Understanding Depression in Rural Chiapas: Contextualizing Quantitative Measures and Patients’ Experiences

Depressive disorders are highly prevalent in primary care settings and are associated with severe physical and social impairment. However, it is a challenge for primary health care providers to identify depressive disorders early. The Patient Health Questionnaire-2 (PHQ-2) and PHQ-9 have been widely used for screening and diagnosis of depression in primary care settings. We used a mixed methods design to assess the validity of the PHQ-9 for diagnosis of depression; to assess the sensitivity and specificity of the PHQ-2 for screening of depression; and to characterize the experience of participants living with depression in rural Spanish-speaking settings. The study was conducted in a rural community of Chiapas, Mexico. Quantitative data was collected using the PHQ-2, the PHQ-9, and the WHO Quality of Life BREF (WHOQOL-BREF) scales during an active case finding activity (n=223). Qualitative data was collected through semi-structured interviews (n=20). The internal consistency of the PHQ-9 was good (Cronbach’s alpha >= 0.8) for the overall PHQ-9 and by subgroups. The PHQ-9 also had good construct validity: participants with a PHQ-9 diagnosis of depression had statistically significantly lower scores on the overall WHOQOL-BREF scale and each of its domains. The optimal PHQ-2 cutpoint score for screening of depression when compared with the PHQ-9 was 3 (sensitivity 80.00%, specificity 86.88%). Four main categories were derived from the qualitative analysis, including life events as triggers for depression; common feelings of sadness and desesperación, thinking too much, and somatization; a experience seeking care influenced by the local conceptualization of depressive illness, the lack of availability of health services, and physicians’ failure to recognize symptoms of depressive illness; and a experience of accompaniment perceived as therapeutic. Evidence supports the validity of the PHQ-2 and PHQ-9 to screen and diagnose for depression in rural Spanish-speaking populations, and the association of depression with lower quality of life. The study findings highlight the role of the local context on triggering depression and influencing care-seeking behavior, and on how depressive illness is experienced by patients. Therefore, in order to improve mental health care delivery strategies, strategies and interventions should be adapted to the local context