Psychometric properties of a short form of the Center for Epidemiologic Studies Depression (CES-D-10) scale for screening depressive symptoms in healthy community dwelling older adults
Introduction
A systematic review of depression prevalence in elderly populations showed that the prevalence of major depression ranges from 0.9% to 9.4% in private households and from 14% to 42% in institutional living; and the prevalence of clinically relevant depressive symptoms in similar settings varies between 7.2% and 49% [1]. Another systematic review on depression prevalence in later life (≥ 75 years) illustrated that the prevalence of major depression ranged from 4.6% to 9.3%, and that of depressive disorders from 4.5% to 37.4% [2]. Depression is a major contributor to healthcare costs in older populations, and is projected to be the leading cause of disease burden in older populations by the year 2020 [3], [4]. The prevalence of depression in patients aged ≥ 65 years may be as high as 40% in hospitalised and nursing home patients, and 8–15% in community settings [5].Depression in the elderly is associated with an increased risk of mortality, dementia and substantial psychosocial disability [6], resulting in an economic burden of $15 billion in Australia [7] and $83 billion in the United States [8].
The Center for Epidemiologic Studies Depression Scale (CES-D) has been widely used to assess depressive symptoms in community and population-based epidemiological studies [9]. The scale's validity and internal consistency in the detection of both clinical and non-clinical depressive symptoms have been established. It has however been suggested that the length of the 20-item CES-D could be halved without appreciable loss to reliability and validity. Various short and/or simplified forms of the 20-item CES-D have been evaluated [10], [11], [12], [13], [14]. The Boston form (10 dichotomously scored items), the Iowa form (11 items with three response options) developed by Kohout et al. [15] and the four-category response 10-item form (CES-D-10) developed by Andresen et al. [10] are most commonly used. The Andresen version, CES-D-10, has strong reliability and excellent sensitivity and specificity in screening for major depression in older adults [14]. Construct validity of the short form of the CES-D has been examined in Singaporean older adults in community settings [16], Chinese elderly in community dwelling [17] and older Chinese in social centres [18].While the published validity studies of the CES-D-10 illustrated acceptable factorial validity there were indications that the factorial structure has not been consistently determined. For example while studies among adults in Zulu, Xhosa and Afrikaans in South Africa [19] and the USA Hispanics population [20] concluded a one factor solution had the best model fit, studies in Canadian adolescents [21] and Singaporian elderly [16] resulted in a two-factor model and validation studies in older Chinese populations [17], [18] reported two-factor and three-factor models of the CES-D-10 respectively. These contradictory findings may be due in part to the use of: i) individuals with different cultural background; ii) differences in study sample age ranges; iii) participant characteristics (e.g. a psychiatric sample as compared with community-based participants) or; iv) small sample size (sample size in the studies with factorial validation in elderly populations was 231, 742 and 1013 respectively (16–18)). In such situations, performing confirmatory factor analyses (CFA), a commonly approach for the evaluation of the construct validity of psychometric inventories, on a large sample of community-based elderly individuals with diverse ethnic and cultural backgrounds [22], is a unique opportunity to clarify this issue.
Reise, Widaman and Pugh [23] further recommend the use of measurement invariance tests within the CFA framework to examine the invariance of the instrument's psychometric properties across different groups. The goal of the present study was to investigate the internal consistency and construct validity of the CES-D-10, relying on a CFA approach in healthy community-dwelling older Australian and American adults who participated in the ASPirin in Reducing Events in the Elderly (ASPREE) trial [24]. ASPREE is a placebo-controlled trial of low-dose aspirin to determine whether 5 years of daily 100-mg enteric-coated aspirin extends disability-free and dementia-free life in a healthy elderly population and whether these potential benefits outweigh the risks. We also aimed to evaluate measurement invariance across the two countries and sexes and examine item-response bias analyses of the exogenous variables: age, gender, ethnicity, race and education.
Section snippets
Participants
This study included all 19,114 community-based individuals who participated in the baseline measurements of the ASPREE trial and were subsequently randomised. The participants were recruited from general practice services in Australia and community-based centres in the United States (U.S.). Recruitment ended in December 2014 with 16,703 Australian and 2411 American participants. Readers are referred to the work of the ASPREE Investigator Group [24] and Berk et al. [25] for details regarding the
CFA model evaluation
Model fit indices indicated poor fit for a single factor structure with uncorrelated errors: df = 35, χ2/df = 131.51, GFI = 0.950, AGFI = 0.926, RMSEA = 0.083, SRMR = 0.051, CFI = 0.836 and TLI = 0.789. In an attempt to improve model fit, two pairs of error terms (e4–e10, e5–e8) were correlated based on modification indices and the CFA re-computed. The fit of this model was excellent with df = 33, χ2/df = 30.44, GFI = 0.989, AGFI = 0.982, RMSEA = 0.039, SRMR = 0.024, CFI = 0.965 and TLI = 0.952. This final model is
Discussion
The purpose of this study was to explore the psychometric properties, and validate the factor structure, of the CES-D-10. We found that a one-factor CFA model of the CES-D-10 was appropriate in healthy Australian and American elderly community dwelling people. Overall, the analysis suggested a satisfactory fit of the specified model to participant responses, indicating that the CES-D-10 is a psychometrically sound self-report depression scale suitable for use in an otherwise healthy elderly
Conclusion
Data from a healthy elderly population across Australia and the United States suggested enhanced construct validity and internal consistency of the CES-D-10, making the scale summary score a useful tool for assessing depressive symptoms in this population. CFA results indicated good model fit of a one-factor model in the overall sample, Australia and U.S. sub-samples and gender sub-groups. Although there are no a-priori assumptions on proposed potential correlations between Item 5 (‘hopeful’)
Acknowledgements
The authors acknowledge the efforts of research personnel and long term involvement of participants of the ASPREE Study. The study is supported by the National Institute on Aging and the National Cancer Institute at the National Institutes of Health (grant number U01AG029824); the National Health and Medical Research Council of Australia (grant numbers 334047, 1127060); Monash University (Australia); the Victorian Cancer Agency (Australia). MB is supported by a NHMRC Senior Principal Research
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
References (49)
- et al.
Age-and gender-specific prevalence of depression in latest-life–systematic review and meta-analysis
J Affect Disord
(2012) Association between physical activity and mental disorders among adults in the United States
Prev Med
(2003)- et al.
Treatment of depression in the elderly: a Canadian view
Prog Neuropsychopharmacol Biol Psychiatry
(1990) - et al.
Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale)
Am J Prev Med
(1994) - et al.
Factorial validity of the Center for Epidemiologic Studies Depression Scale short form in older population in China
Int Psychogeriatr
(2014) - et al.
Test of item-response bias in the CES-D scale: experience from the new haven EPESE study
J Clin Epidemiol
(2000) Prevalence and predictors of depression in populations of elderly: a review
Acta Psychiatr Scand
(2006)- et al.
Increased medical costs of a population-based sample of depressed elderly patients
Arch Gen Psychiatry
(2003) - et al.
Depression and comorbid medical illness: therapeutic and diagnostic challenges
J Fam Pract
(2003) The economic cost of serious mental illness and comorbidities in Australia and New Zealand Royal Australian and New Zealand College of Psychiatrists (RANZCP)
(2016)
The economic burden of depression in the United States: how did it change between 1990 and 2000
J Clin Psychiatry
The CES-D scale: a self-report depression scale for research in the general population
Appl Psychol Measur
Cross-validation of a short form of the CES-D in Chinese elderly
Int J Geriatr Psychiatry
Psychometrics for two short forms of the Center for Epidemiologic Studies-Depression Scale
Issues Ment Health Nurs
Screening for depression among first-visit psychiatric
Psychiatry Clin Neurosci
Screening for depression in the older adult: criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D)
Arch Intern Med
Two shorter forms of the CES-D depression symptoms index
J Aging Health
Factor structure of the 10-item CES-D scale among community dwelling older adults in Singapore
Int J Geriatr Psychiatry
Factorial structure of a short version of the Center for Epidemiologic Studies Depression Scale
Int J Geriatr Psychiatry
Validation of the 10-item Centre for Epidemiological Studies Depression Scale (CES-D-10) in Zulu, Xhosa and Afrikaans populations in South Africa
BMC Psychiatry
Measurement properties of the Center for Epidemiologic Studies Depression Scale (ces-d 10): findings from Hchs/sol
Psychol Assess
Factorial validity of the Center for Epidemiological Studies depression 10 in adolescents
Issues Ment Health Nurs
Factor analysis in counseling psychology research, training, and practice principles, advances, and applications
Couns Psychol
Confirmatory factor analysis and item response theory: two approaches for exploring measurement invariance
Psychol Bull
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- 1
Joint first authors.
- 2
ASPREE Investigator Group listed on www.aspree.org.