Feature

Ricardo Muñoz is at home in the Mission District, San Francisco's Latino barrio. In fact, he's only moved eight blocks in 40 years.

In 1961, at age 10, Muñoz immigrated with his family from Peru to the Mission District. They made their home on 14th Street. He went to school on 16th Street, worked his way through college at the Pacific Gas and Electric Company on 18th Street, and, in 1977, six days after completing his doctoral degree at the University of Oregon, Eugene, he came back to work on 22nd Street at San Francisco General Hospital (SFGH), where he's been for 25 years.

"As immigrants, we used the public-sector clinics, like the University of California, San Francisco (UCSF) School of Dentistry, and the Mission's Spanish-speaking stores. Now, I am providing Spanish-speaking services at San Francisco General as a professor of psychology at UCSF," notes Muñoz.

As psychology professor and chief psychologist at SFGH, he directs the UCSF clinical psychology training program and the UCSF/SFGH Latino Mental Health Research Program. From his office at San Francisco General, Muñoz can see his grammar school, the streets he walked as a child, and places he played. Measuring his journey in blocks illustrates Muñoz's devotion to the people in the barrio.

Muñoz is among the many psychologists giving back to their communities by identifying problems and working to solve them. His work includes establishing a depression clinic, directing a depression-prevention research project and constructing a Web site to conduct smoking-cessation clinical trials.

And his work is making an impact well beyond the barrio--it's felt worldwide.

"Why wait until people are suffering from a clinical condition to provide them with the knowledge psychology has developed?" he asks. "Why not add preventive services to the activities that mental health professionals carry out? Why not act systematically to avoid unnecessary suffering?"

Those questions are always on Muñoz's mind.

Preventing depression

In the early 1980s, Muñoz and colleagues developed, in Spanish and English, an eight-session group cognitive behavioral intervention for primary-care patients at SFGH--the Depression Prevention Course. In 1983, he carried out the first randomized control trial for the prevention of onset of depression with funding from the National Institute of Mental Health (NIMH). As of now, there are still only four such trials.

From his initial study, he found that many primary-care patients were already suffering from depression and not receiving treatment. So, in 1985, he co-founded the Depression Clinic at San Francisco General with psychologists Jeanne Miranda, PhD, and Sergio Aguilar-Gaxiola, PhD.

No patient was ever billed for the services provided. The clinic was so successful that, in 1995, its services were expanded into a full-service outpatient clinic as part of a newly formed psychosocial medicine division. "For 10 years we provided free individual and group cognitive therapy, in Spanish and English, to a population that otherwise would not have gotten it, by staffing the clinic with trainees whom we supervised," he says.

Although immigrants have comparatively low rates of depression and substance abuse disorders when they first arrive in the United States, "the longer they remain here the more symptoms they have," says Muñoz. In fact, "their children born here have the highest rates," he notes.

"If we know there's a population that's at risk for increased psychological problems, it makes sense to try to protect that population," he says.

That's also the thinking behind his creation of the "Mamás y Bebés/Mothers and Babies: Mood and Health Project." Muñoz oversees the project as director of the Latino Mental Health Research Program through the University of California. The goal of the program is to prevent depression and its negative effects on English- and Spanish-speaking pregnant women receiving prenatal care at San Francisco General.

"The idea is to test whether we can avert a woman from sliding into serious depression," Muñoz explains. "If so, we might be able to prevent a major depressive episode and the chronic recurrent course of major depression, as well as the negative effects on babies whose mothers are depressed during and after pregnancy."

He and his colleagues invite these women, who are using public-sector clinics, to come to an adapted Depression Prevention Course--the "Mothers and Babies Course"--at no charge. The women in the program are at risk for depression. "These are women who may have had a depressive episode in the past or who have trouble regulating their moods but are not currently clinically depressed," he notes.

Women who do meet the criteria for a clinical depressive episode are referred for standard treatment.

The interventions he uses are currently being developed and tested with funding from NIMH. "We're testing the course, doing focus groups with women and they really like it. These women want to be the best mothers in the world, so we focus on the development of their babies," he says enthusiastically. "It's exciting to see how some of these women use these ideas right away."

Creating a healthy world

In addition to Mamás y Bebés, Muñoz is hard at work on another project--the "Spanish/English Web site for Smoking Cessation Trials"--also under the auspices of the UCSF/SFGH Latino Mental Health Research Program, with Eliseo Pérez-Stable, MD, Leslie Lenert, MD, and Jackie Stoddard, a postdoctoral intern. The project is designed to conduct randomized control trials via the Web, to gradually develop more effective interventions that can be administered without participants having to go to professionals' offices.

The site, http://stopsmoking.ucsf.edu or http://dejardefumar.ucsf.edu, provides information about quitting smoking and invites users to participate in the study. Smokers can choose to give consent to participate in the research study and if so, their data are collected online. Those who don't want to take part are able to browse the site. Participants fill out questionnaires and get feedback about their responses and strategies for quitting.

The personalized feedback seems to be all the incentive needed to participate--92 percent of participants complete all questionnaires. Then they gain access to an online intervention--a smoking cessation guide and nicotine replacement information. At one month and six months, they receive e-mail with a link to the site so that data can be collected about whether they quit successfully.

As the site becomes more advanced, Muñoz says there will be audio information, such as relaxation instructions, designed to reach those with lower reading levels. In the future, participants will be randomly assigned to different interventions to gather information on what works best over the Web for different types of smokers.

More than 1,500 English speakers and 800 Spanish speakers--some in other countries--have signed up so far. Although the gender breakdown is very different, he says he is finding that smoking patterns are very similar. Most smokers started smoking when they were 15 and became regular smokers at 18.

"It's really an example of the use of technology to reach the underserved," as well as an example of how his work to help people in his own back yard is reaching far outside his own community, he says. They have participants from 75 countries so far, even his native Peru. He hopes this study will spark "more evidence-based, health-related offerings on the Web so that Spanish-speaking U.S. Latinos will learn to use this medium too."

Serving communities well beyond the Mission

Muñoz is proud to say he's come eight blocks in 40 years. But he's also proud to point out that his work, which has emanated from his home in the barrio, has reached much farther than those eight city blocks.

The Depression Prevention Course has been translated into Chinese, Japanese, Korean, German and Finnish--with a version for hearing-impaired people in Finland--and used in the Outcomes of Depression International Network in England, Ireland, Norway, Finland and Spain. Muñoz is contributing to the World Health Organization report on prevention of mental disorders. And he is co-chairing the Psychosocial Intervention Development Workgroup for NIMH's project: "Breaking Ground, Breaking Through," which is reviewing research on mood disorders and preparing a plan for research for the next few years.

Muñoz also feels a great sense of pride in his role as director of the UCSF Clinical Psychology Training Program.

"The SFGH psychiatry department is very diverse. The faculty and staff serve as a critical mass that attracts more minority faculty and trainees," he explains. "Many of our minority psychology fellows have gone on to great careers. And through our trainees, our work here in the Mission at San Francisco General Hospital has an impact elsewhere."

Summing up his career and the long reach of his work from the barrio, he says, "It's important to help your community by providing services and teaching others. And I'm still amazed that I am able to work within the community I grew up in and still have my work have an impact far away."