THE CENTRE FOR EPIDEMIOLOGIC STUDIES DEPRESSION

SCALE: WORKING PAPER

Darcy A. Santor
Department of Psychology
Dalhousie University
Copyright  1998

Original Use and Purpose. The Centre for Epidemiologic Studies Depression Scale
(CES-D; Radloff, 1997) was originally developed by Ben Locke and Peter Putnam to assess
severity of depressive symptoms in community-residing adults. The measure consists of 20 items
assessing depressed affect, lack of positive affect, somatic symptoms, and interpersonal
difficulties. Items are rated on a four-point scale according to the frequency with which
symptoms were experienced during the preceding week. The scale has been translated in to
several languages, including German (Weyerer, Geiger-Kabisch, Denzinger, & Pfeifer-Kurda,
1992), French (Fuhrer & Rouillon, 1989), Spanish (Caraveo, Medina, Villatoro, & Rascon, 1994),
Russian (Dershem, Patsiorkovski, & O’Brien, 1996) and Italian (Fava, 1983), as well Chinese
(Lin et al., 1996), Japanese (Iwata, Saito, & Roberts, 1994), and Korean (Noh, Avison, & Kaspar,
1992), and has been used with children (Weissman, Orvaschell, & Padian,1980), adolescents
(Garrison et-al, 1992; Roberts, Andrews, Lewinsohn, & Hops, 1990; Swanson et al., 1992), adults
(Gatz & Hurwicz, 1990) and elderly persons (Lewinsohn, Seeley, Roberts, & Allen, 1997;
Radloff & Teri, 1986). Although initially developed to assess the severity of depression, one of
the primary uses of the CES-D has been to estimate the prevalence of depression in large
epidemiological samples as well as to screen for depressive illness in medical settings.
Psychometric Properties. Reliability and validation studies have shown that the CES-D
is internally consistent, moderately stable over several weeks (rs ≈ 0.57; Radloff, 1977) and
months (rs ≈ 0.50; Lin & Ensel, 1984; Lewinsohn, Hoberman & Rosenbaum, 1988) and
correlates strongly with many other measures of depression. Confirmatory factor analyses support
the existence of four factors, initially identified in the original validation sample, but that a single
higher-order factor may account for responses to individual items equally well (Hertzog et al.,
1990). Studies suggest that the CES-D may not effectively discriminate between clinical
depression and other psychiatric conditions (Roberts, Rhoades & Vernon, 1989) and may be
equally related to depressed and anxious mood states (Breslau, 1985; Orme, Reis, & Herz, 1986).
However, psychometric analyses based on item response models (Santor, Zuroff, & Ramsay,
1996) suggest that the CES-D may be better at detecting individual differences in depressed mood

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in nonclinical populations than measures designed for clinical populations, such as the Beck
Depression Inventory (Beck, Ward, Mendelsohn, Mock & Erlbaugh, 1961). To date, short-forms
consisting of 4, 8, 10 and 11 items have appeared (Andresen, Malmgren, Carter, & Patrick, 1994;
Kohout, Berkman, Evans, & Cornoni-Huntley, 1993; Melchior, Huba, Brown, & Reback, 1993;
Santor & Coyne, 1997) and a variety of improvements to the scoring methods have been
recommended (Furukawa et al., 1997; Craig & Van Natta, 1979; Santor & Coyne, 1997). Few
studies have examined the degree to which gender bias may be observed in individual responses
to items (Stommel et al, 1993).
Initial studies suggested that individuals scoring 16 or more on the scale (Radloff, 1997,
Weisman et al., 1977) could be used to designate individuals as depressed; however, other
cutpoints have been suggested, ranging as high as 19 in chronic pain patients (Turk & Okifuji,
1994), 21 in the elderly; and 24 and 27 in adolescents (Gotlib, Lewinsohn, & Seeley, 1995;
Roberts et al., 1991) and medical patients (Costello & Devins, 1989). However, the efficiency of
alternate cutoff scores on CES-D have focused primarily on measures of efficiency, like
sensitivity and specificity, with correspondingly less attention to other measures of efficiency like
positive or negative predictive values. In general, estimates of the sensitivity and specificity for
most cutpoints exceed 0.80; however, estimates of the positive predictive value are much lower
(Beekman et al., 1997; Fechner-Bates, Coyne, Schwenk, 1994; Santor & Coyne, 1997; Coyne,
Schwenk, & Smolinski, 1991). Most clinically depressed individuals obtain scores exceeding
standard cutpoints; however, a substantial number of depressed persons will not. Moreover, most
persons obtaining high scores will not meet formal diagnostic criteria for depression. Given the
unavoidable tradeoff between maximizing the proportion of depressed individuals who are
identified as depressed (sensitivity) and maximizing the proportion of individuals identified as
depressed who are actually depressed (positive predictive value), the costs of using the CES-D as
a screening tool either to improve the detection of cases of depression in primary care or to
identify research samples should be considered carefully.
Concerns Regarding Use of the CES-D. Two related issues involving the use of the CES-
D remain controversial, namely the suitability of the CES-D as a tool for identifying clinically
depressed individuals, as well as the use of the CES-D as a measure of depressive
symptomatology. First, problems overdiagnosing the prevalence of depression with the CES-D
have been well-documented in medical patients (Fechner-Bates et al., 1994), adolescents
(Roberts, Andrews, Lewinsohn, & Hops, 1990), college students (Santor, Zuroff, Ramsay,
Cervantes, & Palacios, 1995), and community-residing adult populations (Breslau, 1985; Myers
& Weissman, 1980). Estimates with standard cutpoints in similar populations vary from 9%

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(Stallones & Garrity, 1990) to well over 40% (Hauenstein & Boyd, 1994; Swanson et al., 1992),
which has raised concerns about the use of self-report measures, such as the CES-D, as screening
tools for depression (Roberts et al, 1991; Santor & Coyne, 1997; United States Preventive Task
Force, 1996).
Attempts to improve the efficiency of the CES-D have been numerous. Detecting the
presence or absence of a depressive disorder was never the criterion against which individual
items were included or excluded from the original scale. Indeed, assessing the severity of distress
(a continuum) and detecting cases of depression (a categorical variable) requires scales with very
different psychometric properties. Most attempts to improve the CES-D have relied on adjusting
cutoff scores rather on identifying effective items (cf. Santor & Coyne, 1997). However, even
after identifying effective items, limitations of the CES-D as a self-report screening measure
persist (Coyne & Schwenk, 1997; Santor & Coyne, 1997).
Second, although research has demonstrated that elevated scores on the CES-D are
associated with a variety of psychosocial difficulties (Gotlib, Lewinsohn, & Seeley, 1995) and
may represent a risk for a depressive disorder (Lewinsohn, Hoberman & Rosenbaum, 1988),
caution must be exercised in viewing the CES-D as a measure of depression (Coyne, 1994).
Items are assessed with respect to the past week and therefor may measure only transient distress;
many items do not correspond to actual symptoms of depression; and most individuals scoring
high on the CES-D will not become depressed (Lewinsohn et al., 1988). As a result, individuals
may score high on the CES-D by endorsing a large number of items at relatively mild levels of
dysphoria that may not be long-lasting. In conclusion, evidence supports the CES-D as an
excellent measure of general distress and dysphoria rather than as a tool for identifying cases of
depression.

Words 1,108

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