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      Validated Screening Tools for Common Mental Disorders in Low and Middle Income Countries: A Systematic Review

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      1 , 2 , * , 3 , 2 , 4 , 2
      PLoS ONE
      Public Library of Science

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          Abstract

          Background

          A wide range of screening tools are available to detect common mental disorders (CMDs), but few have been specifically developed for populations in low and middle income countries (LMIC). Cross-cultural application of a screening tool requires that its validity be assessed against a gold standard diagnostic interview. Validation studies of brief CMD screening tools have been conducted in several LMIC, but until now there has been no review of screening tools for all CMDs across all LMIC populations.

          Methods

          A systematic review with broad inclusion criteria was conducted, producing a comprehensive summary of brief CMD screening tools validated for use in LMIC populations. For each validation, the diagnostic odds ratio (DOR) was calculated as an easily comparable measure of screening tool validity. Average DOR results weighted by sample size were calculated for each screening tool, enabling us to make broad recommendations about best performing screening tools.

          Results

          153 studies fulfilled our inclusion criteria. Because many studies validated two or more screening tools, this corresponded to 273 separate validations against gold standard diagnostic criteria. We found that the validity of every screening tool tested in multiple settings and populations varied between studies, highlighting the importance of local validation. Many of the best performing tools were purposely developed for a specific population; however, as these tools have only been validated in one study, it is not possible to draw broader conclusions about their applicability in other contexts.

          Conclusions

          Of the tools that have been validated in multiple settings, the authors broadly recommend using the SRQ-20 to screen for general CMDs, the GHQ-12 for CMDs in populations with physical illness, the HADS-D for depressive disorders, the PHQ-9 for depressive disorders in populations with good literacy levels, the EPDS for perinatal depressive disorders, and the HADS-A for anxiety disorders. We recommend that, wherever possible, a chosen screening tool should be validated against a gold standard diagnostic assessment in the specific context in which it will be employed.

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          Most cited references34

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          Depression, chronic diseases, and decrements in health: results from the World Health Surveys

          Depression is an important public-health problem, and one of the leading causes of disease burden worldwide. Depression is often comorbid with other chronic diseases and can worsen their associated health outcomes. Few studies have explored the effect of depression, alone or as a comorbidity, on overall health status. The WHO World Health Survey (WHS) studied adults aged 18 years and older to obtain data for health, health-related outcomes, and their determinants. Prevalence of depression in respondents based on ICD-10 criteria was estimated. Prevalence values for four chronic physical diseases--angina, arthritis, asthma, and diabetes--were also estimated using algorithms derived via a Diagnostic Item Probability Study. Mean health scores were constructed using factor analysis and compared across different disease states and demographic variables. The relation of these disease states to mean health scores was determined through regression modelling. Observations were available for 245 404 participants from 60 countries in all regions of the world. Overall, 1-year prevalence for ICD-10 depressive episode alone was 3.2% (95% CI 3.0-3.5); for angina 4.5% (4.3-4.8); for arthritis 4.1% (3.8-4.3); for asthma 3.3% (2.9-3.6); and for diabetes 2.0% (1.8-2.2). An average of between 9.3% and 23.0% of participants with one or more chronic physical disease had comorbid depression. This result was significantly higher than the likelihood of having depression in the absence of a chronic physical disease (p<0.0001). After adjustment for socioeconomic factors and health conditions, depression had the largest effect on worsening mean health scores compared with the other chronic conditions. Consistently across countries and different demographic characteristics, respondents with depression comorbid with one or more chronic diseases had the worst health scores of all the disease states. Depression produces the greatest decrement in health compared with the chronic diseases angina, arthritis, asthma, and diabetes. The comorbid state of depression incrementally worsens health compared with depression alone, with any of the chronic diseases alone, and with any combination of chronic diseases without depression. These results indicate the urgency of addressing depression as a public-health priority to reduce disease burden and disability, and to improve the overall health of populations.
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            Poverty and common mental disorders in low and middle income countries: A systematic review.

            In spite of high levels of poverty in low and middle income countries (LMIC), and the high burden posed by common mental disorders (CMD), it is only in the last two decades that research has emerged that empirically addresses the relationship between poverty and CMD in these countries. We conducted a systematic review of the epidemiological literature in LMIC, with the aim of examining this relationship. Of 115 studies that were reviewed, most reported positive associations between a range of poverty indicators and CMD. In community-based studies, 73% and 79% of studies reported positive associations between a variety of poverty measures and CMD, 19% and 15% reported null associations and 8% and 6% reported negative associations, using bivariate and multivariate analyses respectively. However, closer examination of specific poverty dimensions revealed a complex picture, in which there was substantial variation between these dimensions. While variables such as education, food insecurity, housing, social class, socio-economic status and financial stress exhibit a relatively consistent and strong association with CMD, others such as income, employment and particularly consumption are more equivocal. There are several measurement and population factors that may explain variation in the strength of the relationship between poverty and CMD. By presenting a systematic review of the literature, this paper attempts to shift the debate from questions about whether poverty is associated with CMD in LMIC, to questions about which particular dimensions of poverty carry the strongest (or weakest) association. The relatively consistent association between CMD and a variety of poverty dimensions in LMIC serves to strengthen the case for the inclusion of mental health on the agenda of development agencies and in international targets such as the millenium development goals. Copyright 2010 Elsevier Ltd. All rights reserved.
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              The diagnostic odds ratio: a single indicator of test performance.

              Diagnostic testing can be used to discriminate subjects with a target disorder from subjects without it. Several indicators of diagnostic performance have been proposed, such as sensitivity and specificity. Using paired indicators can be a disadvantage in comparing the performance of competing tests, especially if one test does not outperform the other on both indicators. Here we propose the use of the odds ratio as a single indicator of diagnostic performance. The diagnostic odds ratio is closely linked to existing indicators, it facilitates formal meta-analysis of studies on diagnostic test performance, and it is derived from logistic models, which allow for the inclusion of additional variables to correct for heterogeneity. A disadvantage is the impossibility of weighing the true positive and false positive rate separately. In this article the application of the diagnostic odds ratio in test evaluation is illustrated.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                16 June 2016
                2016
                : 11
                : 6
                : e0156939
                Affiliations
                [1 ]Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
                [2 ]Centre for Global Mental Health, London, United Kingdom
                [3 ]Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
                [4 ]Department of Population, Environment and Health, Wellcome Trust, London, United Kingdom
                University of Kwazulu-Natal, SOUTH AFRICA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: GCA MJDS. Performed the experiments: GCA GR. Analyzed the data: GCA. Wrote the paper: GCA. Reviewed and edited the manuscript: GR MJDS.

                Author information
                http://orcid.org/0000-0001-7510-2034
                Article
                PONE-D-16-01844
                10.1371/journal.pone.0156939
                4911088
                27310297
                669c13f4-cb84-4942-81b9-04f7949778bf
                © 2016 Ali et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 14 January 2016
                : 23 May 2016
                Page count
                Figures: 2, Tables: 5, Pages: 14
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100004828, Grand Challenges Canada;
                Award ID: EPPHZG35-10
                Grand Challenges Canada EPPHZG35-10 http://www.grandchallenges.ca/. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Mood Disorders
                Depression
                Research and Analysis Methods
                Database and Informatics Methods
                Database Searching
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Neuropsychiatric Disorders
                Anxiety Disorders
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Neuroses
                Anxiety Disorders
                Research and Analysis Methods
                Research Assessment
                Research Validity
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Medicine and Health Sciences
                Public and Occupational Health
                Health Screening
                Research and Analysis Methods
                Research Assessment
                Systematic Reviews
                Biology and Life Sciences
                Psychology
                Psychometrics
                Social Sciences
                Psychology
                Psychometrics
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                Uncategorized

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