Sydney Melancholia Prototype Index (SMPI): translation and cross-cultural adaptation to Brazilian Portuguese

Abstract Introduction Depression is possibly not a single syndrome but rather comprises several subtypes. DSM-5 proposes a melancholia specifier with phenotypic characteristics that could be associated with clinical progression, biological markers or therapeutic response. The Sydney Melancholia Prototype Index (SMPI) is a prototypic scale aimed to improve the diagnosis of melancholia. So far, there is only an English version of the instrument available. The aim of this study is to describe the translation and adaptation of the English version of the SMPI into Brazilian Portuguese. Methods Translation and cross-cultural adaptation of the self-report (SMPI-SR) and clinician-rated (SMPI-CR) versions into Brazilian Portuguese were done following recommendations of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). This guideline includes the following steps: preparation, forward translation, reconciliation, back translation, back translation review, harmonization, cognitive debriefing, debriefing results review, proofreading and final report. Results The Brazilian Portuguese versions of the SMPI were well-accepted by respondents. Changes in about two-thirds of the items were considered necessary to obtain the final Brazilian Portuguese version of the SMPI. Conclusions Both versions of the SMPI are now available in Brazilian Portuguese. The instrument could become an important option to enhance studies on melancholia in Portuguese-speaking samples.


Introduction
The idea that depression is not a single syndrome but rather an entity that comprises several subtypes has been widely debated over the past few decades.
Various views in this regard might be clustered around two main poles, namely, the unitary and the binary perspectives. [1][2][3] According to the former, there is one single type of depression with variable intensity, with melancholic depression being the most severe one. 4 The latter, i.e., the binary perspective, in turn, describes two main types of depression, namely: 1) reactive, neurotic or non-melancholic; and 2) endogenous, psychotic or melancholic. 1

Current issues on a melancholia specifier for major depression
The notion of major depressive disorder as seen through a specifier for major depression. However, the items described in the DSM have been called into question for being unspecific and redundant vis-àvis the larger notion of major depression. 5 Also, DSM criteria are based on number of symptoms rather than on their intensity or quality, following the psychometric model instead of the clinimetric approach, in which major and minor symptoms of depression should be treated differently. 6,7 Several authors have formulated specific scales to measure melancholia, the most significant of which are the Bech-Rafaelsen Melancholia Scale (MES), 8 The aim of the present study was to describe the cross-cultural adaptation of the SMPI by means of methods known to be efficient for this purpose.

Methods
There are many methods to perform the crosscultural adaptation of health assessment instruments.

Preparation
Preparation comprises the following procedures:

Forward translation
Translators should be selected who are native speakers of the target language and fluent in the source instrument language. Three translations are independently obtained in compliance with these criteria, which are then compared. The research group discusses the conceptual basis of the items and their context to avoid mistranslation and unclear terms.

Reconciliation
Discrepancies between the three independent translations are synthesized, resulting in a fourth version. Reconciliation might be performed by a) an independent native speaker; b) a group including the project manager and the forward translators; or c) the investigator charged with cognitive debriefing.

Back translation
This step provides quality control of the translated version. It is carried out by an external translator without previous contact with the original instrument or the forward translators.

Back translation review
This is one of the most important steps. The incountry project manager compares the back translated and source versions to check the equivalence of terms and solve discrepancies. The instrument developer is called to review the terms used to ensure the conceptual validity of the translated version.

Harmonization
Comparison of the back translation with back translations from other languages within the context of multicenter studies (not applicable to the SMPI).

Cognitive debriefing
The harmonized version in the target language is presented to a sample of in-country native speakers of the target language. A spreadsheet is used for each participant to assess each statement in the instrument.
This step allows for: a) assessment of the level of comprehensibility and cognitive equivalence of the translation; b) testing translation alternatives suggested by the participants; c) highlighting any terms that might be inappropriate at a conceptual level; and d) identifying any other issues that cause confusion.

Review of cognitive debriefing results
This stage consists of discussion between the project manager and the research group to incorporate findings (more familiar terms or terms commonly used by respondents) of the debriefing process to improve the performance of the translation.

Proofreading
Final review, the aim of which is to check for minor errors that have been missed in the translation process.

Final report
The full process is described, including clear

Application of the ISPOR translation methodology
For the three first steps, permission for use and

Relevant changes made in specific items
Overall, the version presented was well-understood and accepted by the tested patients and physicians, except for five items in Description A and nine items in both Descriptions (A and B). Item #5 in Description A  I think nothing will make me feel pleasure.
10-I don't think that my early years were any more difficult -when compared to most people -in terms of having any major difficulties with parents or bullying.
-I don't think my childhood was more difficult -when compared to most people -regarding any major problems with parents or bullying (intimidation or mistreatment).

RATING (please tick or circle one):
-Punctuation (please check or circle one alternative): Pontuação (por favor assinale ou circule uma alternativa): 1-Description A best matches my overall profile.
-Description "A" best represents my general profile.

5-Description B best matches
my overall profile.
-Description "B" best represents my general profile.

Description B -Description B Descrição B
6-I often get (non-medication related) food cravings and/ or increased appetite when I'm depressed.
I often have (non-drug related) food "cravings" (compulsive eating) and/or increased appetite when depressed.
I often have (non-drug related) food "cravings" (compulsion) and/or increased appetite when depressed.
Eu geralmente tenho "fissura" (compulsão) por alimento e/ou aumento do apetite quando estou deprimido (não-associados ao uso de medicações). ("Can't look forward to anything in life") contains the phrasal verb "look forward," which lacks a semantic equivalent in the Portuguese language. The instrument developer was thus consulted to develop an adequate translation. According to him, the core aspect of this item is to investigate "anhedonia relative to the future." Therefore, the final version reads "acho que nada vai me fazer sentir prazer" in the SMPI-SR ("I think nothing will make me feel pleasure") and "acha que nada vai lhe fazer sentir prazer" in the SMPI-CR ("The patient thinks nothing will make him or her feel pleasure"). Tables 1   and 2  In the SMPI-SR, "my way of being" was used as a more colloquial expression for the term "personality," which was kept, however, between brackets.
In the case of Description B, item #6, formulated in the SMPI-SR as "I often get (non-medication related) food cravings and/or increased appetite when I'm depressed," and in the SMPI-CR as "Often gets (nonmedication related) food cravings and/or increased appetite when depressed," the order of the sentence was inverted, because that sounds more natural in the Portuguese language. The term "compulsion" was added between brackets to make the colloquial term "fissure" (craving) clearer.
In Description A, item #10 reads as follows in the SMPI-SR: "I don't think that my early years were any more difficult -when compared to most people -in terms of having any major difficulties with parents or bullying"; and in the SMPI-CR: "Early years were no more difficult -when compared to most people -in terms of having any major difficulties with parents or bullying." In these segments, the anglicism "bullying" was maintained because it is a commonly used word in Portuguese. Synonyms were added between brackets to make the meaning of this word clear.  Has no major expectations in life.
The patient thinks nothing will make him or her feel pleasure.
10-Early years were no more difficult -when compared to most people -in terms of having any major difficulties with parents or bullying.
-Early years were no more difficult -when compared to most people -in terms of having any major difficulties with parents or bullying (intimidation or mistreatment).

RATING (please tick or circle one):
-Punctuation (please check or circle one alternative): Pontuação (por favor assinale ou circule uma alternativa): 1-Description A best matches the overall profile.
-Description 'A' is the one that best depicts the overall profile.

5-Description B best matches
the overall profile.
-Description 'B' best depicts the overall profile.

Description B -Description B Descrição B
6-Often gets (non-medication related) food cravings and/ or increased appetite when depressed.
Often has (non-drug related) food "cravings" (compulsive eating) and/or increased appetite when depressed.
Oftentimes has food 'cravings' (compulsion) and/or increased appetite when depressed (these events are non-drug-related).
9-The severity of depressions can be explained by the type of stressful events that precede them and their impact with personality style. - The severity of the depressions can be explained by the kind of stressful events that precede them, considering the personality style to evaluate the impact of these events.

Discussion
The The SMPI has some limitations. Its original (prototypical) format may require additional explanations to those provided in the instructions.
Additionally, the fact that the SMPI is not a quantitative, but rather a prototypical instrument, hinders its use for evaluating response to treatment, thus only allowing one to establish diagnostic categories (melancholic vs. non-melancholic depression).

Conclusion
The present study made the SMPI available in the Brazilian Portuguese language. This is one of the few instruments developed specifically for assessing melancholia. It comprises a clinician-rated and a patient self-report version, both of them now available in Portuguese.