Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Home
  • Home
Article
  • Access
  • Open access

The development of an ultra-short, maternal mental health screening tool in South Africa

  • T. van Heyningen (a1) (a2), L. Myer (a2), M. Tomlinson (a3), S. Field (a1) and S. Honikman (a1)...

Abstract

Purpose.

The burden of common perinatal mental disorders (CPMD) in low-and-middle-income countries is substantially higher than high-income countries, with low levels of detection, service provision and treatment in resource-constrained settings. We describe the development of an ultra-short screening tool to detect antenatal depression, anxiety disorders and maternal suicidal ideation.

Methods.

A sample of 376 women was recruited at a primary-level obstetric clinic. Five depression and anxiety symptom-screening questionnaires, demographics and psychosocial risk questionnaires were administered. All participants were assessed with the Mini-International Neuropsychiatric Interview (MINI), a structured, diagnostic interview. Screening tool items were analysed against diagnostic data using multiple logistic regression and receiver operating curve (ROC) analysis.

Results.

The prevalence of MINI-defined major depressive episode (MDE) and/or anxiety disorders was 33%. Overall, 18% of participants expressed suicidal ideation and behaviour, 54% of these had no depression or anxiety diagnosis. Multiple logistic regression identified four screening items that were independently predictive of MDE and anxiety disorders, investigating depressed mood, anhedonia, anxiety symptoms and suicidal ideation. ROC analysis of these combined items yielded an area under the curve of 0.83 (95% CI 0.78–0.88). A cut-off score of 2 or more offered a sensitivity of 78% and specificity of 82%.

Conclusion.

This novel screening tool is the first measure of CPMD developed in South Africa to include depressed mood, anxiety symptoms and suicidal ideation. While the tool requires further investigation, it may be useful for the early identification of mental health symptoms and morbidity in the perinatal period.

  • View HTML

      • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      The development of an ultra-short, maternal mental health screening tool in South Africa
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      The development of an ultra-short, maternal mental health screening tool in South Africa
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      The development of an ultra-short, maternal mental health screening tool in South Africa
      Available formats
      ×

Copyright

COPYRIGHT: © The Author(s) 2019
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

*Address for correspondence: T. van Heyningen, Perinatal Mental Health Project, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa. (Email: thandivh@gmail.com)

References

Hide All
Afulani, PA, Diamond-Smith, N, Golub, G, Sudhinaraset, M (2017). Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population. Reproductive Health 14, 1–18.
Akena, D, Joska, J, Obuku, EA, Amos, T, Musisi, S, Stein, DJ (2012). Comparing the accuracy of brief versus long depression screening instruments which have been validated in low and middle income countries: a systematic review. BMC Psychiatry 12, 187.
Austin, MP (2014). Marce International Society position statement on psychosocial assessment and depression screening in perinatal women. Best Practice & Research. Clinical Obstetrics & Gynaecology 28, 179–187.
Austin, MP, Colton, J, Priest, S, Reilly, N, Hadzi-Pavlovic, D (2011). The Antenatal Risk Questionnaire (ANRQ): acceptability and use for psychosocial risk assessment in the maternity setting. Women and Birth 26, 17–25.
Barthel, D, Barkmann, C, Ehrhardt, S, Schoppen, S, Bindt, C, Appiah-Poku, J, Baum, J, Te Bonle, M, Burchard, GD, Claussen, L, Deymann, S, Eberhardt, KA, Ewert, H, Feldt, T, Fordjour, D, Guo, N, Hahn, A, Hinz, R, Jaeger, A, Koffi, JE, Koffi, M, Kra, E, Loag, W, May, J, Mohammed, Y, N'Goran, E, Nguah, SB, Osei, Y, Posdzich, S, Reime, B, Schlüter, L, Tagbor, H, Tannich, E (2015). Screening for depression in pregnant women from Cote d'Ivoire and Ghana: psychometric properties of the Patient Health Questionnaire-9. Journal of Affective Disorders 187, 232–240.
Benatar, SR (2013). The challenges of health disparities in South Africa. South African Medical Journal 103, 154–155.
Bhana, A, Rathod, SD, Selohilwe, O, Kathree, T, Petersen, I (2015). The validity of the Patient Health Questionnaire for screening depression in chronic care patients in primary health care in South Africa. BMC Psychiatry 15, 1–9.
Biaggi, A, Conroy, S, Pawlby, S, Pariante, CM (2016). Identifying the women at risk of antenatal anxiety and depression: a systematic review. Journal of Affective Disorders 191, 62–77.
Blumberg, SJ, Bialostosky, K, Hamilton, WL, Briefel, RR (1999). The effectiveness of a short form of the household food security scale. American Journal of Public Health 89, 1231–1234.
Brittain, K, Myer, L, Koen, N, Koopowitz, S, Donald, KA, Barnett, W, Zar, HJ, Stein, DJ (2015). Risk factors for antenatal depression and associations with infant birth outcomes: results from a South African birth cohort study. Paediatric and Perinatal Epidemiology 29(6), 505–514. doi: https://doi.org/10.1111/ppe.12216.
Cholera, R, Gaynes, BN, Pence, BW, Bassett, J, Qangule, N, Macphail, C, Bernhardt, S, Pettifor, A, Miller, WC (2014). Validity of the patient health questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South Africa. Journal of Affective Disorders 167, 160–166.
Coelho, HF, Murray, L, Royal-lawson, M, Cooper, PJ (2011). Antenatal anxiety disorder as a predictor of postnatal depression: a longitudinal study. Journal of Affective Disorders 129, 348–353.
Condon, J (2010). Women's mental health: a ‘wish-list’ for the DSM V. Archives of women's Mental Health 13, 5–10.
Cronbach, LJ (1951). Coefficient alpha and the internal structure of tests. Psychometrika 16, 297–334.
Draper, CE, Lund, C, Kleintjes, S, Funk, M, Omar, M, Flisher, AJ (2009). Mental health policy in South Africa: development process and content. Health Policy and Planning 24, 342–356.
Eberhard-gran, M, Eskild, A, Tambs, K, Opjordsmoen, S, Samuelsen, SO (2001). Review of validation studies of the Edinburgh postnatal depression scale. Acta Psychiatrica Scandinavica 104, 243–249.
Field, S, Onah, M, van Heyningen, T, Honikman, S (2018). Domestic and intimate partner violence among pregnant women in a low resource setting in South Africa: a facility-based, mixed methods study. BMC Women's Health 18, 1–13.
Fisher, J, De Mello, MC, Patel, V, Rahman, A, Tran, T, Holton, S, Holmes, W (2012). Prevalence and determinants of common perinatal mental disorders in women in low and lower middle income countries: a systematic review of the evidence. Bulletin of the World Health Organization 90, 139–149.
Gentile, S (2015). Untreated depression during pregnancy: short- and long-term effects in offspring. A systematic review. Neuroscience 342, 154–166. doi: https://doi.org/10.1016/j.neuroscience.2015.09.001.
Glover, V, O'Connor, T (2002). Effects of antenatal stress and anxiety. British Journal of Psychiatry 180, 389–391.
Goodman, JH, Chenausky, KL, Freeman, MP (2014). Anxiety disorders during pregnancy: a systematic review. Journal of Clinical Psychiatry 75, e1153–e1184.
Hanlon, C, Medhin, G, Alem, A, Tesfaye, F, Lakew, Z, Worku, B, Dewey, M, Araya, M, Abdulahi, A, Hughes, M, Tomlinson, M, Patel, V, Prince, M (2009). Impact of antenatal common mental disorders upon perinatal outcomes in Ethiopia: the P-MaMiE population-based cohort study. Tropical Medicine & International Health 14, 156–166.
Herba, CM, Glover, V, Ramchandani, PG, Rondon, MB (2016). Maternal depression and mental health in early childhood: an examination of underlying mechanisms in low-income and middle-income countries. The Lancet Psychiatry 3, 983–992.
Hock, RS, Or, F, Kolappa, K, Burkey, MD, Surkan, PJ, Eaton, WW (2012). A new resolution for global mental health. Lancet 379, 1367–1368.
Honikman, S, van Heyningen, T, Field, S, Baron, E, Tomlinson, M (2012). Stepped care for maternal mental health: a case study of the perinatal mental health project in South Africa. PLOS Medicine 9(5), e1001222. doi: https://doi.org/10.1371/journal.pmed.1001222.
Howard, LM (2016). What Does Excellence in Perinatal Mental Health look Like? Meeting the NICE Guideline for Postnatal Mental Health. King's Health Partners: London, United Kingdom.
Howard, LM, Molyneaux, E, Dennis, C-L, Rochat, T, Stein, A, Milgrom, J (2014). Non-psychotic mental disorders in the perinatal period. Lancet 384, 1775–1788.
Jewkes, R, Dunkle, K, Koss, MP, Levin, JB, Nduna, M, Jama, N, Sikweyiya, Y (2006). Rape perpetration by young, rural South African men: prevalence, patterns and risk factors. Social Science & Medicine (1982) 63, 2949–2961.
Kagee, A, Tsai, AC, Lund, C, Tomlinson, M (2012). Screening for common mental disorders in low resource settings: reasons for caution and a way forward. International Health 5, 11–14.
Kakuma, R, Minas, H, van Ginneken, N, Dal Poz, MR, Desiraju, K, Morris, JE, Saxena, S, Scheffler, RM (2011). Human resources for mental health care: current situation and strategies for action. Lancet 378, 1654–1663.
Kaminer, D (2001). The truth and reconciliation commission in South Africa: relation to psychiatric status and forgiveness among survivors of human rights abuses. British Journal of Psychiatry 178, 373–377.
Kessler, RC, Andrews, G, Colpe, LJ, Hiripi, E, Mroczek, DK, Normand, S-LLT, Walters, EE, Zaslavsky, AM (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine 32, 959–976.
Kroenke, K, Spitzer, RL, Williams, JBW (2001). The PHQ-9. Validity of a brief depression severity measure. Journal of General Internal Medicine 46202, 606–613.
Kroenke, K, Spitzer, R, Williams, J (2007). The 2-item generalized anxiety disorder scale had high sensitivity and specificity for detecting GAD in primary care. Annals of Internal Medicine 146, 317–325.
Langer, A, Meleis, A, Knaul, FM, Atun, R, Aran, M, Arreola-Ornelas, H, Bhutta, ZA, Binagwaho, A, Bonita, R, Caglia, JM, Claeson, M, Davies, J, Donnay, FA, Gausman, JM, Glickman, C, Kearns, AD, Kendall, T, Lozano, R, Seboni, N, Sen, G, Sindhu, S, Temin, M, Frenk, J (2015). Women and health: the key for sustainable development. Lancet 386, 1165–1210.
Lawrie, T, Hofmeyer, G, de Jager, M, Berk, M (1998). Validation of the Edinburgh postnatal depression scale on a cohort of South African women. South African Medical Journal 88, 1340–1344.
Lund, C, Kleintjes, S, Cooper, S, Petersen, I, Bhana, A, Flisher, AJ, The MHaPP Research Programme Consortium (2011). Challenges facing South Africa's mental health care system: stakeholders’ perceptions of causes and potential solutions. International Journal of Culture and Mental Health 4, 23–38.
Lund, C, Kleintjes, S, Kakuma, R, Flisher, AJ (2010). Public sector mental health systems in South Africa: inter-provincial comparisons and policy implications. Social Psychiatry and Psychiatric Epidemiology 45, 393–404.
Manikkam, L, Burns, JK (2012). Antenatal depression and its risk factors: an urban prevalence study in KwaZulu-natal. South African Medical Journal 102, 940–944.
Marsay, C, Manderson, L, Subramaney, U (2017). Validation of the Whooley questions for antenatal depression and anxiety among low-income women in urban South Africa. South African Journal of Psychiatry 23, 1–7.
Meltzer-Brody, S, Brandon, A (2015). It is time to focus on maternal mental health: optimising maternal and child health outcomes. BJOG: An International Journal of Obstetrics & Gynaecology 122, 321–321.
Meltzer-Brody, S, Howard, LM, Bergink, V, Vigod, S, Jones, I, Munk-Olsen, T, Honikman, S, Milgrom, J (2018). Postpartum psychiatric disorders. Nature Reviews 4, 1–19.
Moss, SJ, Larouche, R, Assah, F, Oyeyemi, AL, Adedoyin, RA, Kasoma, SS, Aryeetey, R, Lambert, EV, Ocansey, R, Akinroye, KK, Prista, A, Sallis, JF, Cain, KL, Conway, TL, Bartels, C, Kolbe-Alexander, TL, Tremblay, MS, Gavand, KA, Onywera, VO (2016). NEWS for Africa: adaptation and reliability of a built environment questionnaire for physical activity in seven African countries. The International Journal of Behavioral Nutrition and Physical Activity 13, 1–12.
Moultrie, A (2004). Indigenous Trauma Volunteers: Survivors with A Mission. Rhodes University: Grahamstown, South Africa.
Murray, D, Cox, JL (1990). Screening for depression during pregnancy with the Edinburgh depression scale (EDDS). Journal of Reproductive and Infant Psychology 8, 99–107.
Myer, L, Smit, J, Le Roux, L, Parker, S, Stein, DJ, Seedat, S (2008). Common mental disorders among HIV-infected individuals in South Africa: prevalence, predictors, and validation of brief psychiatric rating scales. AIDS Patient Care and STDs 22, 147–158.
National Collaborating Centre for Mental Health (NICE) (2014). Antenatal and postnatal mental health: the NICE guideline on clinical management and service guidance. National Clinical Guideline 192, 1–922.
Nyongesa, MK, Sigilai, A, Hassan, AS, Thoya, J, Odhiambo, R, Van De Vijver, FJR, Newton, CRJC, Abubakar, A (2017). A mixed methods approach to adapting and evaluating the functional assessment of HIV infection (FAHI), Swahili version, for use with low literacy populations. PLoS One 12, 1–22.
Oates, M (2003). Suicide: the leading cause of maternal death. British Journal of Psychiatry 183, 279–281.
Onah, MN, Field, S, Bantjes, J, Honikman, S (2016 a). Perinatal suicidal ideation and behaviour: psychiatry and adversity. Archives of Women's Mental Health 20, 321–331.
Onah, MNM, Field, S, van Heyningen, T, Honikman, S (2016 b). Predictors of alcohol and other drug use among pregnant women in a peri-urban South African setting. International Journal of Mental Health Systems 10, 38.
Orsolini, L, Valchera, A, Vecchiotti, R, Tomasetti, C, Iasevoli, F, Fornaro, M, De Berardis, D, Perna, G, Pompili, M, Bellantuono, C (2016). Suicide during perinatal period: epidemiology, risk factors, and clinical correlates. Frontiers in Psychiatry 7, 1–6.
Parsons, CE, Young, KS, Rochat, TJ, Kringelbach, ML, Stein, A (2012). Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries. British Medical Bulletin 101, 57–79.
Petersen, I, Bhana, A, Campbell-Hall, V, Mjadu, S, Lund, C, Kleintjies, S, Hosegood, V, Flisher, AJ, The Mental Health Poverty Research Programme Consortium (2009). Planning for district mental health services in South Africa: a situational analysis of a rural district site. Health Policy and Planning 24, 140–150.
Rochat, T, Tomlinson, M, Bärnighausen, T, Newell, M, Stein, A, Jean, T (2011). The prevalence and clinical presentation of antenatal depression in rural South Africa. Journal of Affective Disorders 135, 362–373.
Rochat, TJ, Tomlinson, M, Newell, M-L, Stein, A (2013). Detection of antenatal depression in rural HIV-affected populations with short and ultrashort versions of the Edinburgh postnatal depression scale (EPDS). Archives of Women's Mental Health 16, 401–410.
Roos, A, Faure, S, Lochner, C, Vythilingum, B, Stein, DJ (2013). Predictors of distress and anxiety during pregnancy. The African Journal of Psychiatry 16, 118–122.
Saxena, S, Thornicroft, G, Knapp, M, Whiteford, H (2007). Resources for mental health: scarcity, inequity, and inefficiency. Lancet 370, 878–889.
Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E, Hergueta, T, Baker, R, Dunbar, GC, Harnett Sheehan, K (1998). The MINI-international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59, 22–33.
Sidebottom, AC, Harrison, PA, Godecker, A, Kim, H (2012). Validation of the patient health questionnaire (PHQ)-9 for prenatal depression screening. Archives of Women's Mental Health 15, 367–374.
Somerville, S, Dedman, K, Hagan, R, Oxnam, E, Wettinger, M, Byrne, S, Coo, S, Doherty, D, Page, AC (2014). The perinatal anxiety screening scale: development and preliminary validation. Archives of Women's Mental Health 17(5), 443–454. doi: https://doi.org/10.1007/s00737-014-0425-8.
Spies, G, Stein, D, Roos, A, Faure, S, Mostert, J, Seedat, S, Vythilingum, B (2009). Validity of the Kessler 10 (K-10) in detecting DSM-IV defined mood and anxiety disorders among pregnant women. Archives of Women's Mental Health 12, 69–74.
Statistics South Africa (2013). City of Cape Town – 2011 Census – Ward 047. Statistics South Africa: Cape Town, South Africa.
Statistics South Africa (2015). Methodological Report on Rebasing of National Poverty Lines and Development on Pilot Provincial Poverty Lines: Technical Report. Statistics South Africa: Pretoria.
Steering Group for Perinatal Mental Health (2017). World Psychiatric Association Position Statement on Perinatal Mental Health. Steering Group for Perinatal Mental Health: Geneva, Switzerland.
Stein, A, Pearson, RM, Goodman, SH, Rapa, E, Rahman, A, McCallum, M, Howard, LM, Pariante, CM (2014). Effects of perinatal mental disorders on the fetus and child. Lancet 384(9956), 1800–1819. doi: https://doi.org/10.1016/S0140-6736.
Straus, MA, Douglas, EM (2004). A short form of the revised conflict tactics scales, and typologies for severity and mutuality. Violence and Victims 19, 507–520.
Tsai, AC, Scott, JA, Hung, KJ, Zhu, JQ, Matthews, LT, Psaros, C, Tomlinson, M (2013). Reliability and validity of instruments for assessing perinatal depression in African settings: systematic review and meta-analysis. PLoS One 8, 1–12.
van Heyningen, T, Honikman, S, Myer, L, Onah, MNMN, Field, S, Tomlinson, M (2017). Prevalence and predictors of anxiety disorders amongst low-income pregnant women in urban South Africa: a cross-sectional study. Archives of Women's Mental Health 20, 765–775. doi: https://doi.org/10.1007/s00737-017-0768-z.
van Heyningen, T, Honikman, S, Tomlinson, M, Field, S, Myer, L (2018). Comparison of mental health screening tools for detecting antenatal depression and anxiety disorders in South African women. PLoS One 13, e0193697.
van Heyningen, T, Myer, L, Onah, M, Tomlinson, M, Field, S, Honikman, S (2016). Antenatal depression and adversity in urban South Africa. Journal of Affective Disorders 203, 121–129.
Whooley, MA, Avins, AL, Miranda, J, Browner, WS (1997). Case-finding instruments for depression. Two questions are as good as many. Journal of General Internal Medicine 12, 439–445.
World Psychiatric Association (2015). WPA Perinatal Mental Health Position Statement. World Psychiatric Association: Geneva, Switzerland.
Zhong, Q, Gelaye, B, Rondon, M, Sánchez, SE, García, PJ, Sánchez, E, Barrios, YV, Simon, GE, Henderson, DC, May Cripe, S, Williams, MA (2014). Comparative performance of patient health questionnaire-9 and Edinburgh postnatal depression scale for screening antepartum depression. Journal of Affective Disorders 162, 1–7. doi: https://doi.org/10.1016/j.jad.2014.03.028.
Zimet, GD, Dahlem, NW, Zimet, SG, Farley, GK (1988). The multidimensional scale of perceived social support. Journal of Personality Assessment 52, 30–41.

Keywords

  • Access
  • Open access

The development of an ultra-short, maternal mental health screening tool in South Africa

  • T. van Heyningen (a1) (a2), L. Myer (a2), M. Tomlinson (a3), S. Field (a1) and S. Honikman (a1)...

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed