1. A Culturally & Linguistically Specific Web-based Deaf Depression Screener: Validity & Reliability
Elizabeth Eckhardt, LCSW, PhD , Marjorie F. Goldstein, PhD , Patrice Creamer, MSW , Roberta S. Berry, MFA 
APHA Annual Meeting, Chicago- Nov 3, 2015
Deaf Research Projects, Social Sciences Innovations Corp,
71 West 23rd St, 4h floor, New York, NY
Funded by NIMH Grant Phase I - 1R43MH085370
Funded by NCATS Grant Phase II - 1R44TR000345

2. BACKGROUND
Deaf populations who use American Sign Language (ASL) as their main mode of communication are an underserved, low literacy group.
This slide should be title BACKGROUND

3. Prior Deaf Research
Computer delivered questionnaires and curricula on health topics by our research team:
Drug and alcohol use
General mental health
HIV knowledge and risk in deaf adults
HIV knowledge and risk in deaf adolescents
Curricula for high school students

4. Why a deaf-specific depression screener?
Depression is among the most common mental health problems seen in the US.
Depression is at least as common in deaf as hearing persons.
Depression is commonly diagnosed and treated in Primary Care settings. Diagnoses are typically done using written screeners.
Deaf persons are not routinely screened for depression in Primary Care.

5. Deaf persons cannot be easily screened using written screeners:
Low literacy among deaf populations. Average reading level is 4-5th grade in deaf HS grads.
ASL is a separate language with a syntax and grammar unlike English. ASL has no written form.
Many MH idioms are unfamiliar to deaf signers.
Confidentiality may be an issue with an interpreter.
No good way to standardize questions in ASL.

6. Deafness as a Culture
For many prelingually deaf persons, deafness is not seen as a disability.
Deaf persons who use ASL often see themselves as part of Deaf Culture with different cultural norms – akin to an ethnic minority group.
History of poor treatment and misunderstanding by the mental health care system.

7. Deaf Depression Screener Development Phases
SBIR funding received in two phases.
Phase I: Feasibility of developing, and testing of prototype Deaf Depression Screener.
Phase II: Full development and testing of the Deaf Depression Screener.

8. Phase I Prototype Development
Aims:
Qualitative research to explore how deaf persons experience and express depression.
Does deaf experience align with DSM criteria for depression?
Prototype of a self-administered, web-delivered depression screener in American Sign Language that is culturally specific.

9. DSM-IV Depression Symptoms
Depressed mood
Lack of concentration/indecisiveness
Thoughts of death/suicidal ideation
Fatigue/loss of energy
Loss of interest/pleasure
Psychomotor agitation/retardation
Insomnia/Hypersomnia
Weight gain/loss
Low self worth/guilt

10. DSM-IV Depression Criteria
Is symptom present for prior 2 weeks?
Does it interfere with usual life activities and functioning?
Are 5 out of 9 symptoms endorsed and meet the above 2 conditions?

11. Phase I Qualitative Methods
Focus Groups (FGs)
Deaf persons receiving MH services
Deaf persons not receiving MH services
How do they experience and express symptoms of depression?
3. Signing MH providers
How do their patients describe DSM and/or additional symptoms?

12. In-depth Interviews Signing Psychiatrist
How is depression diagnosed, how do patients describe DSM and/or additional symptoms.
2. MH Interpreter
How are DSM criteria for depression interpreted between ASL and English?

13. Qualitative Data Analysis
Transcription of Focus Groups and Interviews.
Analyzed for themes and Signs for symptoms.
Marge check report for more findings?

14. Findings Anger as a commonly reported symptom of depression.
Several variations of Signs found to represent specific depressive symptoms.
Difficult to translate time periods into ASL.
’Guilt’ is associated with the law, should use a different sign (e.g. self blame) and add examples.

15. Translation of Items
Translation team of deaf and hearing signing MH professionals
Development of English script for translation
Complex criteria were divided into two items
Translation and video recording of several versions of each item in ASL.
Video recorded items shown to FGs of deaf MH patients

16. Creation of Prototype Screener
Each depression symptom was signed with response options : ‘always’, ‘sometimes’ or ‘never’ within the previous 2 weeks.
For those answering ‘always’ or ‘sometimes’, a follow up severity item asked if this interfered with their usual functioning ‘a lot’, ‘somewhat’ or ‘not at all’.
English captions were available for all items.
Did we have the calendar for the prototype, any other graphics

17. Prototype Testing and Results
35 deaf mental health patients were recruited from 2 mental health programs. A chart diagnosis was available for all patients.
72 deaf persons recruited from general population.
Time period of ‘the past 2 weeks’ was not understood.
Some participants answered ‘sometimes’ to a symptom, but then indicated that it bothered them ‘not at all’.

18. Additional Focus Groups
Separate FGs were held with the general and mental health samples to try to understand the findings.
Some participants were unable to understand the difference between transient and truly bothersome symptoms.
The period ‘past 2 weeks’ did not translate well into ASL. Participants requested a visual (calendar) representation.

19. Phase II Study
Obtained Phase II funding to refine the Deaf Depression Screener and bring it to acceptable levels of validity and reliability.

20. Features of Deaf Depression Screener
Deaf Depression Screener nearing completion for web-based delivery and scoring.
Calendar Graphic included.
Introduction with explanation of transient vs. bothersome symptoms.
Validity and reliability testing conducted.
Show Demo here

21. Demo of Deaf Depression Screener

22. Validity Testing Recruitment of 247 participants.
Screener results compared to clinical exam (‘gold standard’).
Clinical exam by deaf mental health clinician via tele-mental health.
Line up numbers (1,2,3)

23. Reliability Testing
Additional 115 subjects recruited for test re-test.
Correlation coefficient calculated between Time 1 and Time 2 tests.
Maybe remove since you detail findings later?

24. Participant Demographics
Total 362 Deaf Participants
Age: Mean: 46.7 years (range 19-82)
Male: 43% Female: 57%
Black: 25% White: 34% Hispanic: 30% Asian: 4% Mixed Races: 4% Others: 2%
High School Grad: 44% College +: 18%

25. Results: Validity Sensitivity: True Positive Rate = 85%
Compared to the Signing Clinician, how accurate is the Deaf Depression Screener in detecting true cases of depression?
Specificity: True Negative Rate = 70%
Compared to the Signing Clinician, how accurate is the Deaf Depression Screener in detecting people who are not depressed?

26. Results: Reliability Test Retest Reliability = .87
How accurate is the Deaf Depression Screener in obtaining the same result twice?
Internal Consistency Reliability = .86
How well do the items asked inter-correlate (i.e. measure the same construct)?

27. Conclusion
When finalized, the Web-based Deaf Depression Screener will be available to health care providers who serve deaf patients for single use or unlimited subscription.
Through accurate depression screening, deaf individuals will gain access to mental health treatment and/or referral from primary care, emergency rooms, and deaf services agencies.

28. Phase II Online Deaf Depression Screener

29. Lack of Interest Question
Severity Follow up Question

30. Contact Information
Social Science Innovations Corp.
Elizabeth Eckhardt, LCSW, PhD, Principal Investigator
Marjorie Goldstein, MPH, PhD, CHES, Co-Investigator
voice telephone
videophone
fax