UCSF School of Medicine - Latino Mental Health Research Program

Internet World Health Research Center

The mission of the Internet World Health Research Center (IWHRC, pronounced “I work”) is to harness the power of the Internet to reach those most in need with behavioral health interventions that are as effective as traditional interventions and that can be administered directly to them via the World Wide Web.
www.health.ucsf.edu

The Tobacco Related Disease Research Program funded the establishment of the Spanish/English Web Site for Smoking Cessation Trials at www.stopsmoking.ucsf.edu and www.dejardefumar.ucsf.edu . This project of the University of California, San Francisco/San Francisco General Hospital Latino Mental Health Research Program is being conducted in collaboration with the University of California, San Francisco Medical Effectiveness Research Center for Diverse Populations (MERC) and the University of California, San Diego. During Phase I of the study, we created the basic site and tested its ability to 1) recruit participants, 2) obtain informed consent, 3) obtain initial assessment data, 4) provide one intervention, and 5) obtain follow-up data, all with minimal human intervention. We recruited over 4500 smokers, of whom over 1000 were Spanish-speaking.
During Phase II we carried out three sets of studies comparing two smoking cessation conditions to each other. Publications from the first two phases include:

Funding Sources
Tobacco-Related Disease Research Program Grant # 10RT-0326
“Spanish/English web site for smoking cessation trials.”
Principal Investigator: Ricardo F. Muñoz, Ph.D.
Co-investigators:

Leslie Lenert, M.D.,
Eliseo J. Pérez-Stable, M.D.,
Kevin Delucchi, Ph.D.

During Phase III, we compared four methods to stop smoking via the Web in a randomized control trial. Publications from this phase include:

Muñoz RF, Barrera AZ, Delucchi K, Penilla C, Torres LD, Pérez-Stable EJ. International Spanish/English Internet smoking cessation trial yields 20% abstinence rates at 1 year. Nicotine Tob Res. 2009 Sep;11(9):1025-34. Epub 2009 Jul 29.

Torres LD, Barrera AZ, Delucchi K, Penilla C, Pérez-Stable EJ, Muñoz RF. Quitting smoking does not increase the risk of major depressive episodes among users of Internet smoking cessation interventions. Psychol Med. 2009 Jul 23;:1-9 [Epub ahead of print]

Barrera AZ, Pérez-Stable EJ, Delucchi KL, Muñoz RF. Global reach of an Internet smoking cessation intervention among Spanish- and English- speaking smokers from 157 countries. Int J Environ Res Public Health. 2009 Mar;6(3):927-40. Epub 2009 Feb 26.

During Phase IV, we carried out an exploratory smoking cessation study on the Web to estimate smoking cessation rates in a participant's preference outcome study, in which participants choose among the several self-help elements that we have been testing in the randomized trials described above.

Phase V is currently recruiting participants in the United States.

We welcome Spanish and English speaking smokers to join our study.
English site: www.stopsmoking.ucsf.edu
Spanish site: https://www.stopsmoking.ucsf.edu/es/intro/home.aspx

Mothers and Babies: Mood and Health Project
Mamás y Bebés: El Estado de Animo y la Salud

Risk for major depression appears to be transmitted across generations. Pregnancy and the postpartum period are key periods to study because maternal emotion regulation deficits may affect both maternal and child outcomes. Children of parents with emotion regulation problems are at higher risk for developing similar problems over time.
The Mothers and Babies: Mood and Health Project was launched in 1998 by the Latino Mental Health Research Program at the University of California, San Francisco/San Francisco General Hospital. Its aims are: (1) to identify pregnant women at imminent risk for major depressive episodes, and (2) to test whether a cognitive-behavioral intervention reduces risk for maternal depression and improves maternal and child functioning in high risk low-income pregnant English and Spanish-speaking women.

First Stage:
Depression Risk Study

We recruited 100 Spanish and English-speaking, low-income, pregnant women obtaining their prenatal care at the SFGH Women’s Clinic. Beginning in the second trimester of pregnancy and continuing monthly through the first six months postpartum, we assessed their depression level and associated risk factors. We found that women with emotion regulation deficits (“high risk”), but not suffering from clinical depression when recruited, experienced more new major depressive episodes during the one-year prospective study period than those we had categorized as “low-risk” women. Specifically, 24.1% of the “high-risk” group developed a major depressive episode within one year, compared to 2.6% of the “low-risk” group. Our findings indicate that we are able to identify pregnant women at high risk for developing major depressive episodes.

Diaz, M. A., Le, H-N., Cooper, B. A., & Muñoz, R. F. (2007). Interpersonal factors and perinatal
depressive symptomatology in a Latina sample. Cultural Diversity and Ethnic Minority Psychology, 13(4) 328-336.

Funding Sources
University of California Office of the President
Private donors: Dr. Cloyce L. Duncan and Dr. Gwendolyn Evans-Duncan.
Principal Investigators: Huynh-Nhu Le, Ph.D., and Ricardo F. Muñoz, Ph.D.,

Second Stage:
Intervention Development Study: The Mothers and Babies Course

Building on the results of our Depression Risk Study, we recruited 57 “high-risk” pregnant women for a pilot randomized controlled trial. Our aim was to pilot test the Mothers and Babies Course, an adaptation of our Depression Prevention Course for pregnant women, to see whether difficulties in emotion regulation can be improved with a psycho-educational intervention, and whether promoting optimal levels of emotion regulation produces measurable differences in maternal efficacy. The course includes a 12-week group session that occurs during pregnancy, and 4 booster sessions during the first year postpartum (months 1, 3, 6, and 12). Thirty-four women were randomized to the intervention condition and 23 to a no-intervention control condition. Our results to date indicate that low-income, primarily Latina women found the Mothers and Babies Course useful, attended the course sessions, and are available for follow-up up to 1½ years after birth. We are currently analyzing other study outcomes.

Funding Sources
NIMH R21 MH 596056 Intervention Development Grant (2000-2004)
Principal Investigator: Ricardo F. Muñoz, Ph.D.
Co-investigators: Huynh-Nhu Le, Ph.D., and Chandra Ghosh Ippen, Ph.D.

Third Stage:
First Years Study: Following the babies at 3½ and 1½ years of age

Participants from the Risk and Intervention Development studies were re-contacted to study the socioemotional functioning of the mothers and babies over time. We assessed the children from the Depression Risk Cohort at 3½ years of age, and the children of the Intervention Development Cohort at 1½ years of age. This study's primary aims were (1) to assess the psychosocial and cognitive functioning of each index child, and (2) to examine the relation between the index child's current psychosocial and cognitive development and the mother's depression levels during pregnancy and currently. We collected behavioral and observational data on the children, as well as self-report data from the mothers. This study suggests that we are able to follow up urban, low-income Latinas and their children longitudinally, and that we can reliably measure and document the effects of maternal perinatal depression on the index children's development.

Funding Sources
UC Mexus Grant
Co-principal investigators: Guido Urizar, Ph.D. and Ricardo F. Muñoz, Ph.D.

Untreated depression accounts for more than 11% of the world total disease burden. Depression is associated with up to 60% of suicide deaths, deteriorating health, and social problems. Most affected individuals are not receiving adequate treatment. The long-term objective of this project is to address the issue of untreated depression by developing and evaluating an effective Web-based intervention for depression, available at no cost and in multiple languages to depressed and dysphoric individuals anywhere in the world.

The current project is the first step towards that goal. We have developed a self-contained, interactive, modular, Web-based self-help intervention for depression. The intervention is based on cognitive-behavioral therapy, an empirically supported treatment for depression. Participants from the Internet community are invited to sign up for a customized eight-lesson intervention. This is a proof-of-concept study, with the goal of assessing the degree of interest in and the demand for Web interventions, and to obtain initial information about the effectiveness of this intervention.

The World Health Organization now recognizes depression as one of the most disabling medical conditions in the world. In 2003, in the US alone, depression costs amounted to 44 billion dollars in lost productivity (Stewart, Ricci, Chee, Hahn, & Morganstein, 2003). It has been estimated that one half of all persons with depression in the US, and 75% worldwide, do not receive adequate treatment (Kessler, Berglund, Demler, Jin, Koretz, Merikangas, et al., 2003). Untreated depression is associated with to up to 60% of suicide deaths, deteriorating health, and social problems, accounting for more than 11% of the total disease burden worldwide, with functional disabilities exceeded only by cardiovascular disease and cancer (Greden, 2001).

The Internet Healthy Mood Course/”Logrando un estado de ánimo saludable” is the Web adaptation of the Depression Prevention Course. The Web-adapted intervention takes advantage of the interactive capabilities of the Web. To increase interest in the site, engage participants, and present information verbally to participants who may have trouble reading, videos and audio messages accompany some of the material presented in each module. The adapted intervention includes self-monitoring tools that are displayed in graphs . For instance, participants are able to indicate their mood levels and activities they find pleasant by clicking on an electronic mood scale and activities scale, respectively, which can produce an individualized list of activities that can then be checked off each day.

We are currently recruiting English speaking participants:
Healthy Mood Project

Pharmacotherapy and cognitive behavioral therapy are efficacious
treatments of depression among diverse groups, however adherence to
medication, adherence to CBT homework, and appointment attendance are
barriers to effective treatmen in the community, particularly among
low income populations. This line of research seeks to investigate
whether text messaging (SMS) can be used to improve adherence to
treatment for depression by sending medication and appointment
reminders along with using SMS as a medium for CBT homework completion
to reinforce thought tracking and behavioral activation. This project
is currently in the initial feasibility/usability stage in preparation
for a randomized trial.

The Audio Coach for Depression Project/El Consejero Portátil

Monica J. Garza , M.A., M.P.H
Ricardo F. Muñoz, Ph.D.

With the exception of a few studies on Cognitive Behavioral Therapy (CBT) for Latinos, in general, there is very little research on the utility of other treatment modalities or applications of technology to CBT for Latinos.

Twelve brief psychoeducational sessions that correspond to the Manual for Group Cognitive-Behavioral Therapy of Major Depression (Muñoz, Ghosh Ippen, Rao, Le, and Dwyer, 2000) have been recorded as MP3 files. The will be delivered via an audio intervention during treatment and post treatment. Patients receive an MP3 player with the audio files, a user’s guide, and a tracklisting document. Patients are assigned the files that correspond to the weekly topics presented during each group session. Ultimately, the implementation of the Audio Coach has four aims: (1) It is intended to make the framework of CBT easier to teach before patients initiate group treatment; (2) teach coping skills while patients are in a waitlist condition; (3) augment the impact of treatment in between therapy sessions, and (4) to reduce future risk for relapse. Further, this project hopes to address the need for a further development of depression treatment modalities (e.g. individual, group, workbook, Internet-based treatments) offered to Latinos who may have limited literacy or English language proficiency. The Audio Coach for Depression Project/ El Consejero Portátil was launched during March, 2010 and is currently in the pilot-testing phase. We have used the MP3 adjunct for our Spanish CBT for Depression Groups at San Francisco General Hospital.