title: Validity of the Patient Health Questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South Africa.
abstract: BACKGROUND
  Integration of depression screening into primary care may increase access to mental health services in sub-Saharan Africa, but this approach requires validated screening instruments. We sought to validate the Patient Health Questionnaire-9 (PHQ-9) as a depression screening tool at a high HIV-burden primary care clinic in Johannesburg, South Africa.
  
  
  METHODS
  We conducted a validation study of an interviewer-administered PHQ-9 among 397 patients. Sensitivity and specificity of the PHQ-9 were calculated with the Mini International Neuropsychiatric Interview (MINI) as the reference standard; receiver operating characteristic (ROC) curve analyses were performed.
  
  
  RESULTS
  The prevalence of depression was 11.8%. One-third of participants tested positive for HIV. HIV-infected patients were more likely to be depressed (15%) than uninfected patients (9%; p=0.08). Using the standard cutoff score of ≥10, the PHQ-9 had a sensitivity of 78.7% (95% CI: 64.3-89.3) and specificity of 83.4% (95% CI: 79.1-87.2). The area under the ROC curve was 0.88 (95% CI: 0.83-0.92). Test performance did not vary by HIV status or language. In sensitivity analyses, reference test bias associated with the MINI appeared unlikely.
  
  
  CONCLUSIONS
  We were unable to conduct qualitative work to adapt the PHQ-9 to this cultural context.
  
  
  CONCLUSIONS
  This is the first validation study of the PHQ-9 in a primary care clinic in sub-Saharan Africa. It highlights the potential for using primary care as an access point for identifying depressive symptoms during routine HIV testing. The PHQ-9 showed reasonable accuracy in classifying cases of depression, was easily implemented by lay health workers, and is a useful screening tool in this setting.
authors: Department of Epidemiology, UNC Gillings School of Global Public Health, McGavran-Greenberg Hall, 135 Dauer Drive, Chapel Hill, NC 27599, USA. Electronic address: rcholera@med.unc.edu.
authors: R
authors: R
authors: Cholera
authors: Department of Psychiatry, UNC School of Medicine, USA.
authors: B N
authors: BN
authors: Gaynes
authors: Department of Epidemiology, UNC Gillings School of Global Public Health, McGavran-Greenberg Hall, 135 Dauer Drive, Chapel Hill, NC 27599, USA.
authors: B W
authors: BW
authors: Pence
authors: Collaborative Research Network for Mental Health and Well-being in Rural Communities, University of New England, Armidale, Australia & Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.
authors: J
authors: J
authors: Bassett
authors: Witkoppen Health and Welfare Center, Johannesburg, South Africa.
authors: N
authors: N
authors: Qangule
authors: Collaborative Research Network for Mental Health and Well-being in Rural Communities, University of New England, Armidale, Australia & Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.
authors: C
authors: C
authors: Macphail
authors: Witkoppen Health and Welfare Center, Johannesburg, South Africa.
authors: S
authors: S
authors: Bernhardt
authors: Department of Epidemiology, UNC Gillings School of Global Public Health, McGavran-Greenberg Hall, 135 Dauer Drive, Chapel Hill, NC 27599, USA.
authors: A
authors: A
authors: Pettifor
authors: Department of Epidemiology, UNC Gillings School of Global Public Health, McGavran-Greenberg Hall, 135 Dauer Drive, Chapel Hill, NC 27599, USA; Department of Medicine, UNC School of Medicine, USA.
authors: W C
authors: WC
authors: Miller
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data; D017281:Cost of Illness; D003863:Depression / Q000175:diagnosis* / Q000523:psychology; D003866:Depressive Disorder / Q000175:diagnosis* / Q000523:psychology; D005260:Female; D015658:HIV Infections / Q000453:epidemiology*; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods / Q000706:statistics & numerical data; D008875:Middle Aged; D011320:Primary Health Care; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013019:South Africa / Q000453:epidemiology; D011795:Surveys and Questionnaires / Q000592:standards*
keywords: Africa; Depression; HIV; Screening; Validation study