Reliability and Validity of Instruments for Assessing Perinatal Depression in African Settings: Systematic Review and Meta-Analysis

Abstract

Background: A major barrier to improving perinatal mental health in Africa is the lack of locally validated tools for identifying probable cases of perinatal depression or for measuring changes in depression symptom severity. We systematically reviewed the evidence on the reliability and validity of instruments to assess perinatal depression in African settings. Methods and Findings:Of 1,027 records identified through searching 7 electronic databases, we reviewed 126 fulltext reports. We included 25 unique studies, which were disseminated in 26 journal articles and 1 doctoral dissertation. These enrolled 12,544 women living in nine different North and sub-Saharan African countries. Only three studies (12%) used instruments developed specifically for use in a given cultural setting. Most studies provided evidence of criterion-related validity (20 [80%]) or reliability (15 [60%]), while fewer studies provided evidence of construct validity, content validity, or internal structure. The Edinburgh postnatal depression scale (EPDS), assessed in 16 studies (64%), was the most frequently used instrument in our sample. Ten studies estimated the internal consistency of the EPDS (median estimated coefficient alpha, 0.84; interquartile range, 0.71-0.87). For the 14 studies that estimated sensitivity and specificity for the EPDS, we constructed 2 x 2 tables for each cut-off score. Using a bivariate random-effects model, we estimated a pooled sensitivity of 0.94 (95% confidence interval [CI], 0.68-0.99) and a pooled specificity of 0.77 (95% CI, 0.59-0.88) at a cut-off score of ≥9, with higher cut-off scores yielding greater specificity at the cost of lower sensitivity. Conclusions:The EPDS can reliably and validly measure perinatal depression symptom severity or screen for probable postnatal depression in African countries, but more validation studies on other instruments are needed. In addition, more qualitative research is needed to adequately characterize local understandings of perinatal depression-like syndromes in different African contexts. Funding:The authors received no specific funding to conduct this study but acknowledge the following sources of salary support: U.S. National Institutes of Health (NIH) K23 MH-096620 (ACT), NIH K23 MH-095655 (LTM), NIH K23 MH-096651 (CP), and the National Research Foundation (South Africa) and the Department for International Development (MT). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Competing interests: ACT is a member of the PLoS ONE Editorial Board. MT is a member of the PLoS Medicine Editorial Board. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials. * E-mail: actsai@partners.org IntroductionMajor depressive disorder is a major public health issue and accounts for a large proportion of the global burden of disease impacts provide added impetus for alleviating the burden of perinatal depression in low-and middle-income countries [6,7]. H...

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“…Among Xhosa-speaking women, several studies have supported the construct validity, criterion-related validity, and factor structure of the EPDS-10 (De Bruin et al 2004; Hartley et al 2011; Lawrie et al 1998), and it has also been shown to have a high sensitivity for detecting postnatal depression in numerous other settings worldwide (Tsai et al 2013). Similar to Kabir et al (2008) and Rochat et al (2013), we defined 4 short and ultra-short versions of the EPDS-10: the 2-item analogue of the Patient Health Questionnaire (EPDS-2) (Lowe et al 2005; Monahan et al 2009), the 3-item anxiety subscale (EPDS-3), an abbreviated 5-item version of the depressive symptoms subscale (EPDS-5) (Rochat et al 2013), and the 7-item depressive symptoms subscale (EPDS-7) (Box 1).…”

“…Accurate screening for, and subsequent diagnosis of, perinatal depression will be an essential component of any strategy to funnel patients to appropriate treatments at scale. Short and ultra-short screening instruments -- defined as having 5-14 items and <5 items, respectively (Mitchell and Coyne 2007) -- for perinatal depression have been studied and validated in several sub-Saharan African countries (Tsai et al 2013). Given their brevity, it is possible that these screening instruments may be efficiently incorporated into the routine workflow of overburdened health care workers.…”

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“…It has also been validated globally, though there is some concern in the effective translation of the EPDS into local languages (28,29).…”

“…Another systematic review, a Meta-Analysis, assessed the reliability and validity of EPDS in African settings (29). There was a pooled sensitivity of 0.94 …”