development and validation of a questionnaire for anxiety and depression in pakistan

www.elsevier.com/locate/jad

Journal of Affective Disord

Brief report

Development and validation of a questionnaire for anxiety

and depression in Pakistan

David B. Mumford a,*, Muhammad Ayub b, Raheel Karim b, Nasir Izhar b,

Aftab Asif b, John T. Bavington c

aCentre for Medical Education, University of Bristol, 41 St Michael’s Hill, Bristol BS2 8DZ, UKbDepartment of Psychiatry, King Edward Medical College, Lahore, Pakistan

cTranscultural Psychiatry Unit, Lynfield Mount Hospital, Bradford, UK

Received 9 August 2004; received in revised form 23 May 2005; accepted 26 May 2005

Available online 2 August 2005

Abstract

Background: Currently clinicians and researchers in Pakistan have to use translated western instruments to screen for anxiety

and depressive disorders. This study investigated the local idioms of emotional distress in Pakistan to develop a culturally valid

and easy-to-use instrument to screen for common mental disorders in general clinical settings.

Methods: A systematic survey was conducted of psychiatric case notes of patients attending clinics in Peshawar and Lahore,

diagnosed with anxiety or depressive disorders, to identify the range of common idioms of psychological distress. A pilot

version of the questionnaire was refined and validated among a composite sample of 330 patients in inpatient, outpatient and

rural community settings. ICD-10 Diagnostic Criteria for Research were used to define cases and patients’ relatives acted as

normal controls.

Results: The pilot version of the questionnaire was reduced to 42 items based on odds ratios between cases and controls.

Anxiety symptoms were generally reported by depressed patients, but not vice versa. Finally 30 items were selected, in two sub-

scales. This final version achieved sensitivity, specificity, and positive and negative predicted values of over 90% when

comparing cases and controls.

Limitations: This questionnaire was based on what patients tell doctors and may not capture the entire repertoire of local idioms

of distress. The validation study was conducted only in an Urdu/Punjabi speaking population, in Lahore and surrounding areas.

Conclusions: The Pakistan Anxiety and Depression Questionnaire consists of an anxiety/depression scale and a depression

scale, each of 15 items. It demonstrates excellent validity as screening instrument for anxiety and depressive disorders in clinical

settings in Pakistan.

D 2005 Published by Elsevier B.V.

Keywords: Psychiatric status rating scale; Anxiety disorders; Depression disorder; Pakistan; Cultural diversity; Cross-cultural comparison

0165-0327/$ - s

doi:10.1016/j.jad

* Correspondi

E-mail addre

ers 88 (2005) 175–182

ee front matter D 2005 Published by Elsevier B.V.

.2005.05.015

ng author. Tel.: +44 117 954 6522; fax: +44 117 954 6525.

ss: [email protected] (D.B. Mumford).

D.B. Mumford et al. / Journal of Affective Disorders 88 (2005) 175–182176

1. Introduction

Questionnaires for detecting and monitoring

common mental disorders in Pakistan need to

reflect the way that people experience and express

these disorders in this culture. Currently there is a

very restricted choice of Pakistan-derived instru-

ments. Some western questionnaires, translated

and adapted for Pakistan, demonstrate good validity

with literate and well-educated subjects (Hospital

Anxiety and Depression Scale: Mumford et al., 1991a;

General Health Questionnaire: Minhas and Mubba-

shar, 1996; Self-Reporting Questionnaire: Minhas et

al., 1995; Saeed et al., 2001), but their content and

their format are less appropriate for general use in

Pakistan.

Since many people with anxiety or depressive

disorders in Pakistan present with somatic symp-

toms rather than psychological complaints, one

option is to use a somatic questionnaire to screen

for common mental disorders. The Bradford So-

matic Inventory (BSI: Mumford et al., 1991b) was

developed for this purpose, and has demonstrated

good sensitivity and specificity when screening for

common mental disorders both in medical clinics

(Mumford et al., 1991c) and community-based epi-

demiological studies (Mumford et al., 1996, 1997,

2000). However the BSI score does not allow a

differentiation between anxiety and depressive dis-

orders, and its efficiency as a screening instrument is

sometimes affected by variations in physical health

status.

In the development of any new questionnaire,

careful attention needs to be given to the language

and idiom of emotional distress in Pakistan. One

data source is case notes of people who have been

diagnosed with depressive illness or anxiety disor-

ders. This method has already been used successfully

in the development of the BSI (Mumford et al.,

1991b): the first source of items for the present

questionnaire was the same set of case notes from

the Mental Health Centre in Peshawar, but now

identifying the non-somatic idioms and phrases. To

broaden the ethno-linguistic base to include Urdu

and Punjabi speakers as well as Pushto, items were

also derived from case notes from the Department of

Psychiatry at Mayo Hospital/King Edward’s Medical

College, Lahore.

2. Methods

2.1. Item derivation

A systematic search was made of a consecutive

series of 75 psychiatric case notes from the Mental

Health Centre, Peshawar, in which the clinical diag-

nosis was anxiety disorder or depressive illness.

These case notes often included verbatim accounts

of presenting complaints and symptoms. Lists were

complied of all psychological or behavioural expres-

sions of distress, excluding somatic symptoms. Items

occurring twice or more were used to draft 37 ques-

tions, taking into account the research team’s clinical

experience of symptoms presented by Pakistani

patients.

Experienced clinicians at Mayo Hospital, Lahore,

made a systematic search of a further 200 sets of case

notes using the initial 37-item questionnaire as a

template. Items not represented in the Peshawar case

notes that occurred twice or more in the Lahore case

notes were identified. The eventual pilot version of

the questionnaire consisted of 74 items, redrafted in

Urdu.

2.2. Item validation

The validation study was conducted using equal

numbers of (a) Mayo Hospital inpatients, (b) Mayo

Hospital outpatients and (c) patients attending rural

community clinics 200 km from Lahore. The pilot

version of the questionnaire was administered in Urdu

to 150 patients (75 men and 75 women) with common

mental disorders and 150 controls (75 men and 75

women) who were mostly these patients’ relatives in

attendance. The questionnaire was either completed

by the subject unaided or administered by a doctor

who was blind to the diagnosis. Psychiatric diagnoses

were made systematically according to the ICD-10

Diagnostic Criteria for Research (World Health Orga-

nisation, 1993) by doctors with at least 2 years’

experience in psychiatry.

The total cohort of 300 patients and controls was

randomly allocated into two sub-samples, 200 for the

first stage of analysis (item validation) and 100 for the

second stage (scale evaluation and refinement), stra-

tified to maintain balanced of male/female and case/

control ratios.

D.B. Mumford et al. / Journal of Affective Disorders 88 (2005) 175–182 177

2.3. Item selection

In the first stage, items were selected on the basis of

(i) a high odds ratio between cases and controls, (ii)

item specificity, and (iii) eliminating the less powerful

item when there was a pair of similar questions. In the

second stage, items were selected on the basis of (i) the

frequency with which they were reported in patients

with anxiety and depressive disorders respectively, and

(ii) eliminating any remaining redundancy among clo-

sely related items that were highly inter-correlated.

2.4. Scale evaluation

Scores of patients and controls were compared on

each version of the questionnaire. Sensitivity and

specificity in identifying common mental disorders

were calculated using an optimal threshold.

3. Results

The mean age of patients was 33.2 years and of

controls 33.9 years (t =0.55, NS), with no significant

difference between men (34.0) and women (33.1).

The ICD-10 diagnoses of the 150 patients were:

depressive episode 92%, generalized anxiety disorder

31%, panic disorder 5%, dysthymia 3%, and somati-

zation disorder 2%. Some patients attracted more than

one psychiatric diagnosis because the dexclusionclausesT in the ICD-10 DCR were ignored.

3.1. Initial item validation and selection

The 100 patients and 100 controls were compared in

their responses to each of the 74 items of the pilot ques-

tionnaire. The odds ratios ranged from 1.90 to 88.78, all

but one being statistically significant. 42 items were

selected for inclusion in the next working version of the

questionnaire based on (i) an odds ratio over 7.0 and (ii)

specificity of 75% or more. Some items were eliminated

when there was a pair of very similar questions.

3.2. Initial scale evaluation

The second sub-sample of 50 patients and 50 con-

trols was used to evaluate the 42-item version of the

questionnaire. Scores were calculated from the sum of

responses positive for the symptom. Patients’ mean

score (28.0) was very much higher than controls’ (5.5)

(t =15.6, df =98, p b0.001). Scores were not signifi-

cantly related to either age or gender.

3.3. Specificity for depressive and anxiety disorders

To refine the scale further, we wished to identify

which items were associated with depressive and

anxiety disorders respectively. To increase the number

of anxiety disorders unaccompanied by a diagnosis of

depression, we recruited 30 additional patients with

simple anxiety disorders (15 males and 15 females).

This yielded three principal groups for comparison:

pure depressive disorders (N =30), pure anxiety dis-

orders (N =33), and normal controls (N =50). A fourth

group consisted of patients receiving diagnoses of

both anxiety and depressive disorders (N =14).

About half of the items were reported much more

frequently by depressed patients than by patients with

anxiety disorders. The other half of the items showed

similar response rates between these two diagnostic

groups, with one item occurring significantly more

frequently in anxiety disorders (dDo you have repeti-

tive thoughts?T). The response rates to all items were

much lower in the control group. Patients receiving a

diagnosis of both an anxiety and a depressive disorder

had the highest response rate to most items.

3.4. Final item selection

In the light of these findings, we constructed two

subscales: one consisting of symptoms frequently

reported by patients with either anxiety or depressive

disorders, and the other of symptoms largely reported

by depressed patients. A further 12 items were elimi-

nated at this stage, either because of poor sensitivity

(less than 50% in either the anxiety or the depressive

group), or because a closely similar item performed

better. The resulting dAD scaleT and dD scaleT each

consisted of 15 items (Appendixes A and B). Mean

scores for each diagnostic group and normal controls

are given in Table 1.

3.5. Thresholds and validity/reliability coefficients

A histogram of AD scores showed a clear bimodal

distribution between controls and cases, with a point

Table 1

Mean questionnaire scores by diagnostic group

Scale Depressive disorders

(N =30)

Anxiety disorders

(N =33)

Diagnosis of depression

and anxiety disorder (N =14)

Normal controls

(N =50)

ANOVA

AD scale 11.1 (3.1) 9.9 (2.8) 12.7 (1.8) 2.5 (3.0) F =89.3

df =126

p b0.001

D scale 10.0 (3.3) 4.6 (3.3) 11.4 (2.0) 1.7 (2.2) F =80.2

df =126

p b0.001

Standard deviation in brackets.


of attenuation around a score of 6. The histogram of D

scores was weakly bimodal with a point of attenuation

also around 6.

The sensitivity, specificity, and positive and nega-

tive predictive values are given in Table 2. The mis-

classification rate for the AD scale was 7%, and for

the D scale 7% (depressed versus controls) and 25%

(depressed versus anxiety disorders). A discriminant

function analysis using the AD and D scores to predict

group membership achieved overall 82% of the ori-

ginal group correctly classified between control

group, anxiety and depression groups. 92% of the

controls were correctly classified.

The a coefficient of reliability for the AD scale was

0.92 (95% CI: 0.90–0.94) and for the D scale was

0.91 (95% CI: 0.89–0.93).

4. Discussion

The use of psychiatric case notes to derive items for

a culturally-sensitive questionnaire is a method which

Table 2

Validity coefficients

Scale Cases/controls Threshold Sensitivi

(%)

AD scale 77 all cases 5/6 96

50 controls

D scale 44 depressive disorders 5/6 91

50 controls

D scale 44 depressive disorders 5/6 91

33 anxiety disorders

AD+D scales 100 all cases 11/12 95

100 controls

has successful precedents. Anthropologists might

argue that conducting open-ended interviews in non-

medical settings would have elicited a fuller range of

cultural expressions of distress. However the case note

method used here does focus on dwhat patients tell

doctorsT, which replicates the clinical setting in which

the questionnaire is designed to be used.

The two psychiatric centres, in Peshawar and

Lahore, served both urban and rural patients. Most

people in Peshawar are Pushto-speakers, whereas

Urdu and Punjabi are spoken in Lahore. The idiom

of expression varied slightly between these languages,

although there was a very large overlap in symptoms

derived from the two centres.

How do the symptoms elicited in this study com-

pare with typical symptoms of anxiety and depression

reported by western patients? Reviewing the 74 items

of the pilot version, the most striking difference is the

emphasis on the social impact of mental disorder,

rather than on subjective feelings experienced by

the individual. A typical western patient might

describe their personal feelings of depression,

ty Specificity

(%)

Positive predictive

value (%)

Negative predictive

value (%)

88 93 94

94 93 92

64 69 84

91 91 95

Table 3

Validity coefficients of screening questionnaires in Pakistan

Scale Sample size Optimal threshold Sensitivity (%) Specificity (%) Authors

GHQ-12 238 2/3 93 88 Minhas and Mubbashar (1996)

SRQ 300 4/5 63 77 Minhas et al. (1995)

SRQ 191 7/8 (women) 78 (women) 81 (women) Saeed et al. (2001)

3/4 (men) 78 (men) 70 (men)

BSI-44 191 21/22 (women) 82 (women) 71 (women) Saeed et al. (2001)

13/14 (men) 59 (men) 62 (men)

BSI-21 62 20/21 80 77 Mumford et al. (1996)

PADQ AD scale 130 5/6 96 88

PADQ D scale 130 5/6 91 94


whereas a typical Pakistani patient would describe the

disruption of their social functioning. Pakistani

patients are often acutely aware of their failure to

fulfil basic social obligations in the household and

at work. Talking about personal feelings – especially

to a doctor, someone who occupies a much higher

social status than the patient – does not come easily

or naturally.

Some of these distinctively Pakistani symptoms

were eliminated during the validation stages because

of their less favourable psychometric properties. The

discarded symptoms included some religious items

(dDo you feel like saying your prayers?T, dDo you

have blasphemous thoughts about God and the

Prophet?T) and some interpersonal items (dDo you

argue with people a lot?T, dCan you put up with

noise?T). The item referring to libido (dHave your

sexual feelings decreased?T) had to be discarded as

unacceptable to female respondents.

Many of the 30 items in the final version of the

questionnaire are familiar to western psychiatry. The

idiom of expression is nonetheless more functional

and less abstract than in equivalent western question-

naires, and more family-orientated. Two religiously-

based items have proved robust (dDo you feel you

have committed some serious sin?T, dDo you feel you

are being punished for something?T).We found that it was possible to distinguish

between anxiety and depressive disorders based on

their symptomatology. Many symptoms were

reported by depressed patients significantly more

frequently than by patients with anxiety disorders.

For most items, patients with diagnoses of anxiety

plus depression showed higher rates of endorsement

than those with a single diagnosis. This pattern of

responses led to the decision to construct two sub-

scales, dAnxiety and DepressionT and dDepressionT.Depressed patients score highly on both subscales;

patients with anxiety disorders scored highly only on

the AD subscale.

The sensitivity and specificity of the Pakistan

Anxiety and Depression Questionnaire compares

favourably with that of other screening instruments

for common mental disorders in Pakistan (Table 3).

The PADQ has significant advantages: the questions

reflect local idioms of distress, and the questionnaire

is easy to administer to less educated subjects. The

PADQ shows excellent psychometric properties in

differentiating patients and normal controls, and

good differentiation of anxiety and depressive dis-

orders. It is offered to clinicians and researchers as

an innovative culturally-sensitive questionnaire to

detect these common mental disorders in Pakistan.

Acknowledgements

Our warm thanks to many colleagues in Bradford,

Peshawar and Lahore who contributed in different

ways to the project: Yasmin Hussain and Kumud

Bhatnagar (Bradford); Jaffar Hussain, Zubair Khan,

S Farooq and the late Anis-ur-Rehman (Peshawar);

Sohail Ali, Lutfullah, Raheel Aziz, Imtiaz Cheema,

Abbas Ali Cheema and Nauman Khalil (Lahore).

Copyright

The authors retain the copyright of the Pakistan

Anxiety and Depression Questionnaire, but it may be

used free of charge with due acknowledgement of its

source.


Appendix A. Pakistan Anxiety and Depression Questionnaire

English Translation

AD scale

Do you think that you have some mental problems? yes no

Do you feel anxious amongst a lot of people? yes no

Is your mind in peace? no yes

Do you worry over trivial things? yes no

Has your tolerability decreased? yes no

Does one idea come to your mind again and again? yes no

Have you become more irritable? yes no

Do you feel lazy? yes no

Have you lost your self-confidence? yes no

Do you get frightened? yes no

Do you feel that your mind is not working? yes no

Do you feel that you are being punished for something? yes no

Do you sleep well at night? no yes

Do you keep on thinking without any purpose all the time? yes no

Do you feel that you do not understand anything? yes no

Total

D scale

Are you happy these days? no yes

Do you feel sad at heart? yes no

Do you feel like working? no yes

Do you enjoy this world? no yes

Are you excessively hopeless? yes no

Has your interest decreased? yes no

Do you feel like staying in bed all day? yes no

Do you enjoy your food? no yes

Do you feel like crying? yes no

Do you feel fed up with your family members? yes no

Do you feel you have committed some serious sin? yes no

Do you feel like running away from your home? yes no

Are you fed up with life? yes no

Do you have a wish to die? yes no

Do you ever think that death would be better than this life? yes no

Total

AD scale: score of 6 or more = probable anxiety or depressive disorder

D scale: score of 6 or more = probable depressive disorder

Appendix B. Pakistan Anxiety and Depression Questionnaire (Urdu)


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