Articles

Efficacy of culturally adapted interventions for common

mental disorders in people of Chinese descent: a systematic
review and meta-analysis
Siying Li, Zhenyang Xi, Phoebe Barnett, Rob Saunders, Roz Shafran, Stephen Pilling

Summary
Lancet Psychiatry 2023; Background Evidence suggests that culturally adapted psychological interventions have some benefits in treating
10: 426–40 diverse ethnic groups. However, the effect of such cultural adaptions specifically in Chinese ethnic groups has not
See Comment page 374 been thoroughly reviewed. We aimed to systematically assess the evidence for the efficacy of different cultural
For the Chinese translation of the adaptations in treating common mental disorders in people of Chinese descent (ie, ethnic Chinese populations).
abstract see Online for
appendix 1
Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, CNKI, and
Centre for Outcomes Research
and Effectiveness, Department
WANFANG to identify randomised controlled trials published in English and Chinese from database inception to
of Clinical, Educational and March 10, 2023. We included trials of culturally adapted psychological interventions in people of Chinese descent
Health Psychology (S Li BSc, (with at least 80% of Han Chinese descent) aged 15 years or older with a diagnosis or subthreshold symptoms of
P Barnett MSc, R Saunders PhD, common mental disorders, including depression, anxiety disorders, and post-traumatic stress disorder. We excluded
Prof S Pilling PhD), Department
of Experimental Psychology
studies that included participants with severe mental disorders (eg, schizophrenia, bipolar disorder),
(Z Xi MSci), and Great Ormond neurodevelopmental disorders, or dementia. Study selection and data extraction were done by two independent
Street Institute of Child Health reviewers, who extracted data for study characteristics, cultural adaptations, and summary efficacy. The primary
(Prof R Shafran PhD), University
outcome was post-intervention change in symptoms (both self-reported and clinician-rated). We used random-effects
College London, London, UK;
National Collaborating Centre models to calculate standardised mean differences. Quality was assessed using the Cochrane risk of bias tool. The
for Mental Health, Royal study is registered with PROSPERO (CRD42021239607).
College of Psychiatrists,
London, UK (Prof S Pilling);
Findings We identified 32 791 records, 67 of which were included in our meta-analysis (60 done in mainland China,
Camden and Islington NHS
Foundation Trust, London, UK four in Hong Kong, and one each in Taiwan, Australia, and the USA). We included 6199 participants (mean age
(Prof S Pilling) 39·32 years [range 16–84]), of whom 2605 (42%) were male and 3247 (52%) were female. Culturally adapted
Correspondence to: interventions had medium effect sizes in terms of reducing both self-reported (Hedges’ g 0·77 [95% CI 0·61–0·94];
Ms Siying Li, Centre for I2 84%) and clinician-rated (0·75 [0·54–0·96]; 86%) symptom severity across all disorders at end of treatment,
Outcomes Research and irrespective of adaptation types. We noted no difference in efficacy between culturally modified interventions and
Effectiveness, Department of
Clinical, Educational and Health
culturally specific interventions. Subgroup analyses showed considerable heterogeneity. Inadequate reporting in
Psychology, University College included studies largely restricted risk-of-bias appraisals across all domains.
London, London WC1E 7HB, UK
lyndsey.li.17@ucl.ac.uk
Interpretation Psychological interventions can be transported across cultures with appropriate modifications.
Adaptations to interventions can be made by modifying evidence-based interventions, or in culturally specific ways
that are rooted in the sociocultural context. However, findings are limited by the insufficient reporting of interventions
and cultural adaptations.

Funding None.

Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Introduction characterised by strong collectivism and emphasises

Evidence-based psychological interventions are a social hierarchy, including respect for authority and filial
mainstay of the treatment approach to mental disorders piety.7 These cultural values have shaped Chinese
in most developed health-care systems (as recommended, conceptualisations and manifestations of mental health
for example, by the American Psychological Association1 problems (eg, the notion of integrating body and mind
and UK National Institute for Health and Care proposed in Taoism might mean that Chinese people are
Excellence2). However, the effects of psychological more likely to somatise mental health symptoms).8 As a
interventions could be culturally specific.3 Both the result, help-seeking from mental health services might
conceptualisation and the treatment of mental disorders be lower among Chinese populations than other ethnic
are arguably best understood in a culturally specific groups, leading to more severe clinical profiles at
frame of reference.4,5 treatment initiation and an increased likelihood of poor
Confucianism, Taoism, and Buddhism have treatment outcomes or treatment dropout.9 Therefore,
fundamentally shaped Chinese culture,6 which is psychological interventions developed in North America

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Research in context
Evidence before this study Added value of this study
Most psychological interventions in common use were developed To our knowledge, this systematic review and meta-analysis is
in North America and western Europe, and these interventions the first to assess the efficacy of cultural adaptations of
might be culturally incongruent for people from different psychological interventions for people of Chinese descent. Our
cultures. Previous reviews of cultural adaptations of psychological findings suggest that cultural adaptations increase the efficacy
interventions for diverse ethnic groups have shown that they of psychological interventions in this population. Therapist-
have some positive benefits, but different ethnic groups were related, content-related, and organisational adaptations all
often aggregated in these analyses, which could mean that improved intervention efficacy, but we could not directly
important distinctions between cultures have been overlooked. compare their efficacy. Culturally modified evidence-based
Whether the benefits of different cultural adaptations hold up in psychological interventions and culturally specific
populations of Chinese descent is unclear. In addition, interventions developed within Chinese culture had similar
psychological interventions provided to people of Chinese efficacy.
descent include both culturally adapted interventions developed
Implications of all the available evidence
in North America and western Europe, and novel interventions
We identified some benefits for cultural adaptations to
developed in the Chinese cultural context. We searched
psychological interventions for people of Chinese descent
MEDLINE, Embase, PsychINFO, CNKI, and WANFANG with the
(predominantly of Han Chinese descent), but improved
search terms (China OR Chinese) AND ((systematic review) OR
reporting of methods of development and implementation is
meta-analys*) AND (mental OR psycho* OR *therap*) from
needed to enable more extensive assessments of efficacy. Our
database inception to March 10, 2023, for studies published in
findings highlight the importance of cultural considerations in
English or Chinese. We found no reviews that directly attempted
delivering effective treatments to wider populations. An
to assess the efficacy of cultural adaptations for this population
international consensus on the definition, development, and
and to compare the types of cultural adaptation. We did not
dissemination of methods to support cultural adaptations
identify any reviews that directly assessed the comparable
could substantially improve future research and its clinical
effectiveness of cultural adaptations in treating common mental
application.
disorders of people of Chinese descent.

and western Europe that are grounded in Western eight dimensions (ie, language, persons, metaphors,
epistemological and philosophical traditions might be content, concepts, goals, methods, and context) of the
culturally incongruent for people of Chinese descent (ie, ecological validity model to assess the level of cultural
ethnic Chinese populations) living in China or around adaptation of minimally guided interventions for
the world, who might have a different cultural and social common mental disorders, and noted increasing
context.10,11 For example, assertiveness is a component of intervention effect sizes with increasing numbers of
some evidence-based interventions developed in North dimensions adapted.
America and western Europe, but there is no equivalent A conceptual typology drawing on common factors
term in Chinese.12 shared across psychological interventions and competence
Cultural adaptation has been defined as the systematic frameworks has been developed on the basis of cultural
modification of evidence-based interventions to consider adaptations reported in previous studies.4,16,22 This typology
language, culture, and context so that the interventions incorporates important service-level adaptations (ie,
are congruent with the cultural background of service service design and delivery considerations) beyond the
users.13 Substantial efforts have been made to understand psychological intervention itself, and it has been associated
and assess culturally adapted psychological interventions with improved clinical outcomes.16 In this Article, we are
to improve outcomes in diverse ethnic groups.14,15 adopting this typology to distinguish therapist-related (eg,
Evidence from systematic reviews and meta-analyses16–19 changes to support the development of the therapeutic
suggests that these adaptations have been successful, but relationship, such as ethnic matching of therapists to
a lack of consensus on describing or categorising the service users, whereby service users are matched with
different types of cultural adaptations that have been therapists of the same ethnicity), content-related (eg,
implemented has hindered understanding of which cultural modifications of the use of terms in materials and
types of adaptation might be the most beneficial. resources), and organisational (eg, changes to service
Furthermore, these analyses have combined adaptations design and provision) adaptations.16
for different cultures, meaning that differences between Another approach to providing culturally adapted
cultures might be missed. Several cultural adaptation treatment is the development of culturally specific
frameworks have been developed to address the lack of interventions informed by alternative cultural,
consensus, notably the ecological validity model from philosophical, or religious beliefs that address culturally
Bernal and colleagues.20 A meta-analysis21 used the specific issues.12,23 The core principles and therapeutic

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methods of culturally specific interventions are rooted in challenges of young people.26 Trials of both indicated
the values and traditions of a particular culture. However, prevention and treatments were included. In line with
to our knowledge, despite considerable efforts to adapt the Institute of Medicine Framework, indicated
and develop psychological interventions to mesh more prevention refers to intervention in people who have
closely with Chinese culture, no one has systematically detectable signs or symptoms of a disorder but do not
summarised the efficacy of culturally modified or meet diagnostic criteria, whereas treatment refers to
culturally specific interventions that have been derived intervention in people with a diagnosed disorder.27 Trials
from Chinese culture. of combination psychological and pharmacological
Establishing the efficacy of cultural adaptations of interventions were excluded unless the pharmacological
psychological interventions for almost a fifth of the treatment was already underway before trial initiation or
world’s population could contribute substantially to the constituted treatment as usual.
improvement of global mental health care. In this Our study protocol was registered with PROSPERO
systematic review and meta-analysis, we aimed to (CRD42021239607) and adhered to the PRISMA
establish which types of cultural adaptations for people reporting guidelines.28
of Chinese descent have been developed and assessed in
randomised controlled trials, whether the identified Data extraction
culturally adapted interventions were efficacious, and the Our primary outcome was symptom severity after the
comparative efficacy of culturally modified and culturally intervention of interest as measured on a validated scale.
specific interventions. Preplanned secondary outcomes were attrition by end of
treatment, wellbeing, and social functioning, but we do
Methods not report the social-functioning analyses because data in
Search strategy and selection criteria included studies were scarce. Data extraction was done
In this systematic review and meta-analysis, we by SL and ZX independently. Completed data extraction
systematically searched MEDLINE (inception Jan 1, 1946), sheets were cross-checked for accuracy and consistency,
Embase (inception Jan 1, 1947), PsycINFO (inception with discrepancies resolved by consensus. We extracted
Jan 1, 1806), CNKI (inception June 1, 1999), and and analysed summary estimates for self-reported and
WANFANG (inception Aug 1, 1997) for articles published clinician-rated outcome measures separately at
from database inception to March 10, 2023. We used a four different timepoints (end of treatment, and
search strategy that included a combination of keyword 1–3 months, 4–6 months, and 7–12 months after end of
and subject heading searches, including terms related to treatment). Whenever a study included more than
randomised controlled trials, China or Chinese, common one comparison (eg, if it had more than one primary
mental disorders, and psychological interventions, to outcome, or more than one intervention group) the
identify studies published in English or Chinese. Our sample size was halved to avoid double counting. For
See Online for appendix 2 full search strategy is in appendix 2 (pp 2–10). SL and ZX studies with more than two intervention groups, we
independently screened all identified studies for included each pair-wise comparison separately, but
eligibility. Conflicts were resolved by consensus and divided the sample size of the shared control group
through discussion with a senior reviewer (SP). approximately evenly among the comparisons to avoid
We included randomised controlled trials of double counting that could spuriously increase precision,
psychological interventions that were developed or in line with guidance from the Cochrane Handbook for
modified in a way that was compatible with the Chinese Systematic Reviews of Interventions.29
cultural context or addressed culturally specific issues, We developed a data-extraction form in Microsoft Excel
compared with non-adapted interventions or no to extract data for the number of participants, age, sex,
intervention. Eligible studies were in people aged 15 years mental health conditions, intervention type (indicated
or older with an established diagnosis or sub-threshold prevention or treatment), intervention data (ie, content,
symptoms of common mental disorders, including number of sessions, intervention settings, intervention
depression, anxiety disorders, and post-traumatic stress format, practitioner information, and delivery format),
disorder. We excluded studies that included participants adaptations, approach (culturally modified or culturally
with severe mental disorders (eg, schizophrenia, bipolar specific), comparator (active intervention, attentional
disorder), eating disorders, substance use disorders, control, treatment as usual, waitlist, or no treatment),
neurodevelopmental disorders, or dementia. Our outcome data, and methodical characteristics to inform
inclusion criteria were in line with the definition of the quality assessment. Culturally modified adaptations
common mental disorder in guidelines from the UK were defined as modifications to the content, structure,
National Institute for Health and Care Excellence24 and or delivery of evidence-based interventions to address the
WHO.25 We included only studies in which at least 80% cultural context or culturally specific issues without
of participants were ethnically Han Chinese, irrespective changing the core methods. Culturally specific
of nationality, and we included people from age 15 years interventions were defined as novel intervention types
to capture the increasing interest in the mental health informed by particular cultural, philosophical, or

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religious beliefs that addressed culturally specific issues. could not be reached. Studies were judged to be at low
Cultural adaptations were further coded according to the risk, unclear risk, or high risk of bias on the basis of
conceptual framework,16 as therapist-related adaptations appraisals of selection, performance, detection, attrition,
to support the development of therapeutic relationship and reporting biases.29
(eg, ethnic matching of therapists to service users, use of
pre-intervention discussions to establish rapport, Data analysis
communication informed by cultural values held to be We used random-effects models to calculate effect sizes
important for a particular community), content-related (as standard mean differences) and measures of attrition
adaptations to ensure the acceptability and suitability (as odds ratios), with associated 95% CIs. We used the
of treatment content (eg, cultural modifications to metafor package in R, which corrects for the positive
materials, use of culturally relevant terms of reference, biases of standard mean differences and provided a
incorporation of faith or religious beliefs into treatment), Hedges’ g,30 which enabled comparisons across disparate
or organisational adaptations to service design and outcome measures by pooling variances and standardising
delivery informed by cultural knowledge and interfacing outcomes across studies that used different outcome
with existing service structures (eg, changes to the time measures.31 We considered p values of less than 0·05 to
or length of the intervention or where the intervention is be significant and interpreted effect size conventionally. A
provided, provision of interventions remotely or in group Hedges’ g of less than 0·2 was considered a negligible
settings, making treatment easier to access). Further effect, a value of 0·2 to less than 0·5 a small effect, a value
details on the classification of cultural adaptation in of 0·5 to 0·8 a medium effect, and a value of more than
interventions are in appendix 2 (pp 11–12). 0·8 a large effect.32 Heterogeneity was calculated with the
SL and ZX independently used the Cochrane Risk I² statistic and classified as not important (I² 0–40%)
of Bias tool29 to assess the methodological quality of moderate (30–60%), substantial (50–90%), or
included studies, with discrepancies discussed and considerable (75–100%).29
resolved by consensus, with input from SP if a consensus We did subgroup analyses to assess the efficacy
of interventions grouped by adaptation type (ie,
therapist-related, content-related, or organisational),
32 791 studies identified through searches of
MEDLINE (n=10 464), PsycINFO (n=1628), approach (ie, culturally modified or culturally specific),
Embase (n=5909), CNKI (n=9997), intervention type, region, age group, diagnosis, and
and WANFANG (n=4793)
comparator group. Analyses were done in any subgroup
with more than one comparison. For studies that did
11 790 duplicates removed not report data for outcome measures at the end of
treatment but reported follow-up within a month of the
end of treatment, these follow-up data were taken as the
21 001 titles and abstracts screened
end-of-treatment data. For studies in which data for
interventions targeting any comorbid disorders were
18 977 excluded reported, we extracted all target symptoms and
analysed them separately. We used Cochran’s Q to
test heterogeneity between subgroups. Univariate and
2024 full texts assessed for eligibility
multivariate meta-regression were used to explore the
effect of intervention types, control types, targeting
1953 excluded disorders, adaptation type, and adaptation approaches
1780 incorrect intervention on intervention efficacy for both self-rated and clinician-
106 not in target population
15 incorrect publication type* rated measures. The effect sizes for the primary
13 outcomes not related to mental outcome were assessed for publication bias by visual
health
35 not randomised controlled trials examination of funnel plots. We did all analyses in R
4 secondary publications (version 4.0.0).

Role of the funding source

71 studies included in systematic review
There was no funding source for this study.

4 excluded (extremely large effect sizes) Results

We did three searches of published work between
67 studies included in meta-analysis
Dec 1, 2020, and March 10, 2023. The searches returned
32 791 studies, 71 of which met our inclusion criteria and
Figure 1: PRISMA diagram
were included in the systematic review (figure 1). Most
*Includes studies not published in peer-reviewed journals, dissertations, and included studies were done in mainland China
letters to the editor. (n=64 studies), with four studies done in Hong Kong and

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430
Mean age, Sex Location Control Intervention Intervention Cultural Adaptation area
years (range; type approach
SD)
Therapist-related Content-related Organi­sational
Articles

Anxiety disorder (generalised anxiety disorder)

Deng* (2021; n=80)33 27 (21–76; 3) 29 (36%) female; Liaoning, China TAU CBT with exercise Treatment Modified Yes Yes Yes
51 (64%) male
Gu et al (2022; n=70)34 37 (NR; 11) 38 (54%) female; Henan, China TAU Cognitive coping therapy Treatment Specific Yes Yes Yes
25 (36%) male;
7 (10%) NR
Hu et al (2022; n=64)35 24 (20–30; 3) 45 (70%) female; Beijing, China Active (literal CBT) Metaphorical CBT Indicated Modified No Yes Yes
19 (30%) male prevention
Li et al (2021; n=45)36 24 (NR; 3) 29 (64%) female; Beijing, China Attentional Intolerance of uncertainty Indicated Modified No Yes Yes
11 (24%) male; control cognitive bias modification prevention
5 (11%) NR of interpretation
Li (2022; n=80)37 38 (NR; 6) 35 (56%) female; Guangxi, China TAU Morita therapy and Treatment Specific No Yes Yes
45 (44%) male relaxation
Meng and Li (2008; 34 (16–57; 9) 33 (55%) female; Henan, China TAU Chinese Taoist cognitive Treatment Specific No Yes Yes
n=60)38 27 (45%) male psychotherapy
Wang et al (2022; n=72)39 45 (NR; 6) 42 (58%) female; Beijing, China Attentional Chinese medicine, Treatment Specific No Yes Yes
30 (42%) male control emotional management,
and baduanjin exercise
Yang et al (2017; n=103)40 58 (42–79; 9) 50 (49%) female; Gansu, China TAU Naikan cognitive therapy Treatment Specific No Yes Yes
53 (51%) male
Yu et al (2008; n=84)41 30 (18–64; 14) 49 (58%) female; Liaoning, China TAU Chinese Taoist cognitive Treatment Specific Yes Yes Yes
35 (42%) male psychotherapy
Yu (2021; n=78)42 49 (NR; 3) 35 (45%) female; Shandong, China TAU Integrated psychotherapy Treatment Specific Yes Yes Yes
43 (55%) male
Zhang et al (2002; n=70)43 35 (NR; 20) 63 (44%) female; Hunan, Shanghai, TAU Chinese Taoist cognitive Treatment Specific No Yes Yes
80 (56%) male† Zhejiang, and psychotherapy
Heilongjiang, China
Zhang et al (2002; n=73)43 35 (NR; 20) 63 (44%) female; Hunan, Shanghai, TAU Chinese Taoist cognitive Treatment Specific No Yes Yes
80 (56%) male† Zhejiang, and psychotherapy (with
Heilongjiang, China medication as TAU)
Zhang et al (2014; n=70)44 37 (NR; 10) 32 (46%) female; Shandong, China Active (Morita Naikan and Morita therapy Treatment Specific No Yes Yes
35 (50%) male; therapy)
3 (4%) NR
Anxiety disorder (multiple diagnostic groups)‡
Che et al (2021; n=60)45 27 (25–40; 10) 60 (100%) female Shandong, China TAU Morita therapy Treatment Specific Yes Yes Yes
Feng et al (2017; n=110)46 35 (21–68; 9) 39 (35%) female; Liaoning, China Active (relaxation Chinese medicine, cognitive Treatment Specific No Yes Yes
51 (46%) male; training) therapy
20 (18%) NR
Hou et al (2019; n=78)47 39 (18–65; 5) 35 (45%) female; Sichuan, China Attentional Structural family therapy Treatment Modified Yes Yes Yes
43 (55%) male control
Liu et al (2020; n=54)48 22 (18–28; 3) 46 (85%) female; China Waitlist iCBT Indicated Modified Yes Yes Yes
8 (15%) male prevention
Sun et al (2014; n=70)49 NR (16–35; NR) 70 (100%) NR Shanxi, China No intervention Self-confidence training Treatment Specific No Yes Yes
Wang et al (2014; n=67)50 NR (18–64; NR) 38 (57%) female; Guangdong, China TAU Chinese medicine, cognitive Treatment Specific No Yes Yes
29 (43%) male therapy with relaxation
Wang et al (2021; n=200)51 43 (22–76; 8) 117 (59%) female; Shandong, China TAU Chinese medicine, Treatment Specific Yes Yes Yes
83 (41%) male integrated psychotherapy
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 Mean age, Sex Location Control Intervention Intervention Cultural Adaptation area
years (range; type approach
SD)
Therapist-related Content-related Organi­sational
(Continued from previous page)
Zheng (2016; n=84)52 46 (20–66; 4) 39 (46%) female; Sichuan, China TAU Chinese medicine, cognitive Treatment Specific No Yes Yes
45 (54%) male therapy with relaxation
Anxiety disorder (obsessive compulsive disorder)
Chi et al (2014; n=64)53 26 (NR; 12) 35 (55%) female; Jiangsu, China TAU Integrated psychotherapy Treatment Specific No Yes Yes
29 (45%) male (thinking disrupted-
concentrated reappear
method)

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Mei et al (2000; n=64)54 33 (NR; 19) 36 (56%) female; Jiangsu, China TAU Morita therapy Treatment Specific Yes Yes Yes
28 (44%) male
Meng et al (2019; n=167)55 29 (NR; 14) 66 (40%) female; Beijing, China TAU CBT Treatment Modified Yes Yes Yes
101 (60%) male
Shi et al (2005; n=56)56 32 (18–53; 6) 27 (48%) female; Guangxi, China TAU Morita therapy Treatment Specific Yes Yes Yes
29 (52%) male
Wu (2018; n=90)57 36 (22–62; 5) 42 (47%) female; Zhejiang, China TAU Chinese medicine, cognitive Treatment Specific Yes Yes Yes
48 (53%) male therapy with relaxation
Anxiety disorder (panic disorder)
Guo et al (2013; n=60)58 38 (17–68; NR) 34 (57%) female; Henan, China TAU Integrated psychotherapy Treatment Specific No Yes Yes
26 (43%) male
Wang et al (2021; n=25)59 44 (NR; 12) 11 (44%) female; Shanxi, China Attentional Simplified CBT Treatment Modified Yes Yes Yes
14 (56%) male control
Anxiety disorder (social anxiety disorder)
Ni et al* (2010; n=41)60 21 (20–24; 2) 15 (37%) female; Shandong, China No intervention Morita therapy-based group Treatment Specific Yes Yes Yes
26 (63%) male counselling
Sun et al (2019; n=38)61 21 (NR; 2) 31 (82%) female; Beijing, China Attentional Cognitive bias modification Indicated Modified No Yes Yes
7 (18%) male control prevention
Wen et al (2020; n=64)62 28 (NR; 12) 57 (89%) female; China Active (iCBT) iCBT Treatment Modified No Yes Yes
7 (11%) male
Yang* (2015; n=68)63 22 (15–31; 8) 41 (60%) female; Jilin, China TAU Cognitive insight therapy Treatment Specific Yes Yes Yes
27 (40%) male
Mixed anxiety-depressive disorder
Chen et al (2022; n=118)64 35 (NR; 9) 59 (50%) female; Guangdong, China TAU Online mindfulness-based Treatment Modified Yes Yes Yes
41 (35%) male; stress reduction
18 (15%) NR
Liang et al (2021; n=52)65 21 (NR; 3) 32 (62%) female; Anhui, China Attentional Dialectical behavioural Indicated Modified No Yes Yes
20 (38%) male control therapy prevention
Sun et al (2021; n=114)66 22 (NR; 3) 84 (74%) female; China (27 provinces) Attentional Mindfulness-based mobile Indicated Modified Yes Yes Yes
30 (26%) male control intervention prevention
Yan et al (2022; n=60)67 66 (NR; 9) 90 (75%) female; Beijing, China TAU Transdiagnostic group Treatment Modified Yes Yes Yes
27 (22·5%) male; cognitive behavioural
3 (2·5%) NR† intervention
Yan et al (2022; n=60)67 66 (NR; 9) 90 (75%) female; Beijing, China TAU Transdiagnostic individual Treatment Modified Yes Yes Yes
27 (22·5%) male; cognitive behavioural
3 (2·5%) NR† intervention
Zhang et al (2006; 29 (20–56; NR) 136 (100%) male Zhejiang, China TAU Morita therapy Treatment Specific No Yes Yes
n=136)68
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Mean age, Sex Location Control Intervention Intervention Cultural Adaptation area
years (range; type approach
SD)
Therapist-related Content-related Organi­sational
(Continued from previous page)
Articles

Zhang et al (2017; n=60)69 38 (NR; 11) 70 (52%) female; Shanghai, China TAU Simplified CBT Treatment Modified Yes Yes Yes
64 (48%) male†
Zhang et al (2017; n=74)69 38 (NR; 11) 70 (52%) female; Shanghai, China TAU Simplified CBT (with Treatment Modified Yes Yes Yes
64 (48%) male† medication as TAU)
Zhang et al (2023; 30 (NR; 4) 160 (100%) female Shandong, China TAU Digital guided self-help Indicated Modified No Yes Yes
n=160)70 mindfulness training prevention
Depression
Chan et al (2011; n=40)71 49 (25–64; 11) 30 (75%) female; Hong Kong Active (CBT) Chan-based Dejian mind– Indicated Specific No Yes Yes
10 (25%) male body intervention prevention
Chan et al (2012; n=34)72 47 (28–62; 12) 28 (80%) female; Hong Kong Active (CBT) Chan-based Dejian mind– Treatment Specific No Yes Yes
6 (20%) male body intervention
Cheng and Cui (2022; 31 (NR; 8) 27 (45%) female; Beijing, China Attentional iCBT Treatment Modified No Yes Yes
n=60)73 33 (55%) male control
Choi et al (2012; n=58)74 39 (21–68; 12) 44 (76%) female; Australia Waitlist Brighten your mood iCBT Treatment Modified Yes Yes Yes
11 (19%) male;
3 (5%) NR
Choy and Lou (2016; 79 (NR; 10) 74 (65%) female; Hong Kong Waitlist Instrumental Reminiscence Indicated Modified Yes Yes Yes
n=114)75 40 (35%) male Intervention—Hong Kong prevention
Ding et al (2018; n=64)76 37 (NR; 8) 27 (42%) female; Fujian, China Active (CBT) Culturally adapted CBT Treatment Modified Yes Yes Yes
37 (58%) male
Fu (2018; n=80)77 50 (20–71; 6) 38 (48%) female; Shaanxi, China TAU Traditional Chinese Treatment Specific Yes Yes Yes
42 (53%) male medicine psychotherapy
Guo et al (2020; n=300)78 28 (NR; 8) 23 (8%) female; Guangdong, China Waitlist Run4Love WeChat-based Indicated Modified No Yes Yes
277 (92%) male intervention prevention
Hang et al (2015; n=24)79 46 (NR; 16) 26 (55%) female; Anhui, China Waitlist Online counselling Indicated Modified Yes Yes Yes
21 (45%) male† prevention
Hang et al (2015; n=23)79 46 (NR; 16) 26 (55%) female; Anhui, China Waitlist Face-to-face counselling Indicated Modified Yes Yes Yes
21 (45%) male† prevention
He et al (2022; n=99)80 19 (17–21; 1) 37 (37%) female; Tianjin, China Attentional XiaoE CBT-based chatbot Indicated Modified No Yes Yes
62 (63%) male control prevention
Hsiao et al (2011; n=63)81 37 (NR; 14) 48 (76%) female; Taiwan TAU Body–mind–spirit therapy Treatment Specific Yes Yes Yes
15 (24%) male
Hwang et al (2015; n=50)82 45 (18–65; 12) 36 (72%) female; USA Active (unadapted Culturally adapted CBT Treatment Modified Yes Yes No
14 (28%) male CBT)
Li et al (2013; n=186)83 23 (21–26; 1) 49 (26%) female; China No intervention iCBT Indicated Modified No Yes Yes
32 (17%) male; prevention
105 (56%) NR
Li (2015; n=90)84 68 (NR; 10) 45 (50%) female; Chongqing, China TAU Group reminiscence therapy Treatment Modified Yes Yes Yes
45 (50%) male
Li et al (2019; n=100)85 64 (46–84; 10) 48 (48%) female; Jilin, China TAU Group reminiscence therapy Treatment Modified Yes Yes Yes
38 (38%) male;
14 (14%) NR
Liu et al (2018; n=100)86 67 (60–77; 6) 43 (43%) female; Sichuan, China Active (group Group integrated Treatment Specific No Yes Yes
34 (34%) male; CBT) psychotherapy
23 (23%) NR
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 Mean age, Sex Location Control Intervention Intervention Cultural Adaptation area
years (range; type approach
SD)
Therapist-related Content-related Organi­sational
(Continued from previous page)
Liu et al (2022; n=83)87 23 (19–28; 2) 46 (55%) female; Heilongjiang, Hubei, Active XiaoNan CBT-based chatbot Indicated Modified No Yes Yes
37 (45%) male and Guangdong, China (bibliotherapy) prevention
Lv et al (2022; n=80)88 67 (NR; 7) 29 (36%) female; Hebei, China TAU Reminiscence-themed Indicated Specific Yes Yes Yes
45 (56%) male; reality therapy prevention
6 (8%) NR
Qiao (2013; n=64)89 34 (NR; 10) 43 (67%) female; Liaoning, China TAU Naikan therapy and group Treatment Specific No Yes Yes

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21 (33%) male CBT
Ren et al* (2016; n=62)90 21 (NR; 2) 28 (45%) female; China Waitlist Moodgym iCBT Treatment Modified No Yes Yes
17 (27%) male;
17 (27%) NR
Wang (2018; n=60)91 63 (NR; 11) 35 (58%) female; Beijing, China TAU Low-resistance state Treatment Specific No Yes Yes
25 (42%) male thought induction
psychotherapy with exercise
Wang et al (2019; n=64)92 32 (NR; 18) 39 (61%) female; Guangdong, China TAU Narrative psychotherapy Treatment Modified No Yes Yes
21 (33%) male;
4 (6%) NR
Wei et al (2021; n=70)93 68 (61–78; 8) 28 (40%) female; Henan, China TAU Group reminiscence therapy Indicated Modified No Yes Yes
42 (60%) male prevention
Wen et al (2008; n=63)94 62 (NR; 11) 27 (43%) female; Guangxi, China TAU Chinese Taoist cognitive Treatment Specific Yes Yes Yes
36 (57%) male psychotherapy
Wu and Wang (2018; 26 (21–36; 4) 63 (34%) female; Guangxi, China TAU Morita therapy Treatment Specific No Yes Yes
n=184)95 121 (66%) male
Xiang (2007; n=22)96 NR (NR; NR) 22 (100%) NR Sichuan, China No intervention Group counselling Indicated Modified No Yes Yes
prevention
Xie et al (2019; n=80)97 72 (NR; 4) 47 (59%) female; Hunan, China TAU Modified behavioural Indicated Modified Yes Yes Yes
33 (41%) male activation treatment prevention
Ying et al (2022; n=220)98 42 (NR; 20) 117 (53%) female; Zhejiang, China Active (face-to- WeChat-delivered CBT Indicated Modified No Yes Yes
59 (27%) male; face CBT) prevention
44 (20%) NR
Yu et al (2021; n=65)99 27 (18–38; 10) 44 (68%) female; Shanghai, China Attentional Simplified CBT Treatment Modified Yes Yes Yes
21 (32%) male control
Zhou and Zhang (2018; 41 (19–60; 20) 125 (58%) female; Shandong, China TAU Naikan cognitive therapy Treatment Specific No Yes Yes
n=217)100 92 (42%) male
Zhou et al (2019; n=152)101 NR (NR; NR) 152 (100%) female Guangdong, China TAU Group CBT and mother– Treatment Modified Yes Yes Yes
infant relationship therapy
Post-traumatic stress disorder
Wang et al (2013; NR (NR; NR) 143 (78%) female; Sichuan, China Waitlist Chinese My Trauma Indicated Modified No Yes Yes
n=183)102 40 (22%) male Recovery online self-help prevention
intervention
Wu et al (2014; n=53)103 40 (NR) 17 (32%) female; Hong Kong Active (self-help Brief CBT Indicated Modified Yes Yes Yes
36 (68%) male programme) prevention
For intervention type, indicated prevention describes interventions in people who have detectable signs or symptoms of a disorder but do not meet diagnostic criteria, whereas treatment refers to interventions in people with a diagnosed disorder.
NR=not reported. NA=not applicable. TAU=treatment as usual. CBT=cognitive behavioural therapy. iCBT=internet-based cognitive behavioural therapy. *Included in systematic review but not in meta-analysis. †The study has more than one
experimental group; sex data are reported for all participants in the study and are not available by intervention. ‡Included a mix of participants with various types of anxiety disorders (including generalised anxiety disorder, social anxiety disorder, panic
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disorder, and obsessive compulsive disorder) or did not specify the specific subtype of anxiety disorder.

Table 1: Characteristics of included studies

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Hedges’ g (95% CI)

Chan et al (2011)71 0·35 (−0·28 to 0·97)

Chan et al (2012)72 −1·50 (−2·26 to −0·74)
Che et al (2021)45 0·58 (0·06 to 1·10)
Chen et al (2022)64 (depression outcome) 1·08 (0·66 to 1·50)
Chen et al (2022)64 (anxiety outcome) 0·90 (0·49 to 1·31)
Cheng and Cui (2022)73 0·76 (0·24 to 1·29)
Choi et al (2012)74 0·90 (0·34 to 1·46)
Choy and Lou (2016)75 0·99 (0·53 to 1·45)
Gu et al (2022)34 0·54 (0·04 to 1·04)
Guo et al (2020)78 0·62 (0·39 to 0·86)
Hang et al (2015)79 (in−person group) 1·59 (0·62 to 2·57)
Hang et al (2015)79 (online group) 1·89 (0·89 to 2·90)
He et al (2022)80 1·57 (1·08 to 2·05)
Hou et al (2019)47 1·05 (0·54 to 1·55)
Hsiao et al (2011)81 0·34 (−0·22 to 0·90)
Hu et al (2022)35 −0·16 (−0·65 to 0·33)
Li et al (2013)83 0·11 (−0·35 to 0·56)
Li (2015)84 2·74 (2·16 to 3·31)
Li et al (2021)36 0·34 (−0·29 to 0·96)
Liang et al (2021)65 (anxiety outcome) 0·77 (0·20 to 1·33)
Liang et al (2021)65 (depression outcome) 0·71 (0·15 to 1·27)
Liu et al (2020)48 1·03 (0·39 to 1·67)
Liu et al (2022)87 0·82 (0·37 to 1·27)
Lv et al (2022)88 1·92 (1·37 to 2·47)
Sun et al (2014)49 0·73 (0·22 to 1·24)
Sun et al (2019)61 0·35 (−0·29 to 0·99)
Sun et al (2021)66 (anxiety outcome) 0·01 (−0·36 to 0·38)
Sun et al (2021)66 (depression outcome) 0·26 (−0·11 to 0·63)
Wang et al (2013)102 0·67 (0·37 to 0·96)
Wang et al (2014)50 0·88 (0·38 to 1·39)
Wang (2018)91 0·99 (0·45 to 1·52)
Wen et al (2020)62 0·14 (−0·62 to 0·90)
Wu et al (2014)103 0·24 (−0·41 to 0·89)
Xiang (2007)96 0·25 (−0·59 to 1·09)
Xie et al (2019)97 0·68 (0·21 to 1·16)
Yan et al (2022)67 (group intervention, anxiety outcome) 1·71 (0·84 to 2·59)
Yan et al (2022)67 (group intervention, depression outcome) 1·78 (0·90 to 2·67)
Yan et al (2022)67 (individual intervention, anxiety outcome) 1·05 (0·25 to 1·86)
Yan et al (2022)67 (individual intervention, depression outcome) 1·12 (0·31 to 1·93)
Yang et al (2017)40 1·00 (0·59 to 1·41)
Ying et al (2022)98 0·57 (0·30 to 0·84)
Yu et al (2008)41 0·66 (0·22 to 1·10)
Yu (2021)42 −0·66 (−1·12 to −0·21)
Zhang et al (2002)43 (combined intervention group) 0·92 (0·41 to 1·43)
Zhang et al (2002)43 (single intervention group) 0·90 (0·38 to 1·41)
Zhang et al (2006)68 (anxiety outcome) 2·29 (1·86 to 2·72)
Zhang et al (2006)68 (depression outcome) 1·93 (1·53 to 2·34)
Zhang et al (2017)69 (combined intervention group) 0·09 (−0·42 to 0·59)
Zhang et al (2017)69 (single intervention group) 0·57 (0·03 to 1·11)
Zhang et al (2023)70 (anxiety outcome) 0·85 (0·39 to 1·30)
Zhang et al (2023)70 (depression outcome) 0·55 (0·10 to 1·00)
Zheng (2016)52 0·71 (0·27 to 1·15)
Zhou et al (2019)101 0·56 (0·24 to 0·89)
Overall (I2 84%) 0·77 (0·61 to 0·94)

−3 −2 −1 0 1 2 3 4

Figure 2: Forest plot of effect of adapted interventions on self-reported symptom measures at the end of treatment
The size of the datapoints are proportional to the study sample size.

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one each in Taiwan, Australia, and the USA (table 1). of some of the classifications, are in appendix 2
Studies covered a range of common mental disorders, (pp 13–15, 23).
including interventions targeting depression (n=31), Four studies33,60,63,90 had very large effect sizes
anxiety disorders (n=31), mixed anxiety–depressive (Hedges’ g >3). The scores on symptom measures in
disorder (n=7), and post-traumatic stress disorder (n=2). these studies were unusual compared with those typically
All studies described more than one type of adaptation reported in meta-analyses of common mental disorders
and included content-related adaptations; only one study82 (eg, typically reporting zero change or deterioration of
did not have organisational adaptations. 35 (49%) studies symptoms in control groups, whereas most studies
detailed therapist-related adaptations. 37 (52%) of the reported reductions in symptom severity in both groups)
studies were of culturally modified interventions, and and were excluded from our meta-analysis (as was done
34 (48%) were of culturally specific interventions (table 1). in a similar previous review14). Thus, our meta-analysis
Further intervention characteristics and descriptions of included 67 studies, 6199 patients, and 71 comparisons of
cultural adaptations for included studies, and explanation adapted interventions with controls (22 indicated

Hedges’ g (95% CI)

Chan et al (2012)72 −0·01 (−0·68 to 0·66)

Che et al (2021)45 1·47 (0·90 to 2·04)
Cheng and Cui (2022)73 1·73 (1·13 to 2·32)
Chi et al (2014)53 0·62 (0·12 to 1·12)
Ding et al (2018)76 1·56 (1·00 to 2·12)
Feng et al (2017)46 1·09 (0·69 to 1·49)
Fu (2018)77 0·49 (0·05 to 0·94)
Gu et al (2022)34 0·57 (0·07 to 1·08)
Guo et al (2013)58 0·12 (−0·40 to 0·64)
Hwang et al (2015)82 0·18 (−0·43 to 0·80)
Li et al (2019)85 1·04 (0·59 to 1·49)
Li et al (2022)37 0·71 (0·26 to 1·16)
Liu et al (2018)86 0·80 (0·33 to 1·26)
Mei et al (2000)54 1·91 (1·32 to 2·50)
Meng and Li (2008)38 0·62 (0·10 to 1·14)
Meng et al (2019)55 0·44 (0·08 to 0·81)
Qiao (2013)89 0·65 (0·15 to 1·15)
Shi et al (2005)56 0·46 (−0·07 to 0·99)
Wang et al (2014)50 0·45 (−0·04 to 0·94)
Wang (2018)91 0·75 (0·23 to 1·28)
Wang et al (2019)92 1·18 (0·63 to 1·73)
Wang et al (2021a)51 0·74 (0·46 to 1·03)
Wang et al (2021b)59 0·26 (−0·53 to 1·04)
Wang et al (2022)39 2·08 (1·50 to 2·65)
Wei et al (2021)93 1·51 (0·98 to 2·04)
Wen et al (2008)94 0·35 (−0·15 to 0·85)
Wu (2018)57 −0·40 (−0·69 to −0·11)
Wu and Wang (2018)95 0·54 (0·12 to 0·96)
Yan et al (2022)67 (group intervention, anxiety outcome) 1·39 (0·55 to 2·22)
Yan et al (2022)67 (group intervention, depression outcome) 1·96 (1·06 to 2·87)
Yan et al (2022)67 (individual intervention, anxiety outcome) 1·01 (0·21 to 1·82)
Yan et al (2022)67 (individual intervention, depression outcome) 1·50 (0·66 to 2·35)
Yang et al (2017)40 1·73 (1·28 to 2·19)
Yu (2021)42 −1·40 (−1·90 to −0·91)
Yu et al (2021)99 0·78 (0·27 to 1·28)
Zhang et al (2014)44 0·31 (−0·17 to 0·79)
Zhang et al (2017)69 (combined intervention group) 0·13 (−0·38 to 0·63)
Zhang et al (2017)69 (single intervention group) 0·49 (−0·05 to 1·02)
Zhou and Zhang (2018)100 0·44 (0·17 to 0·71)
Overall (I2 86%) 0·75 (0·54 to 0·96)

−2 −1 0 1 2 3

Figure 3: Forest plot of effect of adapted interventions on clinician-rated symptom measures at the end of treatment
The size of the datapoints are proportional to the study sample size.

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preventions [n=21 studies] and 49 treatments [n=46]). At the end of treatment, culturally adapted interventions
The mean age of the sample was 39·3 years (range 16–84). had medium effect sizes in terms of reducing self-
2605 (42%) participants were male and 3247 (52%) were reported symptom severity (n=42; Hedges’ g 0·77 [95% CI
female. In our risk-of-bias assessments, inadequate 0·61–0·94]; I² 84%; figure 2) and clinician-rated symptom
reporting in included studies largely restricted quality severity (n=35; 0·75 [0·54–0·96]; 86%; figure 3) across all
appraisals across all domains (appendix 2 p 24). For disorders. The subgroup difference between self-reported
example, 46 studies did not include a consort diagram and clinician-rated measures was not significant when
and 31 studies did not report attrition at any stage of the examined with Cochran’s Q (p=0·88; I² 0%). Further
intervention. Funnel plots suggested little publication subgroup analyses by region (ie, China vs Hong Kong),
bias in estimates of effects on both self-reported and diagnosis, and age group did not reduce heterogeneity to
clinician-rated scales (appendix 2 p 25). a moderate level (appendix 2 pp 27–28). Cultural
adaptation showed benefits in studies of both indicated
Number of studies Hedges’ g (95% CI) p value I² prevention and treatment (appendix 2 pp 26–27). In
(comparisons) subgroup analyses, cultural adapations were still
Therapist-related adaptations efficacious in terms of effect on self-reported symptoms
Self-reported when compared with active interventions only (eg,
End of treatment 19 (26) 0·86 (0·60 to 1·12) <0·0001 84% non-adapted alternative psychotherapy, attentional
1–3 months of follow-up 6 (10) 0·65 (0·34 to 0·96) <0·0001 67% control, treatment as usual), rather than with waitlist or
4–6 months of follow-up 4 (5) 0·43 (0·26 to 0·59) <0·0001 8% no intervention (active interventions n=33; 0·77
7–12 months of follow-up 1 (4) 1·73 (0·92 to 2·53) <0·0001 70% [0·56–0·97]; I² 86%; waitlist control n=8; 0·79
Clinician-rated [0·55–1·04]; 57%; appendix 2 pp 26–27). The beneficial
End of treatment 16 (21) 0·72 (0·43 to 1·02) <0·0001 85% effects of culturally adapted interventions persisted at all
1–3 months of follow-up 1 (4) 1·66 (0·98 to 2·33) <0·0001 57% follow-up timepoints (appendix 2 pp 26–27).
4–6 months of follow-up 3 (4) 1·11 (0·02 to 2·21) 0·047 93%
Interventions involving any of the three types of
7–12 months of follow-up 2 (5) 1·58 (0·91 to 2·24) <0·0001 71%
adaptations (ie, therapist-related, content-related, or
Content-related adaptations
organisational adaptations) efficaciously reduced
symptoms compared with any control at the end of
Self-reported
treatment and at the 1–3-month follow-up (table 2). The
End of treatment 42 (53) 0·77 (0·61 to 0·94) <0·0001 84%
32 studies of therapist-related adaptations included in
1–3 months of follow-up 14 (19) 0·74 (0·49 to 0·99) <0·0001 77%
the meta-analysis showed large effect sizes at the end of
4–6 months of follow-up 5 (6) 0·42 (0·27 to 0·57) <0·0001 0%
treatment, and these were larger on self-reported scales
7–12 months of follow-up 1 (4) 1·73 (0·92 to 2·53) <0·0001 70%
(n=19; Hedges’ g 0·86 [95% CI 0·60–1·12]; I² 84%) than
Clinician-rated
on clinician-rated scales (n=16; 0·72 [0·43–1·02]; 85%;
End of treatment 35 (39) 0·75 (0·54 to 0·96) <0·0001 86%
table 2). All studies included in the meta-analysis
1–3 months of follow-up 2 (5) 1·40 (0·69 to 2·11) <0·0001 77%
involved content-related adaptations, which produced
4–6 months of follow-up 3 (4) 1·11 (0·02 to 2·2) 0·047 93%
medium effect sizes on both self-reported (n=42; 0·77
7–12 months of follow-up 2 (5) 1·58 (0·91 to 2·24) <0·0001 71%
[0·61 to 0·94]; 84%) and clinician-rated scales (n=35; 0·75
Organisational adaptations [0·54 to 0·96]; 86%; table 2). Organisational adaptations
Self-reported were reported in 66 studies included in the meta-analysis
End of treatment 42 (53) 0·77 (0·61 to 0·94) <0·0001 84% and had similar results at end of treatment on both
1–3 months of follow-up 14 (19) 0·74 (0·49 to 0·99) <0·0001 77% self-reported (n=42; 0·77 [0·61–0·94]; 4%) and clinician-
4–6 months of follow-up 5 (6) 0·42 (0·27 to 0·57) <0·0001 0% rated scales (n=34; 0·77 [0·55–0·98]; 86%; table 2).
7–12 months of follow-up 1 (4) 1·73 (0·92 to 2·53) <0·0001 70% Subgroup analysis and meta-regression were only
Clinician-rated possible for comparisons based on reporting of
End of treatment 34 (38) 0·77 (0·55 to 0·98) <0·0001 86% therapist-related adaptations (because nearly all studies
1–3 months of follow-up 2 (5) 1·40 (0·69 to 2·11) <0·0001 77% incorporated both content-related and organisational
4–6 months of follow-up 3 (4) 1·11 (0·02 to 2·2) 0·047 93% adaptations). Efficacy (as measured by Cochran’s Q) did
7–12 months of follow-up 2 (5) 1·58 (0·91 to 2·24) <0·0001 71% not differ significantly between studies in which
Culturally specific approaches therapist-related adaptations were reported and those in
Self-reported which such adaptations were not reported (p=0·37, I² 0%
End of treatment 15 (17) 0·76 (0·36 to 1·15) 0·0002 91% for self-reported efficacy; p=0·76, 0% for clinician-rated
1–3 months of follow-up 2 (2) 1·38 (–1·22 to 3·99) 0·30 97% efficacy).
Clinician-rated Both culturally specific and culturally modified
End of treatment 24 (24) 0·62 (0·35 to 0·89) <0·0001 89% interventions had medium-to-large effect sizes for
4–6 months of follow-up 2 (2) 1·96 (0·25 to 3·66) 0·024 93% symptom severity at the end of treatment for self-reported
(Table 2 continues on next page) symptoms (culturally specific Hedges’ g=0·76 [95% CI
0·36–1·15]; culturally modified 0·76 [0·60–0·93]) as well

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as clinician-rated symptoms (culturally specific 0·62

Number of studies Hedges’ g (95% CI) p value I²
[0·35–0·89]; culturally modified 0·98 [0·68–1·27]; (comparisons)
table 2). Culturally specific and culturally modified
(Continued from previous page)
adaptations did not differ significantly from each other
Culturally modified approaches
according to Cochran’s Q (p=0·98, I² 0% for comparison
Self-reported
of self-reported efficacy; p=0·083, 67% for comparison of
End of treatment 27 (36) 0·76 (0·60 to 0·93) <0·0001 76%
clinician-rated efficacy).
Univariate meta-regressions showed no significant 1–3 months of follow-up 12 (17) 0·63 (0·44 to 0·83) <0·0001 60%

associations between intervention types, control types, or 4–6 months of follow-up 3 (4) 0·42 (0·25 to 0·63) <0·0001 22%

diagnosis and symptom reduction measured on either 7–12 months of follow-up 1 (4) 1·73 (0·92 to 2·53) <0·0001 70%
self-reported or clinician-rated measures at end of Clinician-rated
treatment (appendix 2 p 29). Therapist-related adaptations End of treatment 11 (15) 0·98 (0·68 to 1·27) <0·0001 74%
were not significantly associated with symptom reduction 1–3 months of follow-up 1 (4) 1·66 (0·98 to 2·33) <0·0001 57%
(self-reported b 0·16, p=0·37; clinician-rated b –0·07, 4–6 months of follow-up 1 (2) 0·28 (–0·35 to 0·92) 0·38 66%
p=0·76). Compared against each other, neither culturally 7–12 months of follow-up 1 (4) 1·56 (0·64 to 2·48) 0·0009 77%
modified nor culturally specific interventions were Effect sizes are for studies comparing interventions with any control.
associated with significant improvements in treatment
Table 2: Subgroup analyses of effect sizes for interventions incorporating different adaptation types, by
outcomes (self-reported b –0·005, p=0·98; clinician- timepoint
rated b –0·36, p=0·10), even after controlling for targeted
disorders and control type (appendix 2 p 10).
Attrition data were available for 43 interventions (n=40). presumably incorporated therapist-related and content-
Participants were significantly less likely to drop out of related adaptations, such as ethnic matching of therapists
intervention groups than active control groups to service users, therapists’ cultural awareness, translation
(10% vs 15%; odds ratio 0·63 [95% CI 0·49–0·81]; of content, and the use of culturally congruent materials.
p=0·0003). The proportion of participants who dropped The same probably holds for organisational adaptations
out did not differ significantly between intervention because interventions were mostly provided within the
groups and waitlist or no-intervention control groups common standardised approach to care—typically
(21% vs 23%; 1·08 [0·49–2·35]; p=0·86). Further delivered in inpatient and outpatient departments at local
comparison of participant dropout by diagnosis is in hospitals. Extensive attempts to develop new interventions
appendix 2 (p 29). Adapted interventions resulted in within the Chinese cultural context were evident: roughly
significant improvement in wellbeing at the end of half of the included studies reported culturally specific
treatment (n=13, Hedges’ g 1·65 [95% CI 0·87–2·42]; interventions that were based on Chinese philosophical
appendix 2 p 29). underpinnings (eg, Chinese Taoist cognitive therapy,
Morita therapy) or multi-modal interventions closely tied to
Discussion the Chinese sociocultural context (eg, cognitive insight
Our systematic review showed that substantial efforts therapy, Chinese medicine cognitive therapy).43,44,50,63 Despite
have been made to develop culturally appropriate continuous global efforts to develop cultural adaptation
interventions for common mental disorders in people of frameworks,16,20 these frameworks do not seem to have
Chinese descent, but these adaptations varied substantially. been used to guide the cultural adaptation process in many
Our meta-analysis suggested benefits for these adapted of the randomised controlled trials in our study. This issue
interventions, with moderate-to-large effect sizes (as could be addressed by the development and implementation
measured by both self-reported and clinician-rated of an internationally agreed framework on cultural
improvement in symptoms) for both indicated prevention adaptations.
and treatment compared with waitlist, no intervention, or Importantly, the range of effects in the studies reported
non-adapted active controls. All included studies in our review are in line with the effects of treatment
incorporated more than one type of adaptation, which reported in meta-analyses of psychological interventions
might explain why no one adaptation type was significantly delivered in Western health-care systems.104,105 There has
better than any other in subgroup analyses or meta- been considerable debate about the adaptability of
regression. Importantly, we identified no differences in Western psychological interventions, such as cognitive
efficacy between culturally modified interventions adapted behavioural therapy, that are based on specific cultural
from Western interventions and culturally specific conceptions of mental disorders, and whether such
interventions rooted within the Chinese cultural context. interventions might be efficacious only when delivered in
No study focused on one specific adaptation type and a congruent cultural context.3–7 We identified no difference
adaptations across several areas tended to be made in efficacy between culturally specific and culturally
simultaneously, which is typical of most studies of culturally modified interventions, suggesting that evidence-based
based adaptations.16 Most of the included studies were interventions developed in a Western context can be
based in China, which means that these interventions beneficial in Chinese cultural contexts when adapted and

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embedded into health-care systems, without any considerations. Reaching an international consensus on
fundamental modification of the nature of the intervention the definition, development, and dissemination of
or integration of core Chinese cultural values. Cultural cultural adaptations could provide a firm foundation for
adaptations could provide an additive benefit to evidence- future research and implementation of the cultural
based therapeutic models with established efficacy by adaption of psychological interventions.
aligning the construction, conceptualisation, and delivery Contributors
of psychological interventions with cultural values.106 SL, SP, and RSh conceived the study, which was supervised by SP.
This study had several limitiations. First, the validity SL wrote the protocol, managed the bibliographic database searches,
screening, and study-selection processes, extracted data, and ran the
and reliability of the conceptual typology16 we used might analyses. ZX supported the screening, study-selection, and data-
be limited when applied to populations of predominantly extraction processes. PB, SP, RSa, RSh, and SP contributed to the
Han Chinese descent. The original typology16 was research methods, and PB, RSa, and RSh contributed to the data
developed from research in ethnic groups who were analyses. SL wrote the first draft of the article, which was reviewed and
edited by SP, PB, RSa, and RSh. All authors accessed and verified all the
typically minorities in the settings where they were data in the study, and were responsible for the decision to submit for
treated. By contrast, most of the studies included in this publication.
review were done in native communities who would not Declaration of interests
necessarily experience difficulties accessing treatments in We declare no competing interests.
the same way. For example, in the context of improving Data sharing
access to mental health treatment for ethnic minorities, The data extracted and analysed in this study can be made available by
organisational-specific adaptations refer to changes to the the corresponding author upon request.
routinely delivered care to provide culturally informed Editorial note: The Lancet Group takes a neutral position with respect to
and accessible care (eg, novel, culturally appropriate territorial claims in published text.
pathways to care). However, for the studies included in References
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