Health professionals’ perceptions of the South African adapted online Center for Epidemiologic Studies Depression Scale – Revised: properties,implementation,and context

(Mis)fit for purpose

Participants felt that the tool and feedback presentation were aesthetically pleasing and user-friendly, with the potential for the colour-coded risk result to promote urgent help-seeking:

Just looking at it, it’s a nice clean format. It’s not, you know, too compact, and I like the results where it says low risk and high risk. Immediately, I suppose, if the person sees that they’re in a red category they would seriously think, ‘Well, I need to go to my . . .’ or, you know, ‘Next step is to see my doctor or go to the clinic’. (Participant 1, Nurse)

Importantly, one participant explained that the tool’s straightforward format is also sensitive to the experience of depressed individuals, who are the intended tool users:

Someone that’s really depressed, the layout, you know, it’s kind of simple and straightforward. There’s not a lot of information, you know, it’s not overwhelming that someone that’s really depressed will feel overwhelmed. So, literally, how the questions [are asked], the actual layout of it was for me also positive and not threatening. So, I think that, for someone that is depressed, it’s one page, it’s questions I can just tick. (Participant 6, Clinical psychologist)

These tool features make the adapted online CESD-R accessible and promote its use among individuals who may be more severely depressed and most in need of further evaluation. This is similar to results obtained in a recent study in the United States showing that moderate to severely depressed people were more likely to complete a web-based depression screening as opposed to an in-clinic one (Sattler et al., 2024). The relationship between depression and help-seeking is notoriously complicated (Magaard et al., 2017). Poor knowledge about depression is an identified contributor to poor help-seeking and consequently the depression treatment gap in South Africa (Petersen et al., 2016). The screening feedback’s presentation provides a simple way of aiding individuals to recognise their symptoms as problematic as Participant 1 indicated, without necessarily relying on an established understanding of depression.

However, some participants were concerned about the discoverability of a web-based tool:

The only thing that I haven’t put the link in my head to, is how will they find out about it, you know? Like how do you get the word out there that this thing exists for them to do it? (Participant 2, Intern medical doctor)

I don’t think people would necessarily go look for a tool. They will go look for the information about depression . . . I don’t think people will necessarily think, ‘Okay, I need to go look for a tool to measure major depression’. I don’t think they will necessarily go for such an explicit search. (Participant 6, Clinical psychologist)

As Participant 6 suggested, many people use the internet to seek out mental health-related information (Jia et al., 2021). However, the participants’ main concern related to which search terms will retrieve the Major Depression Disorder South Africa website which hosts the screening tool, given that the general public is unlikely to use formal terminology or search specifically for screening tools. This also speaks to the poor knowledge about depression in South Africa (Petersen et al., 2016) and suggests that, in order for the adapted online CESD-R to be fit for purpose as an unsupervised e-Screening tool, the general public needs to be informed that the tool is available to them. Having informational posters containing links to the tool in doctor’s rooms and practitioners themselves advocating for the tool’s use during consultations are two avenues that could bring the screening tool to the general public’s attention. Thus, practitioners in medical centres, community health centres, and outreach organisations can consider displaying information leaflets and/or posters on the tool within these settings to facilitate its use.

In addition, certain items were perceived as ambiguous, and participants suggested that they should be contextualised for better understanding:

For example, ‘I felt that I’ve been moving too slowly’. What do you mean by moving slowly? Is it physically or is it in my work, or is it I haven’t done things fast enough in my, you know, environment? (Participant 1, Nurse)

‘I could not focus on important things’. I didn’t feel that that was really a depression question, but I know where you’re coming from. But I think that won’t we all answer, ‘Yeah’ most or some of the time? We can’t focus because we are at this stage so overloaded with the lifestyles that we are leading. (Participant 5, Counselling psychologist)

The potential for misunderstanding certain tool items, as suggested by Participant 1, or unintentionally providing misrepresentative answers, as indicated by Participant 5, is a unique problem of unsupervised mental health e-Screening because tool users cannot ask a practitioner for clarification and practitioners cannot ask probing questions for context. This has important implications for the validity of the results which, in turn, may negate the screening feedback’s desired impact on help-seeking behaviour if tool users receive a false low-risk result. However, the screening tool’s very high sensitivity (Hassem, 2022) means that false negatives are unlikely. Nonetheless, the screening tool needs to balance the trade-off more carefully between a short, straightforward questionnaire and including enough information to ensure understanding. This can easily be achieved with the inclusion of a relevant practical example.

Living in a (virtue)al reality?

Some participants also had ethical concerns related to the environment in which an individual completes the screening tool and controlling access to the screening feedback:

The problem with online is that sometimes you don’t have privacy if you’re in a house and you can’t go and close the door or it’s not quiet enough. So, it’s not always as private as we think it will be. . . . If somebody uses your laptop, and they see that you have got a medium risk or that you’ve accessed this site, . . . I just think that might put some people in a compromising situation. (Participant 5, Counselling psychologist)

The person that has access to that data [from the screening feedback], you have power with that data. . . . Even when noting down your notes, you know, we’re [as practitioners] using clinical codes to actually document it in our notes. And, I mean, if a layperson has to get it [the screening feedback], what can they do with the data? I mean, you can blackmail people saying, ‘Well, I’m going to tell everyone you’re suffering from depression with this’. (Participant 3, Counselling psychologist)

The participants highlighted that, with the growing ease of access to the internet and digital technologies, there is also an increased risk that unintended parties can gain access to sensitive information. South Africans access the internet in their homes, workplaces, educational institutions, internet cafés, and public hotspots (Statistics South Africa, 2022). When it comes to online depression screening, device sharing and the use of public internet facilities mean that the same security offered by in-person consultations with practitioners is less attainable. As such, just as practitioners use clinical codes to document sensitive information, developing precautions for the screening tool, such as password protecting the downloadable screening feedback, may be necessary to better ensure tool users’ privacy.

Human meets machine

When considering the implementation of the tool in practice, the participants all described a form of integration between the adapted online CESD-R and formal in-person consultations. This included using the screening feedback as part of client intake after the client completes the tool remotely, or recommending that existing clients, suspected of being depressed, complete the tool in their own time and bring the screening feedback to their next session:

If the client could actually print it out and bring it with to say, ‘I completed this and this is my outcome’, and give it to me, then I could obviously see, alright, there’s been a change in sleeping patterns, there’s been a change in eating patterns, and use that as part of a structured interview for the intake. (Participant 5, Counselling psychologist)

Let’s say there’s a first session and you talk about things, and I get the impression this person is depressed. I may not necessarily be able to have a discussion about that and what the symptoms are . . . there’s literally just not time. So, then I think this would be ideal. [I could say to clients], ‘Just do this screening, please bring the feedback back and then we can discuss it next time’. So, it would support me in that way . . . where I can maybe then, in a way, fast track the process and also they can come with questions. (Participant 6, Clinical psychologist)

This integrated approach to implementing the screening tool may assist practitioners who are considering incorporating the tool into their practice in several ways. As indicated by Participants 5 and 6, the screening tool can streamline the process of taking patient information by guiding or supplementing in-person consultations. This will give practitioners more time to explore the issues raised in the screening tool and move forward with treatment, if necessary. The tool is therefore useful for primary physicians as it assists them in coping with high patient loads in the South African health care system (Petersen et al., 2016), which puts pressure on practitioners to comprehensively assess their clients’ physical and mental health concerns within short time frames (Abrahams et al., 2023; Minty et al., 2021). Moreover, such an integrated approach may circumvent the participants’ concerns regarding item phrasing in the first theme, as tool users will have the opportunity to ask specific questions, as indicated by Participant 6.

In addition to clients completing the screening in their own time prior to a first or second consultation, one participant suggested that the tool can be completed on clients’ own devices in practice waiting rooms:

The best way it will work is to actually have a barcode where you just scan it as you come in . . . While patients are waiting in the waiting room, it can be filled out . . . Some of them, it can be forwarded to them if they prefer, if they want it before then, but it can be done in the waiting room very simply. (Participant 7, General practitioner)

Two participants also suggested that the tool can even be completed during consultations:

I think somebody, like a GP, general practice or maybe the clinic services running at Clicks and Dischem and places like that, they might see it as a more useful tool to say, ‘Would you like to actually run through this and let’s get an assessment done before we take next steps’. (Participant 4, Nurse)

What could actually be useful is to have this questionnaire, have this website ready then just ask them to just pull out your phone, put it in front of them and then ask them to just do the questionnaire quickly, just take five minutes, maybe, while you’re, I don’t know, writing up notes or something . . . and then, if it says medium risk, or high risk, you can explain what that means. (Participant 2, Intern medical doctor)

These suggestions for the implementation of the tool closely resemble supervised mental health e-Screening. Even though practitioners hold mixed views regarding supervised e-Screening (Pittman et al., 2019; Proudfoot et al., 2021), the adapted online CESD-R has added benefits compared to traditional supervised e-Screening. The adapted online CESD-R, which people can access from their own devices, maintains the efficiency of supervised e-Screening, while disadvantages, such as distributing devices to patients on which to complete the screening, that can disrupt or add to practice staff’s existing duties, are eliminated. Moreover, this approach directly supports re-engineered primary health care and decentralised mental health services to address the country’s depression treatment gap (NDOH, 2023; Petersen et al., 2016). Specifically, the issue of practitioner confidence in recognising depression symptoms (Petersen et al., 2016) is addressed with the screening tool’s implementation as non-specialists can identify patients at risk, even with limited mental health training, which is a necessary but still evolving focus of intervention programmes (Liu et al., 2016).

A targeted approach

Despite being open to integrating the tool into practice, the participants identified various barriers to the universal implementation of the tool, such as difficulties experienced by public health settings due to limited resources and individual differences in literacy, language, education, affluence, connectivity, and technological savviness:

From a public health perspective, . . . they are so overwhelmed and overburdened and understaffed. To actually be running or using a tool like this, it would have to be a pretty sharp clinic. . . . It’s possible, but I think it would be quite a significant amount of work to actually get it functioning. (Participant 4, Nurse)

I think it will work, but only for certain categories of people, depending on where they are and the language that they speak. This would be very good, for example, for a person who’s got a good command of English, but this questionnaire I feel might need to be translated into all 10 or 12 languages. (Participant 1, Nurse)

It’s maybe more applicable to a younger generation. It’s something they’re familiar with, you know . . . For people that are a bit older, I would not necessarily use it. It would depend on each individual’s own comfort with using anything that is online. (Participant 6, Clinical psychologist)

Although the screening tool is targeted at the general public in South Africa (Hassem, 2021), it has certain restrictions. These results speak to the importance of and need for test adaptation and translation in multicultural contexts such as South Africa (Smith et al., 2022). Therefore, in its current form, practitioners wanting to incorporate the adapted online CESD-R into practice will need to use their discretion to decide whether the screening tool is suitable for their work context and, if so, for which of their clients.