Accuracy of Pro-Active Case Finding for Mental Disorders by Community Informants in Nepal

Abstract

Background: Accurate identification of persons with mental health problems in community settings in low and middle income countries (LMIC) is crucial to reduce the treatment gap between psychiatric burden and service use. The present study evaluates the accuracy of a proactive community-based case-finding strategy designed to initiate pathways for mental health treatment in primary care and community settings. Methods: Nonprofessional community-based women received a 1-day training in use of a structured context-sensitive Community Informant Detection Tool (CIDT).Through pictorial vignettes, community informants can identify persons with possible mental health problems. To validate the instrument, community informants identified a group of CIDT screen positive persons (n=110) and CIDT negative persons (n=85); with positive and negatives cases including both adults and children. The 195 participants were then administered the Composite International Diagnostic Interview (CIDI) by experienced psychosocial counselors. Results: The CIDT has a positive predictive value of .64 (.68 for adults only), positive likelihood ratio of 2.71 (2.79 for adults only) and a sensitivity of .92 (.91 for adults only). The procedure was more accurate when used by mother group participants compared to community health volunteers (positive predictive value of .79 and .60, respectively; positive likelihood ratio of 4.37 and 2.57, respectively), and more accurate for identifying adults compared to children. A pictorial vignette-based community informant detection tool has comparable detection properties for psychiatric caseness to patient checklists, and CIDT does not have literacy constraints or self-report requirements, which are potential barriers to use in LMIC settings. Conclusions: Vignette-based community informant procedures should be further investigated as a feasible and culturally-appropriate strategy to increase demand for, and access to, mental health services and thereby reducing the treatment gap. Keywords: case finding; low and middle income country; mental health; screening; validation.