Validity of the Patient Health Questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South Africa.


Journal Article

Integration 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.We 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.The 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.We were unable to conduct qualitative work to adapt the PHQ-9 to this cultural context.This 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.

Full Text

Duke Authors

Cited Authors

  • Cholera, R; Gaynes, BN; Pence, BW; Bassett, J; Qangule, N; Macphail, C; Bernhardt, S; Pettifor, A; Miller, WC

Published Date

  • January 2014

Published In

Volume / Issue

  • 167 /

Start / End Page

  • 160 - 166

PubMed ID

  • 24972364

Pubmed Central ID

  • 24972364

Electronic International Standard Serial Number (EISSN)

  • 1573-2517

International Standard Serial Number (ISSN)

  • 0165-0327

Digital Object Identifier (DOI)

  • 10.1016/j.jad.2014.06.003


  • eng