Validating the Children’s Depression Inventory in the context of Rwanda

Abstract

BackgroundDepression is often co-morbid with chronic conditions, and when combined with HIV it can increase progression and reduce survival. A brief and accurate screening tool for depression among children living with HIV is necessary to increase access to mental health care and improve HIV-related outcomes in the long-term.MethodsA validation study was conducted, comparing the Children’s Depression Inventory (CDI) with a structured clinical assessment as the gold standard among children living with HIV ages 7-14 years in Rwanda. The response rate was 87 % and the analysis was performed among 100 study participants.ResultsTwenty-five percent of children had a diagnosis of depression based on the clinical interview. Sensitivity of the CDI ranged from 44 to 76 % and specificity was 92 to 100 % for cut-off scores from 5 to 9. The area under the curve (AUC) for receiver operating characteristic analysis, an estimate of overall accuracy, was 0.87 (95 % confidence interval: 0.77 – 0.97).ConclusionsThe significant prevalence of depression among children living with HIV in Rwanda reflects a critical need to advance mental health care in this population. Although overall accuracy of the CDI is reasonable in this context, further research needs to be done to develop a more sensitive measure of depression in this vulnerable population. Development of a highly sensitive screening measure will be a fundamental step towards improving access to mental health care among children living with HIV, potentially improving health outcomes and quality of life in the long-term as this vulnerable population transitions into adulthood.

Mental health challenges among adolescents living with HIV

“…A cross-sectional study of 562 HIV-infected adolescents from Malawi found a depression prevalence of 18.9% [29,30]. Within another study in Rwanda examining 100 HIV-infected children ages 7–14 years, the prevalence of depression reported was 25% [31]. A cross-sectional study of 82 HIV-infected adolescents ages 10–18-years old in Kampala, Uganda found that 51.2% had scores indicating significant psychological distress, 17.1% had attempted suicide in the past year, 19.5% had ever attempted suicide, and 30.5% had experienced psychotic symptoms in the past [32].…”

“…Kim et al ., Mutumba et al ., and Binagwaho et al .tested the validity of these existing mental health measurement instruments within Malawi, Uganda, and Rwande, respectively [29,31,46]. In Malawi, the validation findings suggested that the BDI-II had greater internal consistency and showed greater concordance with the CDRS-R results for this population [29].…”

“…In Malawi, the validation findings suggested that the BDI-II had greater internal consistency and showed greater concordance with the CDRS-R results for this population [29]. The studies from Uganda and Rwanda highlighted the need for a process of cultural adaptation, such as included translation, expert panel review, cognitive interviewing, and pilot testing, followed by full evaluation to modify these instruments and generate sufficient sensitivity for use [31,46]. These studies highlight the importance of cross-cultural modification of instruments and local validation, while also demonstrating the need to employ rigorous measurement of mental health symptoms for HIV-infected populations of children and adolescents in the RLS where most of these children live.…”

“…One study found male sex to be associated with a greater risk of depression than female sex in Kenya [28], while another found female sex to be associated with higher BDI-II scores in Malawi [30]. Another study found depression rates to be higher among HIV-infected adolescent females than males in Rwanda, but this difference was not significant [31], while another found no significant association between sex and suicidal ideation or behaviour in Rwanda [35]. …”

“…There is even more limited evidence for how to examine mental health outcomes among HIV-infected adolescents in RLS. Kim [29,31,46]. In Malawi, the validation findings suggested that the BDI-II had greater internal consistency and showed greater concordance with the CDRS-R results for this population [29].…”