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A valid, culturally adapted tool to screen for depression with Aboriginal and Torres Strait Islander peoples

Depression can be difficult to detect in routine clinical consultations, and health professionals sometimes use brief screening questionnaires to identify people who need further evaluation.

Until recently, it wasn’t known how useful these tools were for Aboriginal and Torres Strait Islander people. Individual clinicians, researchers and services had adapted them for local use, but their ability to pick up on, or rule out, depression hadn’t been evaluated.

A study published recently in the MJA sought to address this knowledge gap.

Below two of the researchers, Professor Maree Hackett and Dr Graeme Gee,  describe the process of validating an adapted version of the nine‐item Patient Health Questionnaire (aPHQ-9), by testing it on 500 people at multiple sites across Australia.


Maree Hackett and Graeme Gee write:

When asking people about their mental health we rely solely on the exchange and shared understanding of our words to determine whether they are unwell. There are no objective diagnostic tests – scans or blood tests for example –  that will tell us if someone is experiencing depression.

This means the words we use to describe depression, or any other form of distress or mental health difficulty for that matter, are important. There are freely available questionnaires (screening tools) we can use when asking people about mental health problems that can assist in determining whether or not they are unwell, and whether they might benefit from professional help.

With regards to depression, words used to describe feelings of sadness and loss of interest and pleasure, in different cultures and language groups do not necessarily translate directly to ‘depression’ in English.

For example, in some non-English language groups the phrase ‘thinking too much’ or ‘tension’ have been associated with how depression is described. In fact, when most people with depression first visit their general practitioner they will often talk about their physical symptoms such as pain or fatigue rather than saying ‘I think I’m depressed’.

Screening for depression in Aboriginal and Torres Strait Islander people: Getting it Right

There has been no free to use, culturally adapted screening tool to help identify depression in Aboriginal and Torres Strait Islander peoples which has been shown to work outside of the community in which the tool was developed. This is why we conducted the NHMRC-funded Getting it Right study.

In Getting it Right we investigated the use of an adapted version of the nine‐item Patient Health Questionnaire (aPHQ-9) (available for download here) as a culturally appropriate and valid tool to screen for depression by and with Australia’s First Nations peoples.

The aPHQ-9 contains culturally appropriate questions that were first developed in conjunction with several Aboriginal communities and researchers. The PHQ-9 and the aPHQ-9 ask questions about mood, sleep, energy for activity, appetite, thoughts and behaviours.

For instance, where the original PHQ-9 questionnaire asks:

Over the past 2 weeks, how often have you been bothered by any of the following problems:

  • little interest or pleasure in doing things?
  • feeling down, depressed or hopeless.

The adapted (aPHQ-9) tool instead asks, over the past 2 weeks:

  • have you been feeling slack, not wanted to do anything?
  • have you been feeling unhappy, depressed, really no good, that your spirit was sad?

A valid, culturally adapted depression screening tool

In the Getting it Right study, the participants were 500 Aboriginal and Torres Strait Islander people attending 10 primary health care services in six states and territories across Australia. Several of these sites were Aboriginal Community Controlled Health Organisations.

Participants first completed the aPHQ-9 with the guidance of a trained interviewer. They then completed a structured psychiatric interview conducted by a different trained interviewer who did not know the aPHQ-9 results.

When the results of both interviews were compared, the aPHQ-9 performed well in identifying those who needed further assessment of their mood, and was also able to identify those who were unlikely to have depression.

It is important to note that the aPHQ-9 is a screening measure only, and no self-report questionnaire on its own can be used to provide a diagnosis. Rather, the aPHQ-9 provides a score for depression symptom severity, and a score equal to or higher than 10 indicates the need for referral to culturally competent clinicians who can conduct careful psychological assessments and determine the need for treatment.

We now have a free-to-use culturally adapted, valid screening tool that can help culturally competent healthcare professionals identify Aboriginal and Torres Strait Islander people at risk for depression.

Professor Maree Hackett is Program Head, Mental Health, at the George Institute for Global Health, and Professor, Faculty of Medicine at UNSW. She is also a Professor of Epidemiology at The University of Central Lancashire, United Kingdom.

Dr Graham Gee is a Clinical Psychologist and Senior Research Fellow in Intergenerational Health at Murdoch Children’s Research Institute, Victoria.

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