A SPANISH VERSION OF THEGERIATRIC DEPRESSION SCALE IN

MEXICAN-AMERICAN ELDERSF.M. BAKER

Professor, University of Maryland, USA

DAVID V. ESPINO

Associate Professor, Department of Family Practice, University of Texas Health Science Centerat San Antonio, USA

ABSTRACT

Objective. The purpose of this study was to establish the sensitivity of a Spanish translation of the 15-item GeriatricDepression Scale (GDS-S) in a sample of 41 elderly Mexican-American psychiatric patients with a diagnosis ofdepressive disorders.

Method. Utilizing the reverse translation technique and bilingual Mexican-American psychiatrists as evaluators,patients with DSM-III-R diagnoses of a�ective disorder who were sequential admissions to an inpatient psychiatricunit were enrolled in the study. The GDS-S was administered by trained interviewers within 2±4 weeks of admissionto 28 patients with major depressive disorder (MDD) and 13 patients with other depressive disorders (ODD). Noother screening instruments for depressive symptoms were used.

Results. Using the original cut-scores of GDS, the sensitivity was 39% in patients with MDD and 77% in patientswith ODD. When a revised cut-score of 4 and above was identi®ed as re¯ective of depressive symptoms, thesensitivity improved to 75% for patients with MDD and 85% for patients with ODD. Because there were no truenegatives, speci®city was not determined.

Conclusions. The GDS-S may have limited value in screening community-resident Mexican-American elders fordepressive symptoms unless they have signi®cant medical problems which limit their function and are associated witha dysthymic disorder. Screening instruments for depression which include neurovegetative or somatic items may be abetter choice in this population.

KEY WORDSÐGeriatric Depression Scale; Spanish; survey

Hispanic Americans comprise 8% of the totalpopulation of the United States (National Centerfor Health Statistics, 1991). Cuellar notes thatHispanic Americans are a heterogeneous popula-tion which includes various national, ethnic andracial groups (Cuellar, 1990). Mexican Americanscomprise the largest group of Hispanic Americans(Cuellar, 1990; Jimenez and de Figueiredo, 1991).Persons over age 65 are a rapidly increasingsegment of this population; 4.2% of MexicanAmericans are age 65 and older (Angel and Hogan,1991).

Mexican-American elders have a higher preva-lence of hypertension, obesity, diabetes mellitus

and cardiovascular disease in comparison to whiteAmericans (Espino, 1990; Espino et al., 1991; TaskForce on Black and Minority Health, 1985). Themorbidity associated with medical illness as well aschronic disease has been shown to increase the riskfor the development of a major depressive disorder(Cassem, 1988; Ruegg et al., 1988; Alexopouloset al., 1988; Rosenthal et al., 1987).

A few studies have addressed the presence ofpsychiatric symptoms and disorders amongMexican Americans of mixed age. Kemp et al.used a modi®cation of the Comprehensive Assess-ment and Referral Evaluation (CARE) items ina probability sample of 700 Hispanic elders inLos Angeles County (Kemp et al., 1987). Twenty-six per cent of this sample met the criteriaof the Diagnostic and Statistical Manual, ThirdEditionÐRevised (DSM-III-R) for depression and

*Address for correspondence: Dr F. M. Baker, Departmentof Psychiatry, University of Maryland School of Medicine,645 Redwood Street, Baltimore, Maryland 21201-1549, USA

CCC 0885±6230/97/010021±05 Received 30 November 1992# 1997 by John Wiley & Sons, Ltd. Accepted 8 December 1994

INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 12: 21±25 (1997)

dysphoria (American Psychiatric Association,1987) that was strongly correlated with medicaldisability and with dementia. In patients withoutthese associated disorders only 5.5% were found tohave depressive illness.

Data from the Los Angeles site of the Epidemio-logic Catchment Area Survey (Burnam et al., 1987)reported a signi®cantly higher prevalence rate ofphobic disorder among Mexican-American womenage 40 and older compared to other age±sexgroups. Other investigators (Mendes de Leon andMarkides, 1988) found comparatively low levels ofdepressive symptoms, particularly among males,using the Center for Epidemiologic StudiesDepression Scale (CES-D) to screen 1074 MexicanAmericans of three generations. In a triracial studyof adult patients (Mexican American, AfricanAmerican and white Americans), the DiagnosticInterview Schedule (DIS) was used to establish thepresence of depression or anxiety. In 14.3% ofwomen over age 65 depression or anxiety wasfound (Hoppe et al., 1989).Garcia andMarks (1989) analyzed data from the

Hispanic Health and Nutrition ExaminationSurvey collected between 1982 and 1984 in ®vesouthwestern states. A total of 3084 Mexican-American adults between the ages of 20 and 74were interviewed with the CES-D. These authorsfound that persistent hopelessness about thefuture, lack of enjoyment of life and feelings ofself-deprecation were more prevalent amongMexican Americans than white Americans.Persons with less adaptation to American culturewere found to have a higher prevalence of thesesymptoms. In this study, the overall CES-D scoresacross all ages and between sexes were lower thanreported in other studies. Only 17% of women and7.4% of men had scores of 16 or higher (usualthreshold for depressive symptoms). These authorscautioned that internalized cultural values andperceived sanctions could in¯uence responses tospeci®c items on the CES-D and warned that theseshould be interpreted with caution.

Given the studies that demonstrate the presenceof depressive symptoms and conditions thatincrease the risk for depressive symptoms amongMexican-American elders, a screening instrumentdi�erent from the CES-D to identify the presenceof depressive symptoms amongMexican-Americanelders was sought. The 15-item Geriatric Depres-sion Scale (GDS) was developed (Yesavage andBrink, 1983) from the initial 30-item GDS (Sheikhand Yesavage, 1986) to provide such a screening

instrument to assess depressive symptoms in olderpopulations. Somatic complaints and neuro-vegetative changes were deleted from the GDSbecause these items could be positive in the elderlyon the basis of normal age-related changes as wellas due to medical illnesses and the e�ects of pres-cribed medications. We report on a study thatassessed the reliability and validity of a Spanishtranslation of the 15-item GDS (GDS-S) in asample of Mexican-American elders with estab-lished DSM-III-R diagnoses of a�ective disorder.

METHODOLOGY

Awareness of and sensitivity to speci®c culturalde®nitions of illness and treatment are crucialconcerns in the studies involving persons ofvarying cultures (Baker, 1990). Cultural factorscan in¯uence the threshold of symptoms that resultin the seeking of health care and the speci®cindividual (traditional healerÐcurandero) or phys-ician approached for treatment (Baker, 1990;Espino et al., 1991; Martinez, 1988). In order tominimize the potential for cross-cultural e�ects,consecutively admitted Mexican-American elderlypatients hospitalized on an inpatient psychiatricunit with predominantly Mexican-Americanbilingual sta� were recruited for this study.Psychiatric diagnoses of Mexican-American elderswere made based upon a clinical interview of thepatient and the patient's family members and areview of the patient's medical records to establishthe speci®c DSM-III-R diagnoses/diagnoses pre-sent. All diagnoses were made by bilingualMexican-American psychiatrists who had workedfor several years with Mexican-American elders inSan Antonio, Texas, and who were aware of thecultural context of the older patient as well as theirnon-verbal behavior. The reverse translation of theGDS-S developed for this study was based on theinput of community-resident elders as well asMexican-American physicians who were nativesof San Antonio.

A Spanish translation of the 15-item GDS wasadministered to the consenting Mexican-Americanelders with diagnoses of a�ective disorder byvolunteers from the San Antonio chapter of theAmerican Association of Retired Persons (AARP).These AARP members were community-resident,Mexican-American elders who received speci®ctraining in the administration of the GDS-S.Interrater reliability was established at 94%.

22 F. M. BAKER AND D. V. ESPINO

RESULTS

The study sample was composed of 41 patients:23 men and 18 women. The median age was 74 witha range of 62±98 years (Table 1). The samplewas divided into two groups: patients with aDSM-III-R diagnosis of major depressive disorder(N� 28; 68%) and patients with other DSM-III-Rdepressive disorders (N� 13; 32%). In the group ofpatients with major depressive disorder (MDD), 18patients (44%) had a delusional depression and sixof these (33%) had a recurrent a�ective illness. Inthe group of patients with other depressivedisorders (ODD), six patients of the 13 (46%)had a diagnosis of organic mood disorder due tostroke, hypothyroidism, B12 de®ciency or Parkin-son's disease. Three of the 13 (23%) had adiagnosis of dysthymic disorder. Two patients(15%) had a major depressive disorder with panicattacks and two patients (15%) had a diagnosis ofbipolar disorder, depressed.

The most frequently reported medical problemswere non-insulin dependent diabetes (N� 11;27%), hypertension cardiovascular disease(N� 11; 27%), chronic obstructive pulmonarydisease (N� 6; 15%) and cerebrovascular accidents(N� 5; 12%). The most frequently prescribedmedications were antidepressants (nortriptyline:N� 23; 56%, desipramine: N� 5; 12%, amitrip-tyline: N� 4; 10%), antipsychotics (haloperidol:N� 15; 37%, perphenazine: N� 4; 10%, thiori-dazine: N� 2; 5%), antianxiety agents (lorazepam:N� 5; 12%) and others (N� 4; 10%). Twenty-fourper cent of the sample (N� 10) had their medica-tion changed (usually during the fourth to sixthweek of hospitalization) due to non-response to anantidepressant. Five patients (10%) were changedfrom nortriptyline to desipramine and two patients(5%) from doxepine and amitriptyline to trazodoneand nortriptyline, respectively.

In this sample, the total GDS-S score rangedfrom 1 through 14. Using the original cut-scores(0±5� normal; 6±10�mildly suggestive ofdepression; 11±15� strongly suggestive of depres-sion (Table 2)), 39% of the MDD group (11 of 28)screened positive for depression symptoms.Seventy-seven per cent (10 of 13) of the ODDgroup screened positive for depressive symptoms.The di�erence between the MDD and ODDgroups was greater than a p value of 0.10, but thedi�erence was not statistically signi®cant at the 0.5level (�2 � 2.8273; df� 1). Because there were notrue negatives in our study design, speci®city was

not calculated. Using a revised threshold of scoresof 4 or higher suggestive of depression (Table 3),75% of the MDD (21 of 28) and 85% of the ODDgroup (11 of 13) screened positive for depressivesymptoms. The di�erence between the groups wasnot statistically signi®cant (�2� 0.1614; df� 1).

Table 1. Age±Gender Distribution of the Sample

Age group Men Women Total

N % N % N %

60±64 2 9 1 5 3 7

65±74 9 39 9 50 18 44

75±84 9 39 5 28 14 34

85±99 3 13 3 17 6 15

Totals 23 56 18 44 41 100

Table 2. Comparison of results of total scores ofGDS-SÐoriginal threshold. Scores of 6 and abovesuggestive of depressive symptoms

0±5 0±10 11±15 Totals

Normal Mildly Strongly

suggestive of suggestive of

depression depression

N % N % N % N %

Major 17 61 9 32 2 7 28 100

Depressive

Disorders

Other 3 23 8 62 2 15 13 100

Depressive

Disorders

Totals 20 49 17 41 4 10 41 100

Table 3. Comparison of results of total scores ofGDS-SÐrevised threshold. Scores of 4 and abovesuggestive of depressive symptoms

GDS-S Scores

0±3 4±15 Totals

Normal Suggestive of

depression

N % N % N %

Major 7 25 21 75 28 100

Depressive

Disorders

Other 2 15 11 85 13 100

Depressive

Disorders

Totals 9 22 32 78 41 100

23THE SPANISH GERIATRIC DEPRESSION SCALE

When the frequency of positive response toindividual items was assessed, 76% (N� 31) of thesample reported having dropped many of theiractivities and interests. Seventy-one per cent of thesample (N� 29) stated that they preferred to stayat home. Sixty-three per cent of the sample(N� 26) stated that they thought that most peoplewere better o� than they were. Fifty-one per cent ofthe sample (N� 21) reported that they were oftenbored and that they felt that their lives were empty.

DISCUSSION

Although there are limitations to this study, thereare speci®c strengths. This is one of the few studiesthat has used a screening instrument for depressionin a sample of Mexican-American elders withknown DSM-III-R psychiatric diagnoses in orderto assess its reliability. Our research design wasdeveloped to minimize the e�ect of cross-culturalmiscommunication by choosing a site with bi-lingual Mexican-American sta� with bilingualMexican-American psychiatrists. Thus, under-standing the cultural nuances and non-verbalcommunication of the Mexican-American elderwas optimized.

The prevalences of medical illnesses were similarin the MDD and ODD group, with non-insulindependent diabetes mellitus present equally in eachgroup. The ODD patients had greater functionaldisability due to medical illnesses (eg severe osteo-arthritis, nephropathy and neuromuscular eso-phageal dysfunction). Among patients with MDDwho screened negative on the GDS-S with theoriginal scores, three patients hadmalignancies andone patient had severe lung disease. The bettersensitivity of the GDS-S in the ODD group mayre¯ect the secondary dysthymia associated withmedical illness (Blazer et al., 1987). The recentreview of depression associated with Parkinson'sdisease was found to be di�erent from the depres-sion of MDD. Guilt, self-blame, or feelings offailure or punishment were not seen in depressionassociated with Parkinson's disease. The pattern ofincreased levels of dysphoria and pessimism aboutthe future, irritability, sadness and suicidal ideationseen in depressed Parkinsonian patients is similarto the pattern of depressive symptoms reported bythese Mexican-American elders.

Further studies will be necessary to con®rm thatamong Mexican-American elders, elders withdepressive symptoms in the context of medical

illness will screen positive on the GDS-S in contrastto Mexican-American elders with only MDD. It ispossible that the spectrum of depressive illness is acrucial consideration. Mexican-American elderswith severe depression (MDD) in this samplereported a decrease in activities and interests, apreference to stay at home and that they wereworse o� than other people. The GDS-S in itsdesign eliminated questions related to somaticcomplaints. Given the suggested di�erence in sensi-tivity between the MDD and the ODD groups, itwould be of interest to establish whether the MDDgroup reported more somatic symptoms than theODD or manifested another presentation ofdepressive illness not assessed by the GDS-Squestions. Perhaps, the observed depressive illnessis closer to the model of depression hypothesizedfor Parkinson's disease. Our ®ndings suggest thatamong Mexican-American elders depressive illnessis a complex process requiring further clari®cation,with speci®c attention to those with and withoutmedical illnesses which limit functional status.

ACKNOWLEDGEMENTS

The authors wish to acknowledge the outstandingcontribution made to this study by Mr DennisFabrizio in his role as research assistant. Thesuccess of our project was due in a signi®cantmanner to his e�orts.

The study was supported in part by the SouthTexas Health Research Center Grant #15 and byNIMH #2 K07 MH000816-02.

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25THE SPANISH GERIATRIC DEPRESSION SCALE