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RehabMeasures Instrument

Center for Epidemiological Studies Depression Scale (CES-D)

Purpose

The CES-D is a brief self-report measure that assesses symptoms of depression in the general population.

Link to Instrument

Instrument Details

Acronym CES-D

Area of Assessment

Depression

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Not Free

Cost Description

Available in:

Radloff, L. (1977). ""The CES-D Scale: A Self Report Depression Scale for Research in the General."" Applied psychological measurement 1(3): 385-401

Diagnosis/Conditions

  • Arthritis + Joint Conditions
  • Brain Injury
  • Cancer Rehabilitation
  • Spinal Cord Injury
  • Stroke Recovery

Key Descriptions

  • A 20-item, self-report measure designed to be used in the general population that assess current symptoms of depression (i.e. this week).
  • Items are based on symptoms associated with depression used in previously validated measures of depression.

Number of Items

20

Equipment Required

  • Pencil
  • Paper

Time to Administer

20 minutes

10-20 minutes

Required Training

No Training

Age Ranges

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

ICF Domain

Activity

Measurement Domain

Emotion

Considerations

  • 10 and 4 Item versions of the CES-D are available
  • The CES-D has been translated into a number of languages
  • The CES-D requires a 6th grade reading level
  • A children's version is also available

Chronic Stroke: (Agrell & Dehlin, 1989)  

Some items contained in the CES-D did not significantly correlate with the sum of the measures score, these include:

  • I felt fearful
  • People were unfriendly
  • I felt that people disliked me

 

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Non-Specific Patient Population

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Standard Error of Measurement (SEM)

Hepatitis C population: (Clark et al, 2002; n = 116; median age = 46 (range = 27–63) years)

CES-D scores pre and post-treatment:

Assessment

Mean

SEM*

95% CI

Pre-treatment

13.974

0.907

12.177–15.771

4 weeks post

19.543

0.977

17.607–21.479

24 weeks post

19.966

1.053

17.880–22.051

*SEM = Standard Error of the Mean

 

Cut-Off Scores

Original Validation Study: (Radloff 1977; General population)

  • The standard cut-off score suggesting depression > 16 (Sensitivity = 0.95, Specificity = 0.29)

General Population: (Wada et al 2006, n = 2219; age 21–68 years; used to assess depression in the workplace; Japanese sample)

  • Cut-off suggested for Japanese general population > 19 points (Sensitivity = 92.7%, Specificity = 91.8%)

Test/Retest Reliability

Original Validation Study: (Radloff, 1977):

 

Original Test-Retest by Time and Mode of Administration Indicating Depression:

By mail (Completed by participant):

Time Interval

n

Strength

r (between administrations)

2 Week

139

Adequate

0.51

4 Weeks

105

Adequate

0.67

6 Weeks

97

Adequate

0.59

8 Weeks

78

Adequate

0.59

Total

419

Adequate

0.57

Reinterview:

Time Interval

n

Strength

r (between administrations)

3 Months

378

Adequate

0.48

6 Months

349

Adequate

0.54

12 Months

472

Adequate

0.49

 

Psychiatric Patients: (Roberts et al, 1989; n = 562, study designed to assess possible language and/or cultural differences between groups when assessed with the CES-D)

CES-D Test Re-test Reliabilities for the CES-D Scale by Ethnic/Language Group and Time Interval between Interviews

 

1 to 7 day Test-retest Interval

> 7 day Test-retest Interval

Group

Strength

Reliability

n

Strength

Reliability

n

Anglo

Adequate

.741

51

Adequate

.781

28

Hispanic English / English

Adequate

.764

13

Poor

.627

9

Hispanic Spanish / Spanish

Poor

.497

19

Adequate

.797

7

Hispanic English / Spanish

Adequate

.711

27

Poor

.432

21

Hispanic Spanish / English

Poor

.608

24

Excellent

.835

15

Construct Validity

Hepatitis C Population: (Clark et al, 2002) Four factors were found, they include:

  • Negative affect
  • Positive affect
  • Somatic
  • Depressed affect/somatic

Content Validity

Original Validation Study: (Radloff, 1977): Symptoms of depression were identified from both clinical literature and factor analytic studies.  Components of the measure include:

  • Depressed mood

  • Feelings of guilt and worthlessness

  • Feelings of helplessness and hopelessness

  • Psychomotor retardation

  • Loss of appetite

  • Sleep disturbance

Meta-analysis of Depression Scales: (Shafe, 2006; n = 91 studies with 51,210 participants)

Common Factors Across Measures of Depression:

 

CES-D

BDI

HRSD

Zung

General Depression

Depressed affect

Negative attitude toward self

Depression

Negative symptoms

Somatic Symptoms

Somatic

Somatic

Somatic

Somatic

Positive Symptoms

Positive affect

 

 

Positive symptoms

CES-D = Center for Epidemiological Studies Depression Scale
BDI = Beck Depression Inventory
HRSD = Hamilton Rating Scale for Depression
Zung = Zung Self-Rating Depression Scale

Two items were more likely to be endorse by African American than white Participants

  • People are unfriendly
  • People dislike me


One item was more Likely to be endorsed by Female than male participants

  • Crying spells

Face Validity

Not statistically assessed

Responsiveness

Rhinitis (Chen, 2005; n = 109; mean age = 40 (8.2) years; assessed at baseline and 24 months.

  • Baseline CES-D mean (SD) = 10.5 (10)
  • 24 month follow-up CESD 11.5 (9.9)
  • Observed change* = 1.0 (1.3)
  •  Standardized Response Mean (SRM)** = 0.09 (Moderate)

*(score at followup) - (score at baseline)
**(score at follow-up) - (score at baseline)/(SD of observed change)

Stroke

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Cut-Off Scores

 

Chronic Stroke: (Agrell & Dehlin, 1989)

CES-D Cut-off Scores, Sensitivity & Specificity; A Comparison Across Measures Indicating Depression

 

Recommended cut-score

Sensitivity (%)

Specificity (%)

CES-D

20

56

91

GDS

10

88

64

Zung

45

76

96

CES-D = Center for Epidemiologic Studies Depression Scale
GDS = Geriatric Depression Scale

Internal Consistency

Chronic Stroke: (Agrell & Dehlin, 1989; n = 39; mean age = 80 (range 61-93) years; mean time since stroke onset = 14 months)

Poor internal consistency; (Cronbach’s alpha = 0.64)

Criterion Validity (Predictive/Concurrent)

Chronic Stroke: (Agrell & Dehlin, 1989)

  • Excellent: CES-D and the Zung (r = 0.81)
  • Excellent: CES-D and the Geriatric Depression Scale (r = 0.82)

Construct Validity

Acute Stroke: (Shinar et al, 1986; n = 27; median age = 56 (range = 28 to 73) years, all participants non-aphasic; first assessed 7 to 10 days post stroke)

CES-D Administered by a Nurse and Psychiatric Research Assistant

Measure:

Strength

r

p

Psychiatric diagnosis, DSM-III

Excellent

0.77*

p < .0001

Zung depression scale

Excellent

0.65

p < .002

Hamilton depression test

Adequate

0.57

p < .002

Present state exam

Excellent

0.74

p < .0001

*Spearman's rho

 
 

Cancer

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Test/Retest Reliability

 

Cancer Patients: (Hann et al, 1999; n = 117; mean age = 53.7 (12.4) years; healthy comparison n = 62, mean age = 53.5 (11.3) years)

 

CES-D test re-test scores of Cancer patients and healthy comparisons

Interval

Patient Group*

Healthy Comparison*

Sig

Time 1

10.9 (8.9)

8.1 (7.0)

p < 0.05

Time 2 (2–3 weeks later)

12.8 (10.2)

7.8 (7.5)

p< 0.001

*Mean (SD)

Older Adults and Geriatric Care

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Interrater/Intrarater Reliability

Community Dwelling Elderly Women: (Bassett et al, 1990; n = 532; mean age = 75 years)

  • Adequate Inter-rater reliability (r = .597, p < .001)

 

Content Validity

Elderly: (Cole et al, 2000; n = 2340; sample all > 65 years old; mean CES-D scale score = 8)

Orthopedic Surgery

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Normative Data

Orthopaedic & Neurological Patients: (Caracciolo & Giaquinto, 2002; n = 101 orthopaedic and 50 neurological patients)

 

CES-D and Other Common Measures of Impairment Across Diagnostic Categories:

 

Orthopaedic Patients

Neurological Patients

Measures

1st Q

Median

3rd Q

1st Q

Median

3rd Q

CES-D

9

15

24

14

18.5

29

MMSE

25

27

28

23.2

25.6

27.9

CIRS-SI

1.1

1.2

1.3

1.2

1.3

1.5

FIM

72

81

103

65

85

99

Ham-D

5

8

13

6

12.5

18

Age (years)

61

70

77

50

67

73

1st Q = first quartile
3rd Q = third quartile

CES-D = Center for Epidemiological Studies-Depression scale
MMSE = Mini Mental State Examination
CIRS-SI = Cumulative Illness Rating Scale
FIM = Functional Independence Measure
Ham-D = Hamilton rating scale for Depression

Criterion Validity (Predictive/Concurrent)

Orthopaedic & Neurological Patients: (Caracciolo & Giaquinto, 2002

  • Excellent correlation between CES-D and Ham-D suggesting concurrent validity (r > 0.60)

Spinal Injuries

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Normative Data

Chronic SCI: (Miller et al, 2008; n = 55; mean age = 40.6 (12.6) years; ASIA A = 62%, ASIA B = 38%; mean time since injury = 15.2 (11.7) years)

  • Mean CES-D scores = 15.2 (range 0–42)
    • 30% scored over 19 points
    • 39% scored over 15 points

Test/Retest Reliability

Chronic SCI: (Miller et al, 2008, 2 weeks between assessments)

  • Excellent total score test–retest reliability (ICC = 0.87; 95% C.I. 0.79–0.93)

Internal Consistency

Chronic SCI: (Miller et al, 2008)

  • Excellent internal consistency (Cronbach’s alpha = 0.91)

Construct Validity

Chronic SCI: (Miller et al, 2008)

 

CES-D, VAS-F and SF-36 Correlations:

Measure

Strength

CES-D

VAS-F

Adequate

0.52

SF-36 mental health

Excellent

0.75*

SF-36 emotional role function

Adequate

0.55*

SF-36 vitality

Adequate

0.54*

SF-36 pain

Poor

0.27*

SF-36 social role function

Adequate

0.37*

SF-36 physical function

Adequate

0.34*

SF-36 physical role function

Adequate

0.40*

SF-36 general health

Adequate

0.57*

VAS-F = visual analogue scale of fatigue.
*P < 0.05

 

Chronic SCI: (Anton et al, 2008; n = 48 (ASIA A = 30, ASIA B = 18); mean time since injury = 14.9 years)

 

Correlation Between the FSS, CES-D, VAS-F and SF-36:

Variable

FSS

p

CES-D

0.58

.001

VAS-F

0.67

.000

SF-36 vitality score

- 0.48

.010

FSS = Fatigue Severity Scale
VAS-F = Visual Analog Scale for Fatigue
SF-36 = Medical Outcomes Study 36-Item Short-Form Health Survey

 

Floor/Ceiling Effects

Chronic SCI: (Miller et al, 2008)

—Less than 15% of participants scored at one extreme or the another suggesting minimal to no floor or ceiling effect

Bibliography

Agrell, B. and Dehlin, O. (1989). "Comparison of six depression rating scales in geriatric stroke patients." Stroke 20(9): 1190-1194. Find it on PubMed

Anton, H. A., Miller, W. C., et al. (2008). "Measuring fatigue in persons with spinal cord injury." Arch Phys Med Rehabil 89(3): 538-542. Find it on PubMed

Bassett, S. S., Magaziner, J., et al. (1990). "Reliability of proxy response on mental health indices for aged, community-dwelling women." Psychol Aging 5(1): 127-132. Find it on PubMed

Caracciolo, B. and Giaquinto, S. (2002). "Criterion validity of the center for epidemiological studies depression (CES-D) scale in a sample of rehabilitation inpatients." J Rehabil Med 34(5): 221-225. Find it on PubMed

Chen, H., Katz, P., et al. (2005). "Evaluating change in health-related quality of life in adult rhinitis: Responsiveness of the Rhinosinusitis Disability Index." Health and Quality of Life Outcomes 3(1): 68. Find it on PubMed

Clark, C. H., Mahoney, J. S., et al. (2002). "Screening for depression in a hepatitis C population: the reliability and validity of the Center for Epidemiologic Studies Depression Scale (CES-D)." J Adv Nurs 40(3): 361-369. Find it on PubMed

Cole, S., Kawachi, I., et al. (2000). "Test of item-response bias in the CES-D scale: experience from the New Haven EPESE study." Journal of Clinical Epidemiology 53(3): 285-289. Find it on PubMed

Hann, D., Winter, K., et al. (1999). "Measurement of depressive symptoms in cancer patients: evaluation of the Center for Epidemiological Studies Depression Scale (CES-D)." J Psychosom Res 46(5): 437-443. Find it on PubMed

Miller, W. C., Anton, H. A., et al. (2008). "Measurement properties of the CESD scale among individuals with spinal cord injury." Spinal Cord 46(4): 287-292. Find it on PubMed

Radloff, L. (1977). "The CES-D Scale: A Self Report Depression Scale for Research in the General." Applied psychological measurement 1(3): 385-401.

Roberts, R. E., Vernon, S. W., et al. (1989). "Effects of language and ethnic status on reliability and validity of the Center for Epidemiologic Studies-Depression Scale with psychiatric patients." J Nerv Ment Dis 177(10): 581-592. Find it on PubMed

Shafer, A. (2006). "Meta analysis of the factor structures of four depression questionnaires: Beck, CES D, Hamilton, and Zung." Journal of Clinical Psychology 62(1): 123-146. Find it on PubMed

Shinar, D., Gross, C. R., et al. (1986). "Screening for depression in stroke patients: the reliability and validity of the Center for Epidemiologic Studies Depression Scale." Stroke 17(2): 241-245. Find it on PubMed

Wada, K., Tanaka, K., et al. (2007). "Validity of the Center for Epidemiologic Studies Depression Scale as a screening instrument of major depressive disorder among Japanese workers." American journal of industrial medicine 50(1): 8-12. Find it on PubMed

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