Antenatal depression case finding by community health workers in South Africa: feasibility of a mobile phone application

Abstract

Purpose Randomised controlled trials conducted in resource-limited settings have shown that once women with depressed mood are evaluated by specialists and referred for treatment, lay health workers can be trained to effectively administer psychological treatments. We sought to determine the extent to which community health workers could also be trained to conduct case finding using short and ultra-short screening instruments programmed into mobile phones. Methods Pregnant, Xhosa-speaking women were recruited independently in two cross-sectional studies (N=1,144 and N=361) conducted in Khayelitsha, South Africa and assessed for antenatal depression. In the smaller study, community health workers with no training in human subjects research were trained to administer the Edinburgh Postnatal Depression Scale (EPDS) during the routine course of their community-based outreach. We compared the operating characteristics of 4 short and ultra-short versions of the EPDS with the criterion standard of probable depression, defined as an EPDS-10 ≥13. Results The prevalence of probable depression (475/1144 [42%] and 165/361 [46%]) was consistent across both samples. The 2-item subscale demonstrated poor internal consistency (Cronbach’s α ranged from 0.55-0.58). All 4 subscales demonstrated excellent discrimination, with area under the receiver operating characteristic curve (AUC) values ranging from 0.91-0.99. Maximal discrimination was observed for the 7-item depressive symptoms subscale: at the conventional screening threshold of ≥10, it had 0.97 sensitivity and 0.76 specificity for detecting probable antenatal depression. Conclusions The comparability of the findings across the two studies suggests that it is feasible to use community health workers to conduct case finding for antenatal depression.

A systematic review of screening instruments for depression for use in antenatal services in low resource settings

“…Most of the articles ( n  = 18) were cross sectional prevalence studies and five ( n  = 5) were psychometric validation studies measuring reliability and validity of screening instruments. In reviewing these studies for reported psychometrics of sensitivity, specificity, Area under the curve and the relevant gold standards, two studies [32, 33] were excluded (no gold standard as defined by this study) and a further 23 studies were excluded due to inadequate reporting of psychometrics. One third of the articles ( n  = 11) reported psychometrics and a gold standard and met the final selection criteria for inclusion in the review (Table 2).…”

Reliability and Validity of Depression Assessment Among Persons With HIV in Sub-Saharan Africa

“…Shifting responsibility for mental health screening and/or treatment monitoring to non-specialist lay health workers is a priority area of research (89) that has been proposed as one potential mechanism for extending limited human resources (90). Such tasks will require brief, locally validated screening instruments (91, 92) whose use can be integrated cleanly into the lay health workers’ overall workflow without causing undue burden (26, 93). In many sub-Saharan African countries, mental health system resource constraints introduce additional concerns.…”

Food insufficiency, depression, and the modifying role of social support: Evidence from a population-based, prospective cohort of pregnant women in peri-urban South Africa

“…The EPDS measures the affective and cognitive symptoms that typically accompany depressive disorders (Kagee, Tsai, Lund, & Tomlinson, 2013). In this specific population of Xhosa-speaking pregnant and postpartum women, the EPDS has been shown to have a coherent internal structure (De Bruin, Swartz, Tomlinson, Cooper, & Molteno, 2004), high sensitivity and specificity for detecting major depressive disorder (Hung et al, 2014; Tsai et al, 2013; Tsai et al, 2014), and good construct validity (Dewing, Tomlinson, le Roux, Chopra, & Tsai, 2013; Hartley et al, 2011). Its internal consistency was confirmed in the baseline sample: the Cronbach’s alpha was 0.89, with a 95% confidence interval [CI] (computed using 500 bootstrap replications) of 0.88-0.90.…”

“…Thus, the pooled regression estimates provided information about the association between food insufficiency at one time point and depression symptom severity at the subsequent time point (e.g., food insufficiency at 6 months was correlated with depression symptom severity at 18 months). To aid in interpretation of the estimates and because caseness for (probable) depression is frequently of clinical interest, we defined probable depression as EPDS ≥13 (Hung et al, 2014; Rochat et al, 2006; Tsai et al, 2014) and re-fit a logistic regression model to the data. This model specified probable depression as the binary dependent variable and lagged food insufficiency as the explanatory variable of interest.…”