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Chibanda, D., Verhey, R., Gibson, L. J., Munetsi, E., Machando, D., Rusakaniko, S., ... Abas, M. (2016).
Validation of screening tools for depression and anxiety disorders in a primary care population with high HIV
prevalence in Zimbabwe. Journal of Affective Disorders, 198, 50-5. https://doi.org/10.1016/j.jad.2016.03.006
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Author’s Accepted Manuscript
Validation of screening tools for depression and
anxiety disorders in a primary care population with
high HIV prevalence in Zimbabwe
Dixon Chibanda, Ruth Verhey, Lorna J Gibson,
Epiphania Munetsi, Debra Machando, Simbarashe
Rusakaniko, Ronald Munjoma, Ricardo Araya,
Helen A Weiss, Melanie Abas
PII:
DOI:
Reference:
www.elsevier.com/locate/jad
S0165-0327(15)31311-2
http://dx.doi.org/10.1016/j.jad.2016.03.006
JAD8093
To appear in: Journal of Affective Disorders
Received date: 23 November 2015
Revised date: 3 March 2016
Accepted date: 5 March 2016
Cite this article as: Dixon Chibanda, Ruth Verhey, Lorna J Gibson, Epiphania
Munetsi, Debra Machando, Simbarashe Rusakaniko, Ronald Munjoma, Ricardo
Araya, Helen A Weiss and Melanie Abas, Validation of screening tools for
depression and anxiety disorders in a primary care population with high HIV
prevalence
in
Zimbabwe, Journal
of
Affective
Disorders,
http://dx.doi.org/10.1016/j.jad.2016.03.006
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Validation of screening tools for depression and anxiety disorders in a primary
care population with high HIV prevalence in Zimbabwe
Dixon Chibanda1,*, Ruth Verhey1, Lorna J Gibson2, Epiphania Munetsi1, Debra
Machando3, Simbarashe Rusakaniko1, Ronald Munjoma1, Ricardo Araya2, Helen A
Weiss2, Melanie Abas4
1
Zimbabwe Aids Prevention Project-University of Zimbabwe Department of
community medicine, 92 Prince Edward Street, Harare, Zimbabwe
2
London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
3
Women’s University in Africa, Brighton Road, Mount Pleasant, Harare, Zimbabwe
4
Institute of Psychiatry, Psychology and Neurosciences, King’s College, London
*
Corresponding author: dichi@zol.co.zw
Abstract:
Background
In low income countries in Sub-Saharan Africa there are few validated tools to screen
for common disabling mental disorders such as depression and general anxiety
disorder (GAD).
Objectives
We validated three screening tools: the Shona Symptom Questionnaire for common
mental disorders (SSQ-14), the Patient Health Questionnaire for depression (PHQ9), and the Generalized Anxiety Disorder questionnaire (GAD-7). The study
participants were attendees at a primary health care clinic in Harare, Zimbabwe.
Methods
Consecutive adults aged 18 and above attending the clinic were enrolled over a twoweek period in September 2013. Trained research assistants administered the
screening tools to eligible participants after obtaining written consent. Participants
were then interviewed by one of four psychiatrists using the Structured Clinical
Interview of the DSM-IV (SCID). Performance characteristics were calculated for
each tool, against the SCID as the gold standard.
Results
A total of 264 participants were enrolled, of whom 52 (20%) met the SCID criteria for
depression alone, 97 (37%) for mixed depression and anxiety and 9 (3%) for anxiety
alone. Of the 237 where HIV status was known, 165 (70%) were HIV positive. With
the optimal cutoff of >9, the sensitivity and specificity for the SSQ-14 against a
diagnosis of either depression and/or general anxiety were 84% (95%CI:78-89%)
and 73% (95%CI:63-81%) respectively. Internal reliability was high (Cronbach α
=0.74). The optimal cutoff for PHQ-9 was >11, which provided a sensitivity of 85%
(95%CI:78-90%) and specificity of 69% (95%CI:59-77%) against a SCID diagnosis of
depression (Cronbach α=0.86). The GAD-7 (optimal cutoff >10) had sensitivity and
specificity of 89% (95%CI:81-94%) and 73% (95%CI:65-80%) respectively against a
SCID diagnosis of GAD (Cronbach α=0.87).
Conclusion
Screening tools for depression and GAD had good performance characteristics in a
primary health care population in Zimbabwe with a high prevalence of HIV. These
can be used for research and also in clinical care to screen patients who may benefit
from treatment
Keywords: depression, general anxiety disorder, validation, sensitivity,
specificity, sub-Saharan Africa
Introduction
Common mental disorders (CMD) which consist of depression and anxiety disorders
(Goldberg and Huxley, 1992; Todd et al., 1999) are a leading cause of disability
globally (Steel et al., 2014). Almost three-quarters of people with CMD in low and
middle income countries (LMIC) are estimated to be untreated (Lancet Global Mental
Health Group et al., 2007). This is important because depression and anxiety are
associated with consequences including lack of work productivity, loss of
relationships and adverse impacts on development of offspring (Prince et al., 2007).
Treating depression has been highlighted as a ‘best-buy’ condition globally (WHO,
2013). This has particular importance in settings with high HIV prevalence because
detection and treatment of depression and other CMD in people living with HIV
(PLWH) has the potential to improve adherence to antiretroviral therapy (ART) and
thus physical outcomes (Abas et al., 2014a; Sin and DiMatteo, 2014). Identifying
people with CMD using appropriately validated tools is the first step towards
providing care for CMD (Akena et al., 2012b). Culturally appropriate and user friendly
validated tools will be helpful for non-specialist workers, including lay health workers,
to use to assess CMD and to guide clinical care.
The most widely used tool for screening for common mental disorders in Zimbabwe
is the Shona Symptom Questionnaire (SSQ-14) (Patel et al., 1997), a non-specific
tool that screens for possible depressive and anxiety disorders. The SSQ was
previously validated in a general primary health care (PHC) population at a time
when HIV prevalence in the general Zimbabwean population was only 5% (Mertens
et al., 1989). At that time the prevalence of CMD in primary care in Harare was
reported to be 52% using international criteria (i.e. criteria influenced by external
western models, also known as etic criteria) and 59% using indigenous criteria (i.e.
criteria influenced by culture and tradition, also known as emic criteria (Patel and
Mann, 1997). The current national prevalence of HIV infection is approximately 15%
(Silverman et al., 2007) and contributes to the high public health burden at PHC level
(Ferrand et al., 2010). As depression is twice as common in PLWH as in general
populations and because depression symptoms in PLWH can overlap with HIV
physical symptoms such as fatigue and appetite disturbance, it is important to
validate tools for CMD in populations with high HIV prevalence (Tsai, 2014b). In
LMIC, there are few validated tools for the screening of CMD in populations with a
high prevalence of HIV (Chibanda et al., 2015a).
A further reason for validating tools is the emphasis in the last decade on disorderspecific tools both to improve care pathways for depression and anxiety and for
research (Chibanda et al., 2014). The Patient Health Questionnaire (PHQ-9) for
depression, and the Generalized Anxiety Disorder questionnaire (GAD-7) have each
been found to be suitable screening tools for use at the PHC level in different
settings (Kroenke and Spitzer, 2002; Kroenke et al., 2001; Monahan et al., 2009;
Spitzer et al., 2006) but have not been validated in Zimbabwe, particularly in a high
HIV-prevalent setting. Validating these tools both for
screening and to guide
treatment algorithms in our setting will enable researchers to better compare their
findings with other populations receiving treatment in different locations, and to
understand how depression and anxiety differ by geographic location and the
composition of the patient population.
The aim of this study was to validate screening tools against a reference standard,
the Structured Clinical Interview (SCID) of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV), in a population with high prevalence of HIV in urban
Zimbabwe.
Methods
Translation of tools
The first author, a bilingual psychiatrist (DC), carried out the first translation of the
English versions of the PHQ-9 and GAD-into the local language, Shona. This draft
Shona version was reviewed by a team including five Lay Health Workers (LHWs)
working in a primary care mental health program (Chibanda et al., 2011) a bilingual
clinical psychologist (DM), a bilingual counselor (EpM) and DC. This phase focused
on ensuring contextual equivalence to the original versions based on their
understanding and use of local terms for mental distress including kufungisisa
(thinking too much) (Kidia et al., 2015; Patel and Mann, 1997), kusuwa (to feel sad),
kusuwisisa (to feel very sad) and mwoyo unorwadza (painful heart) (Abas et al.,
1994).
The Shona versions of the tools were back-translated into English by a different
independent language expert. A committee of the first author with the clinical
psychologist and counselor examined both the original and back translated versions
and resolved any discrepancies by consensus.
Tools
SSQ-14: The Shona Symptom Questionnaire (Patel et al., 1997) was developed and
validated in Zimbabwe. Most of the items are those common in tools for depression
worldwide such as sleep disturbance and suicidal thoughts; others are local idioms of
emotional distress including ‘thinking too much’. Participants are asked if they have
experienced a list of common mental health symptoms in the past week. Each of the
14 items are scored dichotomously as yes (1) or no (0) (Patel et al., 1997)
PHQ-9: The Patient Health Questionnaire, which asks about symptoms over the past
2 weeks, derives its scoring system from the
DSM-IV criteria for depressive
disorders. Scores: Minor depression (cutoff: 0-9); moderate/moderately severe
depression (cutoff: 15-19); severe depression (cutoff: 20-27) assesses symptoms
of depression as listed in the DSM-IV over the past two weeks. Each of the nine
items is scored from 0 (not at all) to 3 (nearly every day). It is used as a continuous
score ranging from 0 (no depressive symptoms) to 27 (all symptoms occurring daily),
and as a binary measure, with a cut-point of 10 or greater recommended in the US,
(sensitivity and specificity for major depression of 88%) (Kroenke and Spitzer, 2002).
PHQ-2: This screening tool comprises the first two items from the PHQ-9, which
enquire about loss of interest or pleasure in doing things and feeling down, hopeless
or depressed (Lowe et al., 2005). The PHQ-2 is often used as an initial brief
screening for depression, with individuals scoring >3 out of 6 then receiving the full
PHQ-9 (Lowe et al., 2005; Monahan et al., 2009).
GAD-7: The Generalized Anxiety Disorder Screen (GAD-7) is a 7-item Likert scale
that has been validated for the assessment of GAD in both clinical and research
environments in different cultural settings (Kujanpaa et al., 2014; Lowe et al., 2008;
Ruiz et al., 2011; Zhong et al., 2015). It consists of 7 items which measure severity of
symptoms according to reported responses with a maximum possible score of 21
(Spitzer et al., 2006).The questionnaire enquires about symptoms experienced in the
last two weeks, such as “feeling nervous, anxious or on edge” and “not being able to
stop or control worrying” (Lowe et al., 2008).
Structured Clinical Interview of the Diagnostic Statistical Manual for DSM-IV
Axis I Disorders (SCID): The SCID is a diagnostic examination used to
determine major mental disorders. It is administered by a trained mental health
professional such as a psychologist or psychiatrist in order to make a diagnosis
based on the Diagnostic Statistical Manual version IV (DSM-IV) (APA, 1994). The
professional administering the SCID requires clinical skills in the use of open-ended
questions, diagnostic evaluations and cultural knowledge in a wide range of mental,
neurological and substance use disorders (Mezzich et al.). In this validation study,
the SCID was used to make a diagnosis of i) current major depression (mild,
moderate and/or severe) and ii) GAD. Diagnosis of current major depression was
based on the following 5 DSM-IV criteria met: A) Five or more symptoms present for
more than two weeks and represent a significant change from previous functioning;
B) Symptoms did not meet criteria for a mixed episode; C) Symptoms caused
significant impairment in social occupational functioning; D) Symptoms were not due
to the direct effects of a substance; and E) Symptoms were not better accounted for
by bereavement. For GAD, the following DSM-IV criteria were used: A) Excessive
anxiety and worry for at least 6 months; B) Difficulty in controlling the worry; C)
Associated with 3 or more core symptoms; D) The focus of worry is not due to
concerns of an Axis I disorder; E) The anxiety and worry causes clinically significant
distress and impairment in functioning; F) The symptoms are not due to substance
use.
Training procedures
Study personnel (four research assistants, six LHWs and four psychiatrists) attended
a two-week training using a guide initially developed by the authors (DC and RV).
The research assistants were trained in data collection methods using the sociodemographic forms and the screening tools during the first week of the training. The
psychiatrists were trained in the use of the SCID through a discussion forum led by
DC which involved going through the diagnostic criteria, building consensus on how
to manage clinically severe cases during the validation, and procedures for ensuring
fidelity. DC observed the psychiatrists during role-play and the pilot validation where
each psychiatrist used the SCID to interview 4 patients. The referral pathways for
participants meeting criteria for major depression and other acute medical conditions
was that they should be seen by the medical officer first, for assessment, before
being referred to a tertiary psychiatric facility if needed.
Study Design and Location
The validation exercise was carried out as a cross-sectional study at the largest clinic
in the suburb of Mbare, near the central business district of Harare, Zimbabwe. This
clinic has a catchment area of over 200,000 with an average attendance of 140
patients per day. This is a typical primary care clinic in Harare, which is mostly
staffed by nurses and lay health workers
Study population and recruitment
Adults attending the clinic during the two-week study period in September 2013 were
eligible for recruitment, provided they were aged 18 years or older, were able to give
written consent and resided in the area. Pregnant women in their last trimester and
women within the 3-month postnatal period were excluded because for this
population we had previously validated the Edinburgh Postnatal depression Scale
(Chibanda et al., 2009), as were those who were unable to understand the purpose
of the study.
Sample size
We aimed to recruit a representative sample of patients from a primary care clinic. A
minimum of 75 participants who scored positive on the reference standard for
depression (the SCID) and 75 who score negative on the SCID, would provide good
precision for performance indicators: sensitivity of 91% (95%CI:82-96%); specificity
of 80% (95%CI:69-88%), positive predictive value (PPV) of 82% (95%CI:72-90%)
and negative predictive value (NPV) of 90% (95%CI:80-96%). We increased the
sample size to 264 to allow for stratification by HIV status, assuming HIV prevalence
of 60% in the clinic population (Ferrand et al., 2010)
The Validation Procedure:
Stage 1: Each morning during the study period, an appointed research assistant
obtained the register of all adult patients waiting to be seen. The research assistant
randomly selected clinic attendees based on a computer-generated random number
sequence. Fifteen randomly selected participants were invited at one time to a quiet
and private space where eligibility was determined. Informed written consent was
sought from all those eligible. The six research assistants administered the SSQ-14,
PHQ-9, and GAD-7 tools to participants according to a random order determined by
DC and also collected socio-demographic information such as age, gender, HIV
status, marital and employment status. The interviews took 20-30 minutes and were
conducted in a quiet space designated for the study team.
Stage 2: Following administration of the screening tools, participants were referred to
one of four psychiatrists who conducted the SCID. The psychiatrists were blinded to
the screening data. The SCID interview lasted 30 to 60 minutes in a private and quiet
room. All those meeting criteria for DSM IV psychiatric condition were further
assessed for treatment and referral to the psychiatric hospital.
Data collection and management
All data was double entered onto a password-protected database using Stata
(version 13). No participant identifiable information was entered while ethics and
confidentiality for all participants was respected in accordance with the medical
research council of Zimbabwe
Analysis
The performance of each tool against the reference standard (SCID) was as follows:
i) SSQ-14 against any CMD of depression and/or anxiety; ii) SSQ-14 against
depression; iii) PHQ-9 against depression; iv) PHQ-2 against depression; v) GAD-7
against anxiety. For each association, we estimated the sensitivity, specificity,
positive predictive value (PPV) and negative predictive value (NPV) for different cutpoints. For SSQ-14, PHQ-9 and GAD-7, the cut-point was chosen to provide a good
balance of sensitivity and specificity. The PHQ-2 is intended for using as a screening
tool prior to confirmation by PHQ-9, so high sensitivity was chosen for this tool.
Results were presented in the form of a ROC curve which plots the true positive rate
(sensitivity) against the false positive rate (1-specificity) (Pepe, 2003). The area
under a ROC curve (AUC) quantifies the overall ability of the test to discriminate
between those individuals with the outcome and those without the outcome. An AUC
of 0.8 or above is ‘good’. The optimal cut-point was selected to have a good balance
of sensitivity and specificity, except for the PHQ-2 where the tool is used solely as a
screening tool to be confirmed with PHQ-9, so high sensitivity was more important.
Internal reliability was estimated using Cronbachs’ α. All analyses were conducted
using Stata (version 13).
Results
Of the 264 participants, 208 (79%) were female, 157 (60%) were married, and 199
(75%) had completed secondary school education (Table 1). HIV serostatus was
known for 237 (90%) participants, of whom the majority (70%, n=165) were HIV
positive, and 151 (92%) of these were on ART. The prevalence of any CMD by SCID
was high (n=158, 60%), with 52 participants (20%) meeting the SCID criteria for pure
depression, 97 (37%) for mixed depression and anxiety and 9 (3%) for pure anxiety.
CMD prevalence by SCID was substantially higher among PLWH than those without
HIV (67% vs 39%; p<0.001). Prevalence of any CMD was significantly higher among
PLWH than those without HIV (69% vs 41%; p<0.001).
Performance of the SSQ-14 against SCID diagnosis of any CMD (depression
and/or anxiety)
An SSQ-14 cutoff of >9 provided the highest proportion of participants correctly
classified comparing with SCID diagnosis of any CMD (82%). With this cutoff,
sensitivity was 84% (95%CI:78-89%) and specificity was 73% (95%CI:63-81%; Table
2; Figure 1). The ROC curve for the performance of SSQ-14 against any CMD gave
an AUC of 0.86 (95%CI 0.81-0.90; Figure 2) and showed good internal consistency
(Cronbach’s alpha=0.74). With this cutoff of >9 the prevalence of CMD was 61%
(95%CI:55-67%) with PPV 82% (95%CI:75-88%) and NPV 75% (95%CI:66-83%).
Among PLWH, the prevalence of CMD by SSQ-14 was 68% with PPV/NPV of
89%/74%, while among those without HIV the prevalence was 51% with PPV/NPV
62%/80%. Sensitivity and specificity were higher among PLWH than HIV negative
participants (sensitivity=88% vs. 77%; specificity 76% vs. 67%; Table 2; Figure1).
Performance of the SSQ-14 against SCID diagnosis of depression
Similar results were seen for the SSQ-14 against a diagnosis of depression (pure
depression or depression mixed with anxiety), with sensitivity of 86% (95%CI:8092%), specificity 70% (95%CI:61-79%), PPV 79% (95%CI:72-85%) and NPV 79%
(95%CI:70-87%). The tool performed better among PLWH than HIV negative
participants (sensitivity=87% vs. 82%; specificity 71% vs. 66%; Table 2; Figure 1).
Performance of the PHQ-9 against SCID diagnosis of depression
For the PHQ-9, the optimal cutoff of >11 provided sensitivity for detecting depression
(pure depression or depression mixed with anxiety) of 85% (95%CI:78-90%) and
specificity of 69% (95%CI:59-77%; Table 2). The ROC curve gave an AUC of 0.84
(95%CI 0.79-0.88). The PPV was 78% (95%CI:71-84%) and NPV was 77%
(95%CI:68-85%). The sensitivity was higher among PLWH than HIV negative
individuals (88% vs. 79%), but the specificity was similar by HIV status (71 vs. 73%;
Table 2). Internal consistency was very good (Cronbach’s alpha=0.86)
The PHQ-2 had high sensitivity as a screening tool with a cutoff of >2 (sensitivity
91%; 95%CI 86-95%) although this had low specificity (40%; 95%CI:31-50%; Figure
1; Table 2), and this chosen as the optimal cut-point as individuals screening positive
would have a confirmatory test with PHQ-9.
Performance of the GAD-7 against SCID diagnosis of anxiety
A cutoff of >10 for GAD-7 gave a sensitivity of 89% (95%CI:81-94%) and specificity
of 73% (95%CI:65-80%; Table 2; Figure 1), for detecting anxiety (pure anxiety or
depression mixed with anxiety), correctly classifying 79% of participants. The PPV
was 69% (95%CI:60-76%) and NPV was 91% (95%CI 84-95%). The ROC curve
gave an AUC of 0.90 (95%CI 0.87-0.94; Figure 3). Again, the sensitivity was higher
among PLWH than HIV negative individuals (94% vs. 75%) but specificity was lower
among PLWH (68% v 80%; Table 2; Figure 1). There was very good internal
consistency (Cronbachs α=0.87).
Discussion
As interventions for CMD are scaled-up in sub-Saharan Africa, the need for userfriendly validated tools is critical (Abas et al., 2014b). We recently highlighted the
absence of validated tools in clinical trials of psychological interventions for PLWH in
LMIC (Chibanda et al., 2015b). This study demonstrates the feasibility of validating a
series of screening tools for CMD among populations with high prevalence of PLWH
in a resource limited setting. We found the three screening tools (SSQ-14, PHQ-9,
and GAD-7) have good internal consistency and performance characteristics.
All the tools validated in this study were developed in a Western setting (Kroenke et
al., 2001; Lowe et al., 2008) except for the SSQ-14, which was developed in
Zimbabwe using cross-cultural methods in an era of low HIV prevalence (Patel et al.,
1997). The SSQ-14 had been previously validated with a cutoff of >8 (Patel et al.,
1997) but this cut-off provided relatively low specificity (57%) in our current setting
with high HIV prevalence setting. Using a cutoff of >9, we see improved specificity
(70%) with little loss of sensitivity (94% vs. 85%). Overall, 74% of participants were
correctly classified with a cutoff of >8, compared with 79% using a cutoff of >9 and
we recommend use of the higher cutoff in this setting. The high prevalence of CMD
in this population gives stability to the PPV, which is influenced by the prevalence of
the condition under study. Most true positives according to SCID are detected (84%)
with a cutoff of >9 in the total sample and among PLWH (88%).
Our chosen cut-off of >11 for the PHQ-9 is within the range (8-11) reported as
acceptable for detecting depression in a recent meta-analysis on optimal cut-off
scores for diagnosing depression with the PHQ-9 (Manea et al., 2012). A recent
study from South Africa recommended a cut-off of >10, although this gave a low
sensitivity of 49% and a specificity of 94% (Bhana et al., 2015).
The PHQ-2 has been recommended as an initial screen before administering the full
PHQ-9 (Lowe et al., 2005; Monahan et al., 2009) and we recommend a cutoff of >2
which has high sensitivity (91%), assuming that a confirmatory test follows.
The validation of the SSQ-14, PHQ-9, and GAD-7 among PLWH is consistent with
our earlier work which reveals the need to utilize culturally sensitive and adequately
validated tools in LMIC, particularly among PLWH (Abas et al., 2014b). We utilized a
multi-disciplinary team consisting of medical professionals, experts in the English and
Shona (indigenous language) as well as lay health workers who have a deep cultural
understanding of local concepts of depression at community level to ensure
acceptability of our final validated tools. Furthermore, the use of clinicians to
administer the reference standard ensured accuracy in diagnosis by reducing the
risk of misclassification of CMD due, for example, to HIV-associated cognitive
impairment, and general physical symptoms associated with HIV infection as has
been reported
(Tsai, 2014a). Our validated tools have shown good internal
consistency, high sensitivity and acceptable specificity.
Prevalence of HIV is increasing in sub-Saharan Africa due to decreases in mortality
as access to antiretroviral therapy is scaled up, and strength of our study was the
focus on performance of scales among PLWH. The results will enable local
researchers developing epidemiological and intervention studies to work with more
accurate cut-off scores with PLWH. The tools showed consistently better
performance among PLWH than HIV negative individuals, because of the high
prevalence of CMD in the HIV positive group. A limitation of our study is that we had
relatively low precision to evaluate the tools in people living without HIV.
While evidence supporting the use of LHWs is growing (van Ginneken et al., 2013)
the need to build capacity in the area of intervention development and particularly
validation of culturally sensitive tools for use by LHWs has been emphasized (Akena
et al., 2012b). In sub-Saharan Africa, where literacy rates can be extremely low,
there is a need to consider the validation of visual screening tools such as has been
the case in Uganda, where a visual screening tool for depression was found to have
good internal consistency (Akena et al., 2012a). Limitations of our study include the
absence of data on stages of HIV disease, CD4 count, viral load and type of HAART
as these can affect CMD manifestation in PLWH (Akena et al., 2010; Evans et al.,
2002; Pecoraro et al., 2015). Performance of tools for depression could potentially
vary by other factors such as education and gender which we have not investigated
in this paper. There has been concern about using standard tools when screening for
depression in PLWH due to possible overlap of somatic symptoms with HIV-disease
symptoms, and due to the difficulty in separating some depression-related symptoms
from symptoms caused by HIV-associated neurocognitive disorder. This will be a
matter of investigation for a further study.
Conclusion
We have successfully validated different tools for common mental disorders in a high
HIV prevalent setting, showing good performance but with slightly different cutoffs
compared with those used in low HIV prevalence settings. Although our findings can
be generalized to similar settings in Zimbabwe and in the southern African region
where HIV prevalence is high in health service users, there is still need for further
research in sub-Saharan Africa to develop and validate tools that are user-friendly
for LHWs to use in everyday practice.
Acknowledgements
Staff at Edith Opperman Polyclinic Mbare for continued support to the Friendship
Bench initiative, Percy Taruvinga, Tarisai Bere, for training of LHWs and translating
documents.
This study was supported through a Grand Challenges Canada (GCC) grant.
Contribution
DC Study design, initial analysis, first draft and review of subsequent drafts leading
to final manuscript
RV Training of research assistants, review of drafts
EtM Coordinating the recruitment process, review of drafts
RM Recruitment of study participants, data cleaning and review of 3rd draft
EpM Recruitment of participants review of drafts
DM Translation of documents review of drafts
SR review final draft
LG data cleaning, analysis and review of drafts
RA Study design, review of drafts
HW Study design, data analysis, review of drafts
MA Data interpretation, review of drafts
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Figure 1: Sensivitiy and specificity by tool and HIV status
Figure 2: ROC curve for SSQ against CMD - depression and/or anxiety by SCID
(n=264)
Table 1. Characteristics of study participants
Characteristic
Gender
Male
Female
Age group
<30
30-39
40-49
50+
Marital status
Married/partnered
Divorced/widowed
Single
Education
Primary or less
Secondary or more
Current employment status
Unemployed
Permanent full time/part time
Casual/self-employed
Main income source
Own business/salary
Partner/family
No income
Suffer from chronic illness
Negative life eventin last six months
1
HIV prevalence
Prevalence of common mental disorders using the reference standard
SCID-pure depression
SCID- pure anxiety
SCID-mixed depression/anxiety
SCID –any CMD (SCID depression and/or anxiety)
Prevalence of common mental disorders using the tools
SSQ-14 score (median and IQR)
SSQ >= 9
PHQ-9 score (median and IQR)
PHQ-9 >=11
PHQ-2 score (median and IQR)
PHQ-2 >=2
GAD-7 score (median and IQR)
GAD-7>=10
1
Of the 237with known HIV status
All participants
(n=264)
N
%
56
208
21.2%
78.8%
58
91
72
33
22.8%
35.8%
28.4%
13.0%
157
52
55
59.5%
19.7%
20.8%
65
199
24.6%
75.4%
112
26
126
42. 4%
9.9%
47.7%
149
98
17
120
237
165
56.4%
37.1%
6.4%
45.5
89.8%
69.6%
52
9
97
158
19.7%
3.4%
36.7%
59.8%
9
162
13
162
3
205
10
137
7-11
61.4%
8-18
61.4
2-5
77.7%
6-15
51.9%
Table 2. Sensitivity and specificity of tools, overall and by HIV status
Tool
Cutpo
int
Referen
ce
standar
d
All participants
Sensitivity
(95% CI)
Specificity
(95% CI)
HIV positive
participants
Sensiti
Specifi
vity
city
(95%
(95%
CI)
CI)
SSQ>=9
SCID 84% (78-89%) 73% (63-81%)
88%
76%
14
any
(80(631
CMD
93%)
87%)
SSQ>=9
SCID86% (79-91%) 70% (61-79%)
87%
71%
14
depressi
(80(572
on
93%)
82%)
PHQ-9
>=11
SCID85% (78-90%) 69% (59-77%)
88%
71%
depressi
(81(572
on
94%)
82%)
PHQ-2
>=2
SCID91% (86-95%) 40% (31-50%)
92%
25%
depressi
(85(152
on
96%)
39%)
GAD-7
>=10
SCID89% (81-94%) 73% (65-80%)
94%
68%
3
anxiety
(86(5798%)
78%)
1 CMD=any SCID pure depression, pure anxiety or mixed depression/anxiety.
2 Pure Depression or mixed depression/anxiety
3 Pure Anxiety or mixed depression/ anxiety
HIV negative
participants
Sensiti
vity
(95%
CI)
77%
(5890%)
82%
(6394%)
79%
(5992%)
93%
(7699%)
75%
(6890%)
Specifi
city
(95%
CI)
67%
(5080%)
68%
(5281%)
73%
(5785%)
59%
(4374%)
80%
(6888%)
Highlights
Validation of screening tools in sub-Saharan Africa is an important step
towards addressing the treatment gap for common mental disorders.
Special consideration is needed when validating tools in a high HIV prevalent
setting
It is possible to validate multiple tools in a high HIV prevalent setting in low
resource settings.
Figure 1
1.00
Figure 2:
6
5
4
3
2
17
11
7
0.75
8
9
0.50
10
0.25
11
0.00
12
13
14
0.00
0.25
Area under ROC curve = 0.8614
0.50
1 - Specificity
0.75
1.00