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Research article

Prevalence of depression and validation of the Beck Depression

Inventory-II and the Children’s Depression Inventory-Short

amongst HIV-positive adolescents in Malawi

Maria H Kim §, * ,1,2

, Alick C Mazenga* ,2 , Akash Devandra

1 , Saeed Ahmed

1 , Peter N Kazembe

2 , Xiaoying Yu

3 ,

Chi Nguyen 3 and Carla Sharp

4

§ Corresponding author: Maria H Kim, Baylor College of Medicine�Abbott Fund Children’s Clinical Center of Excellence, Private Bag B-397, Lilongwe 3, Malawi. Tel: �265 1 750 877. ([email protected]) *These authors contributed equally to the development of this manuscript.

Abstract

Introduction: There is a remarkable dearth of evidence on mental illness in adolescents living with HIV/AIDS, particularly in the

African setting. Furthermore, there are few studies in sub-Saharan Africa validating the psychometric properties of diagnostic

and screening tools for depression amongst adolescents. The primary aim of this cross-sectional study was to estimate the

prevalence of depression amongst a sample of HIV-positive adolescents in Malawi. The secondary aim was to develop culturally

adapted Chichewa versions of the Beck Depression Inventory-II (BDI-II) and Children’s Depression Inventory-II-Short (CDI-II-S)

and conduct a psychometric evaluation of these measures by evaluating their performance against a structured depression

assessment using the Children’s Rating Scale, Revised (CDRS-R).

Study design: Cross-sectional study.

Methods: We enrolled 562 adolescents, 12�18 years of age from two large public HIV clinics in central and southern Malawi. Participants completed two self-reports, the BDI-II and CDI-II-S, followed by administration of the CDRS-R by trained clinicians.

Sensitivity, specificity and positive and negative predictive values for various BDI-II and CDI-II-S cut-off scores were calculated

with receiver operating characteristics analysis. The area under the curve (AUC) was also calculated. Internal consistency was

measured by standardized Cronbach’s alpha coefficient, and correlation between self-reports and CDRS-R by Spearman’s

correlation.

Results: Prevalence of depression as measured by the CDRS-R was 18.9%. Suicidal ideation was expressed by 7.1% (40) using the

BDI-II. The AUC for the BDI-II was 0.82 (95% CI 0.78�0.89) and for the CDI-II-S was 0.75 (95% CI 0.70�0.80). A score of ]13 in BDI-II achieved sensitivity of �80%, and a score of ]17 had a specificity of �80%. The Cronbach’s alpha was 0.80 (BDI-II) and

0.66 (CDI-II-S). The correlation between the BDI-II and CDRS-R was 0.42 (pB0.001) and between the CDI-II-S and CDRS-R was

0.37 (pB0.001).

Conclusions: This study demonstrates that the BDI-II has sound psychometric properties in an outpatient setting among HIV-

positive adolescents in Malawi. The high prevalence of depression amongst HIV-positive Malawian adolescents noted in this

study underscores the need for the development of comprehensive services for HIV-positive adolescents.

Keywords: HIV; adolescents; depression; prevalence; BDI-II; CDI-II-Short.

Received 19 November 2013; Revised 2 May 2014; Accepted 20 May 2014; Published 30 July 2014

Copyright: – 2014 Kim MH et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium,

provided the original work is properly cited.

Introduction In 2009, an estimated 5 million young people (aged 15�24) and 2 million adolescents (aged 10�19) were living with HIV, the vast majority in sub-Saharan Africa [1]. Nearly one in two

new HIV infections occurs in young people [1]. This, combined

with the successful scale-up of paediatric HIV services re-

sulting in improved survival into the teen years, has led to a

rising demand for comprehensive services focusing on the

special needs of adolescents [2].

Adolescence is a period of vulnerability for a host of well-

documented biological, behavioural, social and structural

reasons. Adolescents living with HIV/AIDS in sub-Saharan

Africa present unique challenges to health care providers

[3,4]. Furthermore, mental health in people living with HIV

and AIDS (PWLHA) is an area of scanty research, and there is

a dearth of evidence for adolescents, particularly in the

African setting.

Depression is a major contributor to the burden of disease

worldwide and is estimated to be the leading cause of

disability as measured by Years Lost due to Disability (YLDs)

[5,6]. The prevalence of depression is estimated to be higher

in developing versus developed countries [7]. In PLWHA, the

Kim MH et al. Journal of the International AIDS Society 2014, 17:18965

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prevalence of depression has been documented to be as high

as double that of the general population [8]. In the few

studies in Africa, estimates of prevalence of depression in

PLWHA range between 12 and 60% [8�14]. Depression has been shown to worsen several HIV-related

health outcomes. It is associated with steeper declines in

CD4 counts, and more rapid progression to AIDS and death

[8,14�16]. Associations with suboptimal antiretroviral therapy (ART) adherence and discontinuation have been reported

with significant implications for long-term treatment efficacy

[17�19]. Depression in youth has also been correlated with high-risk behaviour including earlier sexual debut, low con-

dom use, substance abuse, more frequent sexual partners and

unplanned pregnancy [11,20]. However, most evidence comes

from high-income countries, and few associations have been

firmly established in sub-Saharan Africa, the epicentre of the

HIV epidemic. Other correlates more applicable to Africa and

the Malawian setting in particular, such as orphanhood,

poverty and urban migration, have been poorly described.

The lack of clinical data, limited awareness by healthcare

providers and patients and the scarcity of resources and

interventions, all act as obstacles in the provision of holistic

care to adolescents living with HIV. There is an urgency to

incorporate mental health into adolescent HIV care in Malawi

and sub-Saharan Africa to improve quality of life and health

outcomes.

Unfortunately, there are few studies in sub-Saharan Africa,

and virtually no published studies in Malawi validating the

psychometric properties of the commonly utilized diagnostic

and screening tools for depression amongst adolescents as

compared to adults [13,21�24]. Depression may manifest in a variety of ways across different cultural and age groups,

and research instruments need to be culturally appro-

priate [25]. Traditional instruments developed in the west

should, if used, undergo a careful process of translation,

back-translation and modification to ensure cross-cultural

equivalence [21,25].

The Beck Depression Inventory-II (BDI-II) and the Children’s

Depression Inventory-II-Short (CDI-II-S) were used as depres-

sion screening tools. The BDI-II is a 21-item tool that has been

extensively tested for validity and reliability since the 1960s

[26], including use in the paediatric population. One study in

Nigeria provided psychometric evidence in support of the

BDI-II in the African setting [22]. The CDI-II-S, a symptom-

oriented instrument, is a 12-item self-report tool used for

assessing depression in children aged 7�17 years. Psycho- metric evidence in support of the use of the long version

was provided in a study amongst children in Tanzania [13].

The CDI-II-S has been validated as being equally efficacious for

screening purposes as the long version [27�29]. Both tools can be completed in 5�10 minutes and, therefore, are ideal for use in typical high-volume clinical settings in Malawi. There

has been no assessment of either tool in Malawi to date.

Malawi, a land-locked country located in Southern Africa,

with an HIV prevalence of 11%, has successfully scaled up

access to HIV treatment services with 276,987 patients

retained alive on ART as of June 2011 [30]. However, there

are limited local options for diagnosis and treatment of

mental health problems. One previous survey of depression

in a cohort of orphaned children and adolescents (10�18 years) in the southern region reported a 53.2% prevalence

for clinical depression using the Center for Epidemiological

Studies Depression Scale Modified for Children (CES-DC) [31].

The primary aim of this cross-sectional study was to

estimate the prevalence of depression amongst a sample of

HIV-positive adolescents in Malawi. The secondary aim was

to develop culturally adapted Chichewa (the official and most

widely spoken language in Malawi) versions of the BDI-II and

CDI-II-S and conduct a psychometric evaluation of these

measures for use in HIV-positive adolescents by evaluating

their performance against a structured depression assess-

ment using the Children’s Depression Rating Scale, Revised

(CDRS-R).

Methods Study population

We recruited a convenience sample of adolescents aged

12�18 years from the Baylor College of Medicine Children’s Clinical Center of Excellence (COE) and Zomba ART Clinic. The

COE, the largest and first stand-alone paediatric HIV clinic in

Malawi, is located in Lilongwe, in central Malawi. It serves

both as an outpatient facility and as a national referral centre

for paediatric HIV care. Patients at both sites come from

urban and rural locations and are of various ethnic and socio-

economic backgrounds. As of March 2011, there were �420

(COE) and �200 (Zomba) patients 12�18 years of age active in care.

Informed consent

The National Health Sciences Research Committee (NHSRC) in

Malawi and Baylor College of Medicine Institutional Review

Board in USA approved the study protocol. The COE and

Zomba Central Hospital granted site approvals. All caregivers

and adolescents signed written informed consents/assents.

Measures

The CDI-II-S and the BDI-II were selected as the most appro-

priate tools to translate and evaluate for use in assessing

depression amongst Malawian adolescents living with HIV.

Both tools are widely used and validated self-report measures

of depression in youth.

The CDI-II-S is a 12-item self-report instrument used to

detect the presence and severity of depressive symptoms in

children aged 7�17 years [28,29]. The reading level is rated to be at the 2nd grade, and it can be completed in 5�10 minutes [28,29]. Each itemis scored: 0 for no symptom; 1 for a mild; and

2 for definite symptoms [13,29]. The CDI-II-Long [29,32�34] from which the CDI-II-S is derived has been validated in

a number of countries including Tanzania [13,35�37]. The CDI-II-S is reported to be a psychometrically comparable

screening instrument for depression [27�29]. Therefore, the CDI-II-S was selected as the measure most appropriate to

translate and examine for use in typical high-volume clinical

settings in Malawi.

The BDI-II is a 21-item self-report questionnaire that

assesses the presence and severity of depressive symptoms

in adolescents ]13 years [26,35,38]. Each question is scored:

0�symptom absent; 1�symptom present; 2�moderate symptom; and 3�severe symptom [35,39]. Total potential

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score is 63. The reading level is rated to be at the 6th grade,

and it can be completed in about 10 minutes. The tool has

been validated in other countries where English is not the

primary language [22,35,38].

To achieve accuracy in translation and cultural under-

standing, the tools underwent an adaptation process. The

process integrated input from multiple collaborators includ-

ing US, UK, Malawi-based researchers, linguistic experts

and Malawian adolescents. The tools were translated into

Chichewa by linguistic experts from Mzuzu University Centre

for Language Studies, back-translated, and edited. To help

ensure cultural validity in a Chichewa speaking culture, the

translated tools were checked by a Malawian Mental Health

Clinician, and pre-tested amongst a group of Malawian

adolescents. Translation of the English concepts to Chichewa

was straightforward for both tools. The process did identify

several items that needed clarification, for example, CDI-II-S

#12: in Chichewa ‘‘feeling’’ translated directly to ‘‘kumva’’

which could also mean ‘‘hearing.’’ Therefore, we opted to use

the word ‘‘kusungulumwa’’ meaning, ‘‘feeling alone.’’ BDI-II

#19: ‘‘weight loss’’ would translate to ‘‘decreasing weight’’ in

Chichewa, which would be too long and unclear. Therefore,

we used instead ‘‘kutsika kwa sikelo’’ meaning ‘‘decrease in

scale’’ since weight in Malawi is commonly referred to as

‘‘scale�sikelo.’’ CDRS-R is the most widely used rating tool for the as-

sessment of depressive symptoms in children and adoles-

cents, particularly in international research trials [40�42]. It is a clinician interview hand-rated instrument that covers

17 symptom areas of depression and can be used to both

diagnose and measure treatment response to depression

[36,38,43]. The CDRS-R was based on the adult Hamilton

Depression Rating Scale and can be administered in 15�20 minutes [39,43]. It rates 14 of 17 items from 1 to 7 while

the remaining three items are rated 1�5 [39]. The rating of the items is between 1 (�no difficulties) and 5, or 1 and 7 (7�clinically significant difficulties) summing up to a total potential raw score of 113 [41]. A child’s non-verbal

behaviour is rated by the observer for items 15�17 [39]. A raw score of ]30 with a T-score of ]55 has been

proposed to be indicative of depression [39].

In sub-Saharan Africa, there is scarcity of research in child

mental health and likewise paucity of data concerning the

psychometric properties of the CDRS-R. However, the devel-

opers of the tool report internal consistency (Cronbach’s

alpha) of 0.85, inter-rater reliabilities of 0.92�0.96, test�retest reliability of 0.80 as well as evidence of extensive conver-

gent validity, moderate concurrent validity, discriminative

validity and predictive validity [43]. Many other studies in

Asia, Europe and America have demonstrated excellent

psychometric properties of the CDRS-R [36,39�41,43]. In Malawi, there is currently only one psychiatrist working

in the public sector. Therefore, although published studies

utilizing the CDRS-R in Malawi are lacking, given the strong

evidence supporting the use of CDRS-R internationally, in lieu

of a psychiatric interview to diagnose depression, we utilized

the validated English version of CDRS-R to help assess

convergent validity of the BDI-II and CDI-II-S. To help ensure

optimal administration, only clinicians with mental health

training and over two years of experience in adolescent

HIV care, were selected to undergo one week training in

the administration of the CDRS-R. The training involved

discussing and agreeing upon locally equivalent words for

terminology. The post training competency assessment in-

cluded observed administration of the CDRS-R to ensure

standardized administration and use of culturally accepted

vocabulary. Interviewers received on-going supervision by

a qualified mental health professional with expertise in

adolescent depression.

Procedure

Participants’ interviews were conducted between January

and August 2012. Consents/assents were obtained from

caregivers and adolescents. Adolescents first completed the

CDI-II-S and then the BDI-II in a private room. Finally, trained

clinicians, who were blinded to the results of the CDI-II-S and

BDI-II, administered the CDRS-R. All participants who were

determined as having depression were promptly referred to a

Mental Health Clinical Officer and Psychosocial Counsellor on

site for further assessment and expert management.

Data analysis

Descriptive statistics, such as mean and standard deviation

(SD) for continuous variables, and frequency and proportion

for categorical variables, were calculated. We used CDRS-R

T-score, BDI-II total raw score and CDI-II-S T-score in the

analysis. The CDRS-R was used as gold standard to classify

depression. The prevalence of depression was calculated by

the proportion of subjects with CDRS-R score ]55. Chi-

square test was used to compare the prevalence of depres-

sion between genders. Sensitivity, specificity, and positive

and negative predictive values for various cut-offs were

calculated to determine the optimal screening as well as dia-

gnostic threshold with receiver operating characteristics

(ROC) analysis.

Optimal cut-offs were determined first by identifying the

point that gave the smallest distance from the ROC curve to

the upper left corner of the graph. This point minimizes the

sum of squares of false negative (1-sensitvity) and false

positive (1-specificity). This cut-off gave the best discrimina-

tion between cases and non-cases. The second approach was

to find a point that maximizes both sensitivity and specificity

by determining the point at which sensitivity approximates

specificity. The area under the curve (AUC) was calculated to

determine the tools’ diagnostic ability; AUC of 1.00 indicating

perfect diagnostic ability. The SAS logistic procedure esti-

mated the AUC using the trapezoid rule and compared the

AUCs using the Chi-square test according to DeLong [44].

Since variances between items were widely spread,

internal consistency was measured by standardized Cron-

bach’s alpha coefficient. Measurements were not normally

distributed; therefore, the Spearman’s correlation coefficient

was used to measure the correlation between the two tools

and the clinical interview. For all statistical tests, a two sided

pB0.05 was considered significant. Data was analyzed using

SAS version 9.3 (SAS Institute, Cary, NC).

Kim MH et al. Journal of the International AIDS Society 2014, 17:18965

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Results The two clinics provided a list of 695 potential participants.

Of these, 102 could not be contacted due to death, loss to

follow-up, lack of contact information or transfer to another

facility. Of those contacted, 11 were unable to participate

due to disability. Of the 582 eligible participants, 97% (562)

consented/assented and enrolled in the study.

Descriptive characteristics

Table 1 describes the socio-demographic characteristics of

the adolescent study participants.

The mean scores (9SD) were 11.997.9 for BDI-II and

51.6910.2 for CDI-II-S. Females had significantly higher mean

BDI-II than males (12.898.1 vs. 10.997.5, p�0.005); CDI-II-S scores were similar between genders (p�0.56).

Prevalence of depression

The prevalence of depression as measured by the CDRS-R

was 18.9% (106/562): 21.6% (68/315) in females and 15.4%

(38/247) in males. Although this finding approached sig-

nificance (p�0.06), the difference in mean CDRS-R scores was significant, 48.797.2 (females) and 47.296.7 (males),

p�0.013. Using the CDRS-R (score of �2 on question #13), suicidal ideation was expressed by 3.0% (17), and using BDI-II

(score of �0 on question #9) by 7.1% (40) (pB0.001).

Psychometric evaluation of the BDI-II and CDI-II-S

Diagnostic accuracy

Figure 1 demonstrates the ROC curves for the two tools as

compared to the CDRS-R. The AUC of the BDI-II 0.82 (95%

CI 0.77�0.87) was significantly greater than the AUC of the CDI-II-S 0.75 (95% CI 0.70�0.80) (p�0.003). By gender, the AUCs for the BDI-II were 0.88 (males) and 0.78 (females),

and for CDI-II-S were 0.85 (males) and 0.69 (females). The

difference between the scales was significant among females

(p�0.007) but not among males (p�0.35). The sensitivity, specificity, positive predictive value, and

negative predictive value at various cut-off scores for both

tools are shown in Tables 2 and 3 and Figures 2 and 3.

For the BDI-II, a cut-off of 15 gives both the shortest distance

from the ROC curve to the upper left corner of the graph as

well as the point where specificity approximates sensitivity.

This cut-off remains consistent for both genders. A score of

]13 achieved sensitivity of �80% and, therefore, may be

ideal to screen for cases, whereas a score of ]17 had a

specificity of �80%, making it appropriate for identifying non-

cases (diagnosis).

For the CDI-II-S, a cut-off of 53 gives both the shortest

distance from the ROC curve to the upper left corner of the

graph as well as the point where specificity approximates

sensitivity. Cut-offs differ slightly by gender: 52�53 (females) and 54�57 (males). Specificity approximates sensitivity at 52 (females) and 56 (males). The shortest distance from ROC

curve to the upper left corner of the graph was 53 (females)

and 57 (males). Overall, a score of ]48 achieved sensitivity

of �80% and, therefore, may be ideal as a screening cut-off,

Table 1. Socio-demographic characteristics of the study

participants

Variable

n (%)

N�562

Age (mean9SD) 14.592.0

Sex

Female 315 (56.1)

Male 247 (44.0)

Residential location

Urban 369 (65.7)

Peri-urban 93 (16.5)

Rural 100 (17.8)

Education status

Primary School 402 (71.5)

Secondary School 153 (27.2)

Post-Secondary School 4 (0.7)

Not at School 3 (0.5)

Figure 1. Receiver operating characteristic (ROC) curve for the

BDI-II and CDI-II-S as compared to the CDRS-R.

Table 2. Psychometric properties of the BDI-II in screening for

depression in HIV-positive Malawian adolescents

Cut-off BDI-II

(raw score) Specificity Sensitivity PPV NPV

11 0.588 0.849 0.324 0.944

12 0.638 0.830 0.348 0.942

13 0.686 0.811 0.376 0.940

14 0.739 0.774 0.408 0.934

15 0.774 0.745 0.434 0.929

16 0.794 0.679 0.434 0.914

17 0.829 0.623 0.458 0.904

18 0.866 0.575 0.500 0.898

19 0.906 0.557 0.578 0.898

20 0.930 0.500 0.624 0.889

Kim MH et al. Journal of the International AIDS Society 2014, 17:18965

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whereas a score of ]58 had a specificity of �90%, making

it appropriate for diagnostic use.

Internal consistency and validity

The Cronbach’s alpha for the BDI-II was 0.80 indicating strong

internal consistency. The Cronbach’s alpha for the CDI-II-S

was 0.66. The convergent validity between the BDI-II and

CDI-II-S as calculated by the Spearman correlation was 0.54

(pB0.001). The correlation between the BDI-II and CDRS-R

was 0.42 (pB0.001). The correlation between the CDI-II-S

and CDRS-R was 0.37 (pB0.001). Similar internal consistency

(BDI-II: 0.80 vs. 0.80; CDI-II-S: 0.65 vs. 0.66) and medium

correlation (BDI-II and CDRS-R: 0.38 vs. 0.45; CDI-II-S and

CDRS-R: 0.31 vs. 0.44) were found by female vs. male gender.

Discussion To our knowledge, this is the first study to estimate the

prevalence of depression amongst HIV-positive Malawian

youth as well as the first study to evaluate the psychometric

properties of the BDI-II and CDI-II-S for depression screening

in this population. Our findings suggest that the prevalence

of depression is high and that the BDI-II can be used to

screen for depression amongst this population. The internal

consistency of the CDI-II-S as measured by Cronbach’s alpha

was lower than the 0.73�0.91 established in American samples across all versions of the CDI-II [29]. However, the

internal consistency is similar to what was reported in

Tanzania amongst orphans (0.67) [13]. The relatively lower

internal consistency estimates suggest that additional mod-

ifications may need to be made to the CDI-II-S for use in this

population. In all, the BDI-II had superior internal consistency

and AUC, as well as better concordance with the clinical

interview. Furthermore, our study suggests a score of ]13

in BDI would be appropriate as a screening cut-off score,

whereas a score of ]17 would be more appropriate for

diagnostic use.

Due to the paucity of studies in HIV-positive adolescents,

different age ranges and diverse measures, it is difficult to

make prevalence comparisons. However, our prevalence of

18.9% using the CDRS-R was similar to the 17.8% prevalence

found amongst HIV-positive children, 6�18 years of age in Kenya using the Mini International Neuropsychiatric Inter-

view for Major Depressive Episode (MINI-kid) [14], and 18.3%

found in Malaysia (Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition and MINI-kid) [37]. Since

the CDRS-R, unlike the MINI-kid, was not designed to identify

other mental disorders such as bipolar and anxiety disorders,

we were unable to report on other potentially co-morbid

mental health conditions. Studies in both HIV-positive and

uninfected adolescents and adults have demonstrated that

females show higher rates of depression compared to males

[22,23,45,46]. In our study, the difference in prevalence of

depression between genders appeared to be considerable,

and we found a statistically significant difference in mean

CDRS-R scores between genders. Interestingly, suicidal idea-

tion as expressed by the BDI-II was higher than that found by

the CDRS-R.

Table 3. Psychometric properties of the CDI-II-S in screening

for depression in HIV-positive Malawian adolescents

Cut-off CDI-II-S

(T-score) Specificity Sensitivity PPV NPV

47 0.456 0.868 0.271 0.937

48 0.474 0.868 0.277 0.939

50 0.553 0.792 0.292 0.920

52 0.662 0.689 0.322 0.901

53 0.667 0.689 0.324 0.902

54 0.735 0.594 0.342 0.886

56 0.750 0.594 0.356 0.888

57 0.785 0.509 0.355 0.873

58 0.831 0.472 0.394 0.871

Figure 2. Sensitivity and specificity of the BDI-II.

Kim MH et al. Journal of the International AIDS Society 2014, 17:18965

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It is possible that having a more highly trained and

sympathetic interviewer could encourage a participant to be

more forthcoming in reporting symptoms. However, typically,

there is higher endorsement of all psychopathology on self-

report screening measures like the BDI-II versus interview-

based measures [38]. The youth in this study may have felt

more comfortable answering certain questions by self-report

versus interview.

There were several limitations to the study. Given the

extremely limited number of qualified psychiatrists in

Malawi, we opted for assessment of convergent validity

with the CDRS-R, in lieu of the gold standard diagnosis of

depression via psychiatric interview. Results demonstrated a

medium correlation between the BDI-II and the CDRS-R

probably reflecting a method effect (self-report vs. interview-

based). More research using interview-based tools alongside

self-report measures is needed to clarify these results. In

addition, we cannot definitively conclude that our prevalence

estimate is representative of all HIV-positive adolescents in

Malawi. However, the Baylor COE is the largest referral centre

for paediatric HIV in Malawi, with patients coming from

a wide geographic area. Zomba Central Hospital ART Clinic in

southern Malawi is one of two referral centres for patients

from the southern region. Therefore, sampling from these

centres should provide a fairly reliable estimate of prevalence

of depression amongst HIV-positive Malawian youth.

As the study did not include a control group and national

statistics on depression prevalence in Malawian adolescents

are lacking, we were unable to conclude whether our pre-

valence estimate is higher than that of non-HIV-positive adoles-

cents in Malawi. In addition, caution should be exercised in

generalizing the results, including use of the tools to ado-

lescents without HIV infection. However, the high prevalence

of depression amongst Malawian adolescents living with

HIV highlights a significant mental health need, and raises a

concern regarding how these needs will be met in a resource-

limited setting.

The strength of our study is that it is the first epidemio-

logical study to assess the prevalence of depression in HIV-

positive youth in Malawi, and the first to use two self-report

measures and a semi-structured diagnostic instrument. In

addition, to our knowledge, this is the largest mental health

prevalence study done in HIV-positive youth in Africa.

Conclusions Despite the limitations, this study has demonstrated that the

BDI-II has sound psychometric properties in an outpatient

setting among HIV-positive adolescents in Malawi. Our study

also supports the use of the BDI-II as a viable measure for

identifying possible cases of depression amongst this popula-

tion and, in fact, may be easier to administer as compared to

an interview-based tool for assessing depression. The CDI-II-S

can be used to screen for depressive symptoms. However, the

low internal consistency estimates suggest that modifications

may need to be made. Importantly, our study demonstrates a

high prevalence of depression amongst HIV-positive Malawian

youth and underscores the need for the development of

comprehensive services for HIV-positive adolescents. Further

research is needed to explore factors contributing to and

protective of depression in adolescents living with HIV/AIDS.

Interventional studies are also needed to determine the most

efficacious treatments.

Authors’ affiliations 1 Baylor College of Medicine International Paediatric AIDS Initiative, Texas

Children’s Hospital, Houston, TX, USA; 2 Baylor College of Medicine�Abbott

Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi; 3 Department

of Paediatrics, Epidemiology Center, Baylor College of Medicine, Houston, TX,

USA; 4 Department of Psychology, University of Houston, Houston, TX, USA

Competing interests

The authors have no competing interests to declare.

Authors’ contributions

MHK and ACM conceived and designed the study, were responsible for study

coordination and data management, helped analyze data, interpreted findings

Figure 3. Sensitivity and specificity of the CDI-II-S.

Kim MH et al. Journal of the International AIDS Society 2014, 17:18965

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6

and wrote the manuscript. AD assisted in reviewing the protocol and study

coordination in the field, contributed to data management and reviewed the

manuscript. PNK and SA reviewed the study protocol, provided guidance on

the conduct of the study and critically reviewed the manuscript for important

intellectual content. CN, XY and CS assisted in statistical analysis, interpretation

and manuscript writing. All authors have read and approved the final

manuscript.

Acknowledgements

We thank the Malawi Ministry of Health for their partnership in this endeavour.

We thank the Baylor College of Medicine Children’s Foundation Malawi data

team, clinicians and nurses who participated in data collection including Menard

Bvumbwe, William Kamuyango, Mphatso Machika, and Adamson Munthali.

Special thanks to Joseph Mhango for creation of the study database. We extend

our gratitude to Chrissie Gondwe and Edson Mwinjiwa of Diginitas International

for facilitating and helping us with recruitment of study participants at Zomba

Central Hospital ART Clinic. We are grateful to all the adolescents living with HIV

and their caregivers who participated in this study.This study was made possible

by support from the Texas Children’s Global Health Stimulus Grant and USAID

cooperative agreement number 674-A-00-10-00093-00. MHK was supported

by the Fogarty International Center of the National Institutes of Health under

award number K01 TW009644. Data analysis was provided by the Design and

Analysis Core of the Baylor-UT Houston Center for AIDS Research, an NIH funded

program numbered P30-AI36211.

Disclaimer

The contents are the responsibility of the authors and do not necessarily reflect

the views of the funders, including the National Institutes of Health, USAID and

the United States Government.

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