Center for Epidemiologic Studies Depression Scale

The Center for Epidemiologic Studies Depression Scale (CES-D) is designed to study general patterns of the incidence and prevalence of depression among adults. Lenore S. Radloff published the original report on its development and suitability for use in the general population. The CES-D is frequently used to measure depressed mood and general psychological distress in research settings, and it is popular for screening for clinical levels of depression (such as major depressive disorder) in adult community populations where low levels of incidence are expected. It has been translated into several languages and used in cross-cultural samples. The CES-D was designed to be a self-report measure assessing current symptom levels of depression in the general population. Independently developed short versions with a reported predictive validity comparable to the original are also available.

The CES-D measures levels of depression on a continuous scale and is relatively easy to administer and score. However, it is not intended for use as a clinical diagnostic tool because high scores may also be a result of anxiety or other psychological distress. The CES-D is considered to be good (i.e., high on sensitivity) but relatively inefficient (i.e., low on specificity) at detecting possible cases of depression; its items emphasize a depressed mood state and do not evaluate other possible indicators of mood disorder, such as a loss of previous interest or pleasure in activities, suicide ideation, or duration of symptoms that make up the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. The 20 items in the CES-D sample four domains, each weighted by frequency of occurrence (0–3) during the previous week: depressed affect (seven items; “I felt sad”), lack of positive affect (four items; “I enjoyed life”), somatic and retarded activity (seven items; “I felt that everything I did was an effort”), and interpersonal aspects of depression (two items; “People were unfriendly”). The summed score (after reverse scoring positively worded items) ranges from 0 to 60, with higher scores indicating endorsement of higher depressive symptoms. A cutoff score of 16 is generally accepted for screening purposes; those meeting the cutoff are to be followed up with a diagnostic interview.

Scores that are inflated because of systematically higher endorsements of somatic-domain items have [Page 84]been found in many study samples, such as East Asian and Spanish-speaking individuals, geriatric patients, and cancer patients; therefore, adjusted cutoff scores range from 20 to 34. A tendency to not highly endorse positively worded items may over-estimate depression levels for East Asian and Asian American individuals. Moreover, higher endorsements of scale items in college samples also suggest that cutoff scores should be adjusted or used with caution. Omitting problematic items from the scale is another strategy that has been used to reduce the number of individuals falsely categorized as highly depressed.

Studies have explored the CES-D's suitability for diverse populations. Radloff's original report found comparable reliability, validity, and factor structures for different age, gender, racial (i.e., African American and European American), and education-level subgroups. A review of the literature shows inconsistent results for factor structures among diverse groups. Responses from some study samples replicate Radloff's four structure model, whereas others suggest different factor structures and loadings for these and other groups. Most findings have consistently confirmed gender differences. The majority of studies, however, demonstrate the CES-D's reliability (internal consistency), a property that Radloff originally argued de-emphasizes the importance of its factor structure.

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