Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0158 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYCenter for Epidemiologic Studies Depression Scale:Use among Older AdultsDan G. BlazerDuke University Medical Center, Durham, NC, USAThe Center for Epidemiologic Studies Depression Scale (CES-D)is a depression screening instrument which has been appliedwidely in epidemiologic studies including many community-basedstudies of older adults 1–3 . The scale consists of 20 items which onfactor analysis among older adults fall into four different factors.The first factor is depressed affect, and items that load on thisfactor include: ‘‘bothered by things that usually don’t bother me’’,‘‘I could not shake the blues’’, ‘‘I felt depressed’’, ‘‘I felt lonely’’,‘‘I had crying spells’’ and ‘‘I felt sad’’. The second factor is positiveaffect and includes the items: ‘‘I felt as good as other people’’, ‘‘Ifelt hopeful about the future’’, ‘‘I thought my life had been afailure’’, ‘‘I was happy’’ and ‘‘I enjoyed life’’. The third factor issomatic complaints and includes the items: ‘‘I did not feel likeeating’’, ‘‘I had trouble keeping my mind on what I was doing’’,‘‘My sleep was restless’’, ‘‘I felt like everything was an effort’’, ‘‘Italked less than usual’’ and ‘‘I could not get going’’. The finalfactor is interpersonal relations and includes the items: ‘‘Peoplewere unfriendly’’ and ‘‘I felt that people disliked me’’. Each item israted on a 1–4 scale, depending on the frequency of symptoms theweek prior to the administration of the scale. Therefore, the rangeof answers is 0–60. A score of 16 or greater is consideredindicative of clinically significant depression 1 .Murrell et al. 4 found, when using the CES-D in a community ofover 2000 community-dwelling adults, 55 years of age and older inKentucky, that the mean score was 8.9 for African-Americans and9.2 for Whites. When they applied the cut-off noted above forclinically significant depressive symptoms, 12.8% of African-Americans and 13.7% of Whites had clinically significantdepression 4 . Berkman et al. 5 found that 16% of both African-Americans and Whites in an urban community scored above thethreshold for clinically significant symptoms. When controlvariables are taken into account, such as gender, socioeconomicstatus and functional health, the association of age and depressiondisappears (whereas in uncontrolled analysis there is a positiveassociation between age and depression) using the CES-D 6 .When using the CES-D in older adults, there is little differenceby gender and little difference by race/ethnicity 2 . In a crosssectionalanalysis, age is negatively associated with somaticcomplaints, lower education is associated with more complaintsof depressed affect and interpersonal problems, African-Americanrace is associated with increased interpersonal complaints andcognitive impairment associated with somatic complaints andinterpersonal complaints. Of all control factors, however, disabilityis most closely associated with all four of the factors notedabove.In summary, the CES-D is a useful screening scale fordepressive symptoms in community (and clinical) samples ofolder adults. The one drawback to this scale is that it requiresresponding along a spectrum of four responses (little or none,some of the time, most of the time, or all the time) over theprevious week compared to a simple yes–no format, as is found inother symptom screening scales. The scale has been usedextensively in older adults and therein lies its greatest value forfuture epidemiologic studies as well as clinical screening efforts.REFERENCES1. Radloff LS. The CES-D Scale: a self-report depression scale forresearch in general populations. Appl Psychol Meas 1977; 1: 385–401.2. Blazer DG, Landerman LR, Hays JC et al. Symptoms of depressionamong community-dwelling elderly African-American and White olderadults. Psychol Med 1998; 28: 1311–20.3. Kohout FJ, Berkman LF, Evans DA, Cornoni-Huntley J. Two shorterforms of the CES-D depression symptoms index. J Aging Health 1993;5: 179–93.4. Murrell SA, Himmelfarb S, Wright K. Prevalence of depression and itscorrelates in older adults. Am J Epidemiol 1983; 117: 173–85.5. Berkman LF, Berkman CS, Casl S et al. Depressive symptoms inrelation to physical health and functioning in the elderly. Am JEpidemiol 1986; 12: 372–88.6. Blazer D, Burchette B, Service CS, George LK. The association of ageand depression among the elderly: an epidemiologic exploration. JGerontol Med Sci 1991; 46: M210–15.