Abstract
BackgroundDespite recognition of the burden of disease due to mood disorders in low- and middle-income countries, there is a lack of consensus on best practices for detecting depression. Self-report screening tools, such as the Patient Health Questionnaire (PHQ-9), require modification for low literacy populations and to assure cultural and clinical validity. An alternative approach is to employ idioms of distress that are locally salient, but these are not synonymous with psychiatric categories. Therefore, our objectives were to evaluate the validity of the PHQ-9, assess the added value of using idioms of distress, and develop an algorithm for depression detection in primary care.MethodsWe conducted a transcultural translation of the PHQ-9 in Nepal using qualitative methods to achieve semantic, content, technical, and criterion equivalence. Researchers administered the Nepali PHQ-9 to randomly selected patients in a rural primary health care center. Trained psychosocial counselors administered a validated Nepali depression module of the Composite International Diagnostic Interview (CIDI) to validate the Nepali PHQ-9. Patients were also assessed for local idioms of distress including heart-mind problems (Nepali, manko samasya).ResultsAmong 125 primary care patients, 17 (14 %) were positive for a major depressive episode in the prior 2 weeks based on CIDI administration. With a Nepali PHQ-9 cutoff ≥ 10: sensitivity = 0.94, specificity = 0.80, positive predictive value (PPV) =0.42, negative predictive value (NPV) =0.99, positive likelihood ratio = 4.62, and negative likelihood ratio = 0.07. For heart-mind problems: sensitivity = 0.94, specificity = 0.27, PPV = 0.17, NPV = 0.97. With an algorithm comprising two screening questions (1. presence of heart-mind problems and 2. function impairment due to heart-mind problems) to determine who should receive the full PHQ-9, the number of patients requiring administration of the PHQ-9 could be reduced by 50 %, PHQ-9 false positives would be reduced by 18 %, and 88 % of patients with depression would be correctly identified.ConclusionCombining idioms of distress with a transculturally-translated depression screener increases efficiency and maintains accuracy for high levels of detection. The algorithm reduces the time needed for primary healthcare staff to verbally administer the tool for patients with limited literacy. The burden of false positives is comparable to rates in high-income countries and is a limitation for universal primary care screening.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-016-0768-y) contains supplementary material, which is available to authorized users.
Highlights
Despite recognition of the burden of disease due to mood disorders in low- and middle-income countries, there is a lack of consensus on best practices for detecting depression
After completion of the translation and review by mental health professionals, the draft Nepali patient health questionnaire-9 (PHQ-9) was reviewed by four focus groups: two female groups, one male group, and one group with eight men and one woman (Table 1)
We explored solutions to these constraints in Transcultural Psychosocial Organization Nepal (Nepal) by validating the PHQ-9 for primary care administration and developing an algorithm incorporating the assessment of local idioms
Summary
Despite recognition of the burden of disease due to mood disorders in low- and middle-income countries, there is a lack of consensus on best practices for detecting depression. The World Health Organization (WHO), United Kingdom’s Wellcome Trust, United States’ National Institute of Mental Health (NIMH), and government development programs such as the United Kingdom’s Department for International Development (DFID) and Grand Challenges Canada (GCC) have supported major initiatives to address the gap between the burden of mental illness and lack of mental healthcare. These initiatives are contributing to an evidence base for the effectiveness of treating depression in primary care and community settings, including treatment by nonspecialist health workers [4]. One approach is screening, which is defined as “the use of questionnaires concerning the symptoms of depression or small sets of questions about depression to identify patients who may have depression but who have not sought treatment and whose depression has not already been recognized by health care providers,” [7]
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