Ruth Verhey

Validation of screening tools for depression and anxiety disorders in a primary care population with high HIV prevalence in Zimbabwe

BACKGROUND In low income countries in Sub-Saharan Africa there are few validated tools to screen for common disabling mental disorders such as depression and general anxiety disorder (GAD). OBJECTIVES We validated three screening tools: the Shona Symptom Questionnaire for common mental disorders (SSQ-14), the Patient Health Questionnaire for depression (PHQ-9), and the Generalized Anxiety Disorder questionnaire (GAD-7). The study participants were attendees at a primary health care clinic in Harare, Zimbabwe. METHODS Consecutive adults aged 18 and above attending the clinic were enrolled over a two-week period in September 2013. Trained research assistants administered the screening tools to eligible participants after obtaining written consent. Participants were then interviewed by one of four psychiatrists using the Structured Clinical Interview of the DSM-IV (SCID). Performance characteristics were calculated for each tool, against the SCID as the gold standard. RESULTS A total of 264 participants were enrolled, of whom 52 (20%) met the SCID criteria for depression alone, 97 (37%) for mixed depression and anxiety and 9 (3%) for anxiety alone. Of the 237 where HIV status was known, 165 (70%) were HIV positive. With the optimal cutoff of ≥9, the sensitivity and specificity for the SSQ-14 against a diagnosis of either depression and/or general anxiety were 84% (95%CI:78-89%) and 73% (95%CI:63-81%) respectively. Internal reliability was high (Cronbach α=0.74). The optimal cutoff for PHQ-9 was ≥11, which provided a sensitivity of 85% (95%CI:78-90%) and specificity of 69% (95%CI:59-77%) against a SCID diagnosis of depression (Cronbach α=0.86). The GAD-7 (optimal cutoff ≥10) had sensitivity and specificity of 89% (95%CI:81-94%) and 73% (95%CI:65-80%) respectively against a SCID diagnosis of GAD (Cronbach α=0.87). CONCLUSION Screening tools for depression and GAD had good performance characteristics in a primary health care population in Zimbabwe with a high prevalence of HIV. These can be used for research and also in clinical care to screen patients who may benefit from treatment.

Using a theory driven approach to develop and evaluate a complex mental health intervention: the friendship bench project in Zimbabwe

BackgroundThere is a paucity of data on how to deliver complex interventions that seek to reduce the treatment gap for mental disorders, particularly in sub-Saharan Africa. The need for well-documented protocols which clearly describe the development and the scale-up of programs and interventions is necessary if such interventions are to be replicated elsewhere. This article describes the use of a theory of change (ToC) model to develop a brief psychological intervention for common mental disorders and its’ evaluation through a cluster randomized controlled trial in Zimbabwe.MethodsA total of eight ToC workshops were held with a range of stakeholders over a 6-month period with a focus on four key components of the program: formative work, piloting, evaluation and scale-up. A ToC map was developed as part of the process with defined causal pathways leading to the desired impact. Interventions, indicators, assumptions and rationale for each point along the causal pathway were considered.ResultsPolitical buy-in from stakeholders together with key resources, which included human, facility/infrastructure, communication and supervision were identified as critical needs using the ToC approach. Ten (10) key interventions with specific indicators, assumptions and rationale formed part of the final ToC map, which graphically illustrated the causal pathway leading to the development of a psychological intervention and the successful implementation of a cluster randomized controlled trial.ConclusionToC workshops can enhance stakeholder engagement through an iterative process leading to a shared vision that can improve outcomes of complex mental health interventions particularly where scaling up of the intervention is desired.

Scaling up interventions for depression in sub-Saharan Africa: lessons from Zimbabwe

Background There is a dearth of information on how to scale-up evidence-based psychological interventions, particularly within the context of existing HIV programs. This paper describes a strategy for the scale-up of an intervention delivered by lay health workers (LHWs) to 60 primary health care facilities in Zimbabwe. Methods A mixed methods approach was utilized as follows: (1) needs assessment using a semi-structured questionnaire to obtain information from nurses (n = 48) and focus group discussions with District Health Promoters (n = 12) to identify key priority areas; (2) skills assessment to identify core competencies and current gaps of LHWs (n = 300) employed in the 60 clinics; (3) consultation workshops (n = 2) with key stakeholders to determine referral pathways; and (4) in-depth interviews and consultations to determine funding mechanisms for the scale-up. Results Five cross-cutting issues were identified as critical and needing to be addressed for a successful scale-up. These included: the lack of training in mental health, unavailability of psychiatric drugs, depleted clinical staff levels, unavailability of time for counseling, and poor and unreliable referral systems for people suffering with depression. Consensus was reached by stakeholders on supervision and support structure to address the cross-cutting issues described above and funding was successfully secured for the scale-up. Conclusion Key requirements for success included early buy-in from key stakeholders, extensive consultation at each point of the scale-up journey, financial support both locally and externally, and a coherent sustainability plan endorsed by both government and private sectors.

Psychological interventions for post-traumatic stress disorder in people living with HIV in Resource poor settings: a systematic review.

Post‐traumatic stress disorder is pervasive in low‐ and middle‐income countries. There is evidence to suggest that post‐traumatic stress disorder is more common among people living with HIV than non‐infected matched controls. We carried out a systematic review of interventions for adult post‐traumatic stress disorder from resource poor settings with a focus on people living with HIV.

Validation of the posttraumatic stress disorder checklist – 5 (PCL-5) in a primary care population with high HIV prevalence in Zimbabwe

BackgroundThere is a dearth of validated tools measuring posttraumatic stress disorder (PTSD) in low and middle-income countries in sub-Saharan Africa. We validated the Shona version of the PTSD Checklist for DSM-5 (PCL-5) in a primary health care clinic in Harare, Zimbabwe.MethodAdults aged 18 and above attending the clinic were enrolled over a two-week period in June 2016. After obtaining written consent, trained research assistants administered the tool to eligible participants. Study participants were then interviewed independently using the Clinician Administered PTSD Scale (CAPS-5) as the gold standard by one of five doctors with training in mental health.ResultA total of 204 participants were assessed. Of these, 91 (44.6%) were HIV positive, 100 (49%) were HIV negative, while 13 (6.4%) did not know their HIV status. PTSD was diagnosed in 40 (19.6%) participants using the gold standard procedure. Using the PCL-5 cut-off of ≥33, sensitivity and specificity were 74.5% (95%CI: 60.4–85.7); 70.6% (95%CI: 62.7–77.7), respectively. The area under the ROC curve was 0.78 (95%CI: 0.72–0.83). The Shona version of the PCL-5 demonstrated good internal consistency (Cronbach’s alpha = 0.92).ConclusionThe PCL-5 performed well in this population with a high prevalence of HIV. There is need to explore ways of integrating screening tools for PTSD in interventions delivered by lay health workers in low and middle-income countries (LMIC).