points; 95% CI, −10.4 to −8.2) than those randomised to receive PE (−3.6 points; 95% CI, −4.5 to −2.1) (P < .001). Significantly more participants randomised to SHUTi-BWHS completed the intervention compared with those randomised to SHUTi (86 of 110 [78.2%] vs 70 of 108 [64.8%]; P = .008). Participants who completed either intervention showed greater reductions in insomnia severity compared with noncompleters (−10.4 points [95% CI, −11.4 to −9.4] vs −6.2 points [95% CI, −8.6 to −3.7]).

Conclusions and Relevance
In this randomised clinical trial, both the SHUTi and SHUTi-BWHS programs decreased insomnia severity and improved sleep outcomes more than PE. The culturally tailored SHUTi-BWHS program was more effective at engaging participants with the programme, as a greater proportion completed the full intervention. Program completion was associated with greater improvements in sleep.

 

Undark article – Opinion: Culturally Adapting Therapy Can Help — But Needs Further Research (Open access)

 

JAMA Psychiatry article – Effect of Culturally Tailored, Internet-Delivered Cognitive Behavioral Therapy for Insomnia in Black Women: A Randomized Clinical Trial (Open access)

 

Working with Black vs. White patients: an experimental test of therapist decision-making in cognitive behavioral therapy for depression (Open access)

 

See more from MedicalBrief archives:

 

US health panel calls for routine anxiety screening in adults

 

New US clinical practice guidelines on treatment of chronic insomnia disorder

 

Meta-analysis: Beta-blockers not linked to depression or adverse mental health events

 

In the long run, drugs and talk therapy hold same value for depression patients

 

Insomnia may impact on mental health problems

 

 

 

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