Research report
Detecting perinatal common mental disorders in Ethiopia: Validation of the self-reporting questionnaire and Edinburgh Postnatal Depression Scale

https://doi.org/10.1016/j.jad.2007.10.023Get rights and content

Abstract

Background

The cultural validity of instruments to detect perinatal common mental disorders (CMD) in rural, community settings has been little-investigated in developing countries.

Methods

Semantic, content, technical, criterion and construct validity of the Edinburgh Postnatal Depression Scale (EPDS) and Self-Reporting Questionnaire (SRQ) were evaluated in perinatal women in rural Ethiopia. Gold-standard measure of CMD was psychiatric assessment using the Comprehensive Psychopathological Rating Scale (CPRS). Community-based, convenience sampling was used. An initial validation study (n = 101) evaluated both EPDS and SRQ. Subsequent validation was of SRQ alone (n = 119).

Results

EPDS exhibited poor validity; area under the receiver operating characteristic (AUROC) curve of 0.62 (95%CI 0.49 to 0.76). SRQ-20 showed better validity as a dimensional scale, with AUROC of 0.82 (95%CI 0.68 to 0.96) and 0.70 (95%CI 0.57 to 0.83) in the two studies. The utility of SRQ in detecting ‘cases’ of CMD was not established, with differing estimates of optimal cut-off score: three and above in Study 1 (sensitivity 85.7%, specificity 75.6%); seven and above in Study 2 (sensitivity 68.4%, specificity 62%). High convergent validity of SRQ as a dimensional measure was demonstrated in a community survey of 1065 pregnant women.

Limitations

Estimation of optimal cut-off scores and validity coefficients for detecting CMD was limited by sample size.

Conclusions

EPDS demonstrated limited clinical utility as a screen for perinatal CMD in this rural, low-income setting. The SRQ-20 was superior to EPDS across all domains for evaluating cultural equivalence and showed validity as a dimensional measure of perinatal CMD.

Introduction

Perinatal common mental disorders (CMD) are characterised by significant levels of depressive, anxiety, panic and/or somatic symptoms occurring in pregnancy and the postnatal period. In non-perinatal women from community and primary care settings, there are high levels of co-variance of these symptoms, indicating an underlying unitary construct of CMD (Goldberg, 1996, Lewis, 1992). In perinatal women, the focus of studies is typically narrowed to ‘postnatal depression', although evidence supports the relevance of the broader concept of ‘perinatal CMD’ (Matthey et al., 2003, Aderibigbe et al., 1993).

Perinatal CMD is increasingly recognised to be an important public health issue in low-income countries. In sub-Saharan Africa, the estimated prevalence of CMD ranges from 12.5 to 27.1% in pregnancy (Assael et al., 1972, Cox, 1979, Aderibigbe and Gureje, 1992, Abiodun et al., 1993), and from 10.0 to 34.5% postnatally (Cox, 1983, Nhiwatiwa et al., 1998, Lawrie et al., 1998, Aderibigbe et al., 1993, Cooper et al., 1999, Uwakwe, 2003, Adewuya et al., 2005), and is comparable to estimates from high-income settings (O'Hara and Swain, 1996). Perinatal CMD in low-income settings, mostly South Asia, is associated with maternal disability and early cessation of breast-feeding (Patel et al., 2002), low birth weight (Rahman et al., 2004, Patel and Prince, 2006), infant undernutrition (Patel et al., 2003, Anoop et al., 2004, Rahman et al., 2004), impaired mother–infant relationships (Cooper et al., 1999), poorer infant mental development (Patel et al., 2003), increased frequency of infant diarrhoeal episodes and diminished help-seeking of the mother on behalf of her child (Rahman et al., 2004).

Simple, structured questionnaires may help to improve detection of perinatal CMD in primary health care, which is a prerequisite for appropriate intervention. The Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987) is the most widely validated screening instrument for depression in pregnancy and the postnatal period across a range of cultural settings (Cox and Holden, 2003), although with published validation data from only three countries in sub-Saharan Africa (Lawrie et al., 1998, Uwakwe, 2003, Weobong et al., in press). The EPDS was designed specifically to detect depression; however, the presence of an anxiety sub-scale suggests utility in detection of the broader concept of perinatal CMD (Jomeen and Martin, 2005, Brouwers et al., 2001).

While the omission of somatic symptoms from the EPDS avoids the risk of mislabelling physical changes associated with pregnancy and caring for an infant as somatic aspects of depression, this could be a disadvantage in developing world settings where somatic symptoms are considered to be a common presentation for CMD (Ebigbo, 1982, Harding et al., 1980). In Ethiopia, the Self-Reporting Questionnaire (SRQ-20) (Beusenberg and Orley, 1994), which has six somatic items (out of twenty), has been validated for detection of CMD (Kortmann and Ten Horn, 1988), although not specific to the perinatal period. A local version of the SRQ for Ethiopia, the SRQ-F, has also been developed by augmenting the original scale with local idioms of distress and found to have superior validity coefficients (Zilber et al., 2004).

Validation of a psychiatric rating scale in a new cultural setting requires attention to semantic, technical, content, criterion and conceptual equivalence (Flaherty et al., 1988). Few such studies have been carried out in sub-Saharan Africa for scales purporting to detect perinatal CMD, and none in Ethiopia. In this paper we present validation of the EPDS and SRQ for detection of CMD in pregnant and postnatal women in a predominantly rural area of Ethiopia.

Section snippets

Setting

The studies were undertaken in Butajira, a predominantly rural region of Ethiopia located 130 km south of the capital Addis Ababa. A Demographic Surveillance Site (DSS) was established in this area 20 years ago under the auspices of the Butajira Rural Health Programme (BRHP) (Berhane et al., 1999). Within the densely populated Butajira area there is much ethnic and linguistic diversity, although most people are conversant with Amharic, the working language of the marketplace and the national

Semantic validity

Translation of items 2 and 4 of the EPDS was problematic, for example the Amharic terms used to convey ‘looking forward to’ (Item 2) indicated the sense of anticipating or expecting something to happen, without requiring pleasure. In item 4, the Amharic word ‘chenket’ did not separate the concepts of ‘anxiety’ and worry'. Distinguishing between the four response categories was also difficult, and these were simplified where possible (Appendix A).

Technical validity

To facilitate administration of the EPDS as an

Discussion

In contrast to reports from other developing countries, the EPDS was not found to be a valid measure of perinatal CMD in this rural Ethiopian community setting. The EPDS was poorly understood by participating women, discriminated inadequately between cases and non-cases and showed unacceptably low internal consistency. The SRQ-20 performed somewhat better, proving easy to administer and valid as a dimensional indicator of CMD, with good evidence of convergent validity. The 29-item

Conclusion

The SRQ-20 was found to have superior validity to the EPDS across all domains for evaluating cultural equivalence in detection of perinatal CMD in rural Ethiopia. Identifying an optimal cut-off to distinguish cases from non-cases proved difficult, although the SRQ demonstrated good convergent validity as a dimensional measure. Using symptom burden rather than designating ‘cases’ of perinatal CMD on the basis of a lay-administered self-report scale in a non-Western community setting may be a

Role of funding source

Funding for this study was provided by the Wellcome Trust, Grant GR071643MA; the Wellcome Trust had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of Interest

All authors declare that they have no conflicts of interest.

Acknowledgements

We thank all the women who participated and the staff of the Butajira Rural Health Programme for their generous co-operation and support.

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