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      Challenges in measuring depression among Ugandan fisherfolk: a psychometric assessment of the Luganda version of the Center for Epidemiologic Studies Depression Scale (CES-D)

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          Abstract

          Background

          Depression is a prevalent and serious mood disorder and a major source of disability adjusted life years (DALY) in Uganda. Furthermore, evidence from Uganda and other countries throughout sub-Saharan Africa suggests that nearly a third of persons living with human immunodeficiency virus (HIV) suffer from depression and it adversely affects healthcare seeking behavior. The high burden of disease attributable to depression makes data on the prevalence of depression in Uganda, a country with a generalized HIV epidemic, a public health priority. This paper describes the psychometric properties of the Center for Epidemiologic Studies-Depression (CES-D) measure when administered to men and women residing in three fishing communities along the shore of Lake Victoria.

          Methods

          We applied methods based on item response theory and classical test theory approaches to assess individual item characteristics, conducted exploratory factor analysis and assessed internal reliability, and construct and content validity of the measure. All analyses were performed in R Studio.

          Results

          The study sample consisted of 300 residents of fishing communities in Wakiso District, Uganda. Fifty-six percent of the sample was female and 19.7% reported being HIV positive. Seven items of the measure that did not perform well, either because they could not differentiate between levels of the latent trait or because they did not map onto the primary factor, were removed from the scale. A single factor structure best fit our final set of 13-items and we found an overall coefficient alpha of 0.89, indicating high internal consistency in this population.

          Conclusions

          Based on our findings, we recommend that future use of the CES-D in this population utilize our revised scale with the final set of 13-items. The addition of other measures that can improve the rigor of CES-D validation efforts, such as inclusion of a clinical depression measure and administration in both a clinical and a general population sample in this setting are needed.

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          Most cited references28

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          Coefficient alpha and the internal structure of tests

          Psychometrika, 16(3), 297-334
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            Screening for Depression in the General Population with the Center for Epidemiologic Studies Depression (CES-D): A Systematic Review with Meta-Analysis

            Objective We aimed to collect and meta-analyse the existing evidence regarding the performance of the Center for Epidemiologic Studies Depression (CES-D) for detecting depression in general population and primary care settings. Method Systematic literature search in PubMed and PsychINFO. Eligible studies were: a) validation studies of screening questionnaires with information on the accuracy of the CES-D; b) samples from general populations or primary care settings; c) standardized diagnostic interviews following standard classification systems used as gold standard; and d) English or Spanish language of publication. Pooled sensitivity, specificity, likelihood ratios and diagnostic odds ratio were estimated for several cut-off points using bivariate mixed effects models for each threshold. The summary receiver operating characteristic curve was estimated with Rutter and Gatsonis mixed effects models; area under the curve was calculated. Quality of the studies was assessed with the QUADAS tool. Causes of heterogeneity were evaluated with the Rutter and Gatsonis mixed effects model including each covariate at a time. Results 28 studies (10,617 participants) met eligibility criteria. The median prevalence of Major Depression was 8.8% (IQ range from 3.8% to 12.6%). The overall area under the curve was 0.87. At the cut-off 16, sensitivity was 0.87 (95% CI: 0.82–0.92), specificity 0.70 (95% CI: 0.65–0.75), and DOR 16.2 (95% CI: 10.49–25.10). Better trade-offs between sensitivity and specificity were observed (Sensitivity = 0.83, Specificity = 0.78, diagnostic odds ratio = 16.64) for cut-off 20. None of the variables assessed as possible sources of heterogeneity was found to be statistically significant. Conclusion The CES-D has acceptable screening accuracy in the general population or primary care settings, but it should not be used as an isolated diagnostic measure of depression. Depending on the test objectives, the cut-off 20 may be more adequate than the value of 16, which is typically recommended.
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              Mental health and HIV/AIDS: the need for an integrated response

              Tremendous biomedical advancements in HIV prevention and treatment have led to aspirational efforts to end the HIV epidemic. However, this goal will not be achieved without addressing the significant mental health and substance use problems among people living with HIV (PLWH) and people vulnerable to acquiring HIV. These problems exacerbate the many social and economic barriers to accessing adequate and sustained healthcare, and are among the most challenging barriers to achieving the end of the HIV epidemic. Rates of mental health problems are higher among both people vulnerable to acquiring HIV and PLWH, compared with the general population. Mental health impairments increase risk for HIV acquisition and for negative health outcomes among PLWH at each step in the HIV care continuum. We have the necessary screening tools and efficacious treatments to treat mental health problems among people living with and at risk for HIV. However, we need to prioritize mental health treatment with appropriate resources to address the current mental health screening and treatment gaps. Integration of mental health screening and care into all HIV testing and treatment settings would not only strengthen HIV prevention and care outcomes, but it would additionally improve global access to mental healthcare.
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                Author and article information

                Contributors
                skiene@sdsu.edu
                Journal
                BMC Psychiatry
                BMC Psychiatry
                BMC Psychiatry
                BioMed Central (London )
                1471-244X
                5 February 2020
                5 February 2020
                2020
                : 20
                : 45
                Affiliations
                [1 ]Division of Infectious Disease and Global Public Health, University of California, San Diego, La Jolla, CA USA
                [2 ]ISNI 0000 0001 0790 1491, GRID grid.263081.e, Division of Epidemiology and Biostatistics, , San Diego State University School of Public Health, ; 5500 Campanile Drive (MC-4162), San Diego, CA 92182 USA
                [3 ]Wakiso Integrated Rural Development Association, Entebbe, Uganda
                [4 ]ISNI 0000 0004 1936 9094, GRID grid.40263.33, Alcohol Research Center of HIV, , Brown University School of Public Health, ; Providence, RI USA
                Author information
                http://orcid.org/0000-0001-8922-5289
                Article
                2463
                10.1186/s12888-020-2463-2
                7003345
                32024472
                19ad240c-ff43-4561-8a87-5b041d92fb3f
                © The Author(s). 2020

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 30 May 2019
                : 24 January 2020
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000027, National Institute on Alcohol Abuse and Alcoholism;
                Award ID: P01 AA019072
                Funded by: FundRef http://dx.doi.org/10.13039/100000026, National Institute on Drug Abuse;
                Award ID: T32 DA 023356
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2020

                Clinical Psychology & Psychiatry
                depression,hiv,ces-d scale,uganda,fisherfolk,sub-saharan africa
                Clinical Psychology & Psychiatry
                depression, hiv, ces-d scale, uganda, fisherfolk, sub-saharan africa

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