factor structure and psychometric - CiteSeerX

INT’L. J. AGING AND HUMAN DEVELOPMENT, Vol. 72(2) 83-110, 2011

FACTOR STRUCTURE AND PSYCHOMETRICPROPERTIES OF THE CENTER FOR EPIDEMIOLOGICSTUDIES DEPRESSION SCALE (CES-D) IN OLDERPOPULATIONS WITH AND WITHOUT COGNITIVEIMPAIRMENT

L. ROS J. P. SERRANO

J. M. LATORRE B. NAVARRO

M. J. AGUILAR J. J. RICARTE

University of Castilla La Mancha, Spain

ABSTRACT

The CES-D is widely used for the assessment of depressive symptoms in

the adult population. However, few studies have been performed to assess the

utility of this scale in an older population with cognitive impairment. The

factor structure of the Spanish version of the CES-D was examined in an

observational, cross sectional study in 623 older adults (M = 72.74 years;

SD = 7.7). The validity of the scale was determined in two samples of

older adults, one comprising 162 participants with cognitive impairment

(M = 76.73 years; SD = 8.1) and one with 58 participants without cognitive

impairment (M = 74.64 years; SD = 9.0). The results confirm previous results

of a four factor structure. With regard to the validity of the scale, in the group

with cognitive impairment the area under the ROC curve is 0.84 (95%

CI: 0.77-0.89) and the cut-off point for possible depression is 13, while in the

group without cognitive impairment the area is 0.90 (95% CI: 0.79-0.96)

and the optimal cut-off point is 28. These results show that the Spanish

version of the CES-D is a valid instrument for the identification of depres-

sion in older adults with and without cognitive impairment.

83

� 2011, Baywood Publishing Co., Inc.doi: 10.2190/AG.72.2.ahttp://baywood.com

The Center for Epidemiological Studies-Depression Scale (CES-D; Radloff,

1977) is one of the most widely used self-report scales for depressive symptoms.

This scale was originally designed for use with the general adult population and,

although originally Radloff designed it to be used for scientific ends and not

for clinical purposes, it is currently one of the most commonly used screening

instruments in primary care practice (Schulberg, Saul, McClelland, Ganguli,

Christy, & Frank, 1985; Williams, Pignone, Ramirez, & Perez, 2002).

The aim of this scale is to measure the subject’s mood state based on the

frequency he or she experienced certain depressive symptoms in the past week.

Furthermore, it may be used to assess changes in a person’s mood state over time.

The scale is made up of 20 items that cover areas such as depressed mood, feelings

of guilt and worthlessness, feelings of helplessness and hopelessness, loss of

energy, sleep disturbance and loss of appetite. Radloff (1977) selected these

items from a sample of several previously validated depression scales such as the

Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh,

1961), Zung’s Self-rating Depression Scale (Zung, 1965), or the Minnesota

Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943). The

responses to each of the 20 items are scored on a 4-point Likert-type scale ranging

from “rarely or none of the time” (0) to “most or all of the time” (3). Four of

the items are formulated to have a positive slant to evaluate positive mood and

to break tendencies toward a response set. The total score ranges from 0 to 60

with the higher scores indicating more symptoms of depression. A score of 16

or more has been widely used as the cut-off point for clinically significant

depressive symptomatology (Radloff & Teri, 1986).

With regard to reliability, Radloff (1977) found that the mean correlation

between test-retest scores after 2, 4, 6, and 8 weeks was 0.57; and the test-retest

correlations after 3, 6, and 12 months ranged from 0.32 to 0.54. Subsequently,

several studies have corroborated the opinion that the CES-D is a highly

reliable measurement instrument (Orme, Reis, & Herz, 1986; Roberts, Andrews,

Lewinsohn, & Hops, 1990).

The first validation studies confirmed that the CES-D correlates well with

clinical ratings of depression (Roberts & Vernon, 1983; Weissman, 1987). Since

these initial studies, the CES-D has been widely used as a screening tool in

different populations such as clinical patients, adolescents, older adults, workers,

etc. (e.g. Bay, Hagerty, Williams, Kirsch, & Gillespie, 2002; Chwastiak, Ehde,

Gibbons, Sullivan, Bowen, & Kraft, 2002; Furukawa, Hirai, Kitamura, &

Takahashi, 1997; Grant, Gil, Floyd, & Abrams, 2000; Iwata, Okuyama,

Kawakami, & Saito, 1989; Lee, Stewart, Byrne, Wong, Ho, Lee, et al., 2008;

Liang, Tran, Krause, & Markides, 1989; McArdle, Johnson, Hishinuma,

Miyamoto, & Andrade, 2001; Orme et al., 1986; Paterniti, Niedhammer, Lang,

& Consoli, 2002; Radloff, 1991; Vedhara, Schifitto, & McDermott, 1999;

Verdier-Taillefer, Gourlet, Fuhrer, & Alperovitch, 2001; Yang, Soong, Kuo,

Chang, & Chen, 2004).

84 / ROS ET AL.

According to Radloff and Teri (1986), the CES-D is highly reliable, has a

stable factor structure and age, and demographic variables and physical health

do not significantly affect scores and factors. In this respect, a subsequent study

by Lewinsohn, Seeley, Roberts, and Allen (1997) concluded that the utility of

the CES-D was not degraded by age, physical disease, cognitive, or functional

impairment. O’Rourke (2004) also found that CES-D responses do not vary

depending on the subject’s sex.

Factorial Structure of the CES-D

Radloff (1977) was the first to investigate and identify the factorial structure

of the CES-D through principal component analysis with a varimax rotation. In

her study she found four principal factors that accounted for 48% of the variance:

depressed mood (7 items, e.g., “I thought my life had been a failure”); positive

mood (4 reverse-coded items; e.g., “I felt hopeful about the future”); somatic

symptoms and psychomotor retardation (7 items, e.g., “I did not feel like eating;

my appetite was poor”); and interpersonal difficulties (2 items, e.g., “I felt

that people dislike me”). The original validation study included an adult popu-

lation who were predominantly White and with a certain level of education. The

depressed mood factor accounted for the highest percentage of variation (16%)

and interpersonal factor accounted for the lowest percentage of variance (8%).

Furthermore, Radloff also generated standard data for subgroups of age (less

than 25, 25-64, and over 64 years) for men and women, for African-Americans

and White Americans and for different education levels (primary, secondary,

higher). The exploratory factor analyses indicated that the factorial structure did

not differ among these subgroups, or from the standard generated for the whole

of the sample population.

Since this initial study, the factorial structure of the CES-D has been examined

using many different population samples including age, ethnic group, language,

and geographical characteristics in the general population, as well as patients

with different diseases. Many of these studies have confirmed the validity of the

four factors found by Radloff (1977), although there are some others that have

found different factor structures (see Table 1).

Nevertheless, despite the diversity of results, a systematic review recently

performed by Shafer (2006) found that the four factor structure originally

described by Radloff (1977) is the most common structure and that it is robust

across different patient groups.

Finally, a higher order factor has not always been examined using con-

firmatory factor analysis methodology. However, in general, where it has

been examined a higher order factor has emerged (e.g., Hertzog, Van Alstine,

Usala, Hultsch, & Dixon, 1990; O’Rourke, 2003; Sheehan, Fifield, Reisine, &

Tennen, 1995).

STRUCTURE AND PSYCHOMETRY OF CES-D / 85

Tab

le1.

Stu

die

sE

xam

inin

gth

eFa

ctor

ialS

truc

ture

ofth

eC

ES

-D

Stu

dy

Sam

ple

Fact

orst

ruct

ure

Bus

h,N

ovac

k,S

chne

ider

,&

Mad

an(2

004)

Cla

rk,A

nesh

ense

l,Fr

eric

hs,

&M

org

an(1

981)

Fole

y,R

eed

,Mut

ran,

&D

eVel

lis(2

002)

Gol

ub,L

atke

,Hag

an,H

aven

s,H

udso

n,K

apad

ia,e

tal.

(200

4)

Gua

rnac

cia,

Ang

el,&

Wor

obey

(198

9)

Her

tzog

,Van

Als

tine,

Usa

la,

Hul

tsch

,&D

ixon

(199

0)

Jone

s-W

ebb

&S

now

den

(199

3)

253

pat

ient

sw

ithTB

I(7

1.1%

mal

es)

1000

urb

anad

ults

(41.

2%m

ales

)

227

old

erA

fric

anA

mer

ican

s(2

5%m

ales

)

193

hep

atiti

sC

viru

s-in

fect

edin

ject

ion

dru

gus

ers

(75.

6%m

ales

)

5191

Latin

o-A

mer

ican

adul

ts(4

2.5%

mal

es)

707

adul

ts

414

Bla

ckad

ults

and

292

Whi

tead

ults

(28%

mal

es)

Four

-fact

orst

ruct

ure:

1)so

me

dys

pho

ricaf

fect

and

som

atic

/red

uced

activ

ityite

ms;

2)so

me

dys

pho

ricaf

fect

and

inte

rper

sona

lite

ms;

3)p

ositi

veaf

fect

item

s;an

d4)

som

eso

mat

ic/r

educ

edac

tivity

item

s.

Con

firm

edth

efo

ur-fa

ctor

stru

ctur

ep

rop

osed

by

Rad

loff

(197

7).

Con

firm

edth

efo

ur-fa

ctor

stru

ctur

ep

rop

osed

by

Rad

loff

(197

7).

Two

fact

orst

ruct

ure:

1)ne

gat

ive

affe

ct/d

epre

ssed

affe

ct/s

omat

ic;a

nd2)

pos

itive

affe

ct.

Thre

e-fa

ctor

stru

ctur

e:1)

affe

ct/s

omat

ic;2

)in

terp

erso

nal;

and

3)p

ositi

veaf

fect

.36.

Con

firm

edth

efo

ur-fa

ctor

stru

ctur

ep

rop

osed

by

Rad

loff

(197

7).

Con

firm

edth

efo

ur-fa

ctor

stru

ctur

ep

rop

osed

by

Rad

loff

(197

7).

86 / ROS ET AL.

McC

aule

y,P

edro

za,B

row

n,B

oake

,Lev

in,G

ood

man

,eta

l.(2

006)

Mill

er,M

arki

des

,&B

lack

(199

7)

Ng

uyen

,Kitn

er-T

riolo

,E

vans

,&Z

ond

erm

an(2

004)

Pos

ner,

Ste

war

t,M

arin

,&P

erez

-Sta

ble

(200

1)

Rob

erts

,Ver

non,

&R

hoad

es(1

989)

Thom

as&

Bra

ntle

y(2

004)

Thom

bs,

Hud

son,

Sch

ieir,

Taill

efer

,&B

aron

(200

8)

Thor

son

&P

owel

l(19

93)

340

pat

ient

sw

ithTB

I(70

.9%

mal

es)

2866

old

erM

exic

anA

mer

ican

s

426

low

soci

oeco

nom

icst

atus

Afr

ican

Am

eric

ans

1403

urb

anLa

tino

par

ticip

ants

(62%

mal

es)

562

psy

chia

tric

pat

ient

s

179

low

inco

me

wom

en

470

pat

ient

sw

ithsy

stem

icsc

lero

sis

(86%

fem

ales

)

400

adul

ts(4

9.8%

mal

es)

Con

firm

edth

efo

ur-fa

ctor

stru

ctur

ep

rop

osed

by

Rad

loff

(197

7).

Two

fact

orst

ruct

ure:

1)ne

gat

ive

affe

ct;a

nd2)

pos

itive

affe

ct

Con

firm

edth

efo

ur-fa

ctor

stru

ctur

ep

rop

osed

by

Rad

loff

(197

7).

Four

-fact

orm

odel

pro

pos

edb

yR

adlo

ff(1

977)

pro

vid

ead

equa

tefit

toth

ed

ata

for

Latin

aw

omen

but

notf

itth

ed

ata

for

Latin

om

en.

Con

firm

edth

efo

ur-fa

ctor

stru

ctur

ep

rop

osed

by

Rad

loff

(197

7).

Thre

e-fa

ctor

stru

ctur

e:1)

dep

ress

edaf

fect

/som

atic

sym

pto

ms;

2)p

ositi

veaf

fect

;and

3)in

terp

erso

nal

diff

icul

ties

Con

firm

edth

efo

ur-fa

ctor

stru

ctur

ep

rop

osed

by

Rad

loff

(197

7).

Five

-fact

orm

odel

:1)

dep

ress

edaf

fect

;2)

som

atic

;3)

inte

rper

sona

l;4)

pos

itive

affe

ct;a

nd5)

self-

wor

th.


Use of the CES-D in Older Adults

The CES-D has also been widely used in older adults. It has been determined

that older adults have no difficulty in understanding and following the CES-D

instructions and that its sensitivity and specificity in older adults are comparable

to those in younger adults (Radloff & Teri, 1986). In this respect, a systematic

review by Watson and Pignone (2003) reveals that the CES-D is a useful, valid

screening tool for the detection of non-diagnosed depression in older adults in a

primary care setting. The findings of various studies are along the same lines

(Spijker, van der Wurff, Poort, Smits, Verhoeff, & Beekman, 2004, with elderly

migrants from Turkey and Morocco; Foley, Reed, Mutran, & DeVellis, 2002, with

older African-Americans). In general, the internal consistency of the CES-D is

considered acceptable for both community and clinical samples (e.g., Cronbach’s

� = 0.85 to 0.91; Himmelfarb & Murrell, 1983). In view of this, although the

CES-D was originally developed and validated for a general adult population, it

appears to be appropriate for use in older adult populations.

These good indices also apply to the different adaptations of this scale. For

example, Reyes-Ortega et al. (2003) developed a Hispanic version of the CES-D

in Mexico for use in older adults. They administered the scale to 288 persons

aged over 60 years. A noteworthy result is the scale’s high internal consistency

(Cronbach’s � = 0.90), with no differences between gender and age groups. In

a CES-D validation study among older adults in Brazil, Batistoni, Neri, and

Cupertino (2007) also found good internal validity (Cronbach’s � = 0.86). The

results indicated acceptable sensitivity and specificity (74.6% and 73.6%,

respectively) with a cut-off point of > 11, but with the drawback of having a

high rate of false negatives.

Beekman et al. (1997) studied the criterion validity of the CES-D in a sample of

older adults in the Netherlands using a cut-off point of 16 or over and found very

satisfactory sensitivity and specificity (100% and 88%, respectively). However,

these authors also found that in patients with physical diseases, cognitive impair-

ment, or anxiety, this cut-off point results in high false positive rates. In view of

this and given the prevalence of chronic diseases in this type of population, several

studies have determined that, depending on the context, cut-off points of between

20 and 27 could be recommended (Himmelfarb & Murrell, 1983; Schulberg et al.,

1985; Zich, Atkinson, & Greenfield, 1990). For example, Harringsma, Engels,

Beekman, and Spinhoven (2004) evaluated the validity of the CES-D within the

framework of a depression prevention program in Holland. These authors con-

cluded that the scale’s criterion validity was satisfactory as a screening tool,

setting a score of 25 as the cut-off point for the diagnosis of clinical depression in

persons with psychopathological comorbidity and a history of depressive episodes.

With respect to the CES-D factorial structure in older adults, we found that

the original four-factor structure proposed by Radloff (1977) is repeatedly used.

In the study by Hertzog et al. (1990), the responses of the older adults to the

88 / ROS ET AL.

CES-D items reflect a complex four-factor structure, each of which significantly

contributes to a higher order depression construct. Several studies have replicated

this factorial structure in different types of geriatric populations (Foley et al.,

2002; Jones-Webb & Snowden, 1993; O’Rourke, 2003). However, the explora-

tory factor analysis performed in the study by Batistoni et al. (2007) revealed only

three factors: negative affect, problem initiating behavior, and positive affect.

Spanish Version of the CES-D

In 2001, Mui, Burnett, and Chen published a review in which they analyzed

the utility and psychometric properties of the CES-D. They confirmed its value as

a diagnostic tool for depression in older persons of diverse cultures. Some authors

have suggested that there is a need for validating a CES-D for each cultural group

(Gupta & Yick, 2001; Mui, Burnett, & Chen, 2001; Riddle, Blais, & Hess, 2002).

Latorre and Montañés (1997) used their first Spanish version of the CES-D

in a sample of 230 adults aged over 60 years in Spain. They used the cut-off

point of 16 originally proposed by Radloff (1977). Using exploratory factorial

analysis they identified four factors in their version, which coincided with the

factorial structure proposed by Radloff (1977). They found that these four factors

accounted for 60.8% of the scale’s variance.

Subsequently, the study by Zunzunegui et al. (1998) also attempted to validate

the CES-D scale in older adults in Spain. These authors used the version of the

scale developed for the HHANES, a study on depressive symptoms in a Mexican

American population (Moscicki, Locke, Rae, & Boyd, 1989). Zunzunegui et al.

studied a sample of 98 adults aged over 65 years (4 of whom had major depres-

sion and 13 had dysthymia). Their results revealed that the CES-D had

good internal consistency (Cronbach’s � = 0.89) and, with a cut-off point of

16 or over, the scale had 100% sensitivity and 73% specificity for the diagnosis

of major depression.

This study has two main objectives. First, we aim to determine the internal

consistency and reliability of the CES-D in a sample of older adults much larger

than that of Latorre and Montañés (1997) and of Zunzunegui et al. (1998). We will

also examine the factorial structure of the scale in this type of sample using

structural equation models.

Secondly, we will assess the diagnostic validity of the CES-D in two different

populations of Spanish older adults. The first is a group of older adults without

cognitive impairment. As in previous studies (Himmelfarb & Murrell, 1983;

Schulberg et al., 1985; Zich et al., 1990), we expect the recommended cut-off

point to be higher than the conventionally used one of 16. The second sample

is a group of older adults with mild cognitive impairment. As we have already

seen, the CES-D is recommended for assessing depressive symptoms in old age

(Himmelfarb & Murrell, 1983; Lewinsohn et al., 1997; Radloff & Teri, 1986);

however, it has been rarely examined in older persons with cognitive impairment.


To our knowledge, the only study in this respect is that of Lewinsohn et al. (1997).

These authors found that in a sample of older adults with cognitive impairment a

cut-off point of 12 maximized the scale’s sensitivity and specificity, clearly lower

than the score of 20 suggested by other investigators for an older population

(Himmelfarb & Murrell, 1983; Lyness, Noel, Cox, King, Conwell, & Caine,

1997). In view of this, we aim to evaluate the diagnostic validity of the CES-D

in a sample of older adults with mild cognitive impairment and to determine the

most appropriate cut-off point for this type of population.

METHOD

Participants

The voluntary participants were recruited from six community centers for

older adults in Albacete, Spain (two cultural centers, one social service center,

two centers for retired people, and the geriatric department of a hospital in

Albacete). A total of 623 persons aged over 65 years participated in the study.

The mean age was 72.74 (SD = 7.7), 60% were women and 42.2% had mild

cognitive impairment. As regards educational level, 35.3% of the participants

could read and write at some level but did not attend any school, 46.1% had

completed primary education attending a school (6 years of schooling), 9.3%

secondary education, and 9.3% higher education. The entire sample was assessed

by the five clinical psychologists participating in the study.

For the determination of the diagnostic validity of the CES-D in older adults

with and without cognitive impairment, all the participants came from the geriatric

department of a hospital in Albacete (CHUAB). These participants had been

diagnosed using the Composite International Diagnostic Interview (WHO-CIDI,

2001). The Mini Examen Cognitivo (MEC; Lobo, Ezquerra, Gómez-Burgada,

Sala, & Seva-Diaz, 1979) was used to assess the level of cognitive impairment.

The sample of older adults without cognitive impairment consisted of 58 persons

aged over 65 years (22 had major depression disorder (MDD) and 36 did not).

The mean age of the non-depressed group was 73.31 (SD = 8.0) and 38.9%

were women. As regards educational level, 36.1% of the subjects could read and

write without attending any school, 47.2% had completed primary education,

5.6% had completed secondary education, and 11.1% had completed higher

education. The mean age of the MDD group was 76.82 (SD = 9.8) and 86.4%

were women. Lastly, the educational level of this group was as follows: 63.7%

could read and write without attending any school and 36.4% had completed

primary education.

The sample of older adults with mild or incipient cognitive impairment com-

prised 162 persons aged over 65 years (82 participants with MDD and 80 without

MDD). The mean age in the non-depressed group was 77.01 (SD = 7.9) and

53.8% were women. As regards educational level, 48.7% of the subjects could

90 / ROS ET AL.

read and write without attending any school, 41.3% had completed primary

education, and 10% had completed secondary education. The mean age of the

MDD group was 76.45 (SD = 8.2) and 69.5% were women. Lastly, the educational

level of this group was as follows: 58.5% could read and write without attending

any school and 40.3% had completed primary education and 1.2% had completed

secondary education.

Instruments

Center for Epidemiological Studies-

Depression Scale (CES-D; Radloff, 1977)

The Spanish version of the CES-D developed by Latorre and Montañés (1997)

was used in this study. Two forward and two back translations of the original

CES-D were performed to develop the Spanish CES-D, stressing conceptual and

linguistic equivalence. Two bilingual primary care doctors were asked to translate

the CES-D from English into Spanish. Then, two different doctors translated it

back into English and a public translator compared the original version against the

translated ones. All translators were blind to the translation of the others. Small

semantic differences were discussed and agreed upon to obtain the final version

(see Appendix 1).

Mini Examen Cognitivo

(MEC; Lobo et al., 1979)

The MEC is a screening instrument widely used for the detection of cognitive

impairment. It is made up of 35 items that assess the following cognitive func-

tions: time and space orientation, attention, mental arithmetic, immediate verbal

recall, short-term deferred verbal recall, verbal working memory, abstract verbal

reasoning, language, and visoconstructive praxis. It takes about 10–15 minutes

and it is routinely used in both clinical practice and in research studies.

The MEC is based on the Mini Mental State Examination (MMSE; Folstein,

Folstein, & McHugh, 1975) and has been adapted and validated in Spain by

Lobo et al. (1979), with some differences with respect to the original. In both

clinical samples and the general population, the MEC has demonstrated satis-

factory validity, reliability, and discriminative power with an 82% specificity

and an 84.6% sensitivity increasing to 92.3% and 95.2%, respectively, in geriatric

patients. In a revalidation and standardization study in a population of adults over

65 years, it was found that if a cut off score of 23–24 points is used, the MEC has

a sensitivity of 89% and a specificity of 83.9% (Lobo, Saz, Marcos, Dia, De La,

Ventura, et al., 1999). In a population under 65 years, a cut off point of 27 or

more is established for the diagnosis of cognitive impairment (Lobo et al., 1979).


Composite International Diagnostic Interview

(CIDI; WHO-CIDI, 2001)

The CIDI is a series of structured interviews designed to assess different mental

disorders and addictions according to the diagnostic criteria of DSM-IV and

the ICD-10. It allows the investigator to assign a clinical diagnosis. All the

questions in each of the interviews follow a simple Yes/No response format.

The subject’s responses do not need to be weighed up by the interviewer and this

provides for high test-retest reliability and good internal reliability (Cottler,

Robins, Grant, Blaine, Towle, Wittchen, et al., 1991; Wittchen, 1994; Wittchen,

Robins, Cottler, Sartorius, Burke, Regier, et al., 1991).

For our study we used the structured interview for Major Depression, evalu-

ating nine symptoms:

1. depressed mood state;

2. loss of interest;

3. energy loss/increase;

4. appetite/weight loss/gain (more or less than 2.5 kg);

5. sleep problems;

6. psychomotor problems/listless-agitated;

7. guilt feelings or lack of self-esteem;

8. concentration difficulties; and

9. thoughts about death.

The subjects answered No (1) or Yes (2) to each of the questions. Some symptoms

only have one question and others two or more questions. An affirmative response

to just one of the questions on a symptom is taken to mean that such symptom is

present. If five or more of the nine symptoms are present, then the subject has

Major Depressive Disorder (MDD).

Procedure

Patients from all sites provided informed consent, and the research ethics board

of each study site approved the data collection protocol. Before starting a session,

participants gave consent, received an explanation of the study, provided basic

demographic data, and completed the MEC and CES-D scales. The interviews

were individually administered on a session by five psychologists blind to the

purpose of the study. Participants were told that the study was investigating

the mood state and that the interviews were designed to recruit emotions and

feelings related with the mood.

RESULTS

The frequency distributions of the CES-D scale items indicated that the entire

range of response options were employed for each item with only six items (item 1,

92 / ROS ET AL.

item 2, item 9, item 10, item 15, and item 19) displaying values beyond 1.00 for

kurtosis and skewness. Table 2 contains the descriptive statistics for the items

comprising the CES-D scales.

Reliability of the CES-D

The mean CES-D score for the entire sample (n = 623) was 15.17 (SD = 10.64),

with a score range of 0-50 (from a maximum score of 60) and 40.8% of the sample

scored 16 or more, which is the score commonly used as the cut-off point for

possible depression at a first screening stage. The Cronbach’s alpha is acceptable

(0.88) and, in general, all the items have a good item-total correlation.


Table 2. Means and Standard Deviations of Items Composingthe CES-D Scale (n = 623)

Item Mean SD Kurtosis Skewness

CES-D 1

CES-D 2

CES-D 3

CES-D 4

CES-D 5

CES-D 6

CES-D 7

CES-D 8

CES-D 9

CES-D 10

CES-D 11

CES-D 12

CES-D 13

CES-D 14

CES-D 15

CES-D 16

CES-D 17

CES-D 18

CES-D 19

CES-D 20

0.59

0.50

0.93

0.91

0.77

0.83

0.88

1.30

0.47

0.34

0.84

1.06

0.64

0.73

0.45

1.26

0.72

0.88

0.36

0.77

0.86

0.90

1.07

1.08

0.96

1.03

1.04

1.15

0.88

0.72

1.07

1.01

0.96

1.05

0.73

1.07

1.01

1.02

0.73

1.01

1.06

1.91

–0.78

–0.69

–0.13

–0.34

–0.55

–1.37

2.26

4.65

–0.63

–0.85

0.38

–0.02

2.14

–1.16

0.09

–0.49

4.53

–0.09

1.40

1.76

0.76

0.83

1.01

0.97

0.85

0.27

1.84

2.27

0.89

0.54

1.29

1.18

1.62

0.32

1.18

0.86

2.22

1.08

Table 3 gives the descriptive analysis of each of the CES-D items. From this

table, it may be seen that the responses are skewed toward fewer depressive

symptoms.

Confirmatory Factor Analysis

Confirmatory factor analysis of the CES-D was performed using unweighted

least squares (ULS) estimation for the total sample (n = 623). This method was

used because the scores obtained for the different CES-D items did not follow a

normal distribution (according to the Kolmogorov-Smirnov tests). This made it

impossible to use the maximum likelihood estimation (MLE) procedure as its

supposition of normal distribution of the variables is violated. Each item was

allowed to load on only one factor and the latent variables were allowed to

correlate. No residuals from the items were assumed to be correlated. The

goodness of fit of the model was evaluated using the following fit indices:

goodness of fit index (GFI); root mean-square residual (RMR); normed fit index

(NFI); and relative fit index (RFI). Following the recommendations of Blunch

(2008), the cut-off values for these fit indices are as follows: for the RMR values

below 0.05 are considered a good fit, for the NFI and RFI values above 0.95 are

indicative of a good fit, and GFI has been proposed to be analogous to R2 in

multiple regression.

The confirmatory factor analysis confirmed the original model proposed by

Radloff (1977). This model is made up of four latent variables: depressed affect

(DA); somatic/reduced activity (SRA); interpersonal relationships (IR); and

positive affect (PA; Model 1). Subsequently, a second-order factor version of this

initial four-factor model was performed (Model 2). Model 2 is given in Figure 1,

together with the standardized estimated parameters. The fit indexes for both

models are given in Table 4. It is of note that in both cases, the indices have

an excellent fit.

Lastly, Table 5 reports the correlations between each of the four factors and

the second-order factor loadings for confirmatory factor analysis models. The

inter-correlations among the four factors in Model 1 range from 0.33 to 0.86

and the correlations that include the interpersonal relations factor are the lower

ones. In Model 2, the higher order factor, Depression, accounts for 99% of the

variance of the depressed affect factor, 74% of the variance of the somatic/retarded

activity factor, 49% of the variance of the positive affect factor, and only 23% of

the variance of the interpersonal relationships factor.

Screening Characteristics of the CES-D in

Elderly With and Without Cognitive Impairment

To evaluate the sensitivity and specificity of the CES-D at various cut-off

points, we used ROC analysis. In order to construct a ROC curve, sensitivity

and specificity were calculated for several scores of the CES-D. The sensitivity,

94 / ROS ET AL.

Tab

le3.

Freq

uren

cyD

istr

ibut

ions

,Cor

rect

edIte

m-T

otal

Cor

rela

tions

and

Cro

nbac

h’s

�fo

rth

eC

ES

-DIte

ms

(n=

623)

Item

Item

-tot

alco

rrel

atio

nR

arel

y/no

ne(%

)S

ome/

little

(%)

Occ

asio

nally

/m

oder

ate

(%)

Mos

t/all

(%)

Cro

nbac

h’s

�

Dep

ress

edaf

fect

CE

S-D

3C

ES

-D6

CE

S-D

9C

ES

-D10

CE

S-D

14C

ES

-D17

CE

S-D

18

Som

atic

/Red

uced

activ

ityC

ES

-D1

CE

S-D

2C

ES

-D5

CE

S-D

7C

ES

-D11

CE

S-D

13C

ES

-D20

Inte

rper

sona

lrel

atio

nshi

ps

CE

S-D

15C

ES

-D19

Pos

itive

affe

ctC

ES

-D4*

CE

S-D

8*C

ES

-D12

*C

ES

-D16

*

0.61

0.73

0.44

0.40

0.50

0.60

0.72

0.44

0.31

0.39

0.50

0.37

0.52

0.61

0.30

0.37

0.33

0.34

0.58

0.52

47.7

51.2

72.2

76.8

60.4

59.0

47.9

61.0

71.2

52.5

48.6

54.6

63.1

54.8

66.6

74.7

14.0

22.1

11.3

17.5

23.8

25.6

15.1

15.3

18.4

20.4

27.1

24.6

15.1

25.8

25.8

18.3

17.5

23.8

24.0

17.8

12.7

19.4

20.2

21.6

15.7

11.9 6.2

4.6

9.2

10.4

14.3 9.2

6.5

13.9

14.2

15.6

12.1

11.0 7.2

3.8

24.0

25.0

31.6

30.5

12.7

11.1 6.5

3.3

12.0

10.2

10.7 5.2

7.2

7.8

11.4

11.5 7.3

10.4 2.2

3.7

49.3

33.5

36.9

30.4

0.87

0.86

0.87

0.87

0.87

0.87

0.86

0.87

0.88

0.87

0.87

0.88

0.87

0.87

0.88

0.88

0.88

0.88

0.87

0.87

*For

pre

sent

atio

np

urp

oses

inth

ista

ble

,the

seite

ms

wer

eno

trev

erse

-sco

red

soth

athi

ghe

rsc

ores

ind

icat

ehi

ghe

rp

ositi

veaf

fect

(i.e.

,“R

arel

yor

none

ofth

etim

e”=

0an

d“M

osto

ral

loft

hetim

e”=

3).


96 / ROS ET AL.

Fig

ure

1.C

orre

late

dfo

ur-fa

ctor

seco

nd-o

rder

mod

el.

specificity, positive predictive value (PPV), and negative predictive value (NPV)

are shown in Table 6. The results for the sample without cognitive impairment

suggest a score of 28 as the optimum cut-off point, as this is the cut-off point that

optimizes the sensitivity and specificity of the samples studied (81.82% and

94.44%, respectively). In contrast, a cut-off point of 13 is recommended for the

sample with cognitive impairment, with a sensitivity of 86.25% and a specificity

of 72.37%.

Figures 2 and 3 shows the ROC curve for the CES-D in the samples without

cognitive impairment and with cognitive impairment, respectively. In the sample

without cognitive impairment, the AUC calculated with ROC analysis was 0.90

(95% CI: 0.79-0.96; p < 0.001). In the sample with cognitive impairment, the AUC

was 0.84 (95% CI: 0.77-0.89; p < 0.001). As can be seen, both curves are

substantially above the random ROC (AUC = 0.5), which represents the sensitivity

and specificity or random guesses as to whether an individual is a case or not. The


Table 5. Factor Correlations (Model 1) and Second-Order Factor Loadings(Model 2) for Confirmatory Factor Analysis Models

Correlations and second-orderfactor loadings DA SRA PA IR

Model 1: correlated four-factorDAS/VPAIP

Model 2: second-order factor loadings

—0.860.700.44

0.99

—0.600.47

0.86

—0.33

0.70

—

0.48

Note: DA = depressed affect; SRA = somatic/reduced activity; PA = positive affect;IR = interpersonal relationship.

Italic = standard regression coefficients.

Table 4. Fit Indices for Confirmatory Factor Analysis Models

Model Fit Indices GFI RMR NFI RFI

Model 1: four-factor

Model 2: four-factor, second-order

0.99

0.99

0.04

0.04

0.98

0.98

0.98

0.97

Note: GFI = Goodness of Fit Index; RMR = Root Mean-Square Residual; NFI = NormedFit Index; RFI = Relative Fit Index.

Tab

le6.

Dia

gno

stic

Per

form

ance

ofth

eC

ES

-Dat

Diff

eren

tCut

-Off

Sco

res

for

MD

D

Sen

s(%

Sp

ec(%

)P

PV

(%)

NP

V(%

)

Cut

-off

scor

eN

.S.

S.C

.I.N

.S.

S.C

.I.N

.S.

S.C

.I.N

.S.

S.C

.I

13 16 17 19 20 22 27 28 29 30

86.3

6

86.3

6

86.3

6

81.8

2

81.8

2

81.8

2

81.8

2

81.8

2

77.2

7

68.1

8

86.2

5

67.5

0

62.5

0

53.7

5

52.5

0

51.2

5

28.7

5

27.5

0

26.2

5

23.7

5

69.4

4

71.3

3

72.2

2

72.2

2

75.0

0

77.7

8

88.8

9

94.4

4

94.4

4

97.2

2

72.3

7

85.5

3

86.8

4

88.1

6

88.1

6

89.4

7

93.4

2

93.4

2

94.7

4

94.7

4

63.3

3

64.7

1

65.5

2

64.2

9

66.6

7

69.2

3

81.8

2

90.0

0

89.4

7

93.7

5

76.6

7

83.0

8

83.3

3

82.6

9

82.3

5

83.6

7

82.1

4

81.4

8

84.0

0

82.6

1

89.2

9

89.4

0

89.6

6

86.6

7

87.1

0

87.5

0

88.8

9

89.4

7

87.1

8

83.3

3

83.3

3

71.4

3

68.7

5

64.4

2

63.8

1

63.5

5

55.4

7

55.0

4

54.9

6

54.1

4

No

te:

PP

V=

pos

itive

pre

dic

tive

valu

e;N

PV

=ne

gat

ive

pre

dic

tive

valu

e;N

.S.=

norm

alsa

mp

le(w

ithou

tcog

nitiv

eim

pai

rmen

t);S

.C.I.

=sa

mp

lew

ithco

gni

tive

imp

airm

ent.

The

pre

vale

nce

ofM

ajor

Dep

ress

ive

Dis

ord

erw

as37

.93%

inN

.S.a

nd51

%in

S.C

.I.

98 / ROS ET AL.


Fig

ure

2.R

ecei

ver

oper

atin

gch

arac

teris

tics

ofth

eC

ES

-Dfo

rM

MD

insa

mp

lew

ithou

tcog

nitiv

eim

pai

rmen

t.

100 / ROS ET AL.

Fig

ure

3.R

ecei

ver

oper

atin

gch

arac

teris

tics

ofth

eC

ES

-Dfo

rM

MD

insa

mp

lew

ithco

gni

tive

imp

airm

ent.

fact that the AUC is significantly greater than 0.5 means that the null hypothesis

(i.e., that the CES-D provides no useful information) can be rejected.

DISCUSSION

The two main objectives of this study were:

1. to determine the validity and reliability of the CES-D in a population of

older adults and to examine the factorial structure through confirmatory

factor analysis with structural equations; and

2. to assess the adequacy of the CES-D as a screening instrument in a popu-

lation of older adults with and without cognitive impairment.

In general, we believe that the results support the use of the CES-D as a valid

screening instrument for depression in an older adult population. Nunnally and

Bernstein (1994) proposed that for self-report scales to be used as screening

instruments, they must have an internal consistency of � 0.80. The reliability

indices obtained in our study meet this criterion. Furthermore, the fact that

the items have high internal consistency confirms the unidimensional nature of

the scale.

Regarding the factorial structure of the CES-D, our results, using a structural

equation model, support the original four factor structure proposed by Radloff

(1977): depressed affect; somatic symptoms/psychomotor retardation; positive

affect; and interpersonal relationships. Furthermore, in agreement with the

findings of studies such as those performed by Hertzog et al. (1990) and Sheehan

et al. (1995), our results also lend support to a higher order factor structure of

the CES-D in older adults. It should be pointed out that all the items in both

models adequately saturate on their respective factors, and all first-order factors

significantly saturate on a latent second-order Depression construct. This good

fit of the second-order model supports the use of a total CES-D score as an overall

indicator of depressive symptomatology in older adults. Therefore, although the

interpersonal relationships factor appears to be weakly related with the higher-

order Depression construct, total score may be considered as a valid measure-

ment of depressive symptomatology.

The results of our second objective—assessing the utility of the CES-D in a

sample of older adults with mild cognitive impairment and a sample without

cognitive impairment—suggest that CES-D is an acceptable instrument to

accurately detect MDD in both samples. The criteria validity of the CES-D was

examined by comparing the scale’s cut-off points with those of a gold standard,

the CIDI. As we have seen, the CIDI is a structured interview which allows the

investigator to clinically diagnose MDD. Through ROC analysis, we found that

CES-D is sensitive, specific, and has good positive and negative predictive

values, taking the total score of 28 as the cut-off point for the sample without

cognitive impairment and 13 for the sample with cognitive impairment. Both these


cut-off points concur with those in the literature. The cut-off point of 28, in an

older population without cognitive impairment, is similar to that suggested as

optimum by authors such as Himmelfarb and Murrell (1983) or Schulberg et al.

(1985) in an older population. In the older population with cognitive impairment,

our cut-off point is similar to that found by Lewinsohn et al. (1997), also in a study

in older adults with mild cognitive impairment. It is our opinion that older adults

without cognitive impairment and with a CES-D score of over 28, or older adults

with cognitive impairment and with a score of over 13, should be assessed in a

clinical interview in order to reach a specific clinical diagnosis and administer the

appropriate treatment. It should be remembered that the CES-D is not, strictly

speaking, a diagnostic instrument; however, it has demonstrated to be very

useful as an indicator of probable depression, which should be subsequently

evaluated by clinical criteria (Gatz, Kasl-Godley, & Karel, 1996; Robinson,

Gruman, Gaztambide, & Blank, 2002). Furthermore, the CES-D may also be used

as a measure of treatment results, as it determines the current symptom level

and is sensitive to changes over time (Radloff, 1977; Radloff & Teri, 1986).

It is also noteworthy that the presence of cognitive impairment did not have

a negative effect on the efficacy of the CES-D as a screening instrument in this

sample. This finding is consistent with those in other studies. Parmelee, Katz,

and Lawton (1991) and Parmelee, Lawton, and Katz (1989) found that, with

the exception of the severe dementia group, on comparing participants with

cognitive impairment with those without cognitive impairment, the self-reports

on depression had the same internal consistency and had correlations equivalent

to the examiners’ evaluations. These findings, as do ours, suggest that older

persons are reliable informers of their affective state, regardless of whether

they have of cognitive impairment or not.

Lastly, in our study the proportion of women with depression is greater than

that of men. Nevertheless, we think that this difference does not affect the

validity of the results. O’Rourke (2004) found that CES-D responses do not vary

depending on the subject’s sex. Moreover, different studies have shown that

women have higher rates of depressive symptoms (Thoits, 1995; Vingerhoets

& Van Heck, 1990) and suffer from higher rates of affect disorders (Haro,

Palacin, Vilagut, Martinez, Bernal, Luque, et al., 2006; Nolen-Hoeksema, 2001)

than men. Furthermore, the scales and screening instruments that evaluate

depressive symptoms are usually applied to both men and women with the same

cut-off points.

This study has some limitations. One of them is that the sample of older

persons with cognitive impairment used to assess the validity of the CES-D as a

screening instrument, did not include persons with moderate or severe cognitive

impairment. Therefore, although we can conclude that the CES-D provides an

adequate measure of depressive symptoms in older adults with mild cognitive

impairment, we cannot extend this conclusion to include adults with more severe

cognitive impairment.

102 / ROS ET AL.

Finally, the sample size of the group without cognitive impairment is small for

the type of statistical analysis that is being performed, so these results should

be interpreted with caution. Nevertheless, it should be noted that our results

fit with most of the previous literature in that some investigators have recom-

mended cut-off points between 20 and 27 in older populations.

In summary, we can conclude that the CES-D is a valid, reliable self-report

scale to measure depressive symptoms in an elderly population and an efficient

instrument for MDD screening in an older adult population with or without mild

cognitive impairment. As we have seen, the CES-D is widely used in geriatric

research worldwide and when compared with clinical criteria it has internal

consistency, test-retest reliability, and satisfactory convergent validity (Grayson,

Mackinnon, Jorm, Creasey, & Broe, 2000). We consider that validating its use

in samples of older Spanish adults with or without mild cognitive impairment

extends our knowledge of psychometrics, enables comparisons between different

population types in different countries, and provides for the performance of

inter-cultural studies. In our opinion, future studies should be directed toward

examining how, for example, more severe cognitive impairment, functional dis-

ability, or physical illness in older adults could affect the adequacy of the CES-D

as a measure of depressive symptoms. Furthermore, it would also be useful

to compare the efficacy of different instruments used as screening tools for

depressive disorders in this type of population, such as the GDS (Brink, Yesavage,

& Lum, 1982).

Finally, another interesting area of research is the evaluation of the adequacy

of the CES-D to the immigrant population. Some studies have been shown

that the immigrant experience has various psychosocial effects on older people,

with possible implications for both cognitive functioning and mental health

(Bhugra, 2004; Kulla, Ekman, & Sarvimäki, 2010). Thus, for example, it

would be useful to test if the cut-off points obtained in this study are valid

for screening depression in Spanish-speaking immigrants with and without

cognitive impairment.


(Appendix follows)

104 / ROS ET AL.

APPENDIX

Escala CES-D

Para cada uno de los siguientes enunciados, elija la casilla que mejor describaCÓMO SE SENTÍA LA SEMANA PASADA:

NINGUNAVEZ

POCASVECES

BASTANTESVECES

MUCHASVECES

1. Me molestaron cosas que normalmenteno me molestan

2. Me tenía hambre, no me apetecíacomer

3. Me sentía triste y descorazonado, apesar de la ayuda de mi familia y misamigos

4. Me sentía tan válido y útil comocualquiera

5. Tenía dificultad para concentrarme

6. Me sentía deprimido

7. Para hacer cualquier cosa, tenía quehacer un gran esfuerzo

8. Me sentía con esperanza respecto alfuturo

9. Pensaba que mi vida había sido unfracaso

10. Me sentía atemorizado

11. No me sentía descansado después dehaber dormido

12. Me sentía feliz

13. Hablaba menos de los habitual

14. Me sentía solo

15. La gente no era amable

16. Disfrutaba de la vida

17. Hubo ratos en que lloré

18. Me sentía triste

19. Sentía que no le agradaba a lagente

20. Me encontraba sin fuerzas para hacernada

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Spain

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