Inexpensive depression screening tool works in resource poor countries

A study published in the February 2009 issue of the Journal of General Internal Medicine reports that a highly reliable depression screening tool known as the Patient Health Questionnaire-9 (PHQ-9) used across the United States and Europe can be effectively administered in resource poor Africa to HIV/AID patients, a population whose mental health needs have been underserved.

The work also confirms that Kenyans with HIV/AIDS suffer depression at as high or higher a rate than those with HIV/AIDS in developed countries.

"Learning that the PHQ-9 depression measure can be successfully used in Kenya is very good news for the region. Due to lack of resources, depression in individuals with HIV/AIDS has been largely ignored in sub-Saharan Africa, even though 67 percent of the world’s cases are there. Yet we know that depression is associated with failure to adopt healthy protective behaviors and that people with less depression are more likely to engage in healthy behaviors such as using precautions if engaging in sex," said Patrick O. Monahan, Ph.D., Indiana University School of Medicine associate professor of medicine, first author of the new JGIM study.

"The people of Kenya are very friendly, hard working and responsible. However, given a culture which prizes stoicism in the face of adversity, we were not sure whether it would be possible to discuss depression and suicidal thoughts. On the contrary, we found a high degree of openness and willingness to talk about depression and hopelessness. We found a 13 percent incidence of major depression disorder and a 21 percent incidence of other depressive disorder in the 345 HIV/AIDS Kenyan patients we studied," said Dr. Monahan.

The PHQ-9 was developed in a 1999 study which was co-authored by one of the authors of the new study, Kurt Kroenke, M.D., IU School of Medicine professor of medicine and a Regenstrief Institute research scientist, to screen primary care patients for depression. It is now increasingly used by psychiatrists.

"The PHQ-9 has become an easy to administer, validated means of quantifying the patient's symptoms, what Dr. Kroenke calls "a sort of a blood pressure cuff for depression."

Although the PHQ-9 has been extensively tested, validated and utilized in the United States and West Europe, only one previous study has evaluated use of the PHQ-9 with an HIV-positive population, and that was in the United States, not in Africa. Only three previous studies have looked at the feasibility of administering the PHQ-9 in Africa, none to patients with HIV/AIDS.

"Our study, taken together with the many studies that validated the PHQ-9 in a variety of U.S. samples, strongly suggests that the PHQ-9 would also be valid and reliable with U.S. patients with HIV/AIDS for assessing severity and helping with diagnosis at a low cost," said Dr. Monahan.

Support for the study came from funding provided by the Presidential Emergency Plan for AIDS Relief to the USAID-AMPATH partnership of IU, Moi University and Moi Teaching and Referral Hospital and from the School of Health, Physical Education, and Recreation and the Department of Applied Health Science at IU University-Bloomington.

Additional authors of the JGIM study are, Enbal Shacham, Ph.D., of Washington University, Michael Reece, PhD, MPH, of Indiana University, and Kenyan colleagues Willis Owino Ong’or, MMEd, MPH, Otieno Omollo, MBChB, MMed, Violet Naanyu Yebei, M.A., and Claris Ojwang.