Evaluation of the Integrated Intervention for Dual Problems and Early Action Among Latino Immigrants With Co-occurring Mental Health and Substance Misuse Symptoms: A Randomized Clinical Trial.

Importance: Immigrants are at an increased risk for co-occurring mental health and substance misuse symptoms; however, effective treatments are lacking. Objective: To evaluate the effectiveness of the Integrated Intervention for Dual Problems and Early Action (IIDEA) program compared with enhanced usual care. Design, Setting, and Participants: This effectiveness randomized clinical trial was conducted from September 2, 2014, to February 2, 2017, in 17 clinics or emergency departments and 24 community sites in Boston, Massachusetts, as well as in Madrid and Barcelona, Spain. Equal randomization (1:1) in 2-person blocks was used, assigning participants to either the IIDEA treatment group (n = 172) or the enhanced usual care control group (n = 169). Intent-to-treat analyses assessed effectiveness, and post hoc analyses examined whether results varied by symptom severity or treatment dose. Eligible participants were between 18 and 70 years of age, self-identified as Latino, screened positive for co-occurring symptoms, and were not receiving specialty behavioral health services. Interventions: Participants were randomized to a 10-session IIDEA treatment or to enhanced usual care. Main Outcomes and Measures: Primary outcomes were changes in alcohol and drug misuse and results of a urine test for drug metabolites but not for alcohol misuse. Secondary outcomes were symptoms of depression, generalized anxiety, posttraumatic stress disorder, and overall mental health. Results: In total, 341 participants were randomized to either the IIDEA treatment group (n = 172; 94 [54.7%] female, mean [SD] age, 33.5 [11.6] years) or the enhanced usual care control group (n = 169; 80 [47.3%] female, mean [SD] age, 34.3 [11.8] years). No statistically significant effects of IIDEA were found for primary drug and alcohol outcomes (ASI Lite-drug score: ß = -0.02 [SE, 0.69; P = .88; Cohen d, 0.00; 95% CI, -0.17 to 0.17]; ASI Lite-alcohol score: ß = -0.01 [SE, 1.19; P = .66; Cohen d, 0.00; 95% CI, -0.12 to 0.12]; urine drug test result: ß = -0.36 [SE, 0.43; P = .50; OR, 0.70; 95% CI, 0.30-1.61]), but statistically significant effects were observed for secondary mental health outcomes. The IIDEA treatment was effective in reducing depressive symptoms per the Public Health Questionnaire-9 score (ß = -1.14; SE, 0.47; P = .02; Cohen d, 0.20 [95% CI, 0.04-0.36]), posttraumatic stress disorder symptoms per the Posttraumatic Stress Disorder Checklist-5 score (ß = -3.23; SE, 1.59; P = .04; Cohen d, 0.25 [95% CI, 0.01-0.37]), and overall mental health symptoms per the Hopkins Symptom Checklist-20 (ß = -0.20; SE, 0.07; P = .01; Cohen d, 0.25 [95% CI, 0.08-0.42]) and composite mental health (ß = -3.70; SE, 1.75; P = .04; Cohen d, 0.19 [95% CI, 0.01-0.36]) scores at the 6-month follow-up. Exploratory analyses suggested that 6-month treatment effects occurred for patients whose drug misuse was moderate to severe at the baseline assessment. Among patients with moderate to severe substance misuse, IIDEA substantially reduced substance use per the urine test results (odds ratio, 0.25 [95% CI, 0.09-0.67]; P = .01). Treatment dose showed small to large effect sizes by outcome. Conclusions and Relevance: The IIDEA treatment did not change drug misuse but did improve secondary mental health and substance misuse outcomes for a heterogeneous population with moderate to severe symptoms; this finding provides a path for treating Latino immigrants with co-occurring mental health and substance misuse symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT02038855.

Evaluation of the AC-OK mental health and substance abuse screening measure in an international sample of Latino immigrants.

BACKGROUND: Early detection and intervention in primary care is integral to behavioral health. Valid, practical screening assessments are scarce, particularly for non-English speaking populations. We address this need by evaluating the psychometric properties of the Spanish version of the AC-OK Screen for Co-occurring Disorders for first and second generation immigrant Latinos in Massachusetts, USA, and Madrid and Barcelona, Spain. METHODS: 567 Latino participants were recruited in waiting areas of clinics or by referral from Primary Care, Mental Health, Substance Use, and HIV Treatment Clinics, as well as Community Agencies. We use confirmatory factor analyses to evaluate the factor structure, correlation analysis to examine concurrent and discriminant validity, and receiver operating curves (ROC) to determine the ability of the AC-OK to approximate a composite of established instruments designed to measure depression, generalized anxiety, post-traumatic stress disorder symptoms, alcohol, and drugs (including benzodiazepines) as external criteria. RESULTS: The original two factor structure was replicated in samples of Latino respondents in the US and Spain. Correlations with other measures followed the expected pattern. In both the US and Spain, ROC analyses suggested that the AC-OK scale was an adequate approximation to other specific measures of mental health (ROC=0.90) and substance abuse problems (ROC=0.83). CONCLUSIONS: The Spanish version of the AC-OK Screen has good to excellent psychometric properties in both its subscales. These findings are robust across sites, gender, and type of clinic. We recommend its use for clinical research and for routine screening at treatment centers.

Applying generalizability theory methods to assess continuity and change on the Adolescent Quality of Life-Mental Health Scale (AQOL-MHS).

PURPOSE: The Adolescent Quality of Life-Mental Health Scale (AQOL-MHS) is designed to measure quality of life in clinical samples of Latino adolescents aged 12-18 years. Initial findings support its reliability, validity and conceptual model for use of its three domains (emotional regulation, self-concept and social context). Our current study tests the usefulness of the AQOL-MHS for tracking changes in HRQOL during the course of service use. METHODS: Three waves of data were collected from 59 participants who were recruited from mental health clinics, where waves were spaced 4 months apart. Participants were receiving services at baseline assessment and were tracked for follow-up appointments regardless of treatment status. We analyze conventional reliability statistics for individual differences (e.g., Cronbach's alpha and test-retest correlations), and to estimate the reliability of change, we carried out a variance decomposition analysis. RESULTS: The psychometric analyses from Chavez et al. (Qual Life Res 23(4):1327-1335, 2014) were replicated with comparable results. A generalizability theory (GT) analysis revealed that the AQOL-MHS domains can measure change reliably. The reliability estimates varied from .65 to .78. Although there was reliable change at the individual level, on the average the AQOL-MHS means improved only slightly over time. CONCLUSIONS: The reliability of change for all three scales in the AQOL-MHS was acceptable, but consistently lower than the Cronbach's alpha values for each wave. Future work will use this approach to adapt our current measure to provide a better reliability of within-person change and thus broaden its applicability for prospective use.

Measurement properties of the Adolescent Quality of Life Mental Health Scale (AQOL-MHS).

BACKGROUND: This article presents data on the psychometric properties of a new measure, the Adolescent Quality of Life Mental Health Scale (AQOL-MHS), designed to measure quality of life in clinical samples of Latino adolescents aged 12-18 years. Participants were recruited in Puerto Rico to have one of five prevalent mental health disorders. The initial instrument development was achieved through a grounded theory approach with the use of focus groups and in-depth interviews. METHODS: We conducted two stages of exploratory factor analyses (EFA) on 60 candidate items. The first stage was to establish the number of factors to extract, and the second was to improve the model by selecting the best items. A final EFA model retained 31 items and 3 factors labeled Emotional Regulation (11 items), Self-Concept (10 items) and Social Context (10 items). RESULTS: The instrument showed good internal consistency, test-retest reliability, and construct validity. The hypotheses-driven validity tests were all supportive of the AQOL-MHS. There was evidence for convergent validity and discriminant validity, and results for known-groups' validity were overwhelmingly supportive of the ability of the instrument to identify differences between groups. CONCLUSIONS: These preliminary findings support our conceptual model and the use of the AQOL-MHS domain and overall scores. We believe that this instrument will provide clinicians additional insight into the different aspects of quality of life that are important to adolescents with mental health problems. Therefore, we consider the AQOL-MHS a vital patient-centered outcome measure for assessment strategies in the prevention and treatment of this population.

Ethnic differences in perceived impairment and need for care.

Latino children in the U.S. have high rates of unmet need for mental health services, perhaps due to biased perceptions of impairment and need for care by parents and providers. We tested this argument using an experimental vignette design. Vignettes described children with problems that varied on severity (mild vs. serious), nature of the problem (internalizing vs. externalizing), as well as gender and ethnicity (Latino vs. Anglo). Raters were Latino and Anglo parents (N = 185) and providers (N = 189). Vignettes with Latino names were viewed as more impaired by both parents and providers, and this effect was significantly stronger in Latino vignettes with less severe problems. Severity and Latino features of vignettes also interacted with judgments of need for service. At higher severity, vignettes with Anglo names were judged to need service more than vignettes with Latino names, despite the same judged levels of impairment. Results are discussed in the light of the unmet need for Latinos.

Association between psychiatric disorders and smoking stages within a representative clinic sample of Puerto Rican adolescents.

OBJECTIVE: We examined the prevalence of smoking behaviors and their association with specific psychiatric disorders in a representative sample of youth from behavioral health clinics in Puerto Rico. METHOD: A complex sampling design was used to select the sample, and analyses were conducted to account for the unequal selection probability, stratification, and clustering. All analyses were weighted back to the clinical population from which they were drawn. Psychiatric and substance use disorders were assessed using the parent and youth versions of the Diagnostic Interview Schedule for Children, Version 4.0. RESULTS: More than one third of the sample reported experience with cigarette smoking, and approximately one quarter reported smoking at least once per week (23.4%). As expected, the alcohol and drug use disorders demonstrated some of the strongest associations with individual smoking stages. These were the only disorders that remained significantly associated with nicotine dependence after controlling for comorbidity. CONCLUSIONS: Our findings confirm the need for screening of smoking behavior and nicotine dependence in treatment settings and the integration of psychiatric/substance use treatments with smoking cessation.

Prevalence and factors associated to sexual behavior in Puerto Rican adolescents.

Sexual relations with intercourse (ASR-I) and high prevalence of teen pregnancies (19.2%, in 2002) among adolescents in Puerto Rico constitute a serious biopsychosocial problem. Studying the consequences and correlates of ASR-I in community and mental health samples of adolescents is important in designing and implementing sexual health programs. Randomized representative cross-sectional samples of male and female adolescents from 11-18 years old (N = 994 from the general community, N = 550 receiving mental health services) who had engaged in ASR-I were the subjects of this study. Demographic, family, and sexual data and the DISC-IV were collected from individual interviews. Logistic regression models, bivariate odds ratios, Chi-squares, and t tests were used in the statistical analysis. The mental health sample showed higher rates of ASR-I, lifetime reports of pregnancy and lower age of ASR-I onset for females. No gender difference in the prevalence of ASR-I was observed in both samples. Older adolescents from the community sample meeting psychiatric diagnosis criteria, and with lower parental monitoring, were more likely to engage in ASR-I, whereas in the mental health sample, adolescents with lower parental monitoring and parental involvement reported significantly more ASR-I. Prevalence of ASR-I and Risky Sexual Behavior (RSB) were almost identical. Adolescents with mental health disorders initiate and engage in ASR-I earlier and more frequently regardless of gender. Older adolescents are more likely to engage in ASR-I and parent-child relationships emerged as a highly relevant predictor of adolescent sexual behavior. The high correspondence between ASR-I and RSB has important clinical implications.

Psychometric properties of the Spanish version of two mental health outcome measures: World Health Organization Disability Assessment Schedule II and Lehman's Quality Of Life Interview.

This study presents data on the cultural adaptation to Latino populations of two outcome measures that respond to the need for developing comprehensive instruments for outcome assessments in minority populations. We examined the psychometric properties of outcome measures designed to assess impairment in functioning, and quality of life. Impairment in functioning was measured with the Disability Assessment Schedule II (WHO-DASII) developed by the World Health Organization (1997) and quality of life was measured with A. F. Lehman's (A. F. Lehman, 1983; A. F. Lehman, 1988) shortened Quality of Life Interview (QOLI). Spanish speaking consumers (N = 198) from Fresno (CA), San Antonio (TX) and San Juan (PR) participated in this study. They were recruited from both mental health outpatient clinics and primary care rural clinics. The WHO-DASII showed good to excellent internal consistency in all sites (alpha = .72 to .97) except for one subscale (Self-Care alpha = .47). Test-retest reliability estimates were mostly moderate to substantial (.57 to .83), again with one exception, the Self-Care subscale (.46). For the QOLI internal consistency ranged from .34 to .98 and test-retest reliability ranged from .40 to .86 across all sites. An initial validation strategy using both known-groups and concurrent validity produced promising evidence of the construct validity of both measures. The Spanish versions of the WHO-DASII and the QOLI lend support to the translation and adaptation process to which these instruments were subjected.

Association between psychiatric disorders and smoking stages among Latino adolescents.

OBJECTIVE: We examined the prevalence of smoking behaviors and their association with psychiatric disorders within a representative sample of youth from Puerto Rico. METHOD: A complex sampling design was used and analyses were conducted to account for the unequal selection probability, stratification and clustering. All analyses were weighted back to the population from which they were drawn. Psychiatric and substance use disorders were assessed using the parent and youth versions of the Diagnostic Interview Schedule for Children, Version 4.0 (DISC-IV). RESULTS: After controlling for other comorbidity, major depression and oppositional defiant disorder were significantly associated with nicotine dependence, rather than with lower levels of use. In contrast, conduct disorder was generally associated with lower levels of use rather than with nicotine dependence. As expected, the alcohol and drug use disorders demonstrated some of the strongest associations with individual smoking stages. CONCLUSIONS: By examining psychiatric correlates of smoking stages within an island-wide sample of adolescents, the present study highlights those disorders that may play a role in the development and/or persistence of smoking behavior in Puerto Rico and further clarifies the appropriate targets for smoking intervention conducted in community settings.

The Spanish translation and cultural adaptation of five mental health outcome measures.

In this paper we report on the process of translating five mental health outcome measures into Spanish and adapting them to Latino culture. The instruments considered are the World Health Organization-Disability Assessment Scale, the Burden Assessment Scale, the Family Burden Scale, Lehman's Quality of Life Interview and the Continuity of Care in Mental Health Services Interview. A systematic process of translation and adaptation of the instruments was followed with the goal of achieving cultural equivalence between the English and Spanish versions of the instruments in five dimensions: semantic, content, technical, construct, and criterion equivalence. In this paper we present data about the semantic, content, and technical equivalence. Various steps were taken to achieve equivalence in these dimensions, including the use of a bilingual committee, a multi-national bilingual committee, back-translation, and focus groups with mental health patients and their relatives.

Methodological challenges in assessing children's mental health services utilization.

This paper describes the reliability and validity of the service assessment for children and adolescents (SACA) for use among Spanish-speaking respondents. The test-retest reliability of the instrument was assessed in a randomly selected clinical sample of 146 Puerto Rican children and adolescents aged 4-17. Both parents and children were administered the SACA twice by independent interviewers over an average 12-day follow-up period. The accuracy of parental and youth self-reports was assessed by comparing these reports to information obtained from medical records. The results showed that parents and children (aged 11-17) were able to report with fair to moderate reliability any last year use of mental health services, any outpatient mental health services, and school services. Residential and hospitalization services were reported by both informants with substantial test-retest reliability. Slight or no test-retest reliability was obtained for parent and child on the use of the specific type of mental health professionals, as well as parental reports of several treatment modalities. Substantial sensitivity of the SACA was obtained when comparing medical records to parental and child reports to lifetime use of any service and outpatient mental health service. Moderate sensitivity was obtained for last year use of mental health services for both parent and child informants.