Adaptation and validation of a structured version of the Hamilton Depression Rating Scale for use by non-clinicians in South Africa (AFFIRM-HDRS)

Thandi Davies*, Emily C. Garman, Crick Lund, Marguerite Schneider

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

5 Citations (Scopus)


Rationale, aims and objectives: The Hamilton depression rating scale (HDRS) is seen as an international gold standard for the measurement of depression. High rates of untreated depression, including perinatal depression, support the rationale to adapt and validate a structured version of the HDRS to be used by non-clinicians in low-income settings. Methods: Using previous structured versions of the HDRS as a foundation, the tool was adapted, translated, and then validated with an isiXhosa speaking perinatal population in South Africa (n = 187), using cognitive testing, test-retest reliability, and inter-rater assessments. The AFFIRM-HDRS was compared with the Edinburgh postnatal depression scale (EPDS) using the non-parametric Spearman Rho test to assess concurrent validity. Internal consistency was examined using Cronbach's Alpha, and inter-rater and test-retest reliability were assessed with the intra-class coefficient (ICC). Cohen's Kappa was used to assess the overall percentage agreement for each individual item of the AFFIRM-HDRS. Results: The AFFIRM-HDRS showed good construct and content validity had significant associations with the EPDS (Rho = 0.60 and 0.43, P <.001), and acceptable internal consistency (Cronbach's alpha = 0.74.). Inter-rater reliability and test-retest scores were excellent, with intraclass correlations ranging from 0.97 (0.94-0.99) to 0.98 (0.97-0.99) between raters, and test-retest reliability being 0.90 (95% CI: 0.86-0.93). The tool performed similarly to previous structured versions. Individual item-rest correlations suggest that the items “Weight loss or gain,” “Insight,” and “Libido” did not fit well with the overall instrument, but that the rest of the items performed well. Conclusion: The AFFIRM-HDRS is adequately structured to be used by non-clinicians in an isiXhosa speaking perinatal population. It is hoped that this structured tool can be used to assist with identification and referral of these at-risk populations by non-clinicians in resource-constrained environments, thereby playing a role in addressing the treatment gap for perinatal depression in LMICs.

Original languageEnglish
JournalJournal of Evaluation in Clinical Practice
Publication statusPublished - 1 Jan 2019


  • adaptation
  • depression
  • Hamilton depression rating scale
  • LMIC
  • perinatal
  • reliability
  • South Africa
  • task sharing
  • validity


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