Reliability and validity of depression assessment among persons with HIV in sub-Saharan Africa: systematic review and meta-analysis

Abstract

Objective: The aim of this study was to systematically review the reliability and validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in sub-Saharan Africa.

Design: Systematic review and meta-analysis.

Methods: A systematic evidence search protocol was applied to 7 bibliographic databases. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on the data collected from HIV-positive adults in any African member state of the United Nations. A random-effects meta-analysis was used to calculate pooled estimates of depression prevalence. In a subgroup of studies of criterion-related validity, the bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity.

Results: Of 1117 records initially identified, I included 13 studies of 5373 persons with HIV in 7 sub-Saharan African countries. Reported estimates of Cronbach alpha ranged from 0.63 to 0.95, and analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. The pooled prevalence of probable depression was 29.5% [95% confidence interval (CI): 20.5 to 39.4], whereas the pooled prevalence of major depressive disorder was 13.9% (95% CI: 9.7 to 18.6). The Center for Epidemiologic Studies Depression scale was the most frequently studied instrument, with a pooled sensitivity of 0.82 (95% CI: 0.73 to 0.87) for detecting major depressive disorder.

Conclusions: Depression-screening instruments yielded relatively high false positive rates. Overall, few studies described the reliability and/or validity of depression instruments in sub-Saharan Africa.

Figure 1

Quality of Reporting of Meta-Analyses (QUORUM) flow chart depicting the number of reports screened and included in the systematic review

Figure 2

Forest plot depicting the distribution of estimates of probable depression, with pooled estimates stratified by HIV treatment status

Figure 3

Summary receiver-operating characteristic (ROC) curve plot of diagnosis of major depressive disorder based on CES-D threshold values selected by authors. The solid line depicts the summary ROC curve from the bivariate random-effects model. The solid square depicts the summary operating point, i.e., summary values for sensitivity and specificity. The dotted line depicts the 95% confidence region for the summary operating point.