Psychometric Evaluation of Screens for Common Mental Disorders, Severe Mental Disorders, Substance Use Disorders, and Suicide Risk in Mozambican Healthcare
Main Article Content
Abstract
Globally, mental and substance use disorders are a leading cause of disease burden. In low- and middle-income countries, where there is an extreme shortage of trained mental health specialists, validated, brief screening tools for mental and substance use disorders are required for non-specialists to efficiently identify patients in need of mental health care. Mozambique, one of the poorest countries in the world, has fewer than two mental health specialists for every 100,000 people. In the present study, we evaluated a comprehensive set of seven measures for depression, anxiety, somatization, alcohol use disorder, substance use disorder, psychosis and mania, and suicide risk among N=911 Mozambican adults in general healthcare settings. All instruments demonstrated acceptable internal consistency (α > 0.75). Compared to diagnoses made by the Mini International Neuropsychiatric Interview, all measures showed good criterion validity (AUC > 0.75), except the Psychosis Screening Questionnaire, which showed low sensitivity (0.58) for psychotic disorder. No substantial differences were observed in internal consistency when stratifying by gender, age, education level, primary language, facility-type, and patient status; criterion validity showed some variability when stratified by sub-population, particularly for education, primary language, and whether the participant was seeking care that day. Exploratory factor analyses indicated that the measures best differentiate categories of diagnoses (common mental disorder, severe mental disorders, substance use disorders, and suicide risk) rather than individual diagnoses, suggesting the utility of a transdiagnostic approach. Our findings support the use of these measures in Mozambique to identify common mental disorders, substance use disorders, and suicide risk, but indicate further research is needed to develop an adequate screen for severe mental disorders. Given the limited mental health specialists in this and other LMIC settings, these brief measures can support non-specialist provision of mental health services and promote closure of the treatment gap.
Article Details
How to Cite
LOVERO, Kathryn L. et al.
Psychometric Evaluation of Screens for Common Mental Disorders, Severe Mental Disorders, Substance Use Disorders, and Suicide Risk in Mozambican Healthcare.
Medical Research Archives, [S.l.], v. 12, n. 8, aug. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5294>. Date accessed: 04 dec. 2024.
doi: https://doi.org/10.18103/mra.v12i8.5294.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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5. Ali GC, Ryan G, De Silva MJ. Validated Screening Tools for Common Mental Disorders in Low and Middle Income Countries: A Systematic Review. PLoS One. 2016;11(6):e0156939. doi:10.1371/journal.pone.0156939
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10. Cumbe VF, Muanido A, Manaca MN, et al. Validity and item response theory properties of the Patient Health Questionnaire-9 for primary care depression screening in Mozambique (PHQ-9-MZ). BMC psychiatry. 2020;20(1):1-15.
11. Atkins DL, Cumbe VF, Muanido A, et al. Validity and item response theory properties of the Alcohol Use Disorders Identification Test for primary care alcohol use screening in Mozambique (AUDIT-MZ). Journal of Substance Abuse Treatment. 2021:108441.
12. Lovero KL, Basaraba C, Khan S, et al. Brief screening tool for Stepped-Care management of mental and substance use disorders. Psychiatric Services. 2021:appi. ps. 202000504.
13. Amorim P. Mini International Neuropsychiatric Interview (MINI): validação de entrevista breve para diagnóstico de transtornos mentais. Rev Bras Psiquiatr. 2000;22(3):106-15.
14. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of clinical psychiatry. 1998;
15. Babor TF, de la Fuente JR, Saunders J, Grant M. The Alcohol Use Disorders Identification Test: Guidelines for use in. Primary care. 2001;
16. Bebbington P, Nayani T. The psychosis screening questionnaire. International Journal of Methods in Psychiatric Research. 1995;
17. Gierk B, Kohlmann S, Kroenke K, et al. The somatic symptom scale–8 (SSS-8): a brief measure of somatic symptom burden. JAMA internal medicine. 2014;174(3):399-407.
18. Group WAW. The alcohol, smoking and substance involvement screening test (ASSIST): development, reliability and feasibility. Addiction. 2002;97(9):1183-1194.
19. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatric annals. 2002;32(9):509-515.
20. Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. American journal of psychiatry. 2011;168(12):1266-1277.
21. Prins A, Bovin MJ, Smolenski DJ, et al. The primary care PTSD screen for DSM-5 (PC-PTSD-5): development and evaluation within a veteran primary care sample. Journal of General Internal Medicine. 2016;31(10):1206-1211.
22. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of internal medicine. 2006;166(10):1092-1097.
23. Üstün TB, Kostanjsek N, Chatterji S, Rehm J. Measuring health and disability: Manual for WHO disability assessment schedule WHODAS 2.0. World Health Organization; 2010.
24. Sartorius N, Janca A. Psychiatric assessment instruments developed by the World Health Organization. Social psychiatry and psychiatric epidemiology. 1996;31(2):55-69.
25. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics. 2009;42(2):377-381.
26. Bossuyt PM, Reitsma JB, Bruns DE, et al. STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. Radiology. 2015;277(3):826-832.
27. Massinga LJ GM, Duarte CS, Mandlate F, dos Santos PF, Gouveia L, Oquendo M, Melo MF, Wainberg ML. Screening for post-traumatic stress disorder (PTSD) in Mozambique: Validation of the Primary Care-PTSD Screen for DSM-5 (PC-PTSD-5). In prep;
28. Dunn TJ, Baguley T, Brunsden V. From alpha to omega: A practical solution to the pervasive problem of internal consistency estimation. British journal of psychology. 2014;105(3):399-412.
29. Hayes AF, Coutts JJ. Use omega rather than Cronbach’s alpha for estimating reliability. But…. Communication Methods and Measures. 2020;14(1):1-24.
30. Velicer WF, Jackson DN. Component analysis versus common factor analysis: Some further observations. Multivariate Behavioral Research. 1990;25(1):97-114.
31. Cattell RB. The scree test for the number of factors. Multivariate behavioral research. 1966;1(2):245-276.
32. Hu Lt, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural equation modeling: a multidisciplinary journal. 1999;6(1):1-55.
33. Yu CY. Evaluating cutoff criteria of model fit indices for latent variable models with binary and continuous outcomes, Doctoral Dissertation. 2001.
34. R Core Team. R: A language and environment for statistical computing. 2020. https://www.R-project.org/
35. Muthén LK, Muthén BO. Mplus User’s Guide. Eighth Edition ed. Muthén & Muthén; 1998-2017).
36. Udedi M, Muula AS, Stewart RC, Pence BW. The validity of the patient health Questionnaire-9 to screen for depression in patients with type-2 diabetes mellitus in non-communicable diseases clinics in Malawi. BMC psychiatry. 2019;19(1):81.
37. Akena D, Joska J, Obuku EA, Stein DJ. Sensitivity and specificity of clinician administered screening instruments in detecting depression among HIV-positive individuals in Uganda. AIDS care. 2013;25(10):1245-1252.
38. Nakku J, Rathod S, Kizza D, et al. Validity and diagnostic accuracy of the Luganda version of the 9-item and 2-item patient health questionnaire for detecting major depressive disorder in rural Uganda. Global Mental Health. 2016;3
39. Cholera R, Gaynes B, Pence B, et al. 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. 2014;167:160-166.
40. Adewuya AO, Ola BA, Afolabi OO. Validity of the patient health questionnaire (PHQ-9) as a screening tool for depression amongst Nigerian university students. Journal of affective disorders. 2006;96(1-2):89-93.
41. Pence BW, Gaynes BN, Atashili J, et al. Validity of an interviewer-administered patient health questionnaire-9 to screen for depression in HIV-infected patients in Cameroon. Journal of affective disorders. 2012;143(1-3):208-213.
42. Gelaye B, Williams MA, Lemma S, et al. Validity of the patient health questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry research. 2013;210(2):653-661.
43. Woldetensay YK, Belachew T, Tesfaye M, et al. Validation of the Patient Health Questionnaire (PHQ-9) as a screening tool for depression in pregnant women: Afaan Oromo version. PloS one. 2018;13(2):e0191782.
44. Molebatsi K, Motlhatlhedi K, Wambua GN. The validity and reliability of the Patient Health Questionnaire-9 for screening depression in primary health care patients in Botswana. BMC Psychiatry. 2020;20(1):1-10.
45. Sebera F, Vissoci JRN, Umwiringirwa J, Teuwen DE, Boon PE, Dedeken P. Validity, reliability and cut-offs of the Patient Health Questionnaire-9 as a screening tool for depression among patients living with epilepsy in Rwanda. Plos one. 2020;15(6):e0234095.
46. Fawzi MCS, Ngakongwa F, Liu Y, et al. Validating the patient health questionnaire-9 (PHQ-9) for screening of depression in Tanzania. Neurology, Psychiatry and Brain Research. 2019;31:9-14.
47. Chibanda D, Verhey R, Gibson LJ, et al. Validation of screening tools for depression and anxiety disorders in a primary care population with high HIV prevalence in Zimbabwe. Journal of affective disorders. 2016;198:50-55.
48. Adewuya AO. Validation of the alcohol use disorders identification test (audit) as a screening tool for alcohol-related problems among Nigerian university students. Alcohol Alcohol. Nov-Dec 2005;40(6):575-7. doi:10.1093/alcalc/agh197
49. Chishinga N, Kinyanda E, Weiss HA, Patel V, Ayles H, Seedat S. Validation of brief screening tools for depressive and alcohol use disorders among TB and HIV patients in primary care in Zambia. BMC Psychiatry. May 4 2011;11:75. doi:10.1186/1471-244X-11-75
50. Kader R, Seedat S, Koch JR, Parry CD. A preliminary investigation of the AUDIT and DUDIT in comparison to biomarkers for alcohol and drug use among HIV-infected clinic attendees in Cape Town, South Africa. Afr J Psychiatry (Johannesbg). Sep 2012;15(5):346-51. doi:http://dx.doi.org/10.4314/ajpsy.v15i5.43
10.4314/ajpsy.v15i5.43
51. Myer L, Smit J, Roux LL, Parker S, Stein DJ, Seedat S. Common mental disorders among HIV-infected individuals in South Africa: prevalence, predictors, and validation of brief psychiatric rating scales. AIDS Patient Care STDS. Feb 2008;22(2):147-58. doi:10.1089/apc.2007.0102
52. Vissoci JRN, Hertz J, El-Gabri D, et al. Cross-Cultural Adaptation and Psychometric Properties of the AUDIT and CAGE Questionnaires in Tanzanian Swahili for a Traumatic Brain Injury Population. Alcohol Alcohol. Jan 1 2018;53(1):112-120. doi:10.1093/alcalc/agx058
53. Seth P, Glenshaw M, Sabatier JH, et al. AUDIT, AUDIT-C, and AUDIT-3: drinking patterns and screening for harmful, hazardous and dependent drinking in Katutura, Namibia. PLoS One. 2015;10(3):e0120850. doi:10.1371/journal.pone.0120850
54. Morojele NK, Nkosi S, Kekwaletswe CT, et al. Utility of Brief Versions of the Alcohol Use Disorders Identification Test (AUDIT) to Identify Excessive Drinking Among Patients in HIV Care in South Africa. J Stud Alcohol Drugs. Jan 2017;78(1):88-96. doi:10.15288/jsad.2017.78.88
55. van der Westhuizen C, Wyatt G, Williams JK, Stein DJ, Sorsdahl K. Validation of the Alcohol, Smoking and Substance Involvement Screening Test in a low- and middle-income country cross-sectional emergency centre study. Drug Alcohol Rev. Nov 2016;35(6):702-709. doi:10.1111/dar.12424
56. Berkson J. Limitations of the application of fourfold table analysis to hospital data. Biometrics. Jun 1946;2(3):47-53.
57. Acharya B, Basnet M, Rimal P, et al. Translating mental health diagnostic and symptom terminology to train health workers and engage patients in cross-cultural, non-English speaking populations. International journal of mental health systems. 2017;11(1):1-6.
58. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fifth Edition ed. Am Psychiatric Assoc. American Psychiatric Publishing; 2013.
59. Caspi A, Houts RM, Belsky DW, et al. The p Factor: One General Psychopathology Factor in the Structure of Psychiatric Disorders? Clinical psychological science : a journal of the Association for Psychological Science. Mar 2014;2(2):119-137. doi:10.1177/2167702613497473
60. Giusto A, Romer A, Lovero K, et al. Examination of the Factor Structure of Psychopathology in a Mozambican Sample. Clinical psychological science : a journal of the Association for Psychological Science. May 2023;11(3):409-424. doi:10.1177/21677026221122773
61. Kane JC, Vinikoor MJ, Haroz EE, et al. Mental health comorbidity in low-income and middle-income countries: a call for improved measurement and treatment. The Lancet Psychiatry. 2018;5(11):864-866.
62. Auerbach RP, Mortier P, Bruffaerts R, et al. Mental disorder comorbidity and suicidal thoughts and behaviors in the world health organization world mental health surveys international college student initiative. International journal of methods in psychiatric research. 2019;28(2):e1752.
2. The World Bank. World Bank Open Data. The World Bank Group. Accessed 2 August, 2021. https://data.worldbank.org/
3. WHO. Mental health atlas 2017. 2018.
4. Raviola G, Naslund JA, Smith SL, Patel V. Innovative models in mental health delivery systems: task sharing care with non-specialist providers to close the mental health treatment gap. Current psychiatry reports. 2019;21(6):1-13.
5. Ali GC, Ryan G, De Silva MJ. Validated Screening Tools for Common Mental Disorders in Low and Middle Income Countries: A Systematic Review. PLoS One. 2016;11(6):e0156939. doi:10.1371/journal.pone.0156939
6. Dos Santos PF, Wainberg ML, Caldas-de-Almeida JM, Saraceno B, de Jesus Mari J. Overview of the mental health system in Mozambique: addressing the treatment gap with a task-shifting strategy in primary care. International journal of mental health systems. 2016;10(1):1-9.
7. Wagenaar BH, Cumbe V, Raunig-Berhó M, et al. Outpatient mental health services in Mozambique: use and treatments. Psychiatric Services. 2016;67(6):588-590.
8. Greene MC, Yangchen T, Lehner T, et al. The epidemiology of psychiatric disorders in Africa: a scoping review. The Lancet Psychiatry. 2021;
9. Wainberg ML, Lovero KL, Duarte CS, et al. Partnerships in research to implement and disseminate sustainable and scalable evidence-based practices (PRIDE) in Mozambique. Psychiatric Services. 2021;72(7):802-811.
10. Cumbe VF, Muanido A, Manaca MN, et al. Validity and item response theory properties of the Patient Health Questionnaire-9 for primary care depression screening in Mozambique (PHQ-9-MZ). BMC psychiatry. 2020;20(1):1-15.
11. Atkins DL, Cumbe VF, Muanido A, et al. Validity and item response theory properties of the Alcohol Use Disorders Identification Test for primary care alcohol use screening in Mozambique (AUDIT-MZ). Journal of Substance Abuse Treatment. 2021:108441.
12. Lovero KL, Basaraba C, Khan S, et al. Brief screening tool for Stepped-Care management of mental and substance use disorders. Psychiatric Services. 2021:appi. ps. 202000504.
13. Amorim P. Mini International Neuropsychiatric Interview (MINI): validação de entrevista breve para diagnóstico de transtornos mentais. Rev Bras Psiquiatr. 2000;22(3):106-15.
14. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of clinical psychiatry. 1998;
15. Babor TF, de la Fuente JR, Saunders J, Grant M. The Alcohol Use Disorders Identification Test: Guidelines for use in. Primary care. 2001;
16. Bebbington P, Nayani T. The psychosis screening questionnaire. International Journal of Methods in Psychiatric Research. 1995;
17. Gierk B, Kohlmann S, Kroenke K, et al. The somatic symptom scale–8 (SSS-8): a brief measure of somatic symptom burden. JAMA internal medicine. 2014;174(3):399-407.
18. Group WAW. The alcohol, smoking and substance involvement screening test (ASSIST): development, reliability and feasibility. Addiction. 2002;97(9):1183-1194.
19. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatric annals. 2002;32(9):509-515.
20. Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. American journal of psychiatry. 2011;168(12):1266-1277.
21. Prins A, Bovin MJ, Smolenski DJ, et al. The primary care PTSD screen for DSM-5 (PC-PTSD-5): development and evaluation within a veteran primary care sample. Journal of General Internal Medicine. 2016;31(10):1206-1211.
22. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of internal medicine. 2006;166(10):1092-1097.
23. Üstün TB, Kostanjsek N, Chatterji S, Rehm J. Measuring health and disability: Manual for WHO disability assessment schedule WHODAS 2.0. World Health Organization; 2010.
24. Sartorius N, Janca A. Psychiatric assessment instruments developed by the World Health Organization. Social psychiatry and psychiatric epidemiology. 1996;31(2):55-69.
25. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics. 2009;42(2):377-381.
26. Bossuyt PM, Reitsma JB, Bruns DE, et al. STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. Radiology. 2015;277(3):826-832.
27. Massinga LJ GM, Duarte CS, Mandlate F, dos Santos PF, Gouveia L, Oquendo M, Melo MF, Wainberg ML. Screening for post-traumatic stress disorder (PTSD) in Mozambique: Validation of the Primary Care-PTSD Screen for DSM-5 (PC-PTSD-5). In prep;
28. Dunn TJ, Baguley T, Brunsden V. From alpha to omega: A practical solution to the pervasive problem of internal consistency estimation. British journal of psychology. 2014;105(3):399-412.
29. Hayes AF, Coutts JJ. Use omega rather than Cronbach’s alpha for estimating reliability. But…. Communication Methods and Measures. 2020;14(1):1-24.
30. Velicer WF, Jackson DN. Component analysis versus common factor analysis: Some further observations. Multivariate Behavioral Research. 1990;25(1):97-114.
31. Cattell RB. The scree test for the number of factors. Multivariate behavioral research. 1966;1(2):245-276.
32. Hu Lt, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural equation modeling: a multidisciplinary journal. 1999;6(1):1-55.
33. Yu CY. Evaluating cutoff criteria of model fit indices for latent variable models with binary and continuous outcomes, Doctoral Dissertation. 2001.
34. R Core Team. R: A language and environment for statistical computing. 2020. https://www.R-project.org/
35. Muthén LK, Muthén BO. Mplus User’s Guide. Eighth Edition ed. Muthén & Muthén; 1998-2017).
36. Udedi M, Muula AS, Stewart RC, Pence BW. The validity of the patient health Questionnaire-9 to screen for depression in patients with type-2 diabetes mellitus in non-communicable diseases clinics in Malawi. BMC psychiatry. 2019;19(1):81.
37. Akena D, Joska J, Obuku EA, Stein DJ. Sensitivity and specificity of clinician administered screening instruments in detecting depression among HIV-positive individuals in Uganda. AIDS care. 2013;25(10):1245-1252.
38. Nakku J, Rathod S, Kizza D, et al. Validity and diagnostic accuracy of the Luganda version of the 9-item and 2-item patient health questionnaire for detecting major depressive disorder in rural Uganda. Global Mental Health. 2016;3
39. Cholera R, Gaynes B, Pence B, et al. 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. 2014;167:160-166.
40. Adewuya AO, Ola BA, Afolabi OO. Validity of the patient health questionnaire (PHQ-9) as a screening tool for depression amongst Nigerian university students. Journal of affective disorders. 2006;96(1-2):89-93.
41. Pence BW, Gaynes BN, Atashili J, et al. Validity of an interviewer-administered patient health questionnaire-9 to screen for depression in HIV-infected patients in Cameroon. Journal of affective disorders. 2012;143(1-3):208-213.
42. Gelaye B, Williams MA, Lemma S, et al. Validity of the patient health questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry research. 2013;210(2):653-661.
43. Woldetensay YK, Belachew T, Tesfaye M, et al. Validation of the Patient Health Questionnaire (PHQ-9) as a screening tool for depression in pregnant women: Afaan Oromo version. PloS one. 2018;13(2):e0191782.
44. Molebatsi K, Motlhatlhedi K, Wambua GN. The validity and reliability of the Patient Health Questionnaire-9 for screening depression in primary health care patients in Botswana. BMC Psychiatry. 2020;20(1):1-10.
45. Sebera F, Vissoci JRN, Umwiringirwa J, Teuwen DE, Boon PE, Dedeken P. Validity, reliability and cut-offs of the Patient Health Questionnaire-9 as a screening tool for depression among patients living with epilepsy in Rwanda. Plos one. 2020;15(6):e0234095.
46. Fawzi MCS, Ngakongwa F, Liu Y, et al. Validating the patient health questionnaire-9 (PHQ-9) for screening of depression in Tanzania. Neurology, Psychiatry and Brain Research. 2019;31:9-14.
47. Chibanda D, Verhey R, Gibson LJ, et al. Validation of screening tools for depression and anxiety disorders in a primary care population with high HIV prevalence in Zimbabwe. Journal of affective disorders. 2016;198:50-55.
48. Adewuya AO. Validation of the alcohol use disorders identification test (audit) as a screening tool for alcohol-related problems among Nigerian university students. Alcohol Alcohol. Nov-Dec 2005;40(6):575-7. doi:10.1093/alcalc/agh197
49. Chishinga N, Kinyanda E, Weiss HA, Patel V, Ayles H, Seedat S. Validation of brief screening tools for depressive and alcohol use disorders among TB and HIV patients in primary care in Zambia. BMC Psychiatry. May 4 2011;11:75. doi:10.1186/1471-244X-11-75
50. Kader R, Seedat S, Koch JR, Parry CD. A preliminary investigation of the AUDIT and DUDIT in comparison to biomarkers for alcohol and drug use among HIV-infected clinic attendees in Cape Town, South Africa. Afr J Psychiatry (Johannesbg). Sep 2012;15(5):346-51. doi:http://dx.doi.org/10.4314/ajpsy.v15i5.43
10.4314/ajpsy.v15i5.43
51. Myer L, Smit J, Roux LL, Parker S, Stein DJ, Seedat S. Common mental disorders among HIV-infected individuals in South Africa: prevalence, predictors, and validation of brief psychiatric rating scales. AIDS Patient Care STDS. Feb 2008;22(2):147-58. doi:10.1089/apc.2007.0102
52. Vissoci JRN, Hertz J, El-Gabri D, et al. Cross-Cultural Adaptation and Psychometric Properties of the AUDIT and CAGE Questionnaires in Tanzanian Swahili for a Traumatic Brain Injury Population. Alcohol Alcohol. Jan 1 2018;53(1):112-120. doi:10.1093/alcalc/agx058
53. Seth P, Glenshaw M, Sabatier JH, et al. AUDIT, AUDIT-C, and AUDIT-3: drinking patterns and screening for harmful, hazardous and dependent drinking in Katutura, Namibia. PLoS One. 2015;10(3):e0120850. doi:10.1371/journal.pone.0120850
54. Morojele NK, Nkosi S, Kekwaletswe CT, et al. Utility of Brief Versions of the Alcohol Use Disorders Identification Test (AUDIT) to Identify Excessive Drinking Among Patients in HIV Care in South Africa. J Stud Alcohol Drugs. Jan 2017;78(1):88-96. doi:10.15288/jsad.2017.78.88
55. van der Westhuizen C, Wyatt G, Williams JK, Stein DJ, Sorsdahl K. Validation of the Alcohol, Smoking and Substance Involvement Screening Test in a low- and middle-income country cross-sectional emergency centre study. Drug Alcohol Rev. Nov 2016;35(6):702-709. doi:10.1111/dar.12424
56. Berkson J. Limitations of the application of fourfold table analysis to hospital data. Biometrics. Jun 1946;2(3):47-53.
57. Acharya B, Basnet M, Rimal P, et al. Translating mental health diagnostic and symptom terminology to train health workers and engage patients in cross-cultural, non-English speaking populations. International journal of mental health systems. 2017;11(1):1-6.
58. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fifth Edition ed. Am Psychiatric Assoc. American Psychiatric Publishing; 2013.
59. Caspi A, Houts RM, Belsky DW, et al. The p Factor: One General Psychopathology Factor in the Structure of Psychiatric Disorders? Clinical psychological science : a journal of the Association for Psychological Science. Mar 2014;2(2):119-137. doi:10.1177/2167702613497473
60. Giusto A, Romer A, Lovero K, et al. Examination of the Factor Structure of Psychopathology in a Mozambican Sample. Clinical psychological science : a journal of the Association for Psychological Science. May 2023;11(3):409-424. doi:10.1177/21677026221122773
61. Kane JC, Vinikoor MJ, Haroz EE, et al. Mental health comorbidity in low-income and middle-income countries: a call for improved measurement and treatment. The Lancet Psychiatry. 2018;5(11):864-866.
62. Auerbach RP, Mortier P, Bruffaerts R, et al. Mental disorder comorbidity and suicidal thoughts and behaviors in the world health organization world mental health surveys international college student initiative. International journal of methods in psychiatric research. 2019;28(2):e1752.