The most frequently described types of reliability and/or validity evidence supplied in these studies were of scale reliability [9 (69%)], criterion-related validity [8 (62%)], and factor structure [8 (62%)]. The reported Cronbach alpha coefficients ranged from 0.63 to 0.95, with only 1 study reporting an estimate below the conventional threshold for “good” internal consistency. Across contexts, depression instruments had statistically significant associations with related constructs, including HIV stigma, social support, and health status. Analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. Of the 5 studies in which a multifactor structure was thought to best fit the data, 4 identified a factor related to somatic symptoms. Only 2 studies, both using qualitative methods, assessed aspects of linguistic or technical equivalence.
Among the 7 studies that used a criterion standard to determine a DSM-consistent diagnosis of major depressive disorder, the prevalence of major depressive disorder varied from 2.7% to 18.1%, with a pooled prevalence of 14.5% (95% CI: 8.9 to 21.2; I 2 = 93.4). Publication bias did not seem to be present (P values ranged from 0.13 to 0.19). HIV treatment status was not a statistically significant effect modifier (P = 0.16); in treated samples, the pooled prevalence was 6.7% (95% CI: 0.6 to 18.5), whereas in naive/mixed samples, the pooled prevalence was 17.9% (95% CI: 11.8 to 24.9).
Too few studies assessed the performance of the same screening instrument (irrespective of setting) to permit pooled estimates of sensitivity and specificity, with the exception of 4 studies that examined the criterion-related validity of the CES-D. When summarized within ROC curve space, the data suggested a pooled sensitivity of 0.82 (95% CI: 0.73 to 0.87) and a pooled specificity of 0.73 (95% CI: 0.63 to 0.80) at threshold values ranging from 16 to 22 (Fig. 3). There was a substantial between-study heterogeneity underlying these estimates, as suggested by I 2 values of 50.2 and 92.4, respectively, but there was limited ability to adequately investigate this heterogeneity given the small number of studies. Examination of the log-diagnostic odds ratios plotted against the inverse square root of effective sample size, and the accompanying linear regression test (P = 0.63), did not suggest small sample size–related bias.
The quality assessment demonstrated several areas in which the studies of criterion-related validity tended to have methodological shortcomings (see Table S3, Supplemental Digital Content, http://links.lww.com/QAI/A532). Specifically, most of these studies were assessed to be at risk of bias due to the use of a screening threshold that was not prespecified (ie, the reported threshold was selected to optimize sensitivity and/or specificity). Otherwise, most studies were at a low risk of bias on the other domains. In general, few concerns were noted about applicability.
In this systematic review and meta-analysis, there were several important findings. First, I identified only 13 unique studies of 9 different instruments used to assess depression among persons with HIV in sub-Saharan Africa. Second, screening instruments were generally found to reliably measure depression-like constructs and to correlate with related constructs in the expected fashion. Third, depression was highly prevalent, particularly in studies of treatment-naive persons or of untreated/mixed samples. However, the prevalence of probable depression (as determined by screening) exceeded the prevalence of DSM-consistent diagnoses of major depressive disorder by a factor of 2. These findings have important research and programmatic implications for persons with HIV in sub-Saharan Africa.
Before each of these findings are discussed in detail, it is important to note that the data identified in this systematic search do not permit conclusions about the reliability or validity of depression assessment in general population samples in African countries. For example, investigators have used qualitative methods to elicit local concepts of distress and then have validated newly developed scales in Rwanda,80–83 Uganda,83–86 and Zimbabwe.42,87–89 Although these studies make important contributions to understanding cultural concepts of distress in African settings, particularly aspects of linguistic and conceptual equivalence, they would not have been included in this review, as they were not based on samples of persons with HIV. Because the primary incremental contribution of validation studies conducted with samples of persons with HIV relates primarily to our understanding of construct and criterion-related validity, it is likely that excluding studies conducted in the general population would result in a sample of studies less focused on aspects of equivalence.
Keeping this limitation in mind, I identified relatively few studies describing the reliability or validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in African settings. Although the evidence search was not limited to sub-Saharan Africa, no studies from northern Africa were identified, and Cameroon was the only study site in western or central Africa. In settings where data were identified, depression instruments were found to correlate with conceptually related constructs in the expected fashion, providing some support for the idea that these Western-derived instruments are measuring the same construct in different cultures.90 Among multifactor instruments, a majority identified a somatic factor, confirming the importance of careful symptom assessment among persons with HIV so that false positives can be minimized.29,30
Among the participants in the studies reviewed, depression screening was associated with relatively high false positive rates: the pooled prevalence of probable depression by screening was 30.2%, whereas the pooled prevalence of major depressive disorder was 14.5%. This 2-fold difference is notable given that screening studies are frequently but inappropriately cited in support of impact statements describing the high prevalence of depressive disorders in the context of the HIV epidemic in sub-Saharan Africa. Yet, although screening instruments may generate overestimates, the 14.5% pooled prevalence rate of major depressive disorder estimated in my study still exceeds the 4%–6% age-standardized prevalence in the region.5 Thus, despite the relatively high rate of false positives identified through screening, the burden of depression among persons with HIV in sub-Saharan Africa should still be considered relatively high.
HIV treatment status seemed to explain some of the variation in outcomes, as the prevalence of depression was greater in treatment-naive samples. This finding is consistent with prior work describing declines in depression symptom severity among persons with HIV undergoing antiretroviral treatment.7,8,91–96 The mechanisms underlying these observed effects are unclear but may be related to biological,7 economic,10,11 or psychosocial54 changes associated with treatment. If confirmed, the “antidepressant” effects of HIV treatment could lend further support to treatment initiation as an HIV prevention strategy.97,98
Interpretation of my findings is subject to 3 primary limitations, in addition to those mentioned previously. First, as with all systematic reviews, my evidence search may have missed some relevant studies. A comparison of my sample with that of a related review by Sweetland et al,99 however, suggests this possibility is unlikely. They searched 2 bibliographic databases for validity studies conducted among adults in sub-Saharan Africa and published before 2012. They identified 4 studies of persons with HIV (compared with 6 studies included in my review that were published before 2012) and 11 studies of pregnant or postpartum women (compared with 25 studies included in a recently published review of perinatal depression28). A second limitation, which applies to interpretation of the pooled prevalence estimates, is that this review was focused specifically on studies of reliability and/or validity. Conventional studies of depression prevalence among persons with HIV that did not also provide evidence of reliability and/or validity, such as those by Nakasujja et al94 (53.9% with probable depression) and Kinyanda et al100 (8.1% with major depressive disorder) in Uganda, would have been excluded. Therefore, it is likely that the studies in my review do not represent the universe of prevalence studies. At the same time, however, this is unlikely to have biased my pooled prevalence estimates in either direction, given that reliability and validity studies are unlikely to systematically overestimate (or underestimate) the prevalence of either probable depression or major depressive disorder. A third limitation is that too few studies of the same instrument were identified to permit comparisons between instruments. Although the CES-D was the most frequently studied instrument, few studies of other instruments were found.
The most important policy and programmatic implications of this systematic review and meta-analysis relate to the possibility of integrating depression assessment and treatment into HIV programs in sub-Saharan Africa. The estimates presented here further underscore the potential public health impacts of effective depression treatment as recognized in the International Association of Physicians in AIDS Care guidelines on improving care for persons with HIV.101 Although effective depression treatment may carry important spillover benefits for persons with HIV,102,103 global disparities in HIV3 are paralleled by disparities in mental health systems and human resources for mental health.38,104 Shifting responsibility for mental health screening and/or treatment monitoring to nonspecialist lay health workers is a priority area of research105 that has been proposed as 1 potential mechanism for extending limited human resources.106 Such tasks will require brief, locally validated screening instruments107,108 whose use can be integrated cleanly into the lay health workers' overall workflow without causing undue burden.26,109 In many sub-Saharan African countries, mental health system resource constraints introduce additional concerns. First, in the absence of appropriate depression care support systems,110 the value of depression screening strategies remains unclear. Second, although screening instruments are generally expected to yield relatively high false positive rates, an excess of false positives could easily overwhelm the capacity for outpatient mental health care delivery.111 The findings presented in this review, although based on a paucity of evidence overall, suggest that more work needs to be done to identify valid and discriminating instruments that can be used for screening and treatment monitoring in these contexts.
The author thanks Jennifer Scott and Jennifer Zhu, for their assistance with data collection; and Dickens Akena, Landon Myer, Enbal Shacham, and Soraya Seedat, for their correspondence in response to his requests for additional information related to their studies.
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