The development and validation of the visual screening tool for anxiety disorders and depression in people living with hypertension and/or diabetes

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Stellenbosch : Stellenbosch University
ENGLISH SUMMARY : People living with hypertension and/or diabetes have an increased prevalence of depression and anxiety disorders. This contributes to functional limitations, poor quality of life, increased financial burden and increased suffering. The identification of these mental disorders can contribute to addressing the burden imposed by them. However, there are barriers to the identification of these disorders, particularly in the South African context. These include a lack of tools that can be applied to the diverse South African cultural and language groups and people with different levels of education; as well as that a number of screening tools fail to meet acceptability for sensitivity in the South African population. Attempts to improve availability of screening tools for use at primary health care have included the translation of screening tools previously developed in high-income countries. However, translated screening tools are often plagued with methodological flaws. In order to address some of these limitations, visual screening tools for depression have been developed. These tools do not require a patient to be able to read and write, and have been found to be appropriate for use in people with low levels of education. They have been shown to be effective in the identification of depression in low-income countries. In this study, I aimed to develop and validate a visual screening tool for both depression and anxiety disorders in people living with hypertension and/or diabetes for use at primary health care level. The items for the visual screening tool were based on the Hospital Anxiety and Depression Scale (HADS). Compared to similar screening tools, the HADS has been found to be an appropriate screening tool for anxiety disorders and depression in people with diabetes, and those with low levels of education. However, the HADS is only appropriate for people who are able to read and write. My study was divided into two phases with each informing the final conclusion. In phase one (reported as one publication), I developed the visual screening tool items by asking an artist, Ms Jane Metelo-Liquito, to draw pictures depicting symptoms of depression and anxiety disorders. The drawings were based on the HADS. These were shown to a group of participants recruited from the general population, primary health care centres and a maternal mental health clinic. This was to ascertain the applicability of the drawings across cultures, languages and varying levels of education. The findings from phase one of the study indicated which drawings were applicable and appropriate for inclusion in the visual screening tool named the Visual Screening Tool for Anxiety Disorders and Depression (VISTAD). In phase two of the study, I validated the VISTAD. Participants diagnosed with hypertension and/or diabetes were recruited from five primary health care centres in the Eastern Cape. This province has been identified to have a high prevalence of hypertension and diabetes. Using the Mini Neuropsychiatric Interview (M.I.N.I) we demonstrated that 40% of our sample had panic disorder, followed by depression (32%), post-traumatic stress disorder (33%), generalised anxiety disorder (17%), and then social phobia and agoraphobia (10% for both). Current available prevalence rates of depression and anxiety disorders in the hypertension and/or diabetes populations are mostly based on research conducted in high-income countries and as such my results are a valuable addition for researchers and clinicians. Using the WHO quality of life assessment instrument (WHOQOL-BREF) as research tool, I found that our participants reported poor quality of life across the domains of physical health, psychological health and environment, but not for the social relationships domain. There were statistically significant differences in the physical and environment domain of people living with hypertension and/or diabetes comorbid with other medical conditions compared to participants without other medical conditions. The majority of participants in my study had lower levels of education, were unemployed and financial dependent on support from others and our results were largely in keeping with available literature in similar groups. The positive association with the social relationships domain could possibly be explained by the fact that most participants were reliant on interdependent social structures. Only 15% of my sample reported hazardous and harmful alcohol use whilst 17% reported any other drug related problems. These are relatively low levels within the South African context but are likely explained by the fact that the majority of my participants were female and that the sample’s average age was 49. The overarching goal of phase two was the validation of the VISTAD (chapter 4) which was developed in phase one. Validation was done against the M.I.N.I and my findings showed that the VISTAD has high accuracy in detecting depression and moderate accuracy in detecting anxiety disorders in adults with a diagnosis of hypertension and/or diabetes attending primary health care centers. The VISTAD is self-administered and any primary health care worker can easily be trained to score it. I demonstrated that it can be administered to patients independent of level of education, language and cultural background. I believe that the VISTAD represents an important contribution towards furthering the integration of the management of mental health conditions into the primary health care system. Firstly, it addresses the challenges posed by cultural, language, educational and time factors when attempting to screen for common mental disorders. Secondly, the VISTAD includes symptoms of depression and anxiety disorders in one screening tool. Literature recommends that the assessment of depressive disorders should include anxiety disorders since these disorders often co-exist in chronic physical conditions. It is well known and widely reported in the literature that primary health care access to mental health specialists is severely limited. Thus, the true integration of mental health care into primary health will improve the early identification and management of depression and anxiety disorders in people living with chronic illnesses. The availability of simple to use and culturally appropriate tools such as the VISTAD brings this goal much closer to becoming a reality.
AFRIKAANSE OPSOMMING : Mense wat saamleef met hipertensie en/of diabetes het ‘n hoër prevalensie van depressie en angssteurings. Dit dra by tot funksionele inkortings, swak lewenskwaliteit, hoër finansiële las en lyding. Identifisering van hierdie psigiatriese siektes kan bydra daartoe om die las wat deur hulle veroorsaak word aan te spreek. Daar bestaan egter struikelblokke wat identifisering bemoeilik, veral in die Suid Afrikaanse konteks. Dit sluit die gebrek van instrumente wat gebruik kan word in die diverse Suid Afrikaanse kulturele- en taalgroepe asook mense met verskillende vlakke van opleiding in, sowel as die feit dat baie siftingsinstrumente nie aanvaarbare sensitiwiteit toon in die Suid Afrikaanse populasie nie. Pogings on die beskikbaarheid van siftingsinstrumente vir gebruik in primêre gesondheidsorg te verbeter het ook die vertaling van siftingsinstrumente wat in hoë inkomste lande ontwikkel is ingesluit. Vertaalde instrumente toon egter dikwels metodologiese foute. Visuele siftingsinstrumente vir depressie is ontwikkel om sommige van hierdie tekortkominge aan te spreek. Sulke instrumente benodig nie dat ‘n pasiënt kan lees of skryf nie en is al gewys om toepaslik te wees vir gebruik in mense met lae vlakke van opleiding. Hulle is bewys om effektief te wees met die identifikasie van depressie in lae inkomste lande. My doel met hierdie studie was om ‘n visuele siftingsinstrument vir beide depressie en angssteurings te ontwikkel en geldig te bewys in mense met hipertensie en/of diabetes vir gebruik op primêre gesondheidsorgvlak. Die items vir die visuele siftingsinstrument was gebaseer op die “Hospital Anxiety and Depression Scale (HADS)”. Die HADS is bewys om, in vergelyking met soortgelyke instrumente, ‘n toepaslike sfitingsinstrument vir angssteurings en depressie te wees in mense met diabetes sowel as diegene met ‘n lae vlak van opleiding. Die HADS is egter net toepaslik vir pasiënte wat kan lees en skryf. My studie was verdeel in twee fases en elk het die finale gevolgtrekking toegelig. Tydens fase een (gerapporteer as een publikasie) het ek die visuele siftingsinstrument items ontwikkel deur ‘n kunstenaar, Me Jane Metelo-Liquito, te vra om sketse te teken wat simptome van depressie en angssteurings voorstel. Die sketse was gebaseer op die HADS. Hierdie is vertoon aan ‘n groep deelnemers wat gewerf is vanuit die algemene populasie, primêre gesondheidsorgsentrums en ‘n moederlike geestesgesondheidskliniek. Dit was om die toepaslikheid te bepaal van die sketse regoor die kulturele, taal en opvoedingsvlak spektrum. Die bevindinge van fase een van my studie het aangedui watter sketse toepaslik en aanvaarbaar was vir insluiting in die visuele siftingsinstrument genoem die “Visual Screening Tool for Anxiety Disorders and Depression (VISTAD)”. Tydens fase twee van die studie is die geldigheid van die VISTAD bewys. Deelnemers, gediagnoseer met hipertensie en/of diabetes, is gewerf vanuit vyf primêre gesondheidsorgklinieke in die Oos Kaap. Die provinsie is geidentifiseer om ‘n hoë prevalensie van hipertensie en diabetes te hê. Deur die “Mini Neuropsychiatric Interview (M.I.N.I)” te gebruik het ons gedemonstreer dat 40% van ons groep aan panieksteuring ly, gevolg deur post traumatiese stresssteuring (33%), depressie (32%), algemene angssteuring (17%) en dan sosiale fobie en agorafobie (beide 10%). Huidig beskikbare prevalensiekoerse vir depressie en angssteurings in hipertensie en diabetes populasies is hoofsaaklik gebaseer op navorsing uitgevoer in hoë inkomste lande en derhalwe is my resultate ‘n waardevolle toevoeging vir navorsers en kliniese personeel. Deur die WGO se lewenskwaliteit assesseringsinstrument “(WHOQOL-BREF)” te gebruik het ek bevind dat ons deelnemers swak lewenskwaliteit rapporteur oor die domeine van fisiese gesondheid, psigiese gesondheid en omgewing, maar nie vir die sosiale verhoudinge domein nie. Daar was statisties beduidende verskille tussen die fisiese en omgewings domeine van mense met hipertensie en/of diabetes te same met ander mediese toestande in vergelyking met die sonder ander mediese toestande. Die meerderheid van die deelnemers in ons studie het laer vlakke van opleiding gehad, was werkloos en finansiëel afhanklik van ander en my resultate is dus meerendeels in lyn met beskikbare resultate in soortgelyke groepe. Die positiewe assosiasie met die sosiale verhoudinge domein kan moontlik verduidelik word deur die feit dat die meeste deelnemers deel van was interafhanklike sosiale strukture. Slegs 15% van studiegroep het gevaarlike en skadelike alkoholgebruik gerapporteer, terwyl 17% enige ander dwelm-verwante probleme gerapporteer het. Binne die Suid Afrikaanse konteks is hierdie relatiewe lae vlakke wat waarskynlik verklaar kan word deur die feit dat die meerderheid van ons deelnemers vroulik was en die gemiddelde ouderdom van die groep 49. Die oorkoepelende doel van fase twee was om die VISTAD (hoofstuk vier), wat in fase een ontwikkel is, geldig te bewys. Dit is gedoen teen die M.I.N.I. en my bevindinge het gewys dat die VISTAD hoë akkuraatheid het om depressie te bespeur en gemiddelde akkuraatheid om angssteurings te bespeur in volwassenes met hipertensie en/of diabetes wat primêre gesondheidsorgsentra bywoon. Die VISTAD word self beantwoord en enige primêre gesondheidsorgwerker kan maklik opgelei word om die totaal te bereken. Ek het demonstreer dat die instrument onafhanklik van opleidingsvlak, taal en kulturele agtergrond gebruik kan word. Ek glo die VISTAD verteenwoordig ‘n belangrike bydrae tot die verbeterde integrasie van die hantering van psigiatriese toestande binne die primêre gesondheidsorgsisteem. Eerstens spreek dit die uitdagings aan wat kultuur, taal, opleidingsvlak en tydsfaktore bring wanneer ons probeer sif vir algemene psigiatriese siektes. Tweedens sluit die VISTAD simptome van beide depressie en angssteurings in een visuele siftingsinstrument in. Literatuur beveel aan dat die assessering van depressiewe steurings ook angssteurings moet insluit aangesien hierdie steurings dikwels saam voorkom in kroniese fisiese siektes. Dit is ook welbekend en word wyd in die literatuur gerapporteer dat die primêre gesondheidsorgvlak se toegang tot psigiatriese spesialiskennis ernstig beperk is. Die ware integrasie van psigiatriese sorg binne primêre gesondheidsorg sal die vroeë identifikasie en hantering van depressie en angssteurings in mense met kroniese siektes verbeter. Die beskikbaarheid van kultureel toepaslike instrumente soos die VISTAD wat eenvoudig is om te gebruik bring hierdie doelwit veel nader aan ‘n realiteit.
Thesis (PhD)--Stellenbosch University, 2018.
The published article for this Doctoral is available at
Medical screening, Depression, Mental, Anxiety disorders, Hypertension -- Patients, Diabetes -- Patients, UCTD