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. Author manuscript; available in PMC: 2020 May 1.
Published in final edited form as: Psychol Serv. 2018 Nov 15;16(2):271–275. doi: 10.1037/ser0000304

¡Aptívate!: A Spanish Language Behavioral Activation Mobile Application for Delivery via Primary Care

Jennifer Dahne 1,2, Anahi Collado 3, C W Lejuez 4, Cristina Risco 5, Vanessa A Diaz 6, Jacob Kustanowitz 7, Michael Zvolensky 8,9, Matthew J Carpenter 1,2
PMCID: PMC6499645  NIHMSID: NIHMS986406  PMID: 30431309

Abstract

Treatment for depression is a core health disparity for Latino/as in the United States. U.S. Latino/as are most likely to report depressive symptoms to primary care physicians (PCPs), who often have limited resources for providing evidence-based psychological depression treatment. This limited treatment accessibility is further compounded by additional treatment barriers including stigma related to seeking mental health treatment and limited English proficiency. Mobile technologies, including smartphones and mobile applications (apps) delivered via smartphone, are promising for addressing this treatment need. Herein, we discuss the development of a Spanish-language Brief Behavioral Activation mobile application, ¡Aptívate!, that was developed to disseminate depression-based psychological treatment via primary care to Spanish-speaking Latino/as. This paper focuses on the description of: a) rationale for ¡Aptívate! treatment development, b) treatment components, and c) a clinical case example describing potential implementation in primary care.

Keywords: mHealth, depression, Behavioral Activation, health disparities, primary care

The greatest burden of mental illness in the United States is shouldered by the largest ethnic and racial minority groups. Latino/as are the largest minority group in the U.S., comprising 17.6% of the U.S. population (United States Census Bureau, 2015). Despite higher rates of depression as compared to Non-Hispanic/Latino/a White Americans (26.1% vs. 21.5%; Pratt & Brody, 2016), Latino/as are less than half as likely as White Americans to receive evidence-based care for depressive symptomatology (Lagomasino et al., 2014). The lack of evidence-based depression care for Latino/as contributes to numerous negative health outcomes, including but not limited to diminished productivity, disability, and ultimately, premature death (Lagomasino et al., 2014).

Latino/as with elevated depressive symptoms are most likely to report their symptoms to primary care physicians (PCPs), where they are typically prescribed antidepressant medication without other psychotherapy options (Miranda & Cooper, 2004). This is concerning because, as compared to White Americans, Latino/as: 1) are less likely to adhere to antidepressant medication when prescribed and 2) prefer psychotherapy as compared to medication for the treatment of depression (Miranda & Cooper, 2004). Thus, there is a clear need to improve dissemination of evidence-based psychotherapy via primary care for this group.

Mobile technologies, including smartphones and mobile applications (apps), are widely used by Latino/as in the U.S. (Pew Research Center, 2017) and offer a convenient vehicle for meeting widespread depression treatment needs. Recent U.S. population-level data suggest that 75% of Latino/a adults in the U.S. own smartphones and at least 58% use mobile apps (Livingston, 2011; Pew Research Center, 2017). A growing body of research highlights that mobile health (mHealth) interventions are feasible and acceptable among Latino/a patients (Bender, Martinez, & Kennedy, 2016; Gordon & Hornbrook, 2016). Such interventions may address treatment barriers including fear of the stigma associated with accessing mental health services and language preference (Muñoz, Bunge, Barrera, Wickham, & Lee, 2016; Sentell, Shumway, & Snowden, 2007). Moreover, evidence-based psychological treatments can be tailored for mHealth delivery and may be efficacious for the treatment of mental health symptoms (e.g., Burns et al., 2011). Despite the promise of mHealth technologies to meet the need for evidence-based depression care for Latino/as, no apps have been developed to date to target this need via primary care.

Because U.S. Latino/as are a heterogeneous group with varied sociocultural and historical origins, an appropriate depression psychotherapy to adapt for mHealth delivery must be idiographic (i.e., focused on the individual, recognizing that each user has a unique cultural background) to accommodate personal beliefs/values on a case-by-case basis. Such a treatment must also be delivered in Spanish because nearly half of U.S. Latino/as have limited English proficiency (LEP) with Spanish language preference (United States Census Bureau, 2013). Despite higher depression severity, these individuals are significantly less likely to receive mental health services when compared to Latino/as with English fluency (Sentell, Shumway, & Snowden, 2007). Further, treatment effectiveness is increased when treatment is conducted in the patient’s native, preferred language (Hall, Ibaraki, Huang, Marti, & Stice, 2016).

Brief Behavioral Activation (Brief BA; Lejuez et al., 2011; Collado, Calderón, MacPherson, & Lejuez, 2016) is a straightforward, concise, and evidence-based idiographic psychotherapy that has shown to be efficacious for Spanish-speaking Latino/as and thus is a promising treatment to adapt for mHealth. Brief BA is grounded in behavioral principles which suggest that depression is caused by a lack of reinforcement in the environment for positive, non-depressed behaviors. Brief BA addresses this mechanism by helping patients to identify their personal values/goals, develop concrete activities that are consistent with those values/goals, and schedule and complete value/goal-driven activities.

Collado and colleagues (2014; 2016) recently translated Brief BA treatment content from English into Spanish for Latino/as with LEP. In their pilot trial (2014) they obtained qualitative data via in-depth interviews with individuals who completed the treatment to guide the potential need for treatment modifications. However, no modifications, cultural or otherwise, were suggested by study participants. In a randomized controlled trial, Spanish-language Brief BA was delivered in person using paper forms. Treatment efficacy was evaluated as compared to a supportive counseling control condition, also delivered in Spanish. Results suggest that, as compared to supportive counseling, Spanish-language Brief BA led to significantly greater decreases (68% vs. 59%) in depressive symptoms as well as greater remission of Major Depressive Disorder (93% vs. 50%) by treatment end, with treatment gains sustained through one-month post-treatment follow-up.

Although Brief BA delivered in Spanish is a promising depression treatment for Latino/as with LEP, few mental health treatment providers are trained and available in sufficient numbers to meet the public health need. Adapting Brief BA, delivered in Spanish, for mHealth delivery and dissemination via primary care holds promise for reaching many Spanish-speaking Latino/as in need of evidence-based treatment for depression. Moreover, existing psychological interventions that have been developed for Spanish-language delivery can only be delivered by Spanish-fluent providers or delivered in conjunction with a translator. In contrast, an evidence based mobile app intervention delivered in Spanish holds the potential to dramatically extend treatment reach by allowing providers who are not Spanish-fluent to recommend an evidence based intervention to their patients with Spanish-language preference and LEP. We herein describe ¡Aptívate!, a Spanish language mobile app adaptation of Brief BA developed specifically for LEP Latino/as with elevated depressive symptoms and delivery via primary care (Note: The name ¡Aptívate! is a neologism). This description is followed by a case example of ¡Aptívate! use in clinical practice.

¡APTÍVATE! TREATMENT DEVELOPMENT AND TREATMENT DESCRIPTION

¡Aptívate! treatment development began as an extension of prior work developing Brief BA and translating the treatment into Spanish as well as recent work developing and testing an English-language self-help Brief BA mobile app (“Moodivate”; Dahne et al., 2017). Consistent with the approach utilized by Collado and colleagues (2014; 2016), to develop ¡Aptívate!, app content from Moodivate was translated from English into Spanish. A back-translation approach was utilized in order to ensure translation quality and accuracy. A team of two bilingual translators with native Spanish fluency who were familiar with the intervention were employed. One translator first translated app content from English to Spanish and then the second translator translated the content from Spanish back into English. With this approach, it could be ensured that treatment content was appropriately delivered in Spanish.

¡Aptívate! is a standalone app comprised of the following components, each described in greater detail below: a) psychoeducation, b) identification of individualized values and value-driven activities, c) scheduling and completing activities, d) eliciting social support to help complete difficult activities, and e) additional features including ratings of daily mood and reinforcement for treatment utilization.

Psychoeducation

To provide Brief BA rationale, users complete a psychoeducational interactive tutorial illustrating the connection between behavior and mood, which ultimately highlights that ¡Aptívate! will focus on increasing activity to improve mood. Users practice generating values and activities and receive instruction regarding how to use the app. The psychoeducational piece was designed with the consideration that mental health self-stigma among Latino/as tends to be high when interventions explain the cause of depression as an individuals’ internal factors, such as cognitions or genetics (Santiago-Rivera et al., 2008). In contrast, Brief BA, and by extension ¡Aptívate!, attributes depression to an environmental depletion of rewards.

Identification of Individualized Values and Value-Driven Activities

Users then begin identifying individualized values/goals across five life areas including relationships, daily responsibilities, recreation, career and education, and health. This value/goal-driven framework helps to ensure that activities will be positively reinforced over time because they are connected to what the user views as important in his/her life. Values then become a framework for generating activities. The generation of values and activities is consistent with Brief BA’s idiographic nature. For example, within the “Relationships” life area, a patient might create a value of “Develop a strong family unit.” Activities consistent with this value might include “Have family dinners twice a week” and “Call my children three times a week.”

Scheduling and Completing Activities

Activities are then scheduled on the user’s calendar within ¡Aptívate!. Here, the user will schedule value-driven activities, monitor already occurring activities, and indicate when an activity has been completed. Color coding distinguishes activities in the past or upcoming, and users can rate how enjoyable each activity was and how important it is to them. After completing an activity, the patient receives reinforcement for completing the activity (e.g., “¡Buen trabajo!, lo hizo”/”Nice going, you did it!”).

Eliciting Social Support to Help Complete Difficult Activities

For activities that are difficult for a user to complete on his/her own, the user can develop an “Acuerdo” (“Assist”) to identify ways to receive help completing the activity from others. Users can proactively create an assist for any activity, but are also given the option to create an assist via a pop-up message that appears when an activity has been scheduled, but not completed. Users should then reach out to their support person to request this help. By incorporating others into activity completion, this may increase the likelihood that an activity is successfully completed.

Ratings of Daily Mood and Reinforcement for Treatment Utilization

Users track daily mood to ultimately track treatment progress. Calendar prompts trigger users to rate their mood each day on a scale of 1 (terrible) to 5 (great). The user can view a graph of fluctuations in daily mood overlaid upon a graph of number of completed activities, illustrating the connection between activity and mood. Users are reinforced for treatment engagement via badges which are accrued through continued utilization of ¡Aptívate!.

CASE EXAMPLE

This vignette is based on participant utilization of ¡Aptívate! within an ongoing clinical trial. It is intended to be illustrative and does not necessarily reflect any one individual’s experience with this approach.

“Mariana,” a 46-year-old Spanish-speaking Latina attended a regularly scheduled, annual appointment with her PCP, “Dr. Williams.” Although Dr. Williams is not a native Spanish-speaker, she is the only PCP within her practice who has professional working proficiency, thus she regularly treats patients with LEP and Spanish language preference. As part of the clinic’s best practices, all patients complete the Patient Health Questionnaire-9 (PHQ-9) at the beginning of each appointment to screen for symptoms of depression, which Mariana completed in Spanish. Mariana scored a 15 on the PHQ-9, in the “moderate depression” range. Mariana endorsed the following symptoms on the PHQ-9: anhedonia/low motivation, depressed mood, lethargy, guilt, difficulty concentrating, sleep disturbance, and diminished appetite. Mariana denied suicidal ideation and psychomotor retardation/agitation. Mariana reported that these symptoms together have made it very difficult for her to work, to take care of things at home, and to get along with other people.

Dr. Williams reviewed Mariana’s PHQ-9 and queried her further regarding her symptoms of depression. Mariana reported that she has been experiencing these symptoms “on and off” for the last five years, since moving to the mainland U.S. from Puerto Rico. She reported that being away from her family makes her feel sad and that it has been difficult for her to meet new people due to language barriers. Dr. Williams asked Mariana if she has ever received treatment for depression and Mariana reported that when she first moved to the mainland U.S. she was prescribed a medication to help with low mood, but that she did not take the medication consistently. She reported that, in general, she would prefer not to take a medication for mood.

Dr. Williams first suggested that Mariana enroll in individual or group therapy for depression. However, Mariana was hesitant due to the time commitment associated with regular therapy and expressed worries about being able to take time from work and finding a treatment provider who could deliver services in Spanish. Dr. Williams then discussed ¡Aptívate! with Mariana, suggesting that she might find the app beneficial. Mariana was interested in trying the mobile app as she has used mobile apps for other purposes, like keeping in touch with her family in Puerto Rico. Dr. Williams wrote down the name of the app for Mariana and suggested that she download it, begin to use it, and return for a follow-up visit in two months at which time they would check in regarding her use of the app and her mood. Dr. Williams discussed with Mariana that they together would continue to monitor her symptoms and, if they did not improve, they would consider adjunctive treatments such as medication or in-person psychotherapy.

Mariana downloaded ¡Aptívate! after her doctor’s appointment and completed the tutorial. The connection between behavior and mood resonated with her as she had noticed that when she does things that are important to her, she normally feels better. After completing the tutorial, Mariana began to identify values across a few different life areas. Within the “Relationships” (“Relaciones”) life area, Mariana recorded that she would like to “Be more connected to the local Puerto Rican community.” She then came up with activities consistent with this value, including searching MeetUp to find a local Puerto Rican community group, signing up for the group, and attending one meeting. Within the “Health” (“Salud”) life area, Mariana recorded that she would like to “Be physically active” and generated activities including going for a 20 min walk three times a week, riding her bike to work once a week, and mowing the lawn once a week.

Mariana then began to schedule in these and other activities gradually, at a pace of around three new activities per week. Some activities, like going for regular walks, she consistently found enjoyable, rating them as having both high enjoyment and high importance. She also noticed that her mood was better on days when she completed those activities that were both enjoyable and important. Other activities, like mowing the lawn, she found she did not enjoy as much, though they were often important, and she began to schedule them less frequently and tried to balance them out with other more enjoyable activities.

Mariana found some activities difficult to complete on her own. Although she could find a local Puerto Rican community group, she was nervous to attend the group on her own and kept rescheduling and then not completing the activity. Mariana used an “Assist” (“Acuerdo”) within ¡Aptívate! to ask her bilingual co-worker to attend the group with her. After attending the group for the first time, Mariana found that she was much less nervous to attend subsequent meetings and eventually scheduled additional activities to take on a bigger role within the group, including helping to organize a fundraising event.

During Mariana’s two-month follow-up with Dr. Williams, she recompleted the PHQ-9 and her score was now a 4 on the measure, a clinically significant decrease from her prior score. Dr. Williams reviewed with Mariana her use of ¡Aptívate! and they together looked at the “Progress” (“Progreso”) tab in the app to review the connection between Mariana’s daily mood and the number of activities she was completing. They noticed that when Mariana began using the app her mood fluctuated, but over time her mood gradually improved and remained improved as she increased her activity level. Dr. Williams encouraged Mariana to continue to push herself to complete activities that are consistent with her values as completing those activities appeared to help improve her mood.

Although Dr. Williams adopted a largely “hands off” approach in terms of instructions provided to Mariana regarding how to use the app and follow-up provided as she used the app, the amount of guidance provided may vary by provider. For example, Dr. Williams (or another medical staff member) could have helped Mariana to download the app during the initial appointment, walked her through the initial steps of creating values and activities, and checked in with her via phone a few days later to confirm that she was using the app and to answer any questions. This additional guidance may help to promote continued app utilization and treatment adherence.

DISCUSSION

¡Aptívate! was developed to meet the need for a disseminable, evidence-based psychological treatment for Spanish-speaking Latino/as treated via primary care. Preliminary examination of treatment feasibility and efficacy is currently underway via a small-scale (N=40) randomized clinical feasibility trial. Study participants are randomized to receive either ¡Aptívate!, an active control mobile app that is also delivered in Spanish (“iCouch CBT”), or no mobile app. Results of this trial will help to determine use patterns of ¡Aptívate! and whether ¡Aptívate! utilization is associated with changes in depressive symptoms over time.

There are a number of limitations that should be noted. Beyond a direct language translation, ¡Aptívate! was not culturally adapted from the English-language Brief BA app. During the app development process, the degree to which the English-language Brief BA app should be culturally adapted was considered. Because Brief BA does not specify what values must be selected or what activities must be scheduled, it was reasoned that the English-language app, without substantial adaptation, would be fitting for accommodating the core values of different cultural groups. For example, familism, or the centrality of the family unit, is a commonly held Latino/a value. This cultural value can be accommodated within ¡Aptívate! by generating familism-consistent values within the “Relationships” life area and then scheduling activities consistent with those values. However, it is possible that more extensive, deep structure cultural adaptations to tailor the app specifically for Latino/as with LEP and elevated depressive symptoms may be needed to promote treatment engagement and remission of depressive symptoms. Future studies should consider ways in which ¡Aptívate! could be culturally adapted to improve treatment benefits.

Although a randomized clinical feasibility trial is currently underway, neither the efficacy nor the effectiveness of ¡Aptívate! has yet been established. As such, it is unclear whether this app will be efficacious for reducing depressive symptomatology among Latino/a adults with LEP and elevated depressive symptoms. If there is any benefit on depressive symptoms of ¡Aptívate! treatment, that benefit may not be uniform across patients with different levels of depressive symptoms. It may be more difficult for those with more severe depressive symptoms to identify values and activities and complete activities. Similarly, those with severe symptoms of depression may not respond to calendar prompts to complete activities or to rate mood daily. Thus, treatment benefits may be limited for those with severe depressive symptoms. Additional treatment approaches such as motivational interviewing may be necessary to promote app engagement and completion of activities scheduled within the app. Future studies should consider examining depression symptom severity as a moderator of treatment impact as well as the impact of utilizing ¡Aptívate! as a treatment adjunct for those with severe depressive symptoms.

Acknowledgements:

The authors would like to thank MountainPass Technology LLC, including Zachary Gavin, Jim Nichols, Bryan Hobbs, Brian Cordyack, and Tamara Wiesen, for their contributions to the development of ¡Aptívate!.

Financial Support and Role of the Funding Source: Funding for this research was provided by the National Institute of Minority Health and Health Disparities (R41 MD010491) and by the National Institute on Drug Abuse (T32 DA007288, K23 DA045766). The funding sources had no role in study design, data collection, data analysis, data interpretation, in writing this report, or in the decision to submit this article for publication.

Footnotes

Disclosure Statement: The authors (JD, JK, CWL) are co-owners of Behavioral Activation Tech, LLC which owns the rights to ¡Aptívate!. The authors report no other actual or potential conflicts of interest that may bias the present work.

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