• R Cholera, B N Gaynes, B W Pence, J Bassett, N Qangule, C Macphail, S Bernhardt, A Pettifor, and W C Miller.
• Department of Epidemiology, UNC Gillings School of Global Public Health, McGavran-Greenberg Hall, 135 Dauer Drive, Chapel Hill, NC 27599, USA. Electronic address: rcholera@med.unc.edu.
• J Affect Disord. 2014 Jan 1;167:160-6.

BackgroundIntegration of depression screening into primary care may increase access to mental health services in sub-Saharan Africa, but this approach requires validated screening instruments. We sought to validate the Patient Health Questionnaire-9 (PHQ-9) as a depression screening tool at a high HIV-burden primary care clinic in Johannesburg, South Africa.MethodsWe conducted a validation study of an interviewer-administered PHQ-9 among 397 patients. Sensitivity and specificity of the PHQ-9 were calculated with the Mini International Neuropsychiatric Interview (MINI) as the reference standard; receiver operating characteristic (ROC) curve analyses were performed.ResultsThe prevalence of depression was 11.8%. One-third of participants tested positive for HIV. HIV-infected patients were more likely to be depressed (15%) than uninfected patients (9%; p=0.08). Using the standard cutoff score of ≥10, the PHQ-9 had a sensitivity of 78.7% (95% CI: 64.3-89.3) and specificity of 83.4% (95% CI: 79.1-87.2). The area under the ROC curve was 0.88 (95% CI: 0.83-0.92). Test performance did not vary by HIV status or language. In sensitivity analyses, reference test bias associated with the MINI appeared unlikely.LimitationsWe were unable to conduct qualitative work to adapt the PHQ-9 to this cultural context.ConclusionThis is the first validation study of the PHQ-9 in a primary care clinic in sub-Saharan Africa. It highlights the potential for using primary care as an access point for identifying depressive symptoms during routine HIV testing. The PHQ-9 showed reasonable accuracy in classifying cases of depression, was easily implemented by lay health workers, and is a useful screening tool in this setting.Copyright © 2014 Elsevier B.V. All rights reserved.

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