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Rehab Measures: Center for Epidemiological Studies Depression Scale (CES-D)

Link to instrument

CES-D can be found at Depression-help-resource.com 

Title of Assessment

Center for Epidemiological Studies Depression Scale (CES-D) 

Acronym

CES-D

Instrument Reviewer(s)

Summary Date

 

Purpose

  • A brief self-report measure designed to assess symptoms of depression in the general population

  • Items are based on symptoms associated with depression used in previously validated measures of depression.

Description

A 20-item, self-report measure designed to be used in the general population that assess current symptoms of depression (i.e. this week)

Area of Assessment

Depression 

Body Part

Not Applicable 

ICF Domain

Activity 

Domain

Emotion 

Assessment Type

Patient Reported Outcomes 

Length of Test

06 to 30 Minutes 

Time to Administer

10 to 20 minutes

Number of Items

20 

Equipment Required

Pencil and paper

Training Required

None

Type of training required

Reading an Article/Manual 

Cost

Not Free 

Actual Cost

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.

Age Range

Adolescent: 13-17 years; Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Acquired Brain Injury; Arthritis; Geriatrics; Multiple Sclerosis; Spinal Cord Injury; Stroke; Traumatic Brain Injury 

Populations Tested

  • Stroke
  • SCI
  • Cancer
  • Psychiatric patients
  • Arthritis
  • Multiple sclerosis
  • Systemic sclerosis
  • Asthma
  • Chronic lung disease
  • Congestive heart failure
  • Diabetes
  • Elderly populations
  • General population
  • Also validated in different ethnic contexts

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

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

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%)
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

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

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

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 Inerval
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 scores of Cancer patients and healthy
comparisons
 
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
Order and language of assessment

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)

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)

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)

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)

Chronic SCI: (Miller et al, 2008)

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

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)

Orthopaedic & Neurological Patients: (Caracciolo & Giaquinto, 2002

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

Construct Validity (Convergent/Discriminant)

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
 

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


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

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

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)

Professional Association Recommendations

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
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

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

Year published

1977 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 1/27/2011 4:16 PM  by Jason Raad 
Last modified at 12/4/2013 6:02 PM  by Jason Raad