|
Center for Epidemiologic Studies Depression Scale (CES-D)
Please note that this section is an archive (last updated in June 2006). [disclaimer]
Sections:
Overview |
Instrument Reviews |
Construct Overviews |
Book Compendium Reviews |
Internet Site Reviews
|
|
|
|
Practical Information
|
Instrument Name:
|
Center for Epidemiologic Studies Depression Scale (CES-D)
|
Instrument Description:
|
The measure is used to assess general psychological impairment, primarily depression. It is not used to make a diagnosis; its purpose is to estimate symptom prevalence and to be used as a first-stage screening device in clinical and research efforts. (Ref: 2) It has been said to measure multiple dimensions of affective symptomatology (Ref: 5), and current depressive symptoms within the last week, in the general population, with an emphasis on mood. (Ref: 1) There are 20 items pooled from various validated depression measures (Beck, Welsh, Gardner, Raskin, Zung). (Ref: 8)
|
Price:
|
Free
|
Administration Time:
|
10 minutes
|
Publication Year:
|
1977
|
Item Readability:
|
Flesch-Kincaid Grade Level 4.1. Items are composed of very simple vocabulary and short sentences.
|
Scale Format:
|
4-point ordinal scale.
|
Administration Technique:
|
Self-report or interview
|
Scoring and Interpretation:
|
0=rarely or none of the time (less than 1 day); 1=some or little of the time (1-2 days); 2=occasionally or a moderate amount of the time (3-4 days); 3=most or all of the time (5-7 days); A score of >=22 indicates probable Major Depression; 15-21 Mild to Moderate Depression; and, <15 does not indicate depression.
|
Forms:
|
Dutch, English, Spanish, Various short versions
|
|
|
Research Contacts
|
Instrument Developers:
|
Lenore S Radloff (1977). Prepared for the National Institute of Mental Health.
|
Instrument Development Location:
|
(Developer’s address): Room 10C-09, Parklawn Building, 5600 Fisher’s Lane, Rockville, Maryland 20852.
|
Instrument Developer Email:
|
|
Instrument Developer Website:
|
|
|
|
Annotated Bibliography
|
1. Himmelfarb S, Murrell SA. Reliability and validity of five mental health scales in older persons. J Gerontol. 1983; 38(3):333-9. [PMID: 6841929]
 |
Purpose: Assessment of five mental health scales in older persons, including the CES-D, to determine if they could discriminate between a clinical and community sample. |
|
Sample: Community sample of 279 older persons and a clinical sample of 109 older persons (46% from a VA hospital) who were in psychiatric inpatient units. |
|
Methods: Five scales were administered to the two groups. |
|
Implications: Internal consistency for the CES-D was high, as well as its ability to discriminate between groups. |
2. Engdahl BE, Page WF, Miller TW. Age, education, maltreatment, and social support as predictors of chronic depression in former prisoners of war. Soc Psychiatry Psychiatr Epidemiol. 1991; 26(2):63-7. [PMID: 2047905]
|
Purpose: The authors examined POW captivity trauma variables and individual protective factors to current depressive symptoms. |
|
Sample: 989 Former U.S. POW’s of WWII and the Korean War. |
|
Methods: This was a longitudinal study that followed subjecs since the 1950s. |
|
Implications: "Age, education, medical symptoms during captivity, and level of social support were related to later levels of adjustment." |
3. Beekman AT, Deeg DJ, Van Limbeek J, Braam AW, De Vries MZ, Van Tilburg W. Criterion validity of the Center for Epidemiologic Studies Depression scale (CES-D): results from a community-based sample of older subjects in The Netherlands. Psychol Med. 1997;27(1):231-5. [PMID: 9122304]
|
Purpose: The authors aimed to study criterion validity of the CES-D in an elderly community based sample. |
|
Sample: A random sample of 487 older adults (55-85 years) was chosen from individuals living in the Netherlands. |
|
Methods: Depression was assessed with the Diagnostic Interview Schedule (DIS) and used as the criterion. The Mini-Mental State Examination (MMSE) and the anxiety subscale of the Hospital Anxiety and Depression scale (HADS-A) was also utilized. |
|
Implications: Criterion validity was reported to be satisfactory. |
4. Lewinsohn PM, Seeley JR, Roberts RE, Allen NB. Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults. Psychol Aging. 1997 Jun;12(2):277-87. [PMID: 9189988]
|
Purpose: The authors examined the efficacy of the CES-D as a screener of clinical depression. |
|
Sample: 1,005 community residing adults (50-96 years). |
|
Methods: Presence of depressive disorder determined by diagnostic interview using the Schedule for Affective Disorders and Schizophrenia Lifetime version (SADS-L).< |
|
Implications: The following did not have a significant negative effect on the psychometrics or screening efficacy: age, gender, cognitive impairment (although participants with more disabling forms of cognitive impairment and physical illness were not included), functional impairment, physical disease, and social desirability. Also, a 5-item scale was devised, which performed as well as the 20-item scale in detecting depression. |
5. Callahan CM, Wolinsky FD. The effect of gender and race on the measurement properties of the CES-D in older adults. Med Care. 1994 Apr;32(4):341-56. [PMID: 8139299]
|
Purpose: The authors examined the effects of gender and race on the psychometric properties of the CES-D. |
|
Sample: 3,047 urban, chronically ill, elderly patients cared for in primary practice (46% Black females). |
|
Methods: The CES-D was administered to each patient in interviews. |
|
Implications: Race-gender differences were found in factor structure, but they were not resolved by eliminating confounding variables. They were, however, resolved by eliminating five items of the CES-D and reducing it to a 15-item scale. |
6. Myers JK, Weissman MM. Use of a self-report symptom scale to detect depression in a community sample. Am J Psychiatry. 1980; 137(9):1081-84.[PMID: 7425160]
|
Purpose: The authors' aim was to evaluate whether the CES-D would be effective as a screening tool for depression in a community population. |
|
Sample: 515 persons in a mental health center catchment area in New Haven, CT were involved in the longitudinal community survey. |
|
Methods: Subjects were given CES-D and the Schedule for Affective Disorders and Schizophrenia (SADS). From the information on the SADS, subjects were given diagnoses based on Research Diagnostic Criteria. |
|
Implications: The CES-D can be used as a screening device to identify major depression, but it is not efficient in identifying minor depression or depressive personality in the community. |
7. Hann D, Winter K, Jacobsen P. Measurement of depressive symptoms in cancer patients: evaluation of the Center for Epidemiological Studies Depression Scale (CES-D). J Psychosom Res. 1999; 46(5):437-43. [PMID: 10404478]
|
Purpose: The authors determined the psychometric properties of the CES-D with cancer patients compared to healthy subjects. |
|
Sample: 117 women undergoing treatment for breast cancer were used as cases and 62 women with no history of cancer were used as controls. |
|
Methods: The CES-D was given prior to treatment and midway through treatment (or at 2 comparative times for those women not in treatment). Construct validity was measured against the Profile of Mood State Fatigue Scale (POMS-F) and State-Trait Anxiety Inventory (STAI-S) |
|
Implications: Internal consistency and test-retest reliability was reported to be good in both groups. Construct validity was also found to be good. |
8. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement. 1997 Summer;1(3):385-401.
|
Purpose: The authors evaluated a scale designed to measure depressive symptomatology in the general population. |
|
Sample: Probability samples of households in Kansas City and Washington County were selected. |
|
Methods: The instrument was tested in household interviews and psychiatric settings. Household Methods included: structured interview in homes (Q1), mailed surveys and a second mailed survey two, four, six or eight weeks later (Q2), and a reinterview of samples from the original survey 3, 6 and 12 months later (Q3). Psychiatric Methods: Patients from Washington County, Maryland and New Haven, Connecticut volunteered to participate, and they were interviewed using the CES-D, the Rockliff Depression Rating Scale, the Raskin Depression Rating Scale, the Hamilton Rating Scale, and the SCL-90. |
|
Implications: The CES-D was shown to have high internal consistency and validity when used in the intended population. |
9. Carpenter JS, Andrykowski MA, Wilson J, Hall LA, Rayens MK, Sachs B, Cunningham LL. Psychometrics for two short forms of the Center for Epidemiologic Studies-Depression Scale. Issues Ment Health Nurs. 1998 Sep-Oct;19(5):481-94. [PMID: 9782864]
|
Purpose: The authors evaluated the psychometric properties of two shorter forms (Boston and Iowa) of the CES-D |
|
Sample: 832 women from six different populations. |
|
Methods: Methods varied between mailed survey, written survey, and in-home interview |
|
Implications: The authors reported that the Iowa form is preferred over the Boston form when a short version of the CES-D is needed |
|
|
top
|
Factors and Norms
|
Factor Analysis Work:
|
Four factors: 1) depressive affect (seven items); 2) somatic symptoms (seven items); 3) positive affect (four items); 4) interpersonal relations (two items).
|
Normative Information Availability:
|
Yes. (Ref: 3, 4, 8) Also, included in the National Health and Nutrition Examination Survey (HANES) of 6,931 adults in the early 1970s. For adults 55 to 74 years old, HANES norms produced a mean CES-D score=8.64. (Ref: 1)
|
|
|
Reliability Evidence
|
Test-retest:
|
Over two and one-half weeks, test-retest r=0.51 (Ref: 7). Test-retest has also been found similar at r=0.52 (Ref: 4). For the developmental study, Q2 vs. mailbacks is as follows (Ref: 8):
| Time Interval
|
Test-Retest r
|
| 2 weeks
|
0.51
|
| 4 weeks
|
0.67
|
| 6 weeks
|
0.59
|
| 8 weeks
|
0.59
|
| Total
|
0.57
|
and Q1/Q2 vs. Q3 is as follows:
| Time Interval
|
Test-Retest r
|
| 3 months
|
0.48
|
| 6 months
|
0.54
|
| 12 months (KC)
|
0.49
|
| 12 months (WC)
|
0.32
|
| Total
|
0.57
|
|
KC=Kansas City; WC=Washington County
|
|
Inter-rater:
|
r=0.97 to 0.99 (Ref: 5)
|
Internal Consistency:
|
Cronbach’s alpha=0.85 (p < 0.001) in a community sample and alpha=0.907 (p < 0.001) in a clinical sample of older adults. (Ref: 1) Cronbach’s alpha=0.82 in older adults. (Ref: 4) In the developmental study, reliability is as follows: coefficient alpha = 0.83 to 0.85 for the three community groups, and 0.90 for the inpatients; split-half r = 0.76 to 0.77 for the three community groups, and .85 for the inpatients; Spearman-Brown=0.86 to 0.87 for the three groups and 0.92 for the inpatients.
|
Alternate Forms:
|
Iowa and Boston forms correlated with original CES-D at r > 0.83. (Ref: 9)
|
|
|
Validity Evidence
|
Construct/ Convergent/ Discriminant:
|
The CES-D correlated with the POMS-F at 0.54 and the STAI-S at 0.65 (both p <0.001). (Ref: 7) CES-D scores and ratings of severity of depression by a nurse clinician was 0.56. (Ref: 8) The correlation of the CES-D with the Hamilton Clinician’s Rating Scale is 0.44 (0.69 after four weeks of treatment in the inpatient facility), and with the Raskin Rating Scale is 0.54 (0.75 after four weeks of treatment in the inpatient facility). (Ref: 8)
|
|
Range for community samples
|
Inpatients
|
|
Measures of depression
|
| Lubin
|
0.37 to 0.51
|
0.70
|
| Bradburn Negative Affect
|
0.60 to 0.63
|
0.55
|
| Bradburn Balance
|
0.61 to 0.62
|
0.72
|
|
Measures of general psychopathology
|
| Langner
|
0.54
|
0.60
|
| Cantril Ladder
|
0.38 to 0.44
|
0.74
|
|
Measures of other variables (discriminant validity)
|
| Bradburn Positive Affect
|
-0.21 to -0.25
|
-0.55
|
| Medications
|
0.20 to 0.24
|
0.22
|
| Disability Days
|
0.28 to 0.32
|
0.30
|
| Social Functioning
|
0.13 to 0.19
|
0.24
|
| Aggression
|
0.26 to 0.29
|
0.21
|
|
Interviewer ratings
|
| Depression
|
0.49 to 0.5
|
0.46
|
| Cooperation
|
-0.03 to -0.01
|
0.11
|
|
Criterion-related/ Concurrent/ Predictive:
|
Using a cut-score of 16, sensitivity for major depression (1 month prevalence) was 100% while specificity was 88%. Sensitivity for Major Depression in the past year was 71%, while specificity was 88%. Sensitivity for lifetime Dysthymia was 41% and specificity was 87%. (Ref: 3) At this cut-off, the false positive rate for Major Depression has been found to be 6.1% and the false negative rate is 36.4%. (Ref: 6) For Minor Depression, the false positive rate was 8% and the false negative rate was 77%. For depressive personality, the false positive rate is 7% while the false negative is 57%. (Ref: 6) At a cut-score of 12, sensitivity=76%, specificity=77%, negative predictive value=97%, positive predictive value=22%. (Ref: 4) Using ROC analysis, the AUC (area under the curve) was 0.86 (0.81-0.92). The correlation of the CES-D score with the clinical diagnosis of depression was 0.45. (Ref: 4)
|
Content:
|
No information found.
|
Responsiveness Evidence:
|
The average CES-D score decreased 20 points in a recovered group of patients and 12 points in a group of “still ill” patients. (Ref: 8)
|
Scale Application in VA Populations:
|
Yes. (Ref: 2)
|
Scale Application in non-VA Populations:
|
Yes. (Ref: 1,3-6, 8)
|
|
|
Comments
|
This measure should be used with caution. It is meant to be used for screening device for research efforts. It is not intended for diagnostic purposes. Interpretation should only be done at a group level, and group averages should be interpreted as level of symptoms of depression, not as rates of illness. The cutoff scores traditionally used is arbitrary and should be used with caution.
Overall usefulness for a certain population: Useful for the general population and for the elderly population.
Advantages: The CES-D has great internal consistency, good test-retest reliability, good discriminant/convergent validity, good responsiveness to change, and good criterion validity evidence. It’s simple and easy to take and to administer.
Disadvantages: Shouldn’t be used for diagnostic purpose. Interpretation should be done at individual level.
Recommendation: Use as screening device at group level for research efforts. Should be interpreted as level of symptoms of depression and not as rates of illness.
|
Updates
No information found.
|
|
|
|
