Properties of the Hopkins Symptom Checklist-25 (HSCL-25) and the Self-Reporting Questionnaire (SRQ-20) as screening instruments used in primary care in Afghanistan

Abstract
Background
Recent epidemiological studies in Afghanistan using mental health questionnaires yielded high prevalence rates for anxiety and depression.
Objectives
To explore the validity in the Afghan cultural context of two mental health questionnaires, the Hopkins Symptom Checklist-25 (HSCL-25) and the Self-Reporting Questionnaire-20 (SRQ-20).
Methods
The two mental health questionnaires were compared against a ‘gold standard’ semi-structured psychiatric interview, the Psychiatric Assessment Schedule (PAS). All instruments were administered to a sample of 116 Pashto-speaking patients (53 men, 63 women) attending primary health care facilities in Eastern Afghanistan.
Results
Both HSCL-25 and SRQ-20 had modest properties to correctly identify mental disorders, with an AUC (area under the curve) of 0.73 and 0.72 respectively. The optimal cut-off points for this population are different from those often used in transcultural research. For women the optimal cut-off points are higher than usual (2.25 for the HSCL-25 and 17 for the SRQ-20). For men the cut-off point for the HSCL-25 is lower than usual (1.50) and for the SRQ-20 it was 10).
Conclusions
This study underlines the necessity of validating instruments along with cultural context and gender. Earlier studies in Afghanistan may have overestimated the prevalence of mental disorders among women and underestimated the prevalence in men.