Validity of an interviewer-administered patient health questionnaire-9 to screen for depression in HIV-infected patients in Cameroon

Abstract

Background In high-income countries, depression is prevalent in HIV patients and is associated with lower medication adherence and clinical outcomes. Emerging evidence from low-income countries supports similar relationships. Yet little research has validated rapid depression screening tools integrated into routine HIV clinical care. Methods Using qualitative methods, we adapted the Patient Health Questionnaire-9 (PHQ-9) depression screening instrument for use with Cameroonian patients. We then conducted a cross-sectional validity study comparing an interviewer-administered PHQ-9 to the reference standard Composite International Diagnostic Interview in 400 patients on antiretroviral therapy attending a regional HIV treatment center in Bamenda, Cameroon. Results The prevalence of major depressive disorder (MDD) in the past month was 3% (n=11 cases). Using a standard cutoff score of ≥10 as a positive depression screen, the PHQ-9 had estimated sensitivity of 27% (95% confidence interval: 6–61%) and specificity of 94% (91–96%), corresponding to positive and negative likelihood ratios of 4.5 and 0.8. There was little evidence of variation in specificity by gender, number of HIV symptoms, or result of a dementia screen. Limitations The low prevalence of MDD yielded very imprecise sensitivity estimates. Although the PHQ-9 was developed as a self-administered tool, we assessed an interviewer-administered version due to the literacy level of the target population. Conclusion The PHQ-9 demonstrated high specificity but apparently low sensitivity for detecting MDD in this sample of HIV patients in Cameroon. Formative work to define the performance of proven screening tools in new settings remains important as research on mental health expands in low-income countries.

Validity of the patient health questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South Africa

“…The performance of the PHQ-9 was similar to that from a range of other settings outside of sub-Saharan Africa (Gilbody et al, 2007, Manea et al, 2012). Compared to other studies within sub-Saharan Africa, the PHQ-9 performed slightly worse than it did among university students in Nigeria (Adewuya et al, 2006) or HIV-infected persons in Uganda (Akena et al, 2013), but it performed significantly better in this study than it did among HIV-infected patients in Cameroon (Pence et al, 2012). To our knowledge, ours is the only diagnostic validation study of the PHQ-9 conducted among a general PHC population in sub-Saharan Africa, and it underscores both the importance of a primary care setting in this region as an access point for identifying depression and as well an accurate tool to do so.…”

“…This tool has been widely utilized in Western settings and more recently in sub-Saharan Africa (Pence et al, 2012, Monahan et al, 2009, Adewuya et al, 2006, Akena et al, 2013). Scores range from 0–27, with a score of 10 or higher typically used to indicate the presence of a depressive disorder that would benefit from treatment.…”

“…A positive screen for probable depression was defined as a score ≥10 on the PHQ-9 (Pence et al, 2012, Adewuya et al, 2006, Akena et al, 2013). Test characteristics including sensitivity, specificity, and categorical likelihood ratios for the PHQ-9 were calculated relative to a diagnosis of a current major depressive episode (MDE) on the MINI.…”

“…A limited number of validation studies of depression screening tools have been conducted against diagnostic reference standards in sub-Saharan African settings, but these studies have varied in their choice of context, screening tool, and diagnostic measure, making the results difficult to apply to a PHC context. (Andersen et al, 2011, Akena et al, 2012a, Akena et al, 2012b, Pence et al, 2012, Chishinga et al, 2011, Monahan et al, 2009, Myer et al, 2008, Nakimuli-Mpungu et al, 2012b, Spies et al, 2009, Adewuya et al, 2006, Akena et al, 2013). In particular, the populations included in these studies, such as university students, household survey participants, pregnant or postnatal women, or HIV-infected patients, are not easily generalizable to a PHC population.…”

Validity of brief screening questionnaires to detect depression in primary care in Ethiopia

“…That review included five studies from middle-income countries but no low-income countries. However, studies of PHQ-9 validity in low-income countries from sub-Saharan Africa (Cameroon and Ghana) found low sensitivity at the standard cut-off point (Pence et al, 2012;Weobong et al, 2009). African validation studies of the PHQ-9 which have found higher cut-off points were conducted in well-educated, urban populations (Adewuya, et al, 2006;Okulate, et al, 2004).…”