Depression symptoms across settings: Development and validation of the International Depression Symptom Scale

Background: Existing measurement instruments for depression are most often based on symptoms observed in western clinical populations. It remains unclear whether these instruments are appropriate for use in epidemiologic, screening, intervention monitoring and evaluation, and clinical settings in non-western contexts. The overall goal of this study was to determine if there is a need for new instruments with global applicability to measure depression, and if so, to develop and test this new instrument. Methods: Two approaches were used in this process: 1) a systematic literature review of qualitative studies to identify common symptoms related to depression across populations; and 2) a quantitative analysis of existing datasets using item response theory (IRT) to identify how different symptom questions related to depression perform across settings. Results from these investigations were used to inform the development of the International Depression Symptom Scale (IDSS), an instrument designed to reflect global presentations of depression. The IDSS was tested in a community sample of adults (N = 147) in Yangon, Myanmar. Results: Results from the literature review and quantitative analysis indicated that most symptoms included in western definitions of depression and on existing measurement instruments are frequently mentioned and perform well across settings. However, additional symptoms need to be included in measurement instruments to more accurately reflect the presentation of depression all over the world. These include: social isolation, anger, hopelessness, thinking too much, confusion, and somatic complaints. The IDSS was developed based on these conclusions. Testing results showed that the IDSS had high internal consistency reliability (α = 0.92), test-retest reliability (r = 0.87) and inter-rater reliability (ICC = 0.90). Construct, criterion, and incremental validity were also supported for the IDSS. Preliminary evidence supports the IDSS use as a screening tool to detect depressive disorders and impaired functioning in this context. Further research needs to be done to explore its validity in other settings and its use as a clinical or epidemiologic tool. Conclusions: Findings contribute to our understanding of how depression manifests globally and demonstrates initial evidence to support the usefulness of a measurement instrument created to reflect the global presentation of depression

Pilot evaluation of a Psychological First Aid online training for COVID-19 frontline workers in American Indian/Alaska Native communities

IntroductionThe COVID-19 pandemic exacerbated mental health concerns and stress among American Indians and Alaska Natives (AI/ANs) in the United States, as well as among frontline workers responding to the pandemic. Psychological First Aid (PFA) is a promising intervention to support mental wellbeing and coping skills during and after traumatic events, such as the COVID-19 pandemic. Since PFA is often implemented rapidly in the wake of a disaster or traumatic event, evidence evaluating its impact is lacking. This paper reports pilot evaluation results from a culturally adapted PFA training designed to support COVID-19 frontline workers and the AI/AN communities they serve during the pandemic.MethodsThis study was designed and implemented in partnership with a collaborative work group of public health experts and frontline workers in AI/AN communities. We conducted a pre-post, online pilot evaluation of a culturally adapted online PFA training with COVID-19 frontline workers serving AI/AN communities. Participants completed a baseline survey and two follow-up surveys 1 week and 3 months after completing the PFA training. Surveys included demographic questions and measures of anxiety, burnout, stress, positive mental health, communal mastery, coping skills, PFA knowledge, confidence in PFA skills, and satisfaction with the PFA training.ResultsParticipants included N = 56 COVID-19 frontline workers in AI/AN communities, 75% were AI/AN, 87% were female, and most (82%) were between the ages of 30–59. Participants reported high satisfaction with the training and knowledge of PFA skills. Pilot results showed significant increases in positive mental health and social wellbeing and reductions in burnout from baseline to 3 months after completing the PFA training among frontline workers. There were no changes in communal mastery, coping skills, stress, or anxiety symptoms during the study period.DiscussionTo our knowledge, this is the first pilot evaluation of a PFA training designed and culturally adapted with and for AI/AN communities. Given that many AI/AN communities were disproportionately impacted by COVID-19 and prior mental health inequities, addressing acute and chronic stress is of crucial importance. Addressing traumatic stress through culturally adapted interventions, including Indigenous PFA, is crucial to advancing holistic wellbeing for AI/AN communities

Psychometric performance of the Mental Health Implementation Science Tools (mhIST) across six low- and middle-income countries

Background Existing implementation measures developed in high-income countries may have limited appropriateness for use within low- and middle-income countries (LMIC). In response, researchers at Johns Hopkins University began developing the Mental Health Implementation Science Tools (mhIST) in 2013 to assess priority implementation determinants and outcomes across four key stakeholder groups—consumers, providers, organization leaders, and policy makers—with dedicated versions of scales for each group. These were field tested and refined in several contexts, and criterion validity was established in Ukraine. The Consumer and Provider mhIST have since grown in popularity in mental health research, outpacing psychometric evaluation. Our objective was to establish the cross-context psychometric properties of these versions and inform future revisions. Methods We compiled secondary data from seven studies across six LMIC—Colombia, Myanmar, Pakistan, Thailand, Ukraine, and Zambia—to evaluate the psychometric performance of the Consumer and Provider mhIST. We used exploratory factor analysis to identify dimensionality, factor structure, and item loadings for each scale within each stakeholder version. We also used alignment analysis (i.e., multi-group confirmatory factor analysis) to estimate measurement invariance and differential item functioning of the Consumer scales across the six countries. Results All but one scale within the Provider and Consumer versions had Cronbach’s alpha greater than 0.8. Exploratory factor analysis indicated most scales were multidimensional, with factors generally aligning with a priori subscales for the Provider version; the Consumer version has no predefined subscales. Alignment analysis of the Consumer mhIST indicated a range of measurement invariance for scales across settings (R2 0.46 to 0.77). Several items were identified for potential revision due to participant nonresponse or low or cross- factor loadings. We found only one item, which asked consumers whether their intervention provider was available when needed, to have differential item functioning in both intercept and loading. Conclusion We provide evidence that the Consumer and Provider versions of the mhIST are internally valid and reliable across diverse contexts and stakeholder groups for mental health research in LMIC. We recommend the instrument be revised based on these analyses and future research examine instrument utility by linking measurement to other outcomes of interest

Comparative effectiveness of in-person vs. remote delivery of the Common Elements Treatment Approach for addressing mental and behavioral health problems among adolescents and young adults in Zambia: protocol of a three-arm randomized controlled trial

Background In low- and middle-income countries (LMIC), there is a substantial gap in the treatment of mental and behavioral health problems, which is particularly detrimental to adolescents and young adults (AYA). The Common Elements Treatment Approach (CETA) is an evidence-based, flexible, transdiagnostic intervention delivered by lay counselors to address comorbid mental and behavioral health conditions, though its effectiveness has not yet been tested among AYA. This paper describes the protocol for a randomized controlled trial that will test the effectiveness of traditional in-person delivered CETA and a telehealth-adapted version of CETA (T-CETA) in reducing mental and behavioral health problems among AYA in Zambia. Non-inferiority of T-CETA will also be assessed. Methods This study is a hybrid type 1 three-arm randomized trial to be conducted in Lusaka, Zambia. Following an apprenticeship model, experienced non-professional counselors in Zambia will be trained as CETA trainers using a remote, technology-delivered training method. The new CETA trainers will subsequently facilitate technology-delivered trainings for a new cohort of counselors recruited from community-based partner organizations throughout Lusaka. AYA with mental and behavioral health problems seeking services at these same organizations will then be identified and randomized to (1) in-person CETA delivery, (2) telehealth-delivered CETA (T-CETA), or (3) treatment as usual (TAU). In the superiority design, CETA and T-CETA will be compared to TAU, and using a non-inferiority design, T-CETA will be compared to CETA, which is already evidence-based in other populations. At baseline, post-treatment (approximately 3–4 months post-baseline), and 6 months post-treatment (approximately 9 months post-baseline), we will assess the primary outcomes such as client trauma symptoms, internalizing symptoms, and externalizing behaviors and secondary outcomes such as client substance use, aggression, violence, and health utility. CETA trainer and counselor competency and cost-effectiveness will also be measured as secondary outcomes. Mixed methods interviews will be conducted with trainers, counselors, and AYA participants to explore the feasibility, acceptability, and sustainability of technology-delivered training and T-CETA provision in the Zambian context. Discussion Adolescents and young adults in LMIC are a priority population for the treatment of mental and behavioral health problems. Technology-delivered approaches to training and intervention delivery can expand the reach of evidence-based interventions. If found effective, CETA and T-CETA would help address a major barrier to the scale-up and sustainability of mental and behavioral treatments among AYA in LMIC. Trial registration ClinicalTrials.gov NCT03458039 . Prospectively registered on May 10, 202

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis.

OBJECTIVES: Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence. STUDY DESIGN AND SETTING: Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status. RESULTS: A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: -13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: -16.4%, 15.0%). CONCLUSION: PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies

Symptom Endorsement and Sociodemographic Correlates of Postnatal Distress in Three Low Income Countries

Background. Maternal mental illness has been implicated in adverse child development outcomes. Factors such as context and culture may influence experiences of maternal distress and explain differences in outcomes across settings. Methods. We analyzed baseline data from 5,647 mothers in Ethiopia, India (Andhra Pradesh), and Vietnam participating in an ongoing cohort study (Young Lives) to compare symptom endorsement and sociodemographic correlates of distress. Maternal distress was assessed using the Self-Reporting Questionnaire-20 Items (cutoff: ≥8). Logistic regressions were stratified by sample to identify correlates of distress. Results. Symptom endorsement was similar among distressed women, particularly with regard to feeling unhappy (76%, 80%, and 79%). Notable differences were observed in three items assessing Depressive Thoughts, which were most highly endorsed in Ethiopia (49%–56%). Having a child experiencing a life-threatening event was correlated with distress in all three samples. A variety of correlates were unique to only one sample. Conclusions. There were multiple similarities but also notable differences across sites in the expression and correlates of maternal distress. Feeling unhappy appears to be a hallmark feature of distress. Correlates highlight the relationship between distress and indicators of poverty, child wellbeing, and economic shocks. Differences demonstrate the value of further exploration of cross-cultural differences

Implementation measurement in global mental health: Results from a modified Delphi panel and investigator survey

Limited guidance exists to support investigators in the choice, adaptation, validation and use of implementation measures for global mental health implementation research. Our objectives were to develop consensus on best practices for implementation measurement and identify strengths and opportunities in current practice. We convened seven expert panelists. Participants rated approaches to measure adaptation and validation according to appropriateness and feasibility. Follow-up interviews were conducted and a group discussion was held. We then surveyed investigators who have used quantitative implementation measures in global mental health implementation research. Participants described their use of implementation measures, including approaches to adaptation and validation, alongside challenges and opportunities. Panelists agreed that investigators could rely on evidence of a measure’s validity, reliability and dimensionality from similar contexts. Panelists did not reach consensus on whether to establish the pragmatic qualities of measures in novel settings. Survey respondents (n = 28) most commonly reported using the Consolidated Framework for Implementation Research Inner Setting Measures (n = 9) and the Program Assessment Sustainability Tool (n = 5). All reported adapting measures to their settings; only two reported validating their measures. These results will support guidance for implementation measurement in support of mental health services in diverse global settings

Measuring Hope Among Children Affected by Armed Conflict:Cross-Cultural Construct Validity of the Children's Hope Scale

We investigated the cross-cultural construct validity of hope, a factor associated with mental health protection and promotion, using the Children’s Hope Scale (CHS). The sample ( n = 1,057; 48% girls) included baseline data from three cluster-randomized controlled trials with children affected by armed conflict ( n = 329 Burundi; n = 403 Indonesia; n = 325 Nepal). The confirmatory factor analysis in each country indicated good fit for the hypothesized two-factor model. Analysis by gender indicated that configural invariance was supported and that scalar invariance was demonstrated in Indonesia. However, metric and scalar invariance were not supported in Burundi and Nepal. In country comparisons, configural and metric invariance were met, but scalar invariance was not supported. Evidence from this study supports the use of the CHS within various sociocultural settings and across genders, but direct comparisons of CHS scores across groups should be done with caution. Rigorous evaluations of the measurement properties of mental health protective and promotive factors are necessary to inform both research and practice. </jats:p

Thinking too much : A systematic review of a common idiom of distress

© 2015 Elsevier Ltd. Idioms of distress communicate suffering via reference to shared ethnopsychologies, and better understanding of idioms of distress can contribute to effective clinical and public health communication. This systematic review is a qualitative synthesis of thinking too much idioms globally, to determine their applicability and variability across cultures. We searched eight databases and retained publications if they included empirical quantitative, qualitative, or mixed-methods research regarding a thinking too much idiom and were in English. In total, 138 publications from 1979 to 2014 met inclusion criteria. We examined the descriptive epidemiology, phenomenology, etiology, and course of thinking too much idioms and compared them to psychiatric constructs. Thinking too much idioms typically reference ruminative, intrusive, and anxious thoughts and result in a range of perceived complications, physical and mental illnesses, or even death. These idioms appear to have variable overlap with common psychiatric constructs, including depression, anxiety, and PTSD. However, thinking too much idioms reflect aspects of experience, distress, and social positioning not captured by psychiatric diagnoses and often show wide within-cultural variation, in addition to between-cultural differences. Taken together, these findings suggest that thinking too much should not be interpreted as a gloss for psychiatric disorder nor assumed to be a unitary symptom or syndrome within a culture. We suggest five key ways in which engagement with thinking too much idioms can improve global mental health research and interventions: it (1) incorporates a key idiom of distress into measurement and screening to improve validity of efforts at identifying those in need of services and tracking treatment outcomes; (2) facilitates exploration of ethnopsychology in order to bolster cultural appropriateness of interventions; (3) strengthens public health communication to encourage engagement in treatment; (4) reduces stigma by enhancing understanding, promoting treatment-seeking, and avoiding unintentionally contributing to stigmatization; and (5) identifies a key locally salient treatment target