Depression scales for use in Parkinson’s Disease
Scale:
Hamilton Depression Rating Scale (HAM-D)
Are there several versions of the
scale? If so, which one has been
assessed?
There are more than 20 different versions (Zitman et
al., 1990). The most widely used are the following:
1. Original 21-item version (Hamilton, 1960)
2. The most frequently used 17-item version
(identical to the original, but excluding the
last 4 items) (Guy, 1976).
3. Hamilton Depression Scale with Melancholia
Scale (23 items) (Bech, 1993).
4. Structured Interview Guide for the HAM-D
(Williams, 1988).
5. There are also 24- and 28-item version that
includes specific items to rate atypical
depression and melancholic features.
Description of scale
(content,
number of items and subscales,
number of answer options
(severity or frequency or both)
Rater: Patient or caregiver or
clinician. If clinician-rated,
training for application required?
Copyright or public domain?
How can the scale can be
obtained (address or website)?
We have assessed the original 21-item version. Only
the first 17 items contribute to the total score (the
remaining four items have either a low frequency in
depression, or do not rate severity) (Snaith, 1996).
The scale contains 21 items: 10 items have scores
ranging from 0 to 4 points, 9 items with scores
ranging from 0 to 2 points, and 2 items with scores
ranging from 0 to 3 points. Higher scores usually
mean more severe symptoms. Frequency of
symptoms usually not rated.
Originally designed to be administered by a trainedclinician. No specific training required, although most
research raters usually undergo training in the
administration and scoring of the scale. Training is
also required for the structured HAM-D.
Public domain.
http://healthnet.umassmed.edu/mhealth/HamD.pdf
Scale properties
Please provide references for all statements or note if this is your personal judgement
Content
Face validity?
Adequate (Bagby et al., 2004; Riskind et
al., 1987).
Is loss of pleasure included?
Not specifically.
Is the scale heavily weighted towards one
Assesses autonomic, vegetative and
aspect of depression? If so, which?
psychological symptoms of depression.
Does it exclude an important aspect of
Anhedonia (loss of pleasure) is poorly
depression? If so, which
assessed (Bagby et al., 2004); neither
worthlessness, concentration difficulties,
nor reverse vegetative symptoms (i.e.,
hyperphagia, increased weight, and
hypersomnia) are assessed (Bagby et al.,
2004). On the other hand, loss of interest is
specifically assessed.
Compatible with DSM IV or other
Does not rate several symptoms (listed
depression criteria (compare content to
above) that are necessary for a DSM-IV
DSM IV, if formally assessed see also
diagnoses of major depression or
criterion validity below)?
dysthymia, or for a diagnosis of depression
based on ICD-10 criteria.
Includes items on anxiety, psychosis and
Rates anxiety symptoms, psychic
cognition as a result of depression?
retardation, concentration difficulties, and
paranoid and nihilistic delusions.
Which areas are not covered?
The original 21-item version does not assess
symptoms of atypical depression or
depression with melancholic features.
However, there are longer versions of the
scale that do rate all these symptoms. There
are no separate items rating concentration
difficulties or nihilistic delusions.
Number/percentage of items that overlap
with symptoms of
Parkinsonism (energy, sleep, fatigue,
8 items pertaining to the following 6
appetite, psychomotor
symptoms: insomnia, psychomotor
retardation/agitation)
retardation, loss of appetite, loss of energy,
loss of weight, and loss of libido.
Cognitive impairment (slowness of
1 specific item (psychomotor retardation),
thinking, clarity of thinking, attention,
and another aspect (loss of concentration) as
memory, concentration)
part of another item.
Apathy (loss of interest, loss of
Rated as loss of interest.
initiative)
What is the time frame/is the time frame
During the past week.
appropriate (e.g. “during the past week”)?
Are the symptoms of Recurrent Brief
Not captured.
Depressive Disorder captured?
Use
Was it designed to measure severity or to
screen for depression?
Is there a cut-off score for diagnosis of
depression (in depression without PD)?
Is this appropriate in depression with PD
(dPD)?
If not, why?
Has a different cut-off score for dPD been
suggested, and if so, is there evidence to
support it?
Has it been used to measure severity or to
screen for depression (in depression without
PD and dPD)?
Originally designed to measure severity
of depression and to assess changes
during treatment (Bech, 1993; Bobes et
al., 2003; Ferreri et al., 1986; Maier et
al., 1988a; Maier et al., 1988b; Mulder et
al., 2003). The 17-item version does not
measure a single dimension, implying
that the total score may not be a valid
measure of the severity of depression
(Licht et al., 2005).
Several different cut-off scores. The
original description suggested the
following cut-off scores: 0-11, minor or
no depression; 12-18, less than major
depression; 19-24, major depression; 25
or more, severe depression. The most
widely accepted cut-off scores are: <8,
normal; 8-13, mild depression; 14-18,
moderate depression; 19-22, severe
depression, >23, very severe depression
(Endicott et al., 1981; Kearns et al.,
1982). A cut-off of 13 on the 17-item
version has adequate sensitivity and
specificity for the diagnosis of depression
(Bagby et al., 2004).
Cut-off scores used for non-PD
individuals should not be applied to PD
given that non-depressed PD patients
have higher HAM-D scores than healthy
controls.
Cutoff points of 15/16 to diagnose
depression (Specificity= 0.99, Positive
Predictive Value= 0.93) (Naarding et al.,
2002), and 13/14 points to diagnose
depression (Specificity= 0.89,
Sensitivity= 0.88, Positive Predictive
Value= 0.74, Negative Predictive Value=
0.96) (Leentjens et al., 2000) have been
proposed to diagnose depression in PD.
A cutoff 9/10 points has been proposed
for depression screening purposes
(Sensitivity= 0.95, Negative Predictive
Value= 0.98) (Naarding et al., 2002).
The HAM-D has been used for both
purposes in both populations (Bagby et
al., 2004; Starkstein and Merello, 2002).
Acceptability
Length
Ambiguities in instructions to patient/rater
Ambiguities in rating anchors
Appropriateness of questions for PD
population
Applicability across PD and depression
disease stages mild – moderate – severe?
Can it be used for “on” and “off” and has this
been done?
Clear instructions to raters
Acceptable; takes about 15 minutes to
assess.
The inter-rater reliability for individual
items is not very good, but is improved
by the use of a structured interview
(Williams, 1988).
Yes
Yes (Starkstein and Merello, 2002;
Starkstein et al., 1998; Starkstein et al.,
1990).
Some of the items do not allow ratings
during short intervals.
The structured versions include scoring
guidelines that improved the reliability
(Williams, 1988).
Clinimetric/psychometric properties
Metric flaws (floor and ceiling effects, score
distributions)?
Lack of a single unifying structure;
differential item weighing, with some
symptoms contributing more to the total
scores than others.
Reliability (internal consistency, inter-rater,
Good internal reliability [0.46-0.97]
test-retest) of total or sub-scales and of
(Bagby et al., 2004).
individual items
Good inter-rater reliability [0.46-0.99]
(Bagby et al., 2004).
Good test-retest reliability [0.81-0.98]
(Bagby et al., 2004). Poor item
reliability.
Validity: assessed – not assessed, good – not good (references); please also comment on
sample sizes
In depression without PD
Face or content validity
Adequate, but does not assess all the
criteria for DSM-IV/ICD-10 depression
sub-types.
Criterion validity (compared to goldInadequate convergent validity with the
standard, e.g. DSM IV (SCID, SCAN,
Structured Clinical Interview for DSMsystematic interviews) or other criteria for
IV (SCID) (it only assesses 4 of the 9
diagnosis)
DSM-IV criteria to diagnose major
depression) (Zimmerman et al., 2005).
Sensitivity, specificity, and negative
predictive value for major depression
are consistently high, but the positive
predictive value is not (Bagby et al.,
2004). Sensitivity (at different cut-offs)
ranges from 0.45 to 0.88, Specificity
ranges from 0.75 to 1.00, Positive
Predictive Value ranges from 0.37 to
1.00, and Negative Predictive Value
ranges from 0.86 to 0.99 (Bagby et al.,
2004).
Construct validity (correlations with
Convergent validity with the BDI, CESother
D, HADS and MADRS is adequate
convergent scales and divergent scales (Bagby et al., 2004). No adequate
(which?);
convergent validity with the major
factor analysis)
depression section of the Structured
Clinical Interview for DSM-IV
(Akdemir et al., 2001), reflecting noncorrespondence between HAM-D and
DSM-IV.
Discriminant validity is adequate,
except for anxiety (Bagby et al., 2004).
It is more sensitive to change than the
BDI and the Zung Depression Scale
Valid in ethnically and culturally
different
populations?
Valid in both genders and at all ages?
Valid in patients with dementia or
significant
cognitive impairment?
In depression in PD (dPD)
Face or content validity
Criterion validity (compared to goldstandard,
DSM IV (SCID, SCAN, systematic
interviews)
other criteria for diagnosis)
Construct validity (correlations with
other
convergent scales and divergent scales
(which?);
factor analysis)
Valid in ethnically and culturally
different
populations?
Valid in both genders and at all ages?
Valid in patients with dementia or
significant
cognitive impairment?
Are you aware of any correlations of the scale
with biological markers?
In patients without PD
(Bagby et al., 2004).
Factor analysis produced general
depression and anxiety/agitation factors
(Bagby et al., 2004).
The 17-item version does not measure a
single dimension, implying that the
total score may not be a valid measure
of the severity of depression (Licht et
al., 2005).
Yes (Sartorius et al., 1980).
Yes (Sartorius et al., 1980).
Yes (Chemerinski et al., 2001;
Migliorelli et al., 1995)
Adequate
High validity for DSM-IV major
depression (Specificity= 0.89,
Sensitivity= 0.88, Positive Predictive
Value= 0.74, Negative Predictive
Value= 0.96, in (Leentjens et al., 2000),
and specificity= 0.99, and Positive
Predictive Value= 0.93 in Naarding et
al (2002).
Convergence with the Beck Depression
Inventory, The General Health
Questionnaire, and the Present State
Exam(Starkstein et al., 1990); and the
Montgomery-Asberg Depression Rating
Scale (Leentjens et al., 2000).
Yes (as demonstrated in Dutch,
Spanish, Italian, Taiwanese, German,
and Korean cultures, among others)
(Fetoni et al., 1999; Leentjens et al.,
2003d; Lemke, 2002; Liu et al., 1997;
Starkstein et al., 1998).
Yes (Starkstein et al., 1990).
Yes (Starkstein et al., 1990).
Yes (Brouwer et al., 2005; Isogawa et
al., 2005; Muck-Seler et al., 2002;
In patients with PD
Demonstrated to be sensitive to change
(change over time or to treatment)
In patients without PD
In patients with PD
Has the minimal clinically important change
and minimal clinically relevant incremental
difference been assessed?
In patients without PD
In patients with PD
Has this scale been assessed or used in
patients with PD? What are the clini- or
psychometric properties in this population?
Has the scale been translated and validated in
other languages?
Overall impression
Advantages and disadvantages
Neumeister et al., 2004; Rafter, 2001).
Yes (Hoogendijk et al., 1998)
(Frochtengarten et al., 1987; Kostic et
al., 1990; Kostic et al., 1996; Mellers et
al., 1995).
No PD: sensitive to change in drug trials
for depression.
PD: sensitive to change in drug trials for
depression (Ceravolo et al., 2000;
Dell'Agnello et al., 2001; Dragasevic et
al., 2002; Fregni et al., 2004; Lemke,
2002; Okabe et al., 2003; Rampello et
al., 2002; Steur and Ballering, 1997;
Tesei et al., 2000).
No PD: No.
PD: No
Yes, extensively (Starkstein and
Merello, 2002).
Psychometric characteristics as
described above.
Yes (most European and Asian
languages).
Advantages
The HAM-D has been in use
consistently for the past 40 years. It is
the most widely used and accepted
outcome measure for evaluating
depression severity (Guy, 1976).
It is the most commonly used
interviewer-rated outcome scale in
treatment studies (it has been used in
about 95% of RCT of SSRIs (Licht et
al., 2005)).
Large data sets have been collected.
It is more sensitive than the MADRS to
detect depression in PD, but the
difference may not be clinically relevant
(Leentjens et al., 2000).
It assesses frequent comorbid symptoms
of depression, such as anxiety and
somatic symptoms (Zimmerman et al.,
2005).
It is in the public domain, and has been
translated to most European and Asian
languages.
Semi-structured interviews have been
developed to improve the reliability of
the scale administration (Williams,
1988).
There are self-rated and over the
telephone-administered formats that
yield comparable results to the
interviewer-administered version (Mundt
et al., 1998).
Disadvantages
Does not fit well with DSM-IV/ICD-10
criteria for depression, and it is not a
diagnostic tool (Bech, 1993).
The incomplete coverage of the
diagnostic criteria for depression limits
its use as a screening and diagnostic
measure (Zimmerman et al., 2005).
Self-report questionnaires may be more
appropriate in clinical practice (Naarding
et al., 2002).
It may not provide a valid measure for
the severity of depression (Licht et al.,
2005).
Somatic symptoms of depression are
over-represented (Zimmerman et al.,
2005).
The incomplete coverage of the
diagnostic criteria for depression limits
its use as a screening and diagnostic
measure (Zimmerman et al., 2005).
Some items include multiple content
constructs, and some symptoms can be
rated on multiple items (Zimmerman et
al., 2005).
Lacks a consistent rating metric.
There are multiple versions of the scale.
Differential item weighing, with some
symptoms contributing more to the total
scores than others (Zimmerman et al.,
2005).
Which type of study is this scale very suitable
for and which one is it unsuitable (screening,
prevalence, aetiological (e.g. case-control or
genetic), treatment trial of PD or depression
medication, correlation with biological
markers or other scales, e.g. of parkinsonism,
clinical practice for diagnosis/screening). List
all
The HAM-D is most suitable for
assessing severity, change of severity
during treatment, and the study of the
phenomenology of depression (Leentjens
et al., 2003a; Leentjens et al., 2003b;
Leentjens et al., 2003c; Leentjens et al.,
2003d).
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Scale: Name
Are there several versions of
the scale? If so, which one
has been assessed?
Description of scale
(content,
number of items and
subscales,
number of answer options
(severity or frequency or
both)
Rater: Patient or caregiver or
clinician. If clinician-rated,
training for application
required?
Copyright or public domain?
How can the scale can be
obtained (address or
website)?
Montgomery - Ǻsberg Depression Rating Scale
(MADRS)
One version (Montgomery & Ǻsberg 1979)
The MADRS is a 10 – item rating scale that consists of 1
observation item and 9 question items. The items cover
all the DSM IV criteria of a major depressive episode,
with the exception of psychomotor retardation or
agitation. It is not possible to rate reversed vital
symptoms on the MADRS (such as hypersomnia and
increased appetite).
Most items rate severity of symptoms. Items 3 (inner
tension) and 6 (concentration difficulties) rate a
combination of frequency and severity. All items are
rated on a 7 point scale ranging from 0 (not present or
normal) to 6 (most severe symptoms). Only the even
numbers of the item scores (0,2,4,6) are anchored.
Uneven scores fall in-between anchor points.
(Montgomery & Ǻsberg 1979)
It is clinician-rated. Especially because of item no. 1
‘observed depression’ the rater should have some
clinical experience with depressive disorder. The rater
does not have to be a clinician or a mental health
professional. The authors of this scale found an interrater
agreement (kappa) of 0.93 to 0 .97 between ratings of
psychiatrists, psychiatric nurses and general practitioners
(Montgomery & Ǻsberg 1979).
Because of its publication in the British Journal of
Psychiatry the scale is formally copyrighted by this
journal (Montgomery & Ǻsberg 1979). In practice
however, the scale is widely used in clinical practice and
in research and generally considered public domain.
The scale was published in full as an appendix to its
original validation study (Montgomery & Ǻsberg 1979).
Webpage: e.g.
http://www.neurotransmitter.net/depressionscales.html
Scale properties
Please provide references for all statements or note if this is your personal judgement
Content
Face validity?
Face validity is good.
There is a large overlap with DSM IV criteria
for major depressive episode. (personal
judgment)
Is loss of pleasure included?
Loss of pleasure is included in item no. 8
‘inability to feel’, which is partly
operationalized as ‘reduced interest in the
surroundings, or activities that normally give
pleasure’ (personal judgment) (Montgomery &
Ǻsberg 1979)
Is the scale heavily weighted towards The scale has physical, emotional and cognitive
one aspect of depression? If so,
items. When compared to other observer rating
which?
scales, such as the Hamilton Depression Scale,
the MADRS has relatively few somatic items.
Does it exclude an important aspect of Psychomotor retardation or agitation, weight
depression? If so, which
loss, and reverse vital symptoms (hypersomnia,
increased appetite and weight gain) are not
included. (Montgomery & Ǻsberg 1979
Compatible with DSM IV or other
All DSM IV criteria are covered in the MADRS
depression criteria (compare content
items with the exception of psychomotor
to DSM IV, if formally assessed see
retardation or agitation. (Montgomery & Ǻsberg
also criterion validity below)?
1979)
Includes items on anxiety, psychosis
and cognition as a result of
depression?
Which areas are not covered?
Number/percentage of items that
overlap with symptoms of
Parkinsonism (energy, sleep, fatigue,
appetite, psychomotor
retardation/agitation)
Cognitive impairment (slowness of
thinking, clarity of thinking, attention,
m
concentration) Apathy (loss of
Anxiety is only included in item no. 3 ‘inner
tension’ which is operationalized as ‘feelings of
ill-defined discomfort, inner turmoil, mental
tension mounting to either panic, dread or
anguish’.
As far as psychosis is concerned, only moodcongruent delusions are included in item 9
‘pessimistic thoughts’.
As far as cognitive symptoms are concerned,
only concentration difficulties are included (item
no. 6) (Montgomery & Ǻsberg 1979)
Psychomotor retardation or
agitation(Montgomery & Ǻsberg 1979)
4 items overlap with parkinsonism: item no. 4
‘reduced sleep’, item no. 5, ‘reduced appetite’
and item no.6 ‘concentration difficulties’, item
no.7 ‘lassitude’. (Montgomery & Ǻsberg 1979).
One item pertains to cognition: concentration
difficulties
If apathy is defined to include ‘loss of interest’,
there is some overlap with item 8 ‘inability to
interest, loss of initiative)
feel’.
What is the time frame/is the time
frame appropriate (e.g. “during the
past week”)?
Are the symptoms of Recurrent Brief
Depressive Disorder captured?
There is no time frame specified for the rating of
symptoms (Montgomery & Ǻsberg 1979).
Use
Was it designed to measure severity
or to screen for depression?
Is there a cut-off score for diagnosis
of depression (in depression without
PD)?
Is this appropriate in depression with
PD (dPD)?
If not, why?
Has a different cut-off score for dPD
been suggested, and if so, is there
evidence to support it?
As no time frame is specified, it may yield
positive results of performed during an episode
of RBDD with no typical specification, which
does not allow differentiation from major
depression, and may lead to unreliability.
The criteria for the proposed DSM IV diagnosis
of ‘recurrent brief depression’(RBD) are the
same as for major depressive disorder, except
for the required minimum duration, which is two
days instead of 2 weeks. Criterium C of the
proposed diagnosis of RBD (presence of these
symptoms at least once a month for 12 months
and not associated with the menstrual cycle)
cannot be captured in the MADRS items.
(personal judgment)
It was designed to measure change in severity of
depressive symptoms during clinical trials with
antidepressants (Montgomery & Ǻsberg 1979)
Generally, the score ranges proposed by Snaith
et al (1986) are quoted: no depression 0 – 6;
minor depression 7 – 19; moderate depression
20 – 34; severe depression 35 – 60. In this
division, minor depression refers to less severe
depression and not to the proposed DSM criteria
for ‘minor depressive disorder’.
No. PD patients will tend to score higher
because of the number of MADRS items
overlapping with PD. This is reflected in the
average score of 8.7 (SD 5.1) in nondepressed
PD patients (Leentjens et al 2000)
Yes. In case of major depressive disorder cut-of
scores of 14/15 have been suggested for
screening purposes and 17/18 for diagnostic
purposes. Evidence comes from the validation
Has it been used to measure severity
or to screen for depression (in
depression without PD and dPD)?
Acceptability
Length
Ambiguities in instructions to
patient/rater
Ambiguities in rating anchors
study by Leentjens et al. 2000.
Slawek et al. (2003 a, 2003b) suggest a higher
cut-off of 19/20 for diagnostic purposes, not
backed by evidence in a PD population, based
on the cut-off score for moderate depression in
non-PD populations.
In non-PD patients: no evidence was found for
the use of the MADRS for screening purposes.
The MADRS is the second most used scale to
measure severity of depression in trials with
antidepressants (many references).
In PD patients it was used to screen for
depression in PD by Slawek et al. (2003a), and
Slawek et al (2003b). Leentjens et al. (2003)
have used the MADRS in a medication trial with
sertraline in depressed PD patients. Rektorova et
al (2003) have used the MADRS in a trial with
pramipexole and pergolide to treat depressive
symptoms in PD.
The interview to complete the 10 item scale
takes about 15 minutes
No. However, only the even scores are
‘anchored’ and well defined. (personal
judgment)
Appropriateness of questions for PD
population
Appropriate (personal judgment)
Applicability across PD and
depression disease stages mild –
moderate – severe?
No specific evidence found. Personal judgment:
good. Concentration difficulties and other
overlap items are likely to inflate the score in
advanced disease.
No. Although the time frame is not set and may
be decided by the user, two items require a
longer duration of time to be rated, namely items
4 ‘reduced sleep’ and 5 ‘reduced appetite’.
To my knowledge, no study has attempted to
limit the time frame to capture mood during ‘on’
or ‘off’ states in PD patients.
There is no formal manual, but the concise
instructions to the questions are clear.
Can it be used for “on” and “off” and
has this been done?
Clear instructions to raters
Clinimetric/psychometric properties
Metric flaws (floor and ceiling effects,
score distributions)?
Unknown; no evidence found. In 569 nondepressed people participating in a total of
10 studies, the mean MADRS score is 4.0
(SD 5.8) (Zimmerman et al, 2004).
The scale is unusual in that it has inbetween points, which are not anchored.
The effect on the linearity of the scale and
score distributions is unknown.
Reliability (internal consistency, interrater, In the original validation study, reliability
test-retest) of total or sub-scales and of
has been shown to be good with alpha’s
individual items
ranging from 0.89 – 0.97 in 106 depressed
in – and outpatients (Montgomery & Ǻsberg
1979).
Satisfactory internal consistency was also
reflected in the study of Davidson in 44
depressed inpatients, with item-total
correlations ranging from 0.12 to 0.84.
‘Reduced appetite’, ‘reduced sleep’ and
‘suicidal thoughts’ failed to correlate
suignificantly with the total score (Davidson
1986).
Interrater reliability for the total score in
several studies ranged from 0.76 to 0.95
(Montgomery & Ǻsberg 2000)
Validity: assessed – not assessed, good – not good (references); please also comment on
sample sizes
In depression without PD
Face or content validity
Face- and content validity are good
(personal judgment). This has not been
assessed as there is no formal measure for
these characteristics
Criterion validity (compared to
Concurrent validity with the Hamilton
gold-standard, e.g.
depression Scale was good in 106 depressed
DSM IV (SCID, SCAN,
in- and outpatients (Montgomery & Ǻsberg
systematic interviews) or
1979) Concurrent validity with the DSM IV
other criteria for diagnosis)
criteria for major depressive disorder was
good (Davidson 1986)
Construct validity (correlations
The same study showed a good concurrent
with other
validity with the HamD with a Spearman
convergent scales and divergent
correlation coefficient of 0.47 (Davidson
scales (which?);
1986).
factor analysis)
Factor analysis of the MADRS has been
performed by different groups. Some have
revealed three factors (Galinowski 2003,
Parker 2003), and one has found two factors
(Hammond 1998). Galinowski (1995) found
a three-factor structure prior to treatment in
137 depressed outpatients, explaining 55.5%
of the variance: depressive mood, somatic
symptoms and a restfactor. After treatment
only one factor was found, representing
Valid in ethnically and culturally
different
populations?
Valid in both genders and at all
ages?
Valid in patients with dementia or
significant
cognitive impairment?
In depression in PD (dPD)
Face or content validity
Criterion validity (compared to
gold-standard, e.g.
DSM IV (SCID, SCAN,
systematic interviews) or
other criteria for diagnosis)
Construct validity (correlations
with other
convergent scales and divergent
scales (which?);
factor analysis)
Valid in ethnically and culturally
different
populations?
Valid in both genders and at all
ages?
Valid in patients with dementia or
significant
cognitive impairment?
66% of the total variance.
In geriatric depression Parker et al (2003)
found a three factor structure in 225
depressed in- and outpatients, that explained
62% of the variance:
‘dysphoric/apathy/retardation’, ‘psychic
anxiety’, and ‘vegetative symptoms’
The study of Hammond (1998) in 100
physically ill medical inpatients revealed
that Cronbach’s alpha was 0.60 for the
unmodified scale. After deletion of three
items with poor inter-item correlations there
were two factors explaining 60% of the
variance: ‘anhedonia’ and ‘dysphoria’.
Yes (many references).
Yes (many references).
No specific evidence found. It has been used
and shown to be sensitive in depressed
patients older subjects with mild cognitive
deficits (Warren et al, 2001; Gabryelewicz
et al 2004).
Good (personal judgment)
Concurrent validity with the DSM IV
criteria for major depression, assessed with
the SCAN was good in a sample of 66
outpatients. At a cut-off of 14/15, the
sensitivity for major depressive disorder
was 0.88 and the specificity 0.89 (Leentjens
et al 2000)
No evidence found
No evidence found
No evidence found
No evidence found
Are you aware of any correlations of the
scale with biological markers?
In patients without PD
In patients with PD
Non-PD patients: no evidence found
PD patients: no
Demonstrated to be sensitive to change
(change over time or to treatment)
In patients without PD
In patients with PD
In patients without PD: Yes. The
MADRS was designed to be sensitive to
change, this was established by 1)
selecting those items of the
Comprehensive Psychopathological
Rating Scale (CPRS, 65 items) that were
most sensitive to change of depressive
symptoms, and 2) by providing a 7 point
rating scale (instead of fewer points).
Sensitivity to change was demonstrated in
the original validation study in 106
depressed in- and outpatients (non-PD)
(Montgomery & Ǻsberg 1979).
A retrospective study that directly
compared the MADRS and HamD in 139
depressed outpatients by Kahn et al.
(2004) showed that in pharmacological
depression trials the MADRS was more
sensitive to change than the HamD.
In PD patients it has not been studied,
though one study that used the MADRS
in the treatment of depressive disorder in
PD has clinically shown sensitivity to
change in 12 PD patients with major
depressive disorder (Leentjens 2003a). In
an open study with pramipexole and
pergolide in the treatment of depressive
symptoms, it also showed sensitivity to
change in 41 mild to moderately
depressed PD patients, not checked for
DSM criteria for MDD (Rektorova et al,
2003).
Non-PD patients: not to my knowledge.
PD patients: no
Has the minimal clinically important change
and minimal clinically relevant incremental
difference been assessed?
In patients without PD
In patients with PD
Has this scale been assessed or used in
patients with PD? What are the clini- or
psychometric properties in this population?
Yes. For the following purposes:
Screening for depression in PD: Slawek
et al, 2003a, Slawek et al, 2003b
Treatment of depression in PD: Leentjens
et al, 2003a, Rektorova et al, 2003
Phenomenological study of depressionin
PD: Leentjens et al, 2003b
Has the scale been translated and validated in It has been translated and validated in
other languages?
many languages, including Dutch,
Spanish and Japanese. Some validation
studies can be traced in Pubmed, but
others will most likely have been
published in national journals of the
respective countries, that are not included
in Pubmed.
Overall impression
Advantages and disadvantages
Advantage: the scale has been studied in
PD and was found to have good
concurrent validity with the DSM criteria,
and with appropriate cut-off can be used
for screening and diagnostic purposes.
Moreover, it was designed to measure
change of depression severity and has
been proven sensitive to change in PD.
Disadvantages are that is an observer
rated scale and requires some (though not
extensive) clinical experience with
depression.
Which type of study is this scale very
It is suitable for screening and diagnostic
suitable for and which one is it unsuitable
purposes when the appropriate cut-off
(screening, prevalence, aetiological (e.g.
scores are used. It is suitable for
case-control or genetic), treatment trial of PD medication trials in PD. It is also useful to
or depression medication, correlation with
study the phenomenology of depression
biological markers or other scales, e.g. of
in PD. It may be suitable for other types
parkinsonism, clinical practice for
of study as well (personal judgment)
diagnosis/screening). List all
References
Davidson J, Turnbull CD, Strickland R, Miller R, Graves K. The Montgomery - Ǻsberg
Depression Scale: reliability and validity. Acta Psychiatrica Scand 1986; 74: 544-548.
Gabryelewicz T, Styczynska M, Pfeffer A, Wasiak B, Barczak A, Luczywek E,
Androsiuk W, Barcikowska M. Prevalence of major and minor depression in elderly
persons with mild cognitive impairment--MADRS factor analysis. Int J Geriatr
Psychiatry. 2004;19:1168-72
Galinowski A, Lehert P. Structural validity of the MADRS during antidepressant
treatment. Int Clin Psychopharm 1995;10:157-161
Hammond MF. Rating depression severity in the elderly physically ill patient: reliability
and factor structur of the Hamilton and Montgomery - Ǻsberg Depression Rating Scales.
Int J geriat Psychiat 1998; 13: 257-261.
Leentjens AFG, Verhey FRJ, Lousberg R, Spitsbergen H, Wilmink FW. The validity of
the Hamilton and Montgomery-Åsberg Depression Rating Scales as screening and
diagnostic tools for depression in Parkinson’s Disease. Int J Geriatr Psychiat
2000;15:644-9.
Leentjens AFG, Marinus J, Van Hilten JJ, Lousberg R, Verhey FRJ. The contribution of
somatic symptoms to the diagnosis of depressive disorder in Parkinson’s disease: a
discriminant analytic approach. J neuropsychiat Clin Neurosc 2003;15:74-77.
Leentjens AFG, Vreeling FW, Luijcks GJ, Troost J. SSRIs in the treatment of depression
in Parkinson’s disease. Int J Geriat Psychiat 2003;18:1-3.
Montgomery SA, Ǻsberg M. A new depression scale designed to be sensitive to change.
Brit J Psychiat1979;134:382-389.
Montgomery SA, Ǻsberg M. Montgomery-Ǻsberg Depression Rating Scale (MADRS).
In: Handbook of Psychiatric Measures. American Psychiatric Association, Washington
DC., 2000.
Parker RD, Flint EP, Bosworth HB, Pieper CF, Steffens DC. A three-factor analystic
model of the MADRS in geriatric depression. Int J Geriat Psychiat 2003;18:73-77.
Rektorova I, rector I, Bares M, Dostal V, Ehler E, Fanfrdlova Z, Fiedler J, Klajblova H,
Kulist’ak P, ressner P, Svatova J, Urbanek K, Veliskova J. Pramipexole and pergolide in
the treatment of depression in Parkinson’s disease: a national prospective randomized
study. Eur Neurol 2003; 10: 399-406.
Slawek J, Derejko M. depression and dementia: the most frequent non-motor symptoms
of Parkinson’s disease. Neurol Neurochir Pol 2003; 37(suppl 5):103-115.
Slawek J, Derejko M, Lass P. Depression in patients with Parkinson’s disease. Neurol
Neurochir Pol 2003; 37: 351-364.
Snaith RP, Harrop FM, Newby DA, Teale C. Grade scores of the Montgomery - Ǻsberg
Depression and the Clinical Anxiety Scales Brit J Psychiat 1986; 148: 599-601.
Taylor WD, Wagner HR, Steffens DC. Greater depression severity associated with less
improvement in depression-associated cognitive deficits in older subjects. Am J Geriatr
Psychiatry. 2002;10:632-5.
Scale: Name
Beck Depression Inventory
Are there several versions of the scale? If so,
which one has been assessed?
BDI (Beck AT, Ward CH, Mendelson
M, Mock J, Erbaugh J. An inventory
for measuring depression. Arch Gen
Psychiatry 1961 June;4:561-71.)
An abbreviated version of the BDI,
containing 13 items was published in
the Early Clinical Drug Evaluation
Programme (ECDEU) assessment
maual (Guy W. ECDEU assessment
manual for psychopharmacology –
revised (DHEW publication no. ADM
76-338). U.S. Department of Health,
Education and Welfare, Public Health
Service, NIMH Psychopharmacology
Research ranch, Division of Extramural
Research Programs, 1976.
BDI-IA (Beck AT, Steer RA. Beck
Depression Inventory: manual (revised
edition). NY Psychological
Corporation; 1978). In this edition
duplicate severity descriptors were
eliminated and certain items were
reworded. In addition, the time frame
was lengthened from ‘right now’ to
‘the last week, including today’.
BDI-II (Beck, Steer, & Brown, NY
Psychological Corporation; 1996). In
this modification items are phrased to
reflect DSM criteria more closely, and
in simpler wordings. In addition, the
time frame was extended to include
‘the last two weeks’.
Beck Depression Inventory® FastScreen (BDI®-FastScreen)
Aaron T Beck, Robert A Steer and
Gregory K Brown, NY Psychological
Corporation; 2000)
The version assessed was BDI-IA
Description of scale
(content,
number of items and subscales,
number of answer options (severity or
frequency or both)
Self-rating instrument assessing the
existence and severity of depressive
symptoms. It consists of 21 items rated
on a four point scale ranging from 0
(symptom not present or least severe)
to 3 (most severe). Thus, the total score
ranges from 0 to 63, with increasing
scores representing increasing severity
of depressive symptoms (Beck et al.,
1961).
Rater: Patient or caregiver or clinician. If
clinician-rated, training for application
required?
Patient-rated instrument
Copyright or public domain?
Copyright owned by Harcourt
Assessment - The Psychological
Corporation, 555 Academic Court, San
Antonio, TX 78204-2498. Phone 800211-8378.
This tool can be purchased at the
address above, or by going to
www.psychcorp.com.
How can the scale can be obtained (address or
website)?
Scale properties
Please provide references for all statements or note if this is your personal judgement
Content
Face validity?
Face validity is readily apparent. Most of the BDI
items correspond with DSM criteria for depression or
other established symptoms of depression (personal
judgment)
Is loss of pleasure included?
Yes, item 4 refers to ‘lack of satisfaction’; item 21
refers to change in interest in sex
Is the scale heavily weighted
Although all symptoms domains are represented, it
towards one aspect of
tends to be weighted towards psychological symptoms
depression? If so, which?
of depression, which is represented by 8 out of 21
items: items 2 (pessimism), 3 (sense of failure), 5
(guilt), 6 (sense of punishment), 7 (disappointment), 8
(selfblame), 9 (suicidality), 14 (body image), 20
(somatic preoccupation). These items refer to DSM
criteria 7 and 9.
Cognition is underrepresented by only 1 item: 13,
(indecisiveness), which refers to criterium 8 of the
DSM) (Beck et al, 1961).
Does it exclude an important
Anxiety symptoms, psychomotor agitation or
aspect of depression? If so,
retardation, and concentration difficulties are not
which
included.
Compatible with DSM IV or
other depression criteria
(compare content to DSM IV, if
formally assessed see also
criterion validity below)?
Corresponding DSM criteria and BDI items:
1. depressed mood: item 1 (mood)
2. diminished interest or pleasure: items 4 (lack of
satisfaction) and 12 (social withdrawal)
3. appetite, weight: items 18 (appetite) and 19
(weight)
4. sleep: item 16 (sleep)
5. psychomotor agitation or retardation: not
represented
6. fatigue, loss of energy: items 15 (work) and 17
(tiredness)
7. worthlessness, guilt: items 3 (sense of failure),
5 (guilt), 6 (sense of punishment), 7
(disappointment), 8 (self blame), 14 (body
image), 20 (somatic preoccupation).
8. cognitive symptoms: item 13 (indecisiveness).
Concentration difficulties not represented.
9. suicidality: item 9 (suicidality)
The time frame (past few days) is different from the
time frame of the DSM (two weeks)
Includes items on anxiety,
psychosis and cognition as a
result of depression?
Which areas are not covered?
Number/percentage of items
that overlap with symptoms of
Parkinsonism (energy,
sleep, fatigue,
appetite, psychomotor
retardation/agitation)
Cognitive impairment
(slowness of
thinking, clarity of
thinking, attention, m
BDI was revised to BDI-II in 1996 to correspond
better with DSM-IV criteria
No item on anxiety is included.
Although psychosis is not included in a specific item,
mood-congruent delusions (delusions of guilt,
hypochondrial delusions, etc) are captured by some of
the cognitive items such as items 3, 5, 7, 8, 14, and 20.
Cognition is poorly represented by only one item, 13
(indecisiveness)
The BDI does not include items for psychomotor
agitation or retardation, anxiety, concentration
difficulties, and loss of energy. Three of these were
added to BDI-II: agitation, concentration difficulties
and loss of energy.
Four items out of 21 correspond with vegetative
symptoms of PD: 15 (work), 16 (sleep), 17 (tiredness),
18 (appetite)
Would you consider item 19 (weight) ?: PD patients
may have weight problems
The BDI includes only one cognitive item: 13
(indecisiveness)
In BDI-II item 15 (concentration) was added
concentration)
Apathy (loss of interest,
loss of initiative)
What is the time frame/is the
time frame appropriate (e.g.
“during the past week”)?
Are the symptoms of Recurrent
Brief Depressive Disorder
captured?
Use
Was it designed to measure
severity or to screen for
depression?
Is there a cut-off score for
diagnosis of depression (in
depression without PD)?
Two items out of 21 represent apathy: 4 (lack of
satisfaction) and 12 (social withdrawal)
In the original publication no time frame is mentioned.
The instrument was ‘presented in such a way as to
elicit the patient’s attitude at the time of the interview’
(Beck et al., 1961). In the BDI-IA revision, the time
frame was extended to 1 week; in the BDI-II, the time
frame was again extended, to 2 weeks, in order to
more closely follow the DSM criteria for MDD. Apart
from this advantage, extending the time frame may
make the instrument less sensitive to change.
No, since the defined time frames do not correspond
with the time frame of two days, required for the
diagnosis ‘brief recurrent depression’.
BDI was constructed as a test for the intensity of
depressive symptoms in healthy adult patients who
received psychoanalytic psychotherapy as treatment for
depression, and to measure a change in this intensity
over time. Items were selected by the senior author of
the original study, from observations and records of the
characteristic attitudes and symptoms of depressed
patients (Beck et al., 1961).
The usual scoring guides proposed by Beck et al.
(1988), based on normative data are:
 0 - 10: no or minimal depression
 10-18: mild to moderate depression
 19-29:moderate to severe depression
 >29: severe depression
(Beck et al, 1988)
However, Beck et al. warn against a rigid adherence to
set cutting points, and state that the specific cut-off
depends on the characteristics of the patients used and
the purpose for which the inventory is administered.
Steer et al (1986) proposed other cut-offs:
 0- 4: no or minimal depression
 5-13: mild depression
 14-20: moderate depression
 >20: severe depression
Cut-offs around 10 are widely used: 10/11 (Moran and
Lambert, 1983); 13/14 for psychiatric patients, 9/10 for
medical patients (Beck et al, 1974); 12/13 (Lasa et al.,
2000).
For diagnostic purposes, Rudd et al. (1995) advise a
cut-off of 17/18.
The most recent guidelines suggest the following cutoffs:
- 0-9 minimal depression
- 10 – 16 mild depression
- 17-29 moderate depression
- 39-63 severe depression
(Beck et al., 2000)
Is this appropriate in
depression with PD (dPD)?
If not, why?
Has a different cut-off score
for dPD been suggested, and if
so, is there evidence to support
it?
Has it been used to measure
severity or to screen for
depression (in depression
without PD and dPD)?
Acceptability
Length
Ambiguities in instructions to
patient/rater
No. Due to a number of items that overlap with
symptoms of PD, it may be expected that PD patients
will score higher than healthy depressed people.
In 53 non-demented outpatients with PD, Leentjens et
al (2000) assessed the concurrent validity of the BDI
with the DSM IV criteria for MDD. They suggest a cutoff of 8/9 for screening purposes (sensitivity 0.92,
specificity 0.52) , a cut-off of 13/14) for
dichotomization (sensitivity 0.67, specificity 0.88, and a
cut-off of 16/17 for diagnostic purposes (sensitivity
0.42, specificity 0.98). No attempt was made at defining
different levels of severity of depression.
Visser et al. (submitted) suggest an optimal cut-off of
13/14 in 92 PD outpatients (sensitivity 0.71 and
specificity 0.90).
In non-PD patients: BDI is one of the 10 most used
instruments in the clinical practice (Watkins et al,
1995), it has been used both to measure severity and to
screen for depression in more than 2000 studies (Steer
et al, 1986; Richter et al, 1998).
In PD patients: it has been used to screen for
depression (Tandberg et al, 1996; Schrag et al, 2001,
Shulman et al, 2001; Shulman et al 2002), to measure
severity (Huber et al; 1990; Brown et al. 1988) and
response to pharmacological or surgical treatment
(Funkiewic et al, 2004; Troster et al. 2003; Avila et al
2003; Hauser et al, 1997, Dell’Agnello et al, 2001)
Although the initial instrument was meant to be read
aloud by an interviewer who would record the subjects
choices, the scale has subsequently been used primarily
as a self-report scale. It’s length is acceptable: it takes
approximately 5-10 minutes to complete the BDI. Oral
administration may require 15 minutes (Beck et al
2000).
Instructions are clear
Some ambiguities are evident in the anchors of some
Ambiguities in rating anchors
items, in which formulations use different phrasings for
different severities of that specific symptom:
Item 4: ‘enjoy’ ‘satisfaction’
Item 7 ‘disappointed’ ‘disgusted’ ‘hate’
Item 8: ‘feeling’ ‘weakness’ ‘mistakes’ ‘blaming’
Appropriateness of questions
for PD population
Appropriate.
Applicability across PD and
depression disease stages mild
– moderate – severe?
Can it be used for “on” and
“off” and has this been done?
Yes (Huber et al, 1990; Brown et al.1988)
Clear instructions to raters
Yes. The original scale was designed to measure the
state of mood of the patient at the time of the interview.
When the time frame is defined as such, the scale can
be used to quantify state-dependent mood states, as has
been done by Troster et al., 2003.
Yes
Clinimetric/psychometric properties
Metric flaws (floor and ceiling effects,
score distributions)?
Reliability (internal consistency,
interrater, test-retest) of total or subscales and of individual items
In non-PD patients:
In the control group of the study by Visser et al
(submitted), consisting of 104 adults, not
suffering from PD, 14 of 21 items showed floor
effects, and none showed ceiling-effects.
In PD patients:
Visser et al (submitted) has shown that in 277
PD outpatients, five items of the BDI exhibited
floor effects: 3 (sense of failure), 5 (guilt), 6
(sense of punishment), 7 (self-hate), and 9
(suicidality). None of the items exhibited
ceiling effects.
In non-PD patients
Internal Consistency
BDI has high internal consistency both in
psychiatric and non-psychiatric patients.
 Beck (1961) used two methods for evaluating
internal consistency. In a Kruskal-Wallis
Non-Parametric Analysis of Variance a
significant relationship of all items o the total
BDO score was demonstrated (p<0.001;
N=200); 2). In a split-half item analysis
revealed an alpha of 0.86, which rose to 0.93
with a Spearman-Brown correction.
 A meta-analysis of 25 studies by Beck et al
(1988) the following alpha’s were found: for
psychiatric patients (9 studies) 0.76-0.95; for
student populations (9 studies) 0.82 – 0.92;
for nonpsychiatric, nonstudent populations (5
studies) 0.73-0.90. For 248 consecutive
admission to the Centre for Cognitive
Therapy in 1978/79, alpha was 0.86 (Beck et
al 1988, Beck et al 2000).
Consistency ratings achieved by various patient
diagnostic groups were: MDD, single episode,
alpha = 0.80; MDD recurrent episode, alpha =
0.86; dysthymic disorder, alpha = 0.79; alcohol
abuse or dependence, alpha = 0.86; heroin
abuse or dependence, alpha = 0.88 (Beck et al
2000).
Inter-rater reliability
In the original paper the scale was administered
by a trained interviewer and the patient had a
copy of inventory; an indirect test of inter-rater
reliability was done (Beck et al, 1961)
However, since the BDI is usually selfadministered, inter-rater reliability cannot be
assessed. (Enns et al, 1998; Schotte et al,1997;
Powell et al, 2003; Lasa et al,2000)
Test-Retest
Beck (1970) reported test-retest correlations at
2-5 weeks of 0.90 (n=38).
According to a meta-analysis, the test-retest
reliability was shown to be dependent on the
temporal distance between the measurements
and the composition of the sample: Pearson
correlations ranged from 0.48 to 0.86 in
psychiatric patients and from 0.60 to 0.83 in
non-psychiatric patients (Beck et al, 1988)
Studies using the origininal version of the BDI,
with a time frame of ‘right now’ and retesting
1-6 hours later sgowed r = 0.83 for retesting
after 1 – 6 hours and r = 0.81 for retesting after
4 – 6 hours in a student population (Beck et al
2000)
In patients with PD
Internal consistency
In a study with 119 PD patients and 76
controls, Cronbach’s alpha was shown to be
0.88 (Levin et al., 1988).
Visser et al. also report an alpha of 0.88 in 277
PD patients and 112 controls. Item-total
correlations ranged from 0.26 to 0.71 (Visser et
al, submitted).
Inter-rater reliability
Not found
Test-Retest reliability
Visser et al. (submitted) report an intra-class
correlation coefficient of 0.89. For individual
items, the reliability ranged from 0.31-0.86.
Validity: assessed – not assessed, good – not good (references); please also comment on
sample sizes
In depression without PD:
Face or content validity
Face validity is good. Most of the BDI items
correspond with DSM criteria for depression or
other established symptoms of depression
(personal judgment) (see above)
Criterion validity (compared to  A correlation coefficient of 0.33 with DSMgold-standard, e.g. DSM IV (SCID,
III diagnosis of depression was reported
SCAN, systematic interviews) or
(Hesselbrock et al., 1983)
other criteria for diagnosis)
 In a group of 150 neurological outpatients
the best cutoff for dichotomization of
patients with and without DSM III R major
depression of was 20. The diagnostic
performance of the BDI for major depressive
disorder was quite satisfactory at a cutoff
score of 29, contrary to dysthymia, in which
the discriminating power of BDI was low
(Lykouras et al, 1998).
 In 307 young adults, Rudd et al (1995)
found a fair concurrent validity with the
DSM III R diagnosis of MDD at different
cut-off scores, e.g. a specificity of 88.36% at
a cut-off of 18.
Construct validity (correlations
with other
convergent scales and divergent
scales (which?);
factor analysis)
Construct Validity
There are numerous papers to support the
construct validity of the BDI.
Some studies have compared the BDI score to
clinical ratings of depression:
 In the original paper the authors concluded
that the BDI correlates well with
psychiatrists’ assessment of the clinical
depth of depression (r=0.65 in n=226 and
r=0.67 in n=183, in both cases psychiatric
outpatients) (Beck et al 1961).
 A meta-analysis of 14 more studies reported
correlations between BDI and clinical
ratings of 0.55 to 0.96, with a mean of 0.72
for psychiatric patients, and of 0.55 to 0.73
(mean 0.60)for non-psychiatric patients.
(Beck et al, 1988)
BDI has been extensively compared to other
depression and psychiatric scales:
- A meta-analysis of correlation between
concurrent measures of depression and BDI
showed the following results.
 BDI vs HRSD (r=0.61 to 0.86) (5
studies)
 BDI vs SDS (r=0.76) ) (8 studies)
 BDI vs MMPI (r=0.76) (7 studies)
 BDI vs MAAC (r=0.59 to 0.66) (3
studies)
 BDI vs HSC (r=059 to 0.66) (3 studies)
(Beck et al, 1988)
- BDI vs STAI-T : r=0.66 (Andrade, et al 2001)
- Another meta-analysis of correlation between
concurrent measures of depression and BDI
showed the following results.
 BDI vs MMPI-D (r=0.59 to 0.70, n=65
to 101) (3 studies)
 BDI vs SDS (r=0.60 to 0.83 , n=30 to
101) (3 studies)
 BDI vs Hamilton-D (r=0.41 to 0,75.,
n=32 to 153) (3 studies)
 BDI vs STAI-T (r=0.60 to 0,82, n=80 to
134) (4 studies)
 BDI vs STAI-S (r=0.60 to 0,82, n=126 to
443) (3 studies)
(Richter et al 1998)
- In a study 137 patients, with DSM-III-R
diagnosis of major depression, the
correlation coefficient between BDI and
BAI was 0.62 (Enns et al, 1998)
- in the test manual (Beck et al 1993) it is
stated that in psychiatric patients,
correlation coefficients between the BDO
and HamD score range from 0.61 – 0.86,
with a mean of 0.73 (
Factor Analysis
According to the review of 13 factor analytic
studies (Beck et al, 1988), BDI has been found
to include three to seven factors, depending on
the method of factor extraction. These include
three intercorrelated factors:
 Negative attitude toward self (or suicide)
 Performance impairment
 Somatic disturbance
When second-order factors are extracted, a
single overall depression factor emerges (Beck
et al, 1988; Shaver & Brennan, 1991; Brown,
et al. 1995, n=157; Enns et al 1998, n=137)
Another review showed different factor
solutions (Schotte et al, 1997):
-A 2-Factor analysis, accounting for the 45% of
the variance, outlined a first factor represented
by the cognitive items and a second one
including the somatic items.
- A 3-Factor solution explained 51% of the
total variance: the first factor represented
several aspects of depressive symptomatology,
the second factor reflected the self-denigratory
cognitive items, and the last factor was labelled
“somatic complaint”.
Discriminant Validity
BDI was shown to have good discriminant
validity. In particular it is able to discriminate:
 between major depression and dysthymic
disorder (Steer et al 1987 n=277; Martinsen
et al 1995 n=117)
 psychiatric patients from non-psychiatric
patients (Groth-Marnat, 1990)
Moreover patients with a positive diagnosis of
a DSM III(-R) personality disorder were shown
to have significantly higher BDI score (n=338)
(Schotte et al, 1997)
Valid in ethnically and culturally BDI is widely used and validated in numerous
different
languages and populations: from Western
populations?
populations to Arabs, from Portuguese to
Japanese, etc. Specific cross-cultural
evaluations argue that biased measurements
might occur due to cultural differences,
although the trans-cultural validity of cognitive
approaches to depression is accepted.
 BDI total scores were shown to be higher for
50 Egyptian than for 45 German depressed
inpatients, presumably due to language
performance ("tendency to hyperbole")
(Rader et al 1990; Rader et al 1991).
 In a sample of 208 community Chinese
people living in the city of Sao Paulo, Brazil,
good internal consistency (Cronbach's alpha
0.82) and high discrimination of depressive
symptoms (75-100%) were observed. Factor
analysis extracted two factors for the total
sample and each gender: cognitive-affective
dimension and somatic dimension. (Wang et
al 2005).
 The Arabic version of BDI, which was
originally validated in Saudi Arabia, was
suggested to be adapted dialectically for
other Arab-speaking regions (West 1985)
 Students from South Asian and South
European ethnic backgrounds were shown to
score higher on the BDI and were also more
likely to be classifiable as mildly depressed
than those from either East European or
Anglo-Celtic backgrounds (Dion et al 1990)
 Regardless of level of depression, Latinos
were shown to be more likely to endorse
items reflecting tearfulness and punishment,
and less likely to endorse inability to work
(Azocar et al 2001).
Valid in both genders and at all
ages?
The scale was applied to both genders and
populations of different ages. It was shown to
be valid at different ages. A differential factoranalytical structure was observed with respect
to gender.
Validity and gender:
 A confirmatory factor analysis did not
support the validity of a two-factor model
(namely cognitive-affective and somatic
factors) in two samples of patients being
treated for alcohol dependence (N(1) = 243,
N(2) = 148) and one clinical sample of
patients admitted to an acute psychiatric
ward because of an act of deliberate selfharm (N(3) = 144). . Gender-specific
findings indicated a better fit of the model in
male samples (Dunkel et al 2002).
In general, women score higher on total BDI
scores (Dion et al 1990; Jolly et al 1994).
Valid in patients with dementia
or significant
cognitive impairment?
Validity and age:
 BDI was shown to be reliable and valid in a
sample of children (Steer et al 2000)
 BDI was shown to be able to discriminate
between 66 depressed and 52 non-depressed
hospitalized adolescents [Carter et al 1996].
Similar findings were confirmed in a sample
of 65 psychiatric hospital adolescent
inpatients and 49 secondary school students
(Barrera et al 1988). In this study a BDI
screening score of 16 resulted in 100%
sensitivity and 93.2% specificity. Ambrosini
(1991) also validated the BDI in a sample of
122 outpatient adolescents.
 BDI was shown to be internally consistent
(Cronbach’s alpha=0.92) in a sample of 56
female and 44 male psychiatric inpatients
whose ages ranged from 12 to 17 years old.
(Krefetz et al 2002)
 Lightfoot et al. (1985) and Burkhart et al.
(1984) validated the BDI in 204 and 50
university students respectively.
 BDI was shown to be reliable and valid in a
sample of 54 older adults diagnosed with
generalized anxiety disorder, 22 of whom
were diagnosed with a coexistent depressive
disorder (Snyder et al 2000)
 The short form of BDI was shown to be
valid when applied to elderly subjects
(Foelker et al 1987)
In patients without PD:
BDI seems to be applicable and valid in
patients with significant cognitive impairment:
 In 120 subject with mental retardation:
Powell [2003] concluded that BDI has
clinical validity. In fact the scale showed
high internal consistency (Cronbach’s
alpha=0.86); factor analysis confirmed the
presence of the underlying dimension of
depression.
 BDI showed significantly different scores
among three groups of first-ever stroke
patients, namely major depressive disorder,
minor depressive disorder, and no
neuropsychiatric disorders. (Spalletta et al
2005; n=200)
 BDI showed good internal consistency and
reliability when rated by caregivers of 76
patients, diagnosed with both depression and
Alzheimer’s disease (Logsdon et al. 1995).
In PD patients:
No study has looked specifically into this issue,
but in a sample of 97 PD patients, self-reported
impairment of cognitive function and the
feeling of stigmatization accounted for > 50%
of the variance of BDI scores (Schrag et al.,
2001).
In depression in PD (dPD)
Face or content validity
Good. Almost all DSM items are represented, as
well as some other items that are established
symptoms of depression (personal judgment).
The BDI, including somatic items, is considered
a measure of depression in PD patients (Levin et
al., 1988).
Criterion validity (compared
Leentjens et al (2000) found a fair concurrent
to gold-standard, e.g. DSM IV
validity with the DSM IV criteria of depression.
(SCID, SCAN, systematic interviews) At the cut-off recommended for screening (8/9),
or
other criteria for diagnosis) sensitivity was 0.92 and specificity 0.52, while at
the cut-off recommended for diagnosis (16/17)
sensitivity was 0.42 and specificity 0.98.
Visser et al (submitted) show that the mean total
BDI score differentiates well between nondepressed PD and depressed PD (p<0.001), and
not between non-depressed PD and nondepressed non-PD
Construct validity
Not found
(correlations with other
convergent scales and
divergent scales (which?);
factor analysis)
Valid in ethnically and
 The BDI has been translated and validated in a
culturally different
large number of languages, including Asian
populations?
and African countries (see below).
Valid in both genders and at
all ages?
Valid in patients with dementia
or significant
Not found
No specific validation study has been found for
PD patients with significant cognitive
cognitive impairment?
Are you aware of any
correlations of the scale with
biological markers?
In patients without PD
In patients with PD
impairment.
In patients without PD
Relationship with the outcome of the Dexamethasone
Suppression TEST (DST), which is considered as a
biological state-marker for major depression (Maes et al,
1986 ) Higher BDI scores predict delayed recovery of
increased epinephrine release after acute psychological
stress in healthy women (Gold et al, 2004)
In patients with PD
Patients with PD and hyperhomocysteinemia
are more likely to show high BDI scores compared with
normohomocysteinemic patients (n=96) (O'Suilleabhain
et al, 2004).
A significant correlation of beta-CIT uptake with the
BDI score was found in 33 patients with a clinical
suspicion of Parkinson’s disease (Eising et al, 1997)
Demonstrated to be sensitive
to change (change over time
or to treatment)
In patients without PD
In patients with PD
Has the minimal clinically
important change and
minimal clinically relevant
incremental difference been
In patients without PD
In the original study, 38 depressed inpatients were rated
again after 2 to 5 weeks. Without formal statistical
analysis it is reported that 33 patients improved and
showed a reduced BDI score (Beck et al, 1961).
Sensitivity to therapeutic change in long-term intervals
of several weeks was also confirmed in another sample
of 103 psychiatric inpatients (Richter et al., 1997).
In 20 patients with a depression in remission after
treatment with an SSRI or cognitive therapy, differential
relapse of depressive mood during acute tryptophan
depletion in the SSRI treated group could be
demonstrated using the BDI (O'Reardon et al. 2004).
In patients with PD
No specific validation study on BDI sensitivity to change
(over time or treatment) has been found.
Clinically, sensitivity to change was demonstrated in a
small open study on nefazodone, where depressed
patients with PD were randomly assigned to 2
therapeutic groups: nefazodone (n = 9) or fluoxetine (n =
7). BDI scores significantly improved within each group
(P < 0.001), with no significant differences between
treatment groups (P = 0.97). (Avila et al., 2003)
In patients without PD
No. In the original paper, the authors concluded that BDI
reflected minor changes since its range was much greater
than the clinic rating scale. In 33 of 38 cases
assessed?
In patients without PD
In patients with PD
Has this scale been assessed
or used in patients with PD?
What are the clini- or
psychometric properties in
this population?
improvement could be demonstrated (Beck et al, 1961).
In patients with PD
Visser et al (submitted) used their test-retest data of 121
PD patients to calculate the smallest real difference
(SRM), which was 3.3 (5% of the maximum score).
BDI is used in a number of studies (including at least one
randomized controlled trial) in PD patients. Validation
has been performed in such population. Here follows the
list of psychometric properties of BDI in PD patients:
Criterion Validity
When SCID and BDI were administered to 53 nondemented PD patients, maximum discrimination was
obtained with a BDI cut-off score of 13/14, although the
authors concluded that a single cut-off score on the BDI
to distinguish non-depressed from depressed patients
with PD is not feasible (Leentjens et al 2000).
Construct Validity
A number of comparisons between BDI and other
depression scales in PD patients has been published. A
good correlation is generally observed:
 In a sample of 30 PD male patients the correlation
coefficient between BDI and HAM-17 was r = 0.69 (P
= 0.001) (Fernandez et al, 2001).
 A comparison of BDI with Hamilton rating scale,
MADRS, CES-D has been performed (Mauduit et al
2000).
 Hamilton rating scale for depression and BDI showed
a similar trend in PD patients under treatment for
depression (Fregni et al 2004).
 BDI and PDQ-39 have high correlation in PD patients
(r=0.73; p<0.0001; n=67) (Harrison et al, 2000).
Factor Analysis
Two subscales were proposed on the basis of face
content, namely somatic symptoms and non-somatic
symptoms. This structure was not tested with statistical
analyses (Levin et al., 1988). A single overall depression
analytic factor was found in PD patients (Levin et al.,
1988). This is in agreement with the findings of factor
analysis applied to depressed non-PD patients [see
above]
.
Discriminant Validity
BDI showed statistical differences between PD patients
and other populations:
 In a sample of 119 PD patients and 76 healthy
controls, PD patients reported higher levels of BDI
scores than controls (p<0.001). However when factor
analysis was performed in each group factor loadings
were similar (Levin et al., 1988).
 45 PD subjects obtained significantly higher BDI
scores than 24 disabled controls. Moreover PD
subjects scored significantly higher than disabled
controls on BDI items grouped to reflect cognitiveaffective and somatic depressive symptoms (Ehmann
et al 1990).
Has the scale been translated
and validated in other
languages?
BDI has been translated into the following languages
(Dianne et al 2002):
Country
Number of
Resp.
225
691
2140
100
217
285
Australia
Bulgaria
Canada
China
Denmark
Finland
Germany
42
West
Greece
37
Iceland
187
India
490
Iran
405
Ireland
359
Israel
574
Italy
445
Kuwait
274
Netherlands
359
New Zealand
844
Nigeria
180
Norway
100
Spain
1524
Sweden
3913
United
4481
Kingdom
USA
5456
Hong-Kong
2780
Total mean
26108
weighted by sample size.
BDI
Samples
3
1
13
1
1
4
Mean
7.57
9.14
8.85
6.68
5.00
2.59
SDa
6.50
—
5.84
4.18
0.40
1.17
Alphaa
—
—
0.82
—
—
—
1
5.30
—
0.60
1
2
3
1
3
2
6
3
3
4
1
1
3
5
4.89
5.77
10.71
11.35
7.32
17.75
8.16
16.59
4.62
7.64
7.30
5.92
7.34
6.18
5.40
5.50
7.02
—
6.57
10.02
6.46
9.27
4.98
7.03
7.90
5.33
7.09
6.37
—
—
0.88
0.82
0.85
0.91
—
—
0.82
0.88
—
—
—
0.89
14
7.25
5.85
—
34
7
117
6.75
11.44
7.98
6.37
8.29
6.50
0.85
0.86
0.86
a
Some other studies show the use of BDI scale in different
countries:
Turkey: Ofluoglu et al, 2005
Israel: Abdallah, 1997
Korea: Sung et al 1992
South Africa: Drennan et al., 1991
Validation in general populations
 Arab (Abdel-Khalek et al 1998) Coefficients alpha
were computed for samples of male and female
undergraduates recruited from Egypt (alpha= 0.77 n=
100), Saudi Arabia (alpha= 0.82, n= 80), Kuwait
(alpha= 0.89, n= 100), and Lebanon (alpha= 0.67, n=
100)
 Brazil- Portuguese (Gorenstein et al, 1996) n=417
 Chinese (Zheng et al 1988) Cronbach’s alpha = 0.85, n
=329
 Russian (Andriushchenko et al, 2003) n =148
(sensitivity/specificity analysis)
 Japanese (Kojima et al 2002) n =766 on BDI-II with
the following results: Cronbach's alpha = 0.87; factor
analysis showing a two-factor structure (cognitive and
somatic-affective); r = 0.69, (P < 0.001) between BDI
and CES-D
 Malaysian (Quek et al, 2001) Cronbach's alpha ranged
from 0.56 to 0.87; high degree of sensitivity and
specificity
 Mexico (Suarez-Mendoza et al 1997) n=35:
comparison with DSM-III, correlation with HAD (r =
0.83)
Overall impression
Advantages and disadvantages
BDI is a well-researched scale, of which some
validation studies in PD are available
It has been argued that the somatic content of
BDI may lead to false-positives among patients
with physical problems (Williams &
Richardson, 1993). Some authors state that the
BDI is weighted toward somatic complains,
making it difficult to distinguish between
symptoms of depression and symptoms of
disease (Levin et al, 1988). These objections are
largely theoretical and not reflected in a reduced
reliability or validity. Although there are no
direct comparative studies, some validation
studies using the same population and the same
design show that the BDI is superior to the
HADS (Leentjens et al 2000, Leentjens et al,
2001). Moreover, it has been demonstrated that
some somatic symptoms in PD are indeed
sensitive for depression and should not be
neglected in the assessment of depression in PD
(Leentjens et al, 2003). Furthermore, potential
overlapping somatic items may cluster with
depression rather than with motor features
(Levin et al, 1988., Starkstein et al, 1990)
Most of validation studies used the original
version of BDI and it is not clear how far these
apply to the revised version (Mc Dowell &
Newell, 1996)
Which type of study is this scale very
suitable for and which one is it
unsuitable (screening, prevalence,
aetiological (e.g. case-control or
genetic), treatment trial of PD or
depression medication, correlation
with biological markers or other
scales, e.g. of parkinsonism, clinical
practice for diagnosis/screening). List
all
The BDI is suitable for screening purposes if an
appropriate cut-off is used.(Leentjens et al.
2000). Although Proudhomme and Baron
(1993) state that the BDI is not suitable for
diagnostic purposes, Leentjens et al, (2000)
show that high specificity can be achieved by
adjusting the cut-off. It is also suitable for
assessing the severity of depressive symptoms
and for monitoring change during treatment. It
can also be used in phenomenological studies of
depression in PD, because items readily
correspond with clinical symptoms of
depression.
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URLs:
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http://www.macses.ucsf.edu/Research/Psychosocial/notebook/depression.html
Scale: Name
Hospital Anxiety and Depression Scale
Are there several versions of
the scale? If so, which one has
been assessed?
Description of scale
(content,
number of items and subscales,
number of answer options
(severity or frequency or both)
One version: Zigmund & Snaith 1983.
Rater: Patient or caregiver or
clinician. If clinician-rated,
training for application
required?
Copyright or public domain?
How can the scale can be
obtained (address or website)?
The HADS is a 14-item self report scale that consists
of a depression and an anxiety subscale. Both
subscales consist of 7 statements. The patient has to
score to extent to which he agrees with each statement
on a four-point scale ranging from 0 to 3, with 0 being
the least severe and 3 being the most severe score.
Statements of the depression and anxiety subscales
alternate. Most questions relate to frequency but 5
items, 4 of which of the depression subscale, relate to
severity (items 2, 3, 4, 10 and 12)
Self report, i.e. patient-rated
As the HADS was originally published in the Acta
Psychiatrica Scandinavica, it is copyrighted by
Blackwell Muncksgaard publishers. However, in their
original publication of 1983, the authors offer to
provide interested users copies of the scale at no
charge. For this reason, and the fact that the HADS is
commonly used, it is generally considered to be in the
public domain.
The APA Handbook of Psychiatric Measures states
that the HADS is copyrighted from Nfer-Nelson,
Darville House, 2 Oxford Road East, Windsor,
Berkshire SL4 IDF, England (email:
information@nfer-nelson.co.uk). This copyright
pertains to publication of the scale by the authors in a
manual accompanying the HADS in 1994 (Snaith &
Zigmund 2000).
The firm supplies the scale, the chart for recording of
scores and the manual with instructions for its use. An
electronic Microsoft Excel version is freely available
to medical practitioners from 'The Medical Algorithms
Project' (http://www.medal.org). For use in large scale
research project, you would need to purchase
quantities of the HADS from the publisher (NferNelson).
The scale can be obtained from Nfer-Nelson at the
address mentioned previously.
Scale properties
Please provide references for all statements or note if this is your personal judgement
Content
Face validity?
Face validity is moderate, as the statements do
not readily refer to DSM criteria for depression,
while on the other hand some of the core criteria
of depression are not included in the scale.
Moreover, some statements seem to be very
similar to others (e.g. items 2, 4, 14)
The anxiety scale includes some symptoms that
can also be considered depressive symptoms
such as items 1, 5, and 11. Moreover, anxiety can
be part of depression. For these reasons some
researchers have used the total HADS instead of
the depression subscale as a measure for
depression. (personal judgment)
Is loss of pleasure included?
Loss of pleasure is reflected in statements 2, 12
and 14 of the depression subscale.
Is the scale heavily weighted towards The depression subscale is weighted towards
one aspect of depression? If so,
anhedonia rather than sadness (Snaith &
which?
Zigmund, 2000). It is also weighted towards the
subjective disturbance of mood accompanying
depression and does not include physical and
cognitive signs of depression. (personal
judgment).
Does it exclude an important aspect
It excludes physical signs of depression, such as
of depression? If so, which
reduced appetite, weight loss, sleeping
disturbances, and fatigue (Constantini et al.
1999). It also excludes cognitive signs such as
concentration difficulties, feelings of guilt and
worthlessness, as well as mood-congruent
delusions. One very important item that is also
excluded is suicidality.
Compatible with DSM IV or other
It only moderately correlates with DSM IV
depression criteria (compare content
major depressive disorder because:
to DSM IV, if formally assessed see
1. Statements do not readily correspond
also criterion validity below)?
with DSM criteria for depression
2. Seven of the nine DSM criteria are not
covered in the HADS (!)
3. The period of duration of symptoms is
two weeks in the DSM and recommended
one week for the HADS.
DSM criteria corresponding with HADS items:
1 (depressed mood): not covered by the HADS
2. (anhedonia): HADS items 2, 4 and 14
3. (appetite, weight loss): not covered by the
HADS
Includes items on anxiety, psychosis
and cognition as a result of
depression?
Which areas are not covered?
Number/percentage of items that
overlap with symptoms of
Parkinsonism (energy, sleep, fatigue,
appetite, psychomotor
retardation/agitation) Cognitive
impairment (slowness of thinking,
clarity of thinking, attention, m
concentration)
Apathy (loss of interest, loss of
initiative)
What is the time frame/is the time
frame appropriate (e.g. “during the
past week”)?
Are the symptoms of Recurrent Brief
Depressive Disorder captured?
Use
Was it designed to measure severity
4. (insomnia, hypersomnia): not covered by the
HADS
5. (psychomotor agitation): HADS item 8
6. (fatigue or loss of energy): not covered by the
HADS
7. (worthlessness, guilt): not covered by the
HADS
8. (concentration): not covered by the HADS
9. (suicidality): not covered by the HADS
The HADS as such includes an anxiety scale; the
depression subscale does not include anxiety
items. Neither psychotic nor cognitive symptoms
are included.
Physical and cognitive signs of depression,
psychotic features and suicidality are not
included.
One statement ‘slowed down’ (8) overlaps with
psychomotor retardation. There are no other
overlapping items
In the original publication a time frame of one
week is suggested (Zigmund & Snaith 1983)
No.
The criteria for the proposed DSM IV diagnosis
of ‘recurrent brief depression’(RBD) are the
same as for major depressive disorder, except for
the required minimum duration, which is two
days instead of 2 weeks. Criterium C of the
proposed diagnosis of RBD (presence of these
symptoms at least once a month for 12 months
and not associated with the menstrual cycle) can
also not be captured in the HADS items.
The same limitations as for major depressive
disorder apply. There is no clear correspondence
with DSM criteria, many DSM criteria are not
covered and the time frame is not the same
(personal judgment)
It was designed to screen for depression and
or to screen for depression?
Is there a cut-off score for diagnosis
of depression (in depression without
PD)?
Is this appropriate in depression with
PD (dPD)?
If not, why?
Has a different cut-off score for dPD
been suggested, and if so, is there
evidence to support it?
Has it been used to measure severity
or to screen for depression (in
depression without PD and dPD)?
Acceptability
Length
anxiety syndromes in medical outpatients in
general hospital (Zigmond & Snaith 1983)
The seven item depression subscale yields a
score between 0- and 21. Score ranges originally
suggested by the authors are 0 – 7 normal; 8 – 10
possible depression; 11 – 21 probable depression
(Zigmond & Snaith 1983). In a HADS manual
they later changed these categories in: 0 – 7 no
mood disorder; 8 – 10 mild mood disturbance; 11
– 14 moderate mood disturbance and 15 – 21:
severe mood disturbance, without presenting
empirical data to substantiate this division
(Zigmund & Snaith 2000)
Yes (personal judgment). Questions pertain to
symptoms experienced during depressive states
irrespective of somatic comorbidity
Yes. Leentjens et al (2001) have suggested a cutoff of 10/11 of the total HADS for screening
purposes, and a cut-off of 23/24 for diagnostic
purposes.
In depression without PD: many studies have
used the HADS for screening or measuring
severity. For a review see Herrmann 1997 and
Bjelland et al 2002.
In depression with PD: Screening purposes: no
study found. To measure severity of depressive
symptoms it has been used in an Ecuadorian
study that validated the Parkinson’s disease
Quality of Life scale in 137 PD outpatients
(Serrano-Duenas et al 2004) and a study into
quality of life in advanced PD patients with
bilateral subthalamic nucleus stimulation
(Martinez-Martin et al. 2002)
Acceptable. (personal judgment) The total scale
consists of 14 items: 7 items in both the
depression and the anxiety subscales. It takes
only a few minutes to complete.
In a study by Shumway et al (2004) the cognitive
complexity of 15 self-administered depression
instruments was compared. The authors
combined four aspects of cognitive complexity
(length, readability, linguistic problems and
numbers) to characterize overall complexity. The
authors show a list in which the 15 scales are put
in order from the easiest to comprehend to the
difficulties to comprehend. In this list the HADS
ranks in eighth place.
Ambiguities in instructions to
patient/rater
Ambiguities in rating anchors
No; questions and anchor points are clear
(personal judgment)
Appropriateness of questions for PD
population
Appropriate (personal judgment)
Applicability across PD and
depression disease stages mild –
moderate – severe?
Applicable for all disease stages.(personal
judgment)
Martinez-Martin et al. (2002) have used the scale
in advanced stages of PD.
The way in which questions are stated, and the
fact that questions pertain to the average state of
mind during the last week make it impossible to
use for mood differences between ‘on’ and ‘off’
states.(personal judgment). This has not been
done to my knowledge.
See above; statements and anchor points are clear
Can it be used for “on” and “off” and
has this been done?
Clear instructions to raters
Clinimetric/psychometric
properties
Metric flaws (floor and
ceiling effects, score
distributions)?
Reliability (internal
consistency, interrater, testretest) of total or sub-scales
and of individual items
non-PD patients: no evidence found
In PD patients: In a validation study with 205 PD patients none of the
items revealed floor – or ceiling effects (Marinus et al 2002)
In non-PD patients: In a large review on the validity of the HADS,
Cronhnbach’s alpha for the depression subscale was found to be on
average 0.82 (range 0.67 – 0.90) and for the anxiety subscale 0.83
(range 0.68 – 0.93) (Bjelland et al. 2002). Correlations between the two
subscales varied from 0.40 to 0.74 (mean 0.56)(Bjelland et al. 2002).
Mykletun et al. (2001) reported an alpha of 0.80 and 0.76 for the
anxiety and depression subscales respectively.
In PD patients these characteristics have been studied by Leentjens et
al (2001) and Marinus et al (2002). Leentjens found a high alpha of
0.909 for the total HADS in 55 outpatients. Marinus et al. report an
alpha of 0.88 for the total HADS. In the latter study, the test- retest
reliability over a two week period was 0.84 for the total HADS and
0.86 and 0.84 for the anxiety and depression subscales. The item-total
correlation ranged from 0.30 – 0.70. The correlation between the two
subscales was 0.61 in the study of Marinus et al. (2002), and 0.68 in
the study of Leentjens et al. (2001)
Validity: assessed – not assessed, good – not good (references); please also comment on sample sizes
In depression without PD
Face or content
Questionable; see above (personal judgment)
validity
Criterion validity
(compared to gold-standard,
e.g.
DSM IV (SCID,
SCAN, systematic interviews)
or
other criteria for
diagnosis)
Construct validity
(correlations with other
convergent scales and
divergent scales (which?);
factor analysis)
Many studies have assessed the concurrent validity with DSM citeria
for major depressive disorder. In the review by Bjelland (2002) an
average sensitivity and specificity of 0.8 was reported for major
depressive disorder in 23 studies, using a cut-of of 8/9 on the
depression subscale.
Bjelland et al (2002) mention 6 studies that have compared the
correlation between the HADS and the BDI. The correlation
coefficients varied from 0.62 to 0.73. The five studies that have
compared the HADS to the Spielberger’s State Trait Anxiety
Inventory found correlations of 0.64 to 0.81 for the HADS-A, of 0.52
to 0.65 for the HADS-D and of 0.68 to 0.71 for the total HADS.
Correlation with the MADRS in four studies ranged from 0.62-0.81
(Bjelland et al. 2002).
Compared
questionnaire
n
Correlation coefficients between
HADS and the other questionnaire
HADS-A HADS-D
HADS-T
BDI for primary care
BDI
1
5
GHQ-12
1
GHQ-28
2
STAI
3
STAI-S
3
STAI-T
1
From 0.68
to 0.50
From 0.64
to 0.66
From 0.64
to 0.81
0.66
MADRS
4
0.37
CAS
3
SCL90,Anxiety,Depression
HAMA-S,
HAMA-P,
HAMA-T
VAS
2
1
1
1
1
From 0.61
to 0.83
0.62
From 0.70
to 0.73
0.73
0.75
From 0.69
to 0.75
From 0.49
to 0.73
0.34
0.40
0.44
0.74
From 0.50
to0 .66
From 0.52
to 0.59
0.65
0.64
From 0.62
to 0.81
0.44
0.68
0.71
0.67
From 0.67
to 0.69
n = number of studies (after: Bjelland et al. 2002)
Among the 19 studies that have assessed the factorial structure of the
HADS, the following results were found for factorial structure:
- 2 factor structure (11 studies N=14.588)
HADS-A Cronbach’s α ranged from 0.80 to 0.93
HADS-D Cronbach’s α ranged from 0.81 to 0.90
- 3 factor structure (5 studies N=3559)
HADS-A Cronbach’s α ranged from 0.76 to 0.85
HADS-D Cronbach’s α ranged from 0.72 to 0.81
- 4 factor structure (2 studies N=235)
HADS-A Cronbach’s α =0.82
HADS-D Cronbach’s α =0.78
Based on these studies HADS performed as a bi-dimensional test,
although the factors were not absolutely consistent with the subscales
of anxiety and depression. The most consistent finding was that the
HADS-A item 4 showed relatively low loadings (<0.60) on the
anxiety factor and some loadings on the depression factor (>0.45)
(Bjelland et al. 2002)
Valid in ethnically and
culturally different
populations?
Valid in both genders
and at all ages?
Valid in patients with
dementia or significant
cognitive impairment?
In depression in PD (dPD)
Face or content
validity
Criterion validity
(compared to gold-standard,
Yes. The HADS was validated and used in many countries in all parts
of the world. For a review see Herrmann (1997)
In a multinational study with 719 European, American, Asian, and
African patients, nationality significantly influenced HADS scores
(p<0.05) (Jones, 1994) The use of this scale in different countries with
different cultural patterns could be influenced by the different
perception and expression of emotions by the patients with different
cultural setting (Herrmann 1997)
Yes. For a review see Herrmann (1997)
Non statistically significant differences with gender and age were
found in the original paper for HADS-D and HADS-A (n=50)
(Zigmund & Snaith, 1983). This was confirmed by a meta analysis,
which showed that women score higher on HADS-A than men,
although gender differences are not significant, and the fact that there
is a non-linear association of the HADS score with age. HADS-A is
highest in patients aged 30-59 years and lowest in those >=70 years.
HADS-D are highest in 50-59 years old patients and lowest in the
youngest group (< 30) (Herrmann, 1997)
Finally, a validation study about HADS in adolescent patients aged 12
to 17, showed that the psychometric properties of the HADS are
confirmed in this subgroup (White et al. 1999)
No evidence found; however HADS has been used in such patients.
In a population of 78 elderly people, the HADS was administered to
evaluate the prevalence of mental illness. Thirty-one (41.0%) patients
had significant cognitive impairment and 14 of these had associated
depression.(Shah et al., 2000) In 50 patients with mild dementia and
134 control the HADS was used; the results show that 38% of
patients and 9% of controls had a possible or probable diagnosis of an
anxiety disorder. Possible or probable depression was found in 28%
of the patients and 3% of the controls (Wands et al., 1990).
Questionable (see above) (personal judgment)
Leentjens et al. found a fair concurrent validity with the DSM criteria
for depression. At the recommended cut-off for screening (10/11),
e.g.
DSM IV (SCID,
SCAN, systematic interviews)
or
other criteria for
diagnosis)
Construct validity
(correlations with other
convergent scales and
divergent scales (which?);
factor analysis)
Valid in ethnically and
culturally different
populations?
Valid in both genders
and at all ages?
Valid in patients with
dementia or significant
cognitive impairment?
sensitivity is 0.92, but specificity only 0.51 for depressive disorder in
a sample of 55 outpatients (Leentjens 2001).
No correlation studies with other scales were found in PD patients.
Factor analysis in 205 PD outpatients revealed a three factor structure
for the total HADS. Factor 1 included all anxiety items with the
exception of item 5 (worrying thoughts)which loaded on the second
factor. Factor 2 included all ‘depression items’ except for items 10
(lost interest in appearance) and 14 (enjoy book or TV
programme).These two items constituted the third factor. Together
they explain 59% of the variance (Marinus et al 2002).
In PD patients: no evidence found
In PD patients: no evidence found
In PD patients: no evidence found. Both Leentjens et al and Marinus
et al have excluded demented patients from their validation studies
(Leentjens et al 2001, Marinus et al. 2002)
Are you aware of any correlations
of the scale with biological
markers?
In patients without PD
In patients with PD
Demonstrated to be sensitive to
change (change over time or to
treatment)
In patients without PD
In patients with PD
Has the minimal clinically
In non-PD patients: no
Levels of tumor markers were not associated with
psychosocial function measured with HADS in 24
patients with carcinoid tumors (Larson et al, 2001).
PD patients: no
In non-PD patients: Yes, a number of studies have
shown good sensitivity to change of the HADS both
for studies evaluating pharmacotherapy and
psychotherapy for depression (Herrmann 1997, Wu,
2002, Kenn et al, 1987, Tignol et al, 1993). In a
sample of 197 breast cancer patients: The mean ±SD
the change was –2.09±6.8 for the overall scale,–
1.45±4.3 for the anxiety scale and –0.64±3.2 for the
depression scale (Costantini et al., 1999).
Sensitivity to change was also demonstrated in 1485
depressed outpatients treated with sertraline. The
mean HADS total score was reduced with 7.35 (SD
6.4) after two weeks and with 15.0 (SD 8.4) after 45
days (p<0.0001). Subscores were also significantly
decreased (p<0.0001) (Friedman et al 2001).
In PD patients: no evidence found. No medication
trial has yet used the HADS for evaluation of
treatment results.
Not to my knowledge
important change and minimal
clinically relevant incremental
difference been assessed?
In patients without PD
In patients with PD
Has this scale been assessed or
used in patients with PD? What
are the clini- or psychometric
properties in this population?
Has the scale been translated and
validated in other languages?
Overall impression
Advantages and disadvantages
Which type of study is this scale
very suitable for and which one is
it unsuitable (screening,
prevalence, aetiological (e.g. casecontrol or genetic), treatment trial
of PD or depression medication,
correlation with biological
markers or other scales, e.g. of
parkinsonism, clinical practice for
The HADS was used in a validation study of the
Ecuadorian version of the PD Quality of Life
Questionaire (Serrano-Duenas et al 2004). As an
indicator of the severity of depressive symptoms, it
was used in a study into quality of life in advanced
PD patients with bilateral subthalamic nucleus
stimulation (Martinez-Martin et al., 2002). In both
studies psychometric properties of the HADS were
not the issue.
The HADS has been translated and validated in
many languages (Herrmann 1997)
Advantage; quick, easy to administer, selfrated
Disadvantage: questionable face validity and no
clear relation with DSM criteria for depression.
Another disadvantage of the HADS in clinical
practice in patients with PD was described by
Leentjens (2002). ‘The HADS has item
formulations that alternatively are assigned
increasing and decreasing scores. This manner of
formulating questions proved difficult for a
substantial number of PD patients, as was indicated
by the number of corrections the patients make
while filling in the questionnaires, and by the
number of inconsistent ratings. By ‘inconsistent
ratings’ we mean that some patients sometimes filed
in extreme ratings on items that were similar to
other items that they had given a low score. In these
cases we assumed that mistakes had been made.
This may be related to the problems with conceptshifting, ….’ (quote).
It is moderately suitable for screening purposes
(Leentjens et al 2000)
Although the HADS has been used as a measure for
severity, and is promoted as such by the designers,
my personal opinion is that it is not a good measure
for severity, because of the fact that items that are
most closely associated with severity of depression
are not part of the scale, such as suicidality,
psychotic features and vital symptoms.
diagnosis/screening). List all
The often praised fact that it excludes all somatic
symptoms cannot be considered an advantage, as
most of the DSM criteria for depression are not
considered. Moreover, Leentjens et al (2002)
showed that some somatic items of depression (such
as reduced appetite and early morning wakening)
are more sensitive indicators for depression than
some of the non-somatic items.
It is not suitable for phenomenological studies of
depression, because of the fact that the statements
used are not clearly related to specified symptoms or
DSM item (personal opinion).
Assessed was the official Dutch version of the HADS, translated with permission of the
publishers by Pouwer F, Snoek FJ and Van der Ploeg (1987). This is an exact translation
of the original scale (Zigmund & Snaith 1983).
References
Bjellard I, Dahl AA, Tangen Haug T, Neckelmann D. The validity of the Hospital
Anxiety and Depression Scale. An updated literatur review. Journal of
Psychosomatic Research, 2002;52:69-77.
Costantini M, Musso M, Viterbori P, Bonci F, Del Mastro L, Garrone O, Venturini M,
Morasso G.
Detecting psychological distress in cancer patients: validity of the Italian version
of the Hospital Anxiety and Depression Scale. Support Care Cancer. 1999
May;7(3):121-7.
Friedman S, Samuelian JC, Lancrenon S, Even C, Chiarelli P. three-dimensional structure
of the Hospital
anxiety Depression Scale in a large French primary care population suffering
from major depression. Psychiatry Research 2001; 104: 247-57.
Herrmann C. International experiences with the hospital anxiety and depression scale; a
review of validation data and clinical results. Journal of Psychosomatic Research,
1997;42:17-41.
Jones PW. Quality of life, symptoms and pulmonary function in asthma: long-term
treatment with
nedocromil sodium examined in a controlled multicentre trial. Nedocromil
Sodium Quality of Life Study Group. Eur Respir J. 1994 Jan;7(1):55-62.
Kenn C, Wood, H, Kucyj M, Wattis JP, Cunane J. Validation of the hospital anxiety and
depression rating
scale (HADS) in an elderly psychiatric population. Int J Geriat Psychiatry
1987;2:189-93.
Larsson G, Sjoden PO, Oberg K, Eriksson B, von Essen L. Health-related quality of life,
anxiety and
depression in patients with midgut carcinoid tumours. Acta Oncol.
2001;40(7):825-31
Leentjens AFG. Parkinson's disease, depression, and serotonin. Maastricht:
Datwyse/Universitaire Pers Maastricht, 2002; pp 160.
Leentjens AFG, Lousberg R, Verhey FRJ. The psychometric properties of the Hospital
Anxiety and Depression Scale in patients with Parkinson's disease. Acta
Neuropsychiatrica 2001,13:83-85.
Leentjens AFG, Lousberg R, verhey FRJ. Markers for depression in Parkinson's disease.
Acta Psychiatrica Scandinavica 2002;106:196-201.
Lowe B, Grafe K, Zipfel S, Witte S, Loerch B, Herzog W. Diagnosing ICD-10 depressive
episodes: superior criterion validity of the Patient Health Questionnaire.
Psychother Psychosom 2004;73:386-390.
MykletunA, Stordal E, Dahl AA. Hospital Anxiety and depression (HAD) scale: factor
structure, item analyses and internal consistency in a large population. Brit j
Psychiat 2001;179:540-544.
Marinus J, Leentjens AFG, Visser M, Stiggelbout AM, Van Hilten JJ. Evaluation of the
Hospital Anxiety and Depression Scale in patients with Parkinson's disease.
Clinical Neuropharmacology 2002;6:318-324.
Martinex-Martin P, Valldeoriola F, Tolosa E., Pilleri M, Molinuevo JL, Rumia J, Ferrer
E. Bilateral subthalamic stimulation and quality of life in advanced Parkinson's
disease. mov Disord 2002;17:372-7.
Serrano-Duenas M, Martinez-Martin P. Vaca-Baquero V. Validation and cross-cultural
adjustment of the PDQL-qustionnaire, Spanish version (ecuador) (PDQL-EV).
Parkinsonism and Related Disorders 2004;10:433-437.
Shah DC, Evans M, King D. Prevalence of mental illness in a rehabilitation unit for older
adults. Postgrad Med J 2000;76:153-156.
Snaith RP, Zigmond AS. Hospital Anxiety and Depression Scale (HADS). In: Task force
for the Handbook of psychiatric measures (ed), Handbook of psychiatric
measures. Washington D.C.: American Psychiatric Association, 2000, pp 547548.
Tignol J A double-blind, randomized, fluoxetine-controlled, multicenter study of
paroxetine in the treatment of depression. J Clin Psychopharmacol. 1993
Dec;13(6 Suppl 2):18S-22S.
Wands K, Merskey H, Hachinski VC, Fisman M, Fox H, Boniferro M. A questionnaire
investigation of
anxiety and depression in early dementia. J Am Geriatr Soc. 1990 May;38(5):5358
White D, Leach C, Sims R, Atkinson M, Cottrell D. Validation of the Hospital Anxiety
and Depression Scale for use with adolescents. Br J Psychiatry. 1999
Nov;175:452-4.
KK Wu Use of Eye Movement Desensitisation and Reprocessing for Treating Posttraumatic Stress
Disorder after a Motor Vehicle Accident KK Wu Hong Kong J Psychiatry
2002;12(2):20-24
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatrica
Scandinavica 1983;67:361-370.
Scale:
Name
Are there
several
versions of
the scale? If
so, which
one has
been
assessed?
The Zung Self-rating Depression Scale (SDS)
Zung,W.W. (1965). A self-rating depression scale. Archives of General
Psychiatry, 12,63-70.
5 Versions. The original version (20 items) is reviewed here.
The other versions:
1) A short form (12 items) of the SDS has been developed, but there has
been little validation of this scale in depressed elderly.
(Gosker et al, 1994; Hulstijn et al 1992)
2) Brief ZSDS: Since there is the potential confounding influence of
somatic symptoms due to cancer on the assessment of depressive
symptoms, an 11-item index was statistically examined after omitting the
Zung items assessing somatic items. (Dugan et al, 1998)
3) Short Zung Interview-assisted Depression Rating Scale (10 items)
[Tucker et al 1987). This short screening instrument takes about 10-15
minutes to administer and is based on 10 questions from the Zung SDS.
Some items are related to subjective feeling, to sleep and to mood in the
morning. Additional questions relate to appetite, to energy, to
concentration and to hopelessness. There are no specific questions related
to anxiety. (Sinoff et al 2002) The short Zung is useful to detect depression
in the absence or presence of anxiety but is less useful in ruling out
depression in those suffering from anxiety.
The individual questions on the short Zung are:
1) I feel down-hearted and blue (1-4)
2) I have trouble sleeping at night (1-4)
3) Morning is when I feel the best (4-1)
4) I can eat as much as I used to (4-1)
5) I get tired for no reason (1-4)
6) I find it difficult to make decisions (1-4)
7) I feel hopeful about the future (4-1)
8) I feel that I am useful and needed (4-1)
9) My life is somewhat empty (1-4)
10) I still enjoy things I used to do (4-1)
4) Modified version of the Zung Self-Rating Depression Scale (MSDS)(Ciacci et al 1998) The M-SDS contains 17 items belonging to the
original version of the SD. The three items evaluating gastroenteric
symptoms of depression (that is, decreased appetite, weight loss, and
constipation) had been removed to avoid bias due to the medical illness.
According to previous reports, the items belonging to the scale have been
classified as ‘biologic’ and ‘psychologic’, and two separate scores
concerning the two classes of symptoms have been considered. The M-
SDS items are:
1) I feel downhearted, blue, and sad.
2) Morning is When I feel the best
3) I have crting spells, or I feel like it
4) I have trouble sleeping through the night
5) I enjoy looking at, and being with attractive men/ women
6) My heart beats faster than usual
7) I get tired for no reason
8) My mind is as clear as it used to be
9) I find it easy to do the things I used to do
10) I am restless and can’t keep still
11) I fill hopeful about the future
12) I am more irritable than usual
13) I find it easy to make decisions
14) I feel that I am useful and needed
15) My life is pretty full
16) I feel that others would be better off if I were dead
17) I still enjoy the things I used to do
P = Psychologic items;
Description
of scale
(content,
number of
items and
subscales,
number of
answer
options
(severity or
frequency
or both)
Rater:
Patient or
caregiver or
clinician. If
clinicianrated,
training for
P
B
P
B
B
B
B
P
B
B
P
P
P
P
P
P
P
B = biologic items
It consists of 20 items that cover affective, psychological and somatic
symptoms. This scale includes 10 positively-keyed items and negativelykeyed items. The scores related to the negatively keyed items are reversed
in order to calculate the total SDS score. (Schotte et al, 1996). Each item is
rated with a 4-point Likert scale with 4 representing the most unfavorable
response. Frequency with which the symptom is experienced experienced
(a little of the time=1, some of the time= 2; a good part of the time= 3; or
most of the time= 4). No subscales.
In scoring the SDS, all the items scored based on severity; Zung and
Durham (1965) report that a value of 1,2,3,and 4 is assigned to a response
depending upon whether the item was positively or negatively keyed. For
example, for item 1: I feel down-hearted and blue, a response of: a little of
the time, some of the time, good part of the time, or most of the time,
would be scored 1,2,3 and 4 respectively. For item 2: Morning is when I
feel the best, a response of: a little of the time, some of the time, good part
of the time, or most of the tim, would be scored 4,3,2 and 1 respectively.
The range of scores is 20-80. The maximum possible score is 80
Rater is the patient (self-rated).
The scale does not require trained personnel.
application
required?
Copyright
or public
domain?
Public domain
How can
the scale
can be
obtained
(address or
website)?
http://healthnet.umassmed.edu/mhealth/ZungSelfRatedDepressionScale.pdf
Scale properties
Please provide references for all statements or note if this is your personal judgement
Content
Face validity?
Yes: in devising the SDScale the clinical diagnostic criteria used
content
comprised of the most commonly found characteristics of depression.
These were divided into the following: pervasive affect, physiological
equivalents or concomitants, and psychological concomitants. (Zung
1965;Fountoulakis et al 2001);
Is loss of
pleasure
included?
Is the scale
heavily
weighted
towards one
aspect of
depression? If
so, which?
Two items (6, 20) deal with the loss of pleasure issue.
For item 6 two different versions are available:
Item 6: “I enjoy looking at, talking to and being with attractive
women/men”. (BMC Psychiatry 2001, I: 6)
Item 6: “I still enjoy sex” (Glaxo Wellcome)
Sakamoto et al. (1998) citated Fukuda and Kobayashi (1973) who
recommended that when administering the SDS to unmarried people,
the wording of Item 6 should be changed to “I enjoy being with
attractive women/men”.
Item 20: “I still enjoy the things I used to do”
According to Faravelli et al, 1986, if the various aspects of depressive
symptoms are grouped empirically in nine areas (depressed mood,
hopelessness, self-accusation, suicide, retardation or inhibition,
insomnia, somatic symptoms, anxiety and other) the relative weight
attributed to the different areas is:
Mood 10%
Hopelessness, <10%
Guilt, <10%
Suicide, <10%
Inhibition 30%
Insomnia, <10%
Somatic < 30%
Anxiety <10%
Other < 10%
This is relative weight of each symptom grouping (percentage
contribution to maximum total score) in Zung SDS.
Does it exclude No exclusion
an important
aspect of
depression? If
so, which
Compatible
with DSM IV
or other
This scale seems compatible with DSM IV criteria for depressive
episode major, but it does not refer to the previous two-week period:
the scale refers to ‘the past several days’ (personal judgment)
depression
criteria
(compare
content to
DSM IV, if
formally
assessed see
also criterion
validity
below)?
Chida et al (2004) conducted a factor analysis on the SDS score of
Japanese general population. From this factor analysis, two factors
consisting of 12 SDS items were extracted. Factor I consisted of item 1,
item 2, item 3, item 4, item 9, item 10, item 11, item 13,and item 15,
and Factor II consisted of item 14, item 18 and item 20. After this
factor analysis, the 12 SDS items were compared with DSM IV criteria
describing psychological disturbances of depression: 10 out of the
extracted 12 items covered six DSM IV criteria for depression
(depressed umor, diminished interest or pleasure, insomnia or
hypersomnia, psychomotor agitation or retardation, fatigue or loss of
energy, diminished ability to think or concentrate, or indecisiveness).
In devising the ZSDS, Zung (1965) used statement which were most
representative for the clinical diagnostic criteria :
Criteria for diagnosis od depressive
disorders
I. Pervasive affect
A. Depressed mood
B. Crying spells
II. Physiological equivalents
A. Rhytmic Disturbances:
1. Diurnal variation
2. Sleep:characteristically early or
frequent waking
3. Appetite
4. Weight loss
5. Sex: decreased libido
B. Other Disturbances
1. Gastrointestinal disturbances
2. Cardiovascular disturbances
3. Musculoskeletal disturbances
III. Psychological equivalents
A. Psychomotor activities
1. Agitation
2. Retardation
B. Ideational
1. Confusion
2. Emptiness
3. Hopelessness
4. Indecisiveness
5. Irritability
6. Dissatisfaction
7. Personal devaluation
8. Suicidal rumination
Includes items
Self-rating Depression Scale Items
I feel down-hearted and blue
I have crying spells, or feel like it
Morning is when I feel the best
I have trouble sleeping at night
I eat as much as I used to
I notice that I am losing weight
I still enjoy sex
I have trouble with constipation
My heart beats faster than usual
I get tired for no reason
I find my self restless and can’t keep still
I find it easy to do the things I used to
My mind is a clear as it used to be
My life is pretty full
I feel hopeful about the future
I find it easy to make decisions
I am more irritable than usual
I still enjoy the things I used to
I feel that I am useful and needed
I feel that others would be better off if I
were dead
About suicide, in reality the item 20 (I
feel that others would be better off if I
were dead) can be considered as an item
about suicidal rumination such as the
developers of the SDS reported.
(Zung, 1965)
According to the Thompson’s criteria (1989), the 20 items of SDS are
on anxiety,
psychosis and
cognition as a
result of
depression?
Which areas
are not
covered?
Number/percen
tage of items
that overlap
with symptoms
of
Parkinsonism
(energy, sleep,
fatigue,
appetite,
psychomotor
retardation/agit
ation)
Cognitive
impairment
(slowness of
thinking,
clarity of
thinking,
attention, m
concentration)
Apathy
divided into five subgroups.
1) Mood depression: depressed mood (item 1); crying spells (item
3); confusion (item 11)
2) Anxiety: tachycardia (item 9); agitation (item 13)
3) Motor symptoms: retardation (item 12)
4) Cognitive symptoms: hopelessness (item 14); irritability (item
15); indecisiveness (item 16); personal devaluation (item 17);
emptiness (item 18) ; suicidal rumination (item 19);
dissatisfaction (item 20)
5) Vegetative symptoms: diurnal variation (item 2); lack of sleep
(item 4); loss of appetite (item 5); loss of sex drive (item 6);
weight loss (item 7); constipation (item 8); fatigue (item 10)
There are no items for Psychosis
I personally disagree with such grouping, in particular with some of the
items included in the cognitive dominion: hopelessness (item 14);
irritability (item 15); personal devaluation (item 17); emptiness (item
18); and suicidal rumination (item 19)
Psychosis, guilt
Number of items: 6
 Item 4: Sleep disturbances
 Item 5: Decreased appetite
 Item 7: Weight loss
 Item 8: Constipation
 Item 10: Fatigue
 Item 12 : Psychomotor retardation
 Item 13: Agitation (restless)
Item 6:I still enjoy sex. Personally, I do not think it is overlapping with
PD vegetative symptoms (impotence).
In my opinion there are two items related to cognitive impairment:
 Item 11: Confusion
 Item 16: Indecisiveness
According to Thompson’s criteria there are 7 items:.
 Hopelessness (item 14);
 Irritability (item 15);
 Indecisiveness (item 16);
 Personal devaluation (item 17);
 Emptiness (item 18);
 Suicidal rumination (item 19);
 Dissatisfaction (item 20)
Number of items: 0
(loss of
interest, loss of
initiative)
What is the
time frame/is
the time frame
appropriate
(e.g. “during
the past
week”)?
Are the
symptoms of
Recurrent Brief
Depressive
Disorder
captured?
This scale refers to “The past several days”.
Yes. However not all the symptoms of a RBDD are covered.
The following symptoms of RBDD are respectively covered by the
SDS items:
Depressed mood: item 1;
Loss of interest and enjoyment: item 6(decreased libido) and 20
(dissatisfaction);
Reduced energy leading to increased fatiguability and diminished
activity: item 10 (Fatigue) and item 12 (Psychomotor retardation);
Reduced concentration and attention: item 11 (confusion) and item 16
(indecisiveness) ;
Reduced self-esteem and self-confidence: item 17 (personal
devaluation);
Ideas of guilt and unworthiness (even in a mild type of episode): not
covered;
pessimistic views of the future: item 14 (Hopelessness);
ideas or acts of self-harm or suicide: not covered;
disturbed sleep: item 4 (sleep disturbance);
diminished appetite: item 5 (decreased appetite) and item 7 (weight
loss)
Use
Was it designed to
measure severity or to
screen for depression?
The Zung SDS was designed for assessing depression in
patients whose primary diagnoses were that of a depressive
disorder (Zung,1965).
Is there a cut-off score
The cut-off score for a diagnosis of depression is 50 points or
for diagnosis of
more
depression (in depression [Zung et al 1965; Thurber et al 2002].
without PD)?
[< 50 no depression;
50-59 mild depression;
60-69 moderate depression;
> 69 severe depression; maximum score 80]
Combining the results of cross-cultural studies using ZSDS,
Zung showed that patients with global ratings of mild to
moderate depressions had ZSDS indices between 50 to 59,
while patients with moderate to severe depression had indices
of 60 to 69, and patients globally rated as severely depressed
had indices of 70 and over (Zung 1973). However, a high
score of ZSDS was not regarded as a clinical diagnosis of
depression but rather as a level of depressive symptoms of
potential clinical significance.
The highest published cut-point for the ZSDS was 60/61,
which had an unusually low sensitivity for detecting major
depression (Raft et al., 1977).
In order to adjust for an expected higher baseline score in
elderly patients seen in medical settings, Zung (personal
communication) recommended that the cutoff index score be
raised to 60 or greater in this population (Okimoto et al 1982)
Is this appropriate in
depression with PD
(dPD)?
If not, why?
It is inappropriate because of items that overlap with
symptoms of
Parkinsonism (energy, sleep, fatigue,
appetite, psychomotor retardation/agitation)are likely to
falsely elevate the total score.
According to Smith et al, 1997, this instrument assesses
psychological and somatic symptoms of depression: half of
the SDS items describe somatic symptoms that could be re
lated not only to depression but also to symptoms of PD.
Has a different cut-off
score for dPD been
suggested, and if so, is
there evidence to support
NO
it?
Has it been used to
measure severity or to
screen for depression (in
depression without PD
and dPD)?
The scale has been used to screen for depression in patients
without PD (see articles in APPENDIX 1)
The scale has been used to measure severity of depression in
depression without PD (see articles in APPENDIX 2).
The scale has been used to assess depressive symptoms in patients with
PD (see articles in APPENDIX 3).
The scale has been used to measure severity of depression in patients with
PD (see article in APPENDIX 3).
Acceptability
Length
The Zung SDS is a short and easy to administer survey to
quantify the depressed status of a patient. Average time of
administration is 5-8 min.
In a study by Shumway et al (2004) the cognitive complexity
of 15 self-administered depression measures was compared.
The authors combined four aspects of cognitive complexity
(length, readability, linguistic problems and numbers) to
characterize overall complexity. The authors show a list in
which the 15 scales are put in order from the easiest to
comprehend to the difficulties to comprehend. In this list the
Zung SDS ranks at the third place.
Ambiguities in
instructions to
patient/rater
Ambiguities in rating
anchors
Ambiguities in rating anchors derive from the presentation of
some items as a positively-keyed and others as negativelykeyed
Appropriateness of
questions for PD
population
No, because there are half of the SDS items that describe
somatic symptoms that could be related not only to
depression but also to symptoms of PD
Applicability across PD
and depression disease
stages mild – moderate –
severe?
Can it be used for “on”
and “off” and has this
been done?
There is no research suggesting that the instrument performs
differently in patients with different severity of PD.
Clear instructions to
raters
Yes, but because the scale is self-administered, it depends on
the cooperation and reading ability of the patient.
Not found
Clinimetric/psychometric properties
Metric flaws (floor and ceiling effects, score
distributions)?
Scoring algorithm:
The scale is composed by 20 items, 10 of which
are worded symptomatically positive and 10
symptomatically negative.
[Zung et al 1965a]
The SDS is constructed so that higher scores
indicate greater severity of depression. In scoring
the SDS, a value of 1,2,3 or 4 is assigned to each
item. An index for the SDS can be derived by
dividing the sum of the value obtained on the 20
items by the maximum possible score of 80 and
expressed as a decimal. [Zung et al 1965a].
Item mean scores were given in Zung et al 1965a.
In that paper the highest mean scores, 3.6, were
observed for “sleep disturbance”, “fatigue” and
“psychomotor retardation” (respectively items n.
4, 10, 12) in depressed patients.
Score distribution:
<50: normal range
50-59: mild to minimal depression
60-69 : moderate to sever depression
>70 : severe depression
[Halverson & Chan, 2004]
Reliability (internal consistency, interrater, test-retest) of
total or sub-scales and of individual items
Cut-off points:
The cut-off score for placing individuals in a
“depressed” category is 50 [Zung et al 1965;
Thurber et al 2002].
However the highest published cut-point for the
SDS was 60/61 [Raft et al 1977]
Internal consistency:
Several studies have estimated the internal
consistency of SDS total score. Cronbach’s alpha
ranging from 0.75 to 0.95 have been reported in:
[Jegede RO., 1976: alpha=0.75; Toner J et al, 1988; Tanaka et al
1986: alpha=0.81; Kaneda Y., 1999: alpha=0.81].
Test-retest:
Test-retest reliability coefficient for the total
SDS was comparatively high (Spearman’s ρ=.87,
p<.001, N=19). (chronic schizophrenic inpatients
without depression – retest was conducted within
a mean period of 17 days) [Kaneda Y., 1999]
Validity: assessed – not assessed, good – not good (references); please also comment on sample sizes
In depression without PD
Face or content validity
In the original paper, the authors concluded that
the SDS was useful in quantitating depression as
a disorder, with a particular focus on sleep
disturbances. [Zung et al 1965a]
Criterion validity (compared to gold-standard, e.g.
DSM IV (SCID, SCAN, systematic interviews) or
other criteria for diagnosis)
In 2002, Thurber and colleagues found
statistically significant differences in the SDS
total score in two main DSM-IV diagnostic
groups, namely depression (n=77) and alcohol
abuse (n=86). When the cut-off score of 50 was
used with respect to the two diagnoses, the
sensitivity was 0.57 and specificity 0.83. The
same results were obtained for comparisons
between depressed and non-depressed subjects
[Thurber et al 2002].
Moreover, major components of SDS in a
Japanese general population covered the DSMIV criteria for psychological disturbances of
depression .[Chida et al, 2004]
Construct validity (correlations with other
convergent scales and divergent scales (which?);
factor analysis)
Construct validity:
The scale seems to have good construct validity:
it was compared to many scales for depression in
different studies. The following references show
the comparisons of SDS with other scales:

SDS vs Minnesota Multiphasic
Personality Inventory-2 (MMPI-2):
The correlation with MMPI-2 was originally
performed [Zung et al 1965b; n=152)]. The highest
correlation between the SDS and the MMPI
scales was with Depression scale (Pearson’s
r=0.70), followed by Psychasthenia (Pearson’s
r=0.68). The lowest correlation coefficient was
0.13, and it was observed with Hypomania. It is
noteworthy that a similar correlation between
SDS and MMPI-2 Depression scale was
observed, i.e. r=0.77 [Thurber et al 2002].( n=259)

SDS vs BDI (r=0.64), DACL (r=0.41),
Zung-A (r=0.63), SAI (r=0.55 ), TAI (r=0.70),
MAS (r=0.64), ESDS (r=-0.58), MCSDS (r=0.15) [Tanaka et al 1986] (n=391 college students,
University of Hawaii)

SDS vs BDI (r=0.74);VAS
(r=0.37);HRSD (r=0.60); Wechsler Depression
Rating Scale (r=0.54); BHRS (r=0.57).
[Faravelli et al 1986] (n=100)

SDS vs Hamilton Rating Scale. In a
sample of 41 patients, a high correlation was
found between the ZSDS and the Hamilton
Rating Scale(Spearman rank correlation
coefficient=0.80, p<0.001). [Biggs et al 1978]
Factor Analysis:
Factor analysis was not performed in the original
paper, where a structure of the items was
suggested on the basis of their face content:
- Pervasive affect
- Physiological equivalents
- Psychological equivalents
[Zung et al 1965a]
Valid in ethnically and culturally different
populations?
Discriminant power:
The SDS was found to be the primary
discriminating variable in distinguishing
depressed ( n=77) from non depressed ( n=182)
individuals.[Thurber et al 2002]
Use and validation of translated versions of the
scale found for:

Japanese (n= 5547) [Chida et al 2004] The
two-factor solution, consisting of 12 items,
explained for the 47.9% of total variance. 10
of 12 iems coverd six DSM-IV criteria
describing psychological disturbance of
depression. However somatic symptoms were
not covered by the SDS items extracted by
factor analysis

Chinese [Leung et al, 1998] (n= 268: factor
analysis; comparison with DSM-IV; cut-off
point=55, Cronbach alpha=0.82)

Greek [Fountoulakis et al, 2001] (n= 40
depressed + 120 normal controls: factor
analysis; discriminant analysis: 100% and 90%
of respectively normal and depressed patients
correctly classified; cut-off point=45,
Cronbach alpha=0.09: very low)

Finnish elderly population [Kivela et al
1987] (factor analysis; Cronbach alpha=0.8)

Italian: comparison between SDS and
other rating scales (vs BDI r=0.74;vs VAS
r=0.37; vs HRSD r=0.60; vs Wechsler
Depression Rating Scale r=0.54; vs BHRS
r=0.57). Factor analysis yelded to three
components which accounted for 47.6% od the
variance, namely confusion, dissatisfaction,
accessory symptoms (diurnal variation,
fatigue, insomnia). [Faravelli et al 1986] (n=100)
Valid in both genders and at all ages?
Valid in patients with dementia or significant
cognitive impairment?
In depression in PD (dPD)
Face or content validity
Criterion validity (compared to gold-standard, e.g.
DSM IV (SCID, SCAN, systematic interviews) or
The scale was applied to both genders and
populations of different ages:

Significant sex differences were found in
mean scores, with females scoring
significantly higher than males [Tanaka et al
1986].

Gender was not shown to interact with
SDS as a predictor in a logistic regression
analysis [Thurber et al 2002].

Used in elderly patients (n=52 mean
age=75). Weak convergent validity with the
primary care internists’ rating for depression
was observed when using a cut-off score of 50
(r=0.65). [Toner et al 1988]

Used in undergraduates. Nonsignificant
sex differences were found in the total score,
whereas for the Somatic Symptoms subscale (a
subscale obtained through factor analysis),
males scored more highly than females
(p<0.001) [Sakamoto et al 1998].
The scale seems to be not so easily applicable in
patients with cognitive impairment:

In patients with mild severity Alzheimer's
disease, SDS correlated with the score on the
rater-administered Hamilton depression scale
[Gottlieb et al 1988] (n=43).

In patients with mental retardation
(n=120), internal consistency measures were
low (alpha=0.58), and factor analysis did not
yield factors having reliably interpretable
loadings. [Powell, 2003]

In oncology patients (n=61), item 11 did
not show to be an accurate means for
identifying actual cognitive impairment
[Kibiger et al 2003].

In schizophrenic inpatients (n=110), it
was shown to be reliable and able to
discriminate between depressed and non
depressed subjects [Kaneda Y, 1999]
SDS is used in many papers and many
populations as a standardized valid and reliable
psychometric test [Happe, 2001], but no citations
have been found regarding validation process in
depressed PD patients
Specific face validity of SDS in PD patients not
found.
Not found
other criteria for diagnosis)
Construct validity (correlations with other
convergent scales and divergent scales (which?);
factor analysis)
Valid in ethnically and culturally different
populations?
Specific validation process in PD not found.
Discriminant Validity
59 PD patients showed significantly higher SDS
scores than 56 age-matched healthy control
subjects [Happe et al 2001]
Use of the SDS in different languages is shown
in the following studies:
-Czech [Pohanka et al 2004]- n=14 PD patients
(male)
-Italy [Pellecchia et al 2004]- n=20 PD patients
-Finlande [Sivenius et al 2001]- n=24 PD patients
-Austria [Happe et al 2001]- n=56 PD patients
-Japan [Goto et al 2000]- n=1 a case report
-Germany [Muller et al, 1997]-n =15 de-novo
patients with idiopathic PD
-UK [Smith et al 1997]- n= 153 PD patients
-Taiwan [Tsai et al 1994]- n= 24 patients with early
onset parkinsonism
Valid in both genders and at all ages?
Specific validation of SDS according to gender
or age in PD patients not found.
Valid in patients with dementia or significant
cognitive impairment?
Not found
Are you aware of any
correlations of the scale with
biological markers?
In patients without PD
In patients with PD
In patients without PD

No significant relationships were established between severity of
illness and either of the biological markers (Cortisol; Post-dexametasone
cortisol:L-TRP/CAA) the multiple regression SDS/biological datayielded no
significant results (F=1.45; p=0.274). [Maes, 1988]

The depression scale correlated positively with C-reactive protein
levels (p < 0:05), white blood cell count (p < 0:05), and fibrinogen (p < 0:05)
in both genders after adjustment for control variables. [Panagiotakos, 2004]
In patients with PD
Not found as regards biological markers, however SDS was found to correlate
with rigidity in PD patients [Ransmayr et al 1986]
Demonstrated to be sensitive In patients without PD
to change
The mean index score for a group of patients who had received treatment for
(change over time or to
depression was significantly lower after the program (0.39) than before (0.74)
treatment)
[Zung et al 1965a].
In patients without PD
In patients with PD
In patients with PD

In 20 PD patients under 5 months physical therapy significant
Has the minimal clinically
important change and
minimal clinically relevant
incremental difference been
assessed?
In patients without PD
In patients with PD
improvement of SDS was observed (from 31.7±8 at baseline to 27.8±6.1 at
the end; p<0.0001) [Pellecchia et al 2004]

In a double-blind clinical trial where the effect of amitriptyline on
headache in 36 PD patients was evaluated, SDS score remained
unchanged.[Indaco et al 1998]

In an open-label randomized study aimed at comparing the effects of
pramipexole and pergolide in 41 PD patients, SDS score decreased
significantly in both groups [Rektorova, 2003]
In patients without PD
In 289 patients affected by chronic low back pain, treated surgically or nonsurgically: The minimal clinically important difference was 8-9 units, which
was equal to the estimated imprecision of the scale itself [Hagg et al, 2003]
In patients with PD
Not found
Has this scale been assessed
or used in patients with PD?
What are the clini- or
psychometric properties in
this population?
Zung Scale is commonly used to evaluate the depression in patient with PD
[Pohanka, 2004; Pellecchia, 2004; Happe, 2001; Kuopio, 2000 ]. However no specific
studies have been found which tested psychometric properties in PD.
Has the scale been translated
and validated in other
languages?
In general populations (either PD or not):
Use of translated versions of the scale found for:
Puerto Rico population (Spanish) [Martinez et al 2003]
German ederly patients [Hodapp et al 1997]
Use and validation of translated versions of the scale found for:
Japanese [Chida et al 2004]
Chinese [Leung et al, 1998]
Greek [Fountoulakis et al, 2001]
Czech [Kozeny, 1987]
Finnish [Sivenius et al 2001]
Italian [Faravelli et al 1986]
Farsi, Indonesian Lithuanian Russian Thai [WHO,
http://www.who.int/substance_abuse/research_tools/zungdepressionscale/en/
Overall impression
Advantages and
disadvantages
SDS seems an internally consistent, highly reliable, valid scale for assessing
depression. It seems to correlate with DSM-IV for depressed patients, to be
able to discriminate both depressed from non-depressed patients and among
different kinds of diagnoses (i.e. depression Vs alcohol abuse).
A lack of information was observed as regards validation of the scale in PD
patients, although it has been applied in a number of studies.
Some authors criticized the mix of positively-keyed and negatively-keyed
items, which may confuse some patients and result in higher mean scores and
affect factor analytic structure. (Toner et al 1988; Schotteet al 1996)
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http://www.musc.edu/dfm/RCMAR/DepressionTools.html
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APPENDIX 1
The scale has been used to screen depression in patients without PD
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Stroke. 1989 Sep;20(9):1190-4.
Arve S, Lauri S, Lehtonen A, Tilvis RS.and general practitioner's different views on
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Bacaner N, Kinney TA, Biros M, Bochert S, Casuto N.The Relationship among
depressive and alcoholic symptoms and aggressive behavior in adult male emergency
department patients. Acad Emerg Med. 2002 Feb;9(2):120-9.
Chida F, Okayama A, Nishi N, Sakai A. Factor analysis of Zung Scale scores in a
Japanese general population. Psychiatry Clin Neurosci. 2004 Aug;58(4):420-6.
Colon de Marti LN, Guzman Yunque FS, Guevara-Ramos LM. Early detection of
depression using the Zung Self-Rating Depression Scale. P R Health Sci J. 1997
Dec;16(4):375-9.
Dugan W, McDonald MV, Passik SD, Rosenfeld BD, Theobald D, Edgerton S. Use of
the Zung Self-Rating Depression Scale in cancer patients: feasibility as a screening tool.
Psychooncology. 1998;7(6):483-93.
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survival in peritoneal dialysis patients. Perit Dial Int. 2004;24(3):256-63.
Gregory RJ.The Zung Self-Rating Depression Scale as a potential screening tool for use
with Eskimos. Hosp Community Psychiatry. 1994 Jun;45(6):573-5.
Halverson J, Chan C.Screening for psychiatric disorders in primary care. WMJ.
2004;103(6):46-51
Kitchell MA, Barnes RF, Veith RC, Okimoto JT, Raskind MA.Screening for depression
in hospitalized geriatric medical patients. J Am Geriatr Soc. 1982 Mar;30(3):174-7.
Lee HC, Chiu HF, Wing YK, Leung CM, Kwong PK, Chung DW. The Zung Self-rating
Depression Scale: screening for depression among the Hong Kong Chinese elderly. J
Geriatr Psychiatry Neurol. 1994 Oct-Dec;7(4):216-20.
Leung KK, Lue BH, Lee MB, Tang LY Screening of depression in patients with chronic
medical diseases in a primary care setting. Fam Pract. 1998 Feb;15(1):67-75.
Magruder KM, Norquist GS, Feil MB, Kopans B, Jacobs D.Who comes to a voluntary
depression screening program? Am J Psychiatry. 1995;152(11):1615-22.
Martinez KG, Guiot HM, Casas-Dolz I, Gonzalez-Tejera G, Colon de Marti LN
Applicability of the Spanish Translation of the Zung Self-Rating Depression Scale in a
general Puerto Rican population. P R Health Sci J. 2003 Jun;22(2):179-85.
Okimoto JT, Barnes RF, Veith RC, Raskind MA, Inui TS, Carter WB Screening for
depression in geriatric medical patients.Am J Psychiatry. 1982 Jun;139(6):799-802
Passik SD, Kirsh KL, Donaghy KB, Theobald DE, Lundberg JC, Holtsclaw E, Dugan
WM Jr. An attempt to employ the Zung Self-Rating Depression Scale as a "lab test" to
trigger follow-up in ambulatory oncology clinics: criterion validity and detection. J Pain
Symptom Manage. 2001 ; 21(4):273-81.
Passik SD, Kirsh KL, Theobald D, Donaghy K, Holtsclaw E, Edgerton S, Dugan W. Use
of a depression screening tool and a fluoxetine-based algorithm to improve the
recognition and treatment of depression in cancer patients. A demonstration project. J
Pain Symptom Manage. 2002;24(3):318-27.
Raft D, Spencer RF, Toomey T, Brogan D. Depression in medical outpatients: use of the
Zung scale. Dis Nerv Syst. 1977 Dec;38(12):999-1004.
Turner JA, Romano JM.Self-report screening measures for depression in chronic pain
patients. J Clin Psychol. 1984 Jul;40(4):909-13.
Thurber S, Snow M, Honts CR The Zung Self-Rating Depression Scale: convergent
validity and diagnostic discrimination. Assessment. 2002 Dec;9(4):401-5
Zung, W. W. K. The role of rating scales in the identification and management of the
depressed patient in the primary care setting. Journal of Clinical Psychiatry 1990, 51 (6,
Suppl.), 72–76.
Zung WW, Magruder-Habib K, Velez R, Alling W. The comorbidity of anxiety and
depression in general medical patients: a longitudinal study. J Clin Psychiatry. 1990
Jun;51 Suppl:77-80; discussion 81
Appendix 2
The scale has been used to measure severity of depression in patients without PD
Aguglia E, Casacchia M, Cassano GB, Faravelli C, Ferrari G, Giordano P, Pancheri P,
Ravizza L, Trabucchi M, Bolino F, et al.Double-blind study of the efficacy and safety of
sertraline versus fluoxetine in major depression. Int Clin Psychopharmacol. 1993
Fall;8(3):197-202
Akashiba T, Kawahara S, Akahoshi T, Omori C, Saito O, Majima T, Horie
T.Relationship between quality of life and mood or depression in patients with severe
obstructive sleep apnea syndrome. Chest. 2002;122(3):861-5.
Benedetti F, Colombo C, Pontiggia A, Bernasconi A, Florita M, Smeraldi E. Morning
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The scale has been used to assess depression in patients with PD
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Scale:
Geriatric Depression Scale (GDS)
Are there several versions of the
scale? If so, which one has been
assessed?
There are two versions of the Geriatric Depression
Scale (GDS), one consisting of 30 items (GDS30)[1] and the other of 15 items (GDS-15)[2]. As
both versions are commonly utilized and have been
well-studied, they are both reviewed herein.
The GDS was developed to provide a reliable, selfreport screening test for depression in the elderly
(age 55 and older), though it has been used
sparingly in non-elderly populations as well. It
was designed to be simple to administer and not
require the time or skills of a trained interviewer.
Specifically, the GDS was constructed with the
following thoughts in mind: 1. that vegetative
symptoms are common in non-depressed elderly
persons; 2. that thoughts of death and hopelessness
about the future have different meanings for those
in the later stages of life; 3. that medical comorbidity is common in the geriatric population
and may be associated with motor retardation or
decreased activity levels; and 4. that co-morbid
cognitive impairment may affect concentration and
cognitive processing[3].
Depending on the version used, there are either
30 or 15 items on the GDS, though even briefer
versions have been proposed and tested (10-item,
4-item, and 1-item versions)[4]. Increasing scores
indicate greater severity of depression, and the
range of scores is 0-30 for the GDS-30 and 0-15
for the GDS-15.
The GDS is in the format of questions, and all
items are answered by circling either “yes” or
“no”. The entire instrument is presented on a
single page, with questions arranged to maximize
patient acceptance of the questionnaire. Ten of the
items on the GDS-30 and five of the items on the
GDS-15 are negatively keyed (i.e., a “no” response
is an endorsement of a depressive symptom).
The GDS was designed to be self-administered,
though it is used as both a self-administered and
observer-administered instrument, the latter
requiring no specific training. Regardless of the
method of administration, the GDS is a self-report
instrument, as the observer only records the
subject’s answers. The subject is instructed to
answer each question based on “how you felt over
Description of scale
(content,
number of items and subscales,
number of answer options (severity
or frequency or both)
Rater: Patient or caregiver or
clinician. If clinician-rated, training
for application required?
Copyright or public domain?
How can the scale can be obtained
(address or website)?
the past week”. A telephone version has
demonstrated good agreement with the self-report
questionnaire[5].
Though concerns have been raised about
measurement error with self-report depression
inventories in the elderly, this is not thought to
occur with the GDS, the exception being when it is
used in patients with dementia[6].
Public domain.
The GDS-30 is published in the Yesavage and
Brink (1983) article in the Journal of Psychiatric
Research[1], and the GDS-15 is published in the
Sheikh and Yesavage (1986) article in Clinical
Gerontologist[2]. The GDS is in the public
domain, and versions in over 20 languages can be
obtained at the website
www.stanford.edu/~yesavage/GDS.html.
Scale properties
Please provide references for all statements or note if this is your personal judgement
Content
Face validity?
The GDS has good face validity, as it
appears to be an instrument that screens for
common emotional and cognitive symptoms
of depression. The items for the GDS-30
were empirically derived to maximize
discrimination of depressed from nondepressed elderly people. The items for the
GDS-15 were the 15 items from the original
scale that showed the highest correlation
with depression. Scores on the GDS-15 and
GDS-30 are highly correlated (r = 0.84)[2].
Is loss of pleasure included?
Loss on interest, but not loss of pleasure, is
included.
Is the scale heavily weighted towards one
The GDS focuses on the psychological
aspect of depression? If so, which?
symptoms of depression, particularly
changes in mood and ideation. A factor
analysis performed by the instrument’s
developers generated five factors: sad
mood, lack of energy, positive mood,
agitation, and social withdrawal[7]. A
subsequent principal components analysis
(PCA) and confirmatory factor analysis
(CFA) also generated five factors that
incorporated 26/30 items on the GDS-30:
dysphoric mood, withdrawal-apathy-lack of
vigor, hopelessness, cognitive impairment,
and anxiety[8]. In this factor analysis, high
withdrawal-apathy-lack of vigor score was
not specific to depression and was
associated with increasing age and health
problems. The authors also thought that the
distribution of items on the GDS-15 across
these factors was congruent with the
structure that was obtained for the GDS-30.
Does it exclude an important aspect of
The primary symptoms covered in the GDS
depression? If so, which
include loss of interest, lowered mood,
helplessness and hopelessness, lack of
energy, poor self-image, fearfulness, and
cognitive problems associated with
depression.
Neither somatic nor neurovegetative items
are included on the GDS, as no symptoms
in these domains were among the 30 items
from the original list of 100 items that
Compatible with DSM IV or other
depression criteria (compare content to
DSM IV, if formally assessed see also
criterion validity below)?
Includes items on anxiety, psychosis and
cognition as a result of depression?
correlated most highly with the total GDS
score. Specifically, sleep, appetite,
gastrointestinal symptoms, autonomic
symptoms, and sexual symptoms are not
assessed.
Of the nine symptoms that can count toward
a diagnosis of major depression according
to DSM-IV criteria, the GDS-30 covers five
of them (lowered mood, loss of interest, loss
of energy, impaired concentration, and
restlessness), and the GDS-15 covers three
(lowered mood, loss of interest, and loss of
energy).
Anxiety, psychosis, and cognitive
impairment are frequently co-morbid with
depression in PD. There are four items on
the GDS-30 and one on the GDS-15 that
assess fearfulness or worrying. There are
four items on the GDS-30 and one on the
GDS-15 that assess cognitive impairment.
Psychosis is not covered on the GDS.
Which areas are not covered?
Number/percentage of items that overlap
with symptoms of
Parkinsonism (energy, sleep, fatigue,
appetite, psychomotor
retardation/agitation)
Cognitive impairment (slowness of
thinking, clarity of thinking, attention,
memory, concentration)
Apathy (loss of interest, loss of
initiative)
What is the time frame/is the time frame
appropriate (e.g. “during the past week”)?
Are the symptoms of Recurrent Brief
Fatigue is the only somatic or
neurovegetative symptom of depression that
is covered on the GDS, thus there is little
symptom overlap between GDS items and
core PD symptoms. Fatigue is common in
PD and may be an independent symptom in
many patients, but it is also been associated
with depression and higher GDS scores in
this population[9].
There are four items on the GDS-30 and one
on the GDS-15 that pertain to cognitive
changes commonly associated with
depression.
Loss of interest, which may be a symptom
of apathy without depression, is covered on
both GDS versions.
Instructions for subjects that are read before
completing the GDS state that responses
should be based on how one has felt in the
past week, a time frame that is similar that
used with many depression rating scales.
Not captured.
Depressive Disorder captured?
Use
Was it designed to measure severity or to
screen for depression?
Is there a cut-off score for diagnosis of
depression (in depression without PD)?
Is this appropriate in depression with PD
(dPD)?
If not, why?
Has a different cut-off score for dPD been
suggested, and if so, is there evidence to
support it?
Has it been used to measure severity or to
screen for depression (in depression
without PD and dPD)?
The GDS was developed to be used as a
screening instrument for depression in the
elderly, not as an instrument to follow
depressive symptoms or assess response to
treatment. Additionally, in the original
publication the authors recommended that
depression rating scales should not be used
as diagnostic instruments, and that a
positive result on any scale should be
followed up by a detailed diagnostic or
clinical interview.
In the original publication for the GDS-30,
a cutoff score of 10/11 on the GDS-30 was
suggested as a possible indicator of
depression (sensitivity=84%,
specificity=95%)[1]. For the GDS-15, cutoff points somewhere between 2/3 and 5/6
have been recommended[10;11], depending
partly on the desired balance between
sensitivity and specificity.
Anecdotally, several items on the GDS are
frequently endorsed by PD patients without
any other symptoms of depression. These
items ask about dropping activities and
interests, preferring to stay home rather
than going out and doing new things, and
loss of energy, all of which are common
either due either to limitations induced by
the illness or as part of the disease process
itself. As a result, reported depression rates
for PD that were based on commonly-used
GDS cutoff points may have been falsely
elevated.
Similar cutoff scores have been proposed
for PD, with evidence in support of this for
both the GDS-30 and the GDS-15 (see
Validity).
The GDS has been used almost exclusively
to screen for depression. The GDS has
been used extensively in the elderly in
psychiatric settings, primary care settings,
nursing homes, in patients with a variety of
co-morbid medical conditions, and in
patients with dementia[3;6]. In addition, it
has also been used sparingly in non-elderly
patients[12].
Acceptability
Length
Ambiguities in instructions to patient/rater
Ambiguities in rating anchors
The yes/no, simple format of the GDS
makes it an easy instrument to administer
and appropriate to use in a clinical setting.
It takes approximately 10 minutes to
complete the GDS-30 and 5 minutes to
complete the GDS-15, leading to high
completion rates[6].
Anecdotally, patients sometimes have
difficulty choosing between “yes” and “no”
on items that do not specify frequency of
symptomatology as part of the question.
For this reason, GDS questions that include
terms such as “most of the time” or “often”
are less ambiguous.
Appropriateness of questions for PD
population
Applicability across PD and depression
disease stages mild – moderate – severe?
Can it be used for “on” and “off” and has
this been done?
Clear instructions to raters
Though empiric evidence is lacking, it is
reasonable to assume that PD patients in the
most advanced stages (i.e., Hoehn and Yahr
stages 4 and 5) would score higher in
general, as one would assume that severe
physical disability would lead to decreased
satisfaction with life, more helplessness and
hopelessness, a preference to stay at home,
and thinking that most people are better off
than oneself is.
It has been demonstrated that the GDS is
able to discriminate between mildly (i.e.,
non-major depression) and severely (i.e.,
major depression) depressed subjects in a
non-PD population, performing as well as
the Hamilton Depression Rating Scale
(Ham-D) and better than the Zung SelfRating Depression Scale (Zung SDS)[1].
The GDS does not query about rapid and
repeated fluctuations in mood and anxiety
symptoms that can occur in patients with
motor fluctuations. Though the GDS
queries about symptoms in general over the
past week, experts have recommended that
psychiatric instruments be administered
when patients are in an “on” state.
There are no specific directions for
administering and scoring the GDS.
Clinimetric/psychometric properties
Metric flaws (floor and ceiling effects, score
distributions)?
Patients without symptoms of depression
commonly score a zero on the GDS,
potentially leading to a skewing of the
distribution of scores toward the lower
end of the scale. However, a floor or
ceiling effect has not been reported for
the GDS.
Reliability (internal consistency, inter-rater,
Tested in a sample of 40 non-depressed
test-retest) of total or sub-scales and of
and 60 depressed non-PD subjects, the
individual items
mean intercorrelation (r) among the
items on the GDS-30 was 0.36, and
Cronbach’s alpha coefficient was 0.94,
demonstrating high internal reliability.
Internal consistency values were
approximately the same to those obtained
when the Ham-D was administered to the
same subjects. Retest reliability studies
reported a correlation (r) of 0.85 in 20
subjects repeating the questionnaire after
1 week[3].
Validity: assessed – not assessed, good – not good (references); please also comment on
sample sizes
In depression without PD
Face or content validity
In non-PD populations, the GDS shows
good convergent validity with the Zung
SDS (r = 0.84)[1], the Ham-D (r =
0.83)[1], and the Beck Depression
Inventory[13]. Regarding discriminant
validity, the GDS-30 had sensitivity of
90% and specificity of 80% in
discriminating depressed psychiatric
inpatients from non-depressed subjects at
a cutoff score of 9, which was similar to
how the Ham-D and better than how the
Zung SDS performed[14]. In addition,
numerous studies have shown both the
GDS-30 and GDS-15 to have adequate
sensitivity and specificity discriminating
depressed from non-depressed patients in
primary care settings[10]. The GDS-30
and GDS-15 have been shown to perform
similarly[15]; even briefer versions of the
GDS (10-items and 4-items) demonstrate
good sensitivity but lower specificity at
proposed cutoff scores[4]. Finally, the
GDS has also been shown to discriminate
Criterion validity (compared to goldstandard, e.g. DSM IV (SCID, SCAN,
systematic interviews) or other criteria for
diagnosis)
Construct validity (correlations with
other
convergent scales and divergent
scales (which?);
factor analysis)
Valid in ethnically and culturally
different
populations?
Valid in both genders and at all ages?
between depressed and non-depressed
subjects with co-morbid conditions,
including arthritis[1] and stroke[16].
All validity information above.
As mentioned previously, the GDS has
been translated into many different
languages and studied in different
cultures, including Chinese, Spanish,
Danish, French, Hindi, and Turkish. The
GDS appears to have good reliability and
validity when utilized in other cultures,
though specific words (e.g., “hopeful” on
item #5 of the GDS-30) may have
different meaning[17].
The GDS has been well-studied in both
men and women, and there is evidence
that in general females score higher than
males[11], which is not surprising given
that the association of sex with
depression in later life has been a
consistent epidemiological finding.
There is also evidence that GDS scores
increase with age[11]; as the association
between age and depression in older
people is more controversial, it is
possible that age effects seen with the
GDS represent measurement error.
Regarding the interaction of sex and age,
another study found that older men
scored lower than older women[18].
Finally, one study reported a potential
bias in GDS scores, in that medically ill
patients who were older or had higher
verbal intelligence scores underreported
depressive symptoms[19].
Though patients with PD are typically
older, there are many younger adults with
the disease, so it is important to know
how depression rating scales perform in
non-elderly patients as well. The GDS
Valid in patients with dementia or
significant
cognitive impairment?
In depression in PD (dPD)
Face or content validity
Criterion validity (compared to goldstandard,
DSM IV (SCID, SCAN, systematic
interviews)
other criteria for diagnosis)
has been tested in the general adult
population, and good internal reliability
has been demonstrated down to age
40[12].
The validity of the GDS in patients with
dementia is unclear. Although some
studies have found that the GDS
performs well in patients with mildmoderate dementia[19;20],
demonstrating good sensitivity and
specificity in patients with a Mini-Mental
State Examination (MMSE) score as low
as 15[21], other research suggests that
only cognitively-intact or mildly
impaired individuals are able to complete
the GDS[22] and that the diagnostic
accuracy of the instrument is diminished
in this population[20;23;24]. The
sensitivity and specificity of the GDS
may also decrease when it is used with
institutionalized elderly people,
particularly those with non-major
depression[6]. If the GDS is used in
patients with clinically-significant
cognitive impairment, it should be
interviewer-administered.
Already covered.
Screening 132 PD patients from a
community-based register and using a
cutoff score of 4/5 on the GDS-15, one
study reported a mean (SD) GDS score
of 5.6 (3.1), and that 64% of patients met
the GDS criterion for clinicallysignificant depressive symptoms[25].
Similar to what has been reported in
many PD studies using other depression
rating scales or formal diagnostic criteria,
subjects with clinically-significant
depressive symptoms had longer disease
duration, more severe parkinsonism, and
greater cognitive impairment. In another
study of 353 PD patients receiving
specialty care, 57% scored ≥11 on the
GDS-30[26]. A third survey of 111 PD
patients found that 56% had depression
based on their GDS score[27]. Finally, a
study of 102 PD patients, most
Construct validity (correlations with
moderately to severely disabled, found
that 52% of patients had clinicallysignificant depressive symptoms (47%
with mild-moderate depression and 5%
with severe depression)[28]. Overall,
these studies suggest that the a priori
choice of commonly-used cutoffs for the
GDS may result in slightly inflated rates
of depression in PD, though there is also
recent research in PD suggesting that the
GDS-30 has adequate discriminant
validity for a DSM-IV diagnosis of major
depression at a cutoff of 9/10 (sensitivity
= .81, specificity = .84)[29], and that the
GDS-15 discriminates patients with a
diagnosis of either major or minor
depression at a cutoff of 4/5 (sensitivity =
.88, specificity = .85)[30].
All validity information above.
other
convergent scales and divergent
scales (which?);
factor analysis)
Valid in ethnically and culturally
different
populations?
Valid in both genders and at all ages?
Valid in patients with dementia or
significant
cognitive impairment?
Are you aware of any correlations of the scale
with biological markers?
In patients without PD
Not tested in PD.
Not tested in PD.
Concerning the use of the GDS in PD
patients with a range of cognitive
abilities, significantly higher GDS-15
scores were reported for PD subjects
with dementia than those without
dementia[31]. The GDS performed
similarly to the Cornell Scale for
Depression in Dementia in this study,
suggesting that the instrument may be a
sensitive indicator of depression severity
in PD patients with dementia.
Not for either population.
In patients with PD
Demonstrated to be sensitive to change
(change over time or to treatment)
No PD: Regarding predictive validity,
there is preliminary evidence from a
In patients without PD
In patients with PD
Has the minimal clinically important change
and minimal clinically relevant incremental
difference been assessed?
In patients without PD
In patients with PD
Has this scale been assessed or used in
patients with PD? What are the clini- or
psychometric properties in this population?
Has the scale been translated and validated in
other languages?
Overall impression
Advantages and disadvantages
Which type of study is this scale very suitable
for and which one is it unsuitable (screening,
prevalence, aetiological (e.g. case-control or
genetic), treatment trial of PD or depression
medication, correlation with biological
markers or other scales, e.g. of parkinsonism,
clinical practice for diagnosis/screening). List
all
geriatric antidepressant treatment study
in non-PD patients that the GDS may be
sensitive to changes in depression
severity[32].
PD: Not tested.
Not for either population.
Already covered.
Already covered.
The GDS is a reliable and valid selfreport screening instrument for
depression in the elderly that is short
and easily understood, making it
appropriate for use in both clinical
research and routine clinical care.
Research suggests that the GDS-15
performs as well as the GDS-30. GDS
items focus on the psychological aspects
of depression, thus avoiding symptom
overlap with other disorders or aging in
general. Though there is limited
published research on its use in PD,
there is emerging evidence that it
performs well as a screening instrument
for depression in this population as well.
However, there are two important
caveats to using the GDS. First,
questions about suicide ideation were
intentionally not included, as it was
thought that death or suicide ideation
could present as part of the aging
process and in patients with chronic
medical problems (e.g., such as PD),
regardless of depression. Therefore,
clinicians evaluating depression and
using the GDS must also query about
suicide ideation. Second, the GDS was
designed as a depression screening
instrument, not as a scale to follow
depressive symptoms. Observer-rated
instruments such as the Ham-D and the
Montgomery Asberg Depression Rating
Scale, both of which have been
validated in PD, are more appropriate
for following depressive symptoms and
measuring depression treatment
response in this population.
Reference List
[1] Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric
depression screening scale: a preliminary report. J Psychiatr Res 1983; 17:37-49.
[2] Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and
development of a shorter version. Clin Gerontol 1986;(5):165-173.
[3] Yonkers KA, Samson J. Mood Disorders Measures. In: Rush AJ, Pincus HA, First
MB, et al., editors. Handbook of Psychiatric Measures. Washington, DC:
American Psychiatric Association, 2000: 544-546.
[4] D'Ath P, Katona P, Mullan E, et al. Screening detection and management of
depression in elderly primary care attenders. I: The acceptability and performance
of the 15 item Geriatric Depression Scale (GDS15) and the development of short
versions. Fam Pract 1994; 11:260-266.
[5] Burke WJ, Roccaforte WH, Wengel SP, et al. The reliability and validity of the
Geriatric Depression Rating Scale administered by telephone. J Am Geriatr Soc
1995; 43:674-679.
[6] Montorio I, Izal M. The Geriatric Depression Scale: A review of its development
and utility. Int Psychogeriatr 1996; 8:103-112.
[7] Sheikh JI, Yesavage JA, Brooks JO, et al. Proposed factor structure of the
Geriatric Depression Scale. Int Psychogeriatr 1991; 3:23-28.
[8] Adams KB, Matto HC, Sanders S. Confirmatory factor analysis of the Geriatric
Depression Scale. Gerontologist 2004; 44:818-826.
[9] Zenzola A, Masi G, De Mari M, et al. Fatigue in Parkinson's disease.
Neurological Sciences 2003; 24:225-226.
[10] Watson LC, Pignone MP. Screening accuracy for late-life depression in primary
care: a systematic review. J Fam Pract 2003; 52:956-964.
[11] Osborn DPJ, Fletcher AE, Smeeth L, et al. Geriatric Depression Scale Scores in a
representative sample of 14 545 people aged 75 and over in the United Kingdom:
results from the MRC Trial of Assessment and Management of Older People in
the Community. Int J Geriatr Psychiatry 2002; 17:375-382.
[12] Rule BG, Harvey HZ, Dobbs AR. Reliability of GDS in adult population. Clin
Gerontol 1989; 9:37-43.
[13] Scogin F. The concurrent validity of the Geriatric Depression Scale with
depressive older adults. Clin Gerontol 1987; 7:23-31.
[14] Brink TL, Yesavage JA, Lum O, et al. Screening tests for geriatric depression.
Clin Gerontol 1982; 1:37-43.
[15] Burke WJ, Roccaforte WH, Wengel SP. The short form of the Geriatric
Depression Scale: a comparison with the 30-item form. J Geriatr Psychiatry
Neurol 1991; 4:173-178.
[16] Agrell G, Dehlin O. Comparison of six depression rating scales in geriatric stroke
patients. Stroke 1989; 20:1190-1194.
[17] Ertan T, Eker E. Reliability, validity, and factor structure of the Geriatric
Depression Scale in Turkish elderly: Are there different factor structures for
different cultures? Int Psychogeriatr 2000; 12:163-172.
[18] Allen-Burge R, Storandt M, Kinscherf DA, et al. Sex differences in the sensitivity
of two self-report depression scales in older depressed inpatients. Psychol Aging
1994; 9:443-445.
[19] Harper RG, Kotik-Harper D, Kirby H. Psychometric assessment of depression in
an elderly general medical population: over- or underassessment. J Nerv Ment Dis
1990; 178:113-119.
[20] Feher EP, Larrabee GJ, Crook TH. Factors attenuating the validity of the Geriatric
Depression Scale in a dementia population. J Am Geriatr Soc 1992; 40:906-909.
[21] McGivney SA, Mulvihill M, Taylor B. Validating the GDS depression screen in
the nursing home. J Am Geriatr Soc 1994; 42:490-492.
[22] Burke WJ, Houston MJ, Boust SJ, et al. Use of the Geriatric Depression Scale in
dementia of the Alzheimer type. J Am Geriatr Soc 1989; 37:856-860.
[23] Kafonek S, Ettinger WH, Roca P, et al. Instruments for screening for depression
and dementia in a long term care. J Am Geriatr Soc 1989; 37:29-34.
[24] Brink TL. Limitation of the G.D.S. Clin Gerontol 1984; 2:60-61.
[25] Meara J, Mitchelmore E, Hobson P. Use of the GDS-15 geriatric depression scale
as a screening instrument for depressive symptomatology in patients with
Parkinson's disease and their carers in the community. Age Ageing 1999; 28:3538.
[26] Rojo A, Aguilar M, Garolera MT, et al. Depression in Parkinson's disease:
clinical correlates and outcome. Parkinsonism and Related Disorders 2003; 10:2328.
[27] Errea JM, Ara JR. Depression and Parkinson disease. Rev Neurol 1999; 28:694698.
[28] Caap-Ahlgren M, Dehlin O. Insomnia and depressive symptoms in patients with
Parkinson's disease. Relationship to health-related quality of life. An interview of
patients living at home. Arch Gerontol Geriatr 2001; 32:23-33.
[29] McDonald WM, Haber MJ, Holtzheimer PE, et al. Using the Geriatric Depression
Scale (GDS) to diagnose depression in patients with Parkinson's disease (PD).
American Psychiatric Association Annual Meeting . 5-25-2005.
Ref Type: Abstract
[30] Weintraub D, Oehlberg KA, Katz IR, et al. Test characteristics of the 15-Item
Geriatric Depression Scale and Hamilton Depression Rating Scale in Parkinson's
disease. Am J Geriatr Psychiatry. In press.
[31] Burn DJ, Rowan EN, Minett T, et al. Extrapyramidal features in Parkinson's
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[32]
Duloxetine versus placebo in the treatment of elderly patients with major
depressive disorder. 04 Oct 14; 2004.
Cornell Scale for Depression in Dementia
Scale: Cornell Scale for Depression in Dementia (CSDD)
Are there several versions of the scale?
If so, which one has been assessed?
Description of scale
(content, number of items and
subscales, number of answer options
(severity or frequency or both)
There is only one version of the scale.
Rater: Patient or caregiver or clinician.
If clinician-rated, training for
application required?
Designed to be administered by a trainedclinician who uses both patient and caregiver
information. No specific training required,
although most research raters usually undergo
training in the administration and scoring of
the scale. The scale is administered in two
steps. First, the clinician interviews the
caregiver on each of the 19 items using
descriptions of each of the 19 items. For
example Item 1 is “Anxiety: anxious
expression, ruminations, worrying”. There is
no formal script and the clinician has the
latitude to ask the questions using additional
descriptors to be certain that the caregiver
The Cornell Scale for Depression in Dementia
(CSDD) (Alexopulos et al., 1988) is a 19-item
clinician administered instrument that uses
information from both the patient and
caregiver(s) to rate symptoms of depression in
patients with dementia. The scale is
subdivided into four domains: mood-related
signs (anxiety, sadness, lack of reactivity to
pleasant events, irritability); behavioral
disturbances (agitation, retardation, multiple
physical complaints, loss of interest); physical
signs (appetite loss, weight loss, lack of
energy); cyclic functioning (diurnal variation
of mood, difficulty falling asleep, multiple
awakenings during sleep, early morning
awakenings); and ideational disturbances
(suicide, poor self-esteem, pessimism, moodcongruent delusions). The items are
constructed so that they can be rated by
observation and for this reason more complex
items that require a cooperative, insightful
patient were not included (e.g., phobias and
obsessions). Each item is rated on four levels
of severity: absent (0), mild or intermittent (1)
or severe (2). There is also an option (a) of
“unable to evaluate”.
understands what is being asked. The
caregiver is asked to consider only the patient’s
behavior in the week prior to the assessment.
Two of the items (“Loss of interest” and “Lack
of energy”) have specific instructions to ask
the caregiver to determine if the changes
occurred acutely and not for more than one
month. Loss of weight is rated on objective
measures of weight loss compared to one
month before the interview.
Copyright or public domain?
The second stage of the interview is to briefly
assess the patient on these same items. If there
is a discrepancy in the ratings after the patient
interview, the rater is instructed to meet again
with the caregiver/ patient to resolve these
discrepancies and make a final rating on each
item.
Public domain.
How can the scale can be obtained
(address or website)?
The scale is part of the original publication
(Alexopoulos et al., 1988).
Scale properties
Please provide references for all statements or note if this is your personal judgement
Content
Face validity?
The scale has face validity and includes all
of the Diagnostic and Statistical Manual
(DSM) criteria except for guilt,
concentration problems (indicisiveness),
hypersomnia, hyperphagia and increased
weight. It does include symptoms of
anxiety and irritability which, although not
a part of the DSM/ICD criteria, can be
important symptoms of depression in the
elderly.
Is loss of pleasure included?
Loss of pleasure is included in the scale
and, in fact, the CSDD requires the rater to
define anhedonia on two questions. The
clinician is asked to rate both “loss of
reactivity to pleasurable events” and “loss
of interest” as shown by being “less
involved in usual activities”. If the loss of
interest was chronic (i.e., greater than one
month) then it is rated as no change. The
validity of the distinction between the loss
of interest in pleasurable vs. usual activities
is not discussed.
Is the scale heavily weighted towards one
If all of the 19 items were rated as severe,
aspect of depression? If so, which?
the total score would be 38. Eight questions
(16 points) assess cognitive depressive
symptoms: Sadness, Lack of reactivity to
pleasurable events, Loss of interest,
Irritability, Suicide, Poor self-esteem,
Pessimism and Mood-congruent delusions.
Two questions assess the overlap of
depression and anxiety symptoms: Anxiety
and Agitation. There is one question each
to assess the overlap of depression with
physical symptoms (Retardation) and
somatization (Multiple somatic complaints).
There are only 7 of the 19 items that focus
on neurovegetative symptoms: Energy (1
item), Sleep (3 items), Appetite (2 items)
and Diurnal variation in mood (1 item).
Does it exclude an important aspect of
Does not rate several symptoms (guilt, lack
depression? If so, which
of concentration or indecisiveness, fatigue,
hyperphagia and hypersomnia) that are part
of the DSM-IV diagnostic criteria for major
depression.
Compatible with DSM IV or other
depression criteria (compare content to
DSM IV, if formally assessed see also
criterion validity below)?
See above.
Includes items on anxiety, psychosis and
cognition as a result of depression?
The scale includes two items to assess
anxiety (Anxiety and Agitation), one item to
assess mood congruent psychosis (and no
items to assess mood incongruent
hallucinations) and one item to assess
cognition (Retardation). The agitation item
does not differentiate agitation due to
dyskinesias and a patient could be rated a
“2” if they were “severely restless”. PD
patients with severe bradykinesia could also
be rated a “2” for retardation which is
described as “slow movements, slow
speech, slow reactions”. The fact that the
psychosis is required to be mood congruent
would eliminate adding points for patients
with mood incongruent hallucinations that
were induced by medication.
Does not rate symptoms of atypical
depression (e.g., hyperphagia and
hypersomnia) or guilt, lack of concentration
or indecisiveness or fatigue.
Which areas are not covered?
Number/percentage of items that overlap
with symptoms of Parkinsonism (energy,
sleep, fatigue, appetite, psychomotor
retardation/agitation)
Cognitive impairment (slowness of
thinking, clarity of thinking, attention,
memory, concentration)
Apathy (loss of interest, loss of initiative)
What is the time frame/is the time frame
appropriate (e.g. “during the past week”)?
There are a number of items, which overlap
with the motor symptoms of PD: Sadness
(“sad expression, sad voice, tearfulness”)
overlaps with PD flat facies, hypophonia;
Reactivity (“lack of reactivity to pleasurable
events”) overlaps with PD apathy; Agitation
(“restlessness, handwringing, hairpulling”)
overlaps with PD dyskinesia, punding and
other stereotypical motor behavior;
Retardation (“slow movements, speech and
reactions”) overlaps with PD bradykinesia,
hypophonia; Physical (“multiple physical
complaints”) overlaps with elderly PD
patients with multiple medical problems;
Interest (“less involved in usual activities”)
overlaps with PD apathy, loss of function,
withdrawal due to embarrassment from
dyskinesia; Energy (“fatigues easily, unable
to sustain activities”) overlaps with “off”
phenomena in PD, fatigue unrelated to
depression; Sleep problems (“problems
falling asleep, multiple awakenings, waking
early”) overlap with chronic PD sleep
problems; Delusions (“mood congruent
delusions”) overlaps with medication
induced psychosis, incongruent delusions.
The examiner is instructed to rate the item
as a 0 if the “symptoms result from physical
disability or illness”.
Retardation (see above). The questions
related to cognitive impairment are omitted
because this scale is designed to distinguish
dementia from dementia with comorbid
depression.
Interest (see above). Two questions related
to anhedonia are asked. The loss of interest
(defined as less involvement in usual
activities) is rated separately from lack of
reactivity to pleasurable events. This
distinction may allow a rater to distinguish
apathy from anhedonia which is not
possible with DSM criteria.
All items are rated “based on symptoms and
signs occurring during the week prior to the
interview” except for Energy and Interest.
The authors attempted to minimize the
overlap of these two symptoms of
Are the symptoms of Recurrent Brief
Depressive Disorder captured?
depression with more chronic health
problems by requiring that Loss of interest
and Lack of energy show a change acutely
(i.e., within the past month) from the
patient’s baseline interest and energy level,
respectively. There was no guidance on
how to score patients who may have had a
more chronic presentation to their
depression so that the symptoms would be
expected to be present for one month or
more.
It would be difficult to determine if a patient
met criteria for brief recurrent depression
which includes depressive episodes that last
at least 2 days but less than 2 weeks and
occur at least once a month for 12
consecutive months without association to
the menstrual cycle. The rater for the
CSDD is only asked to assess symptoms
over the last week. There are no clear
instructions as to whether the symptoms
have to occur on each day of the last week
or if they could have occurred on only one
or two days.
Use
Was it designed to measure severity or to
screen for depression?
Is there a cut-off score for diagnosis of
depression (in depression without PD)?
Is this appropriate in depression with PD
(dPD)?
If not, why?
The CSDD was designed to measure
depression severity and not to be used as a
screen for depression.
Vida et al (1994) examined the sensitivity
and specificity of the CSDD in diagnosing
depression in 34 AD patients with mild to
moderate dementia using nonparametric
receiver operating characteristic analysis.
The subjects were diagnosed using RDC
for major depression and a blinded
investigator administered CSDD. A cutpoint of 7 on the CSDD yielded a
sensitivity of .90 and a specificity of .75
for the CSDD in diagnosing major
depression. This has been the generally
accepted cut-off point for the CSDD in
diagnosing major depression.
In a study of nondemented older Japanese
with both major and minor depression by
DSM-IV criteria, Schreiner et al (2003)
found a cut-off of 5 yielded a sensitivity of
1.00 and a specificity of .919. Lam et al.
(2004) evaluated 88 demented elderly
Chinese with DSM-IV defined major,
dysthymic or minor depression with the
CSDD. The optimal cut-off score was 6/7
(sensitivity 91.7%, specificity 80.0%) in
the mild dementia group and 12/13
(sensitivity 70.0%, specificity 87.0%) in
the more advanced dementia group.
There are no studies that directly address
the validity of the CSDD in PD. Burn et
al. (2003) evaluated depressive symptoms
in patients with PD, dementia of PD (PDD)
and dementia with Lewy Body (DLB)
using the CSDD. Herrmann et al. (1997)
used the CSDD to compare depressive
symptoms in post stroke and PD patients.
However these studies did not compare the
CSDD to other measures of depression.
No evidence.
Has a different cut-off score for dPD been
suggested, and if so, is there evidence to
support it?
Has it been used to measure severity or to
There is relatively little data on the use of
screen for depression (in depression without this scale in PD. The data presented will
PD and dPD)?
be from the studies examining the CSDD
in nondemented patients. The data on
dementia is presented in that section.
In a review of depression screening
instruments by the American Academy of
Family Physicians (Sharp and Lipsky
2002), the Academy recommended that the
most useful scales for screening older
adults with depression were the GDS and
the CSDD. The CSDD has been validated
in nondemented elders (Alexopoulos et al
1988) and appropriate cut-offs for the
diagnosis of depression have been
described (Vida et al 1994; Schreiner et al
2003).
The CSDD has not been shown to be valid
in patients with post stroke depression
(PSD). In a study of 40 elderly stroke
patients, 17 who were diagnosed clinically
with PSD, Agrell and Dehlin (1989)
compared the GDS, Zung Scale, CES-D,
HAM-D, the Comprehensive
Psychopathological Rating ScaleDepression, and the CSDD. External
validity and concurrent validity were good
for all scales except the CSDD.
Acceptability
Length
Ambiguities in instructions to patient/rater
Ambiguities in rating anchors
Appropriateness of questions for PD
population
Applicability across PD and depression
disease stages mild – moderate – severe?
Can it be used for “on” and “off” and has
this been done?
Clear instructions to raters
The total interview time is estimated to be
30 minutes, 20 minutes with the caregiver
and 10 minutes with the patient.
Clinicians must be familiar with both
dementia and depression in order to
accurately administer the CSDD. There
are no clear descriptions for the rating
anchors.
Yes, but as outlined above there is
considerable overlap in the CSDD
questions with the motor symptoms of PD.
There are no studies.
Some of the items do not allow ratings
during short intervals. There are no studies
in dPD in “on” and “off” states.
There are few guidelines as to how to ask
the questions.
Clinimetric/psychometric properties
Metric flaws (floor and ceiling effects, score
distributions)?
Each item is rated on four levels of
severity: absent (0), mild or intermittent
(1) or severe (2). There is also an option
(a) of “unable to evaluate”. No data
was found to determine if the scale is
linear. As discussed above, there are a
total of 19 questions which are equally
weighted and are in the following five
content areas (described in detail above):
mood-related signs (4 questions);
behavioral disturbances (4 questions);
physical signs (3 questions); cyclic
functioning (4 questions); and ideational
disturbances (4 questions).
Reliability (internal consistency, inter-rater,
Alexopoulos et al (1988) validated the
test-retest) of total or sub-scales and of
use of the scale in nondemented elders.
individual items
The CSDD was administered to 15
depressed patients (by RDC criteria), 15
patients with other psychiatric
diagnoses, and 15 control subjects. The
CSDD had high interrater reliability
(Cohen's kappa = 0.74), internal
consistency (Kuder-Richardson's
coefficient = 0.98), and sensitivity.
Validity: assessed – not assessed, good – not good (references); please also comment on
sample sizes
In depression without PD
Face or content validity
The scale has face validity and includes
most of the Diagnostic and Statistical
Manual (DSM) criteria (discussed in
more detail above).
Criterion validity (compared to goldKurlowicz et al. (2002) used exploratory
standard, e.g. DSM IV (SCID, SCAN,
factor analysis and criterion-validity
systematic interviews) or other criteria for
analysis to evaluate the CSDD scores of
diagnosis)
642 frail nursing home patients (some
with dementia). The factor analysis
resulted in four distinct domains:
depression, somatic/vegetative,
disturbed sleep, and anxiety. The indices
generated by the factor analysis
correlated as expected with criterion
variables.
Construct validity (correlations with
Alexopoulos et al (1988) validated the
other convergent scales and divergent scales use of the scale in nondemented elders.
(which?); (factor analysis)
The CSDD was administered to 15
depressed patients (by RDC criteria), 15
Valid in ethnically and culturally
different populations?
Valid in both genders and at all ages?
Valid in patients with dementia or
significant cognitive impairment?
patients with other psychiatric
diagnoses, and 15 control subjects. The
CSDD correlated significantly
(Spearman's r = 0.81) with RDC
diagnoses of various intensity of
depression.
Trials evaluating depression in different
cultural groups in the United States
include the use of the CSDD in elderly
Hispanics (Ownby 2001) and CubanAmericans (Harwood 2000).
No studies found.
Metric flaws
There are no specific problems with the
questions on the CSDD. In general, the
CSDD avoids some of the pitfalls of
diagnosing depression in dementia and
does not have questions related to
memory, attention or concentration.
Delusions, when present, are only rated
if they are mood congruent. However
some symptoms inevitably will overlap
with dementia syndromes (e.g., sleep
disturbance with “sundowning”).
Reliability
Alexopoulos et al. (1988) used DSM-III
criteria to diagnose dementia and
included patients with primary
degenerative dementia (n = 52),
multiinfarct dementia (n = 18) and
mixed primary degenerative dementia
and multiinfarct dementia (n = 13) in the
original study validating the instrument.
A subgroup of 26 patients was used in
the interrater reliability study. The
subjects were divided into the severely
demented (MMSE < 8) and less
demented to determine if reliability
would improve if the patient could
provide additional information.
Interrater reliability for the CSDD total
scores of two psychiatrists rating the
same patient independently was kw =
0.63 for severely demented patients
(mean MMSE = 5) and kw = 0.62 for the
less demented group (mean MMSE =
18).
Validity
Alexopoulos et al used a subgroup of 48
demented subjects to assess concurrent
validity of the scale with the Research
Diagnostic Criteria (RDC) for
depressive syndromes. 22 subjects met
RDC criteria for a depression syndrome
and the severity of their depressive
episode was ranked: no depression <
episodic minor depression < probable
depression < definite depression. When
total CSDD scores were compared with
the severity of the episode by RDC
criteria, the correlation was acceptable (r
= 0.83, p < 0.01) between severity of
depression and total score on the CSDD.
Harwood et al (1998) evaluated 137
outpatients with probable AD on the
CCSD. 43.1% of the common variance
was accounted for by four factors. The
four factors included general depression
(lack of reactivity to pleasant events,
poor self-esteem, pessimism, loss of
interest, physical complaints,
psychomotor retardation, sadness);
rhythm disturbances (difficulty falling
asleep, multiple night awakenings, early
morning awakenings, weight loss,
diurnal variation of mood);
agitation/psychosis (agitation, moodcongruent delusions, suicide); and
negative symptoms (appetite loss,
weight loss, lack of energy, loss of
interest, lack of reactivity to pleasant
events).
Logsdon and Teri (1995) assessed the
reliability of caregivers in reporting
depressive symptoms in AD. The
caregivers of 76 depressed AD patients
(confirmed by the Schedule for
Affective Disorders and Schizophrenia
(SADS)) completed the Beck
Depression Inventory (BDI), the
Geriatric Depression Scale (GDS), and
the Center for Epidemiological StudiesDepression Scale (CESD) that were
modified to allow for caregiver ratings.
A researcher also completed the CSDD
and the Hamilton Depression Rating
Scale (HAM-D) with caregiver input.
The CSDD was the most sensitive
measure tested and the HAM-D was the
least sensitive.
More recently, Muller-Thomsen et al
(2005) compared the scores of 316 AD
patients in an outpatient memory clinic
on the 15-point Geriatric Depression
Scale (GDS), the Montgomery and
Asperg Depression Scale (MADRS), the
CSDD and the Nurses Observation Scale
for Geriatric Patients (NOSGER). The
patients were subdivided into those with
moderate to severe (MMSE < 18) and
mild (MMSE > 18) dementias. Internal
consistency was excellent for the CSDD
in both the moderate/severe and mild
dementia groups (Cronbach’s alpha of
.81 and .82, respectively). All scales
correlated well with the CSDD in the
mild dementia group (r > .60) but only
the MADRS/ CSDD was acceptable in
the more severely demented group (r >
.74, P < .0001). The MADRS has a
number of items which overlap on both
scales.
Sensitive to change over time
Ballard et al. (1996) followed patients
with AD over one year and
demonstrated the persistence of
depressive symptoms using the CSDD.
In contrast to AD patients, Ballard et al.
(2001) showed that depressive
symptoms assessed by the CSDD were
stable or declined over time in dementia
with Lewy Body (DLB).
In one of the few placebo controlled
trials of a serotonin specific reuptake
inhibitor (SSRI) in AD depression,
Steinberg et al (2004) used the HAM-D
and CSDD to show mood changes in
patients with depression. Teri et al
(2003) used the CSDD to evaluate mood
changes in AD patients who were
randomized to either usual medical care
or a program of exercise training
combined with caregiver education on
managing behavioral problems. Finally
van Weert et al (2005) demonstrated
mood changes using the CSDD after
starting an environmental program in
nursing home patients with AD.
In depression in PD (dPD)
Face or content validity
Criterion validity (compared to goldstandard,
DSM IV (SCID, SCAN, systematic
interviews)
other criteria for diagnosis)
Construct validity (correlations with
other
convergent scales and divergent scales
(which?);
factor analysis)
Valid in ethnically and culturally
different
populations?
Valid in both genders and at all ages?
Valid in patients with dementia or
significant
cognitive impairment?
Are you aware of any correlations of the
scale with biological markers?
In patients without PD
In patients with PD
There are no studies that directly address
the validity of the CSDD in PD.
See above
See above.
See above.
See above.
See above.
None found.
None found.
.
Demonstrated to be sensitive to change
(change over time or to treatment)
In patients without PD
See above (Steinberg et al 2004 ; Teri et
al 2003 ; van Weert et al 2005).
In patients with PD
No studies found
Has the minimal clinically important change
No studies found.
and minimal clinically relevant incremental
difference been assessed?
In patients without PD
In patients with PD
Has this scale been assessed or used in
patients with PD? What are the clini- or
psychometric properties in this population?
Has the scale been translated and validated in
other languages?
There are few studies in PD patients as
described above.
The CSDD has been validated in Spanish
(Pujol et al., 2001), French (Camus et al,
1995) and Chinese (Lam 2004) and trials
using the CSDD have been carried out
throughout Europe, Turkey (Amuk et al.
2003), Korea (Shah et al. 2003) and
Japan (Shreiner et al., 2003).
Trials evaluating depression in different
cultural groups in the United States
include the use of the CSDD in elderly
Hispanics (Ownby 2001) and CubanAmericans (Harwood 2000).
Overall impression
Advantages and disadvantages
1. The scale uses reports from both
the caregiver and patient.
Patients with dPD often discount
depressive symptoms and
attribute them to motor
symptoms. The caregiver can
therefore be a reliable informant
to determine if there has been a
change in mood. However, the
CSDD does not formalize how
the rater is supposed to weight
information from the caregiver
and patient in making the final
assessment.
2. The CSDD de-emphasizes
questions related to motor
symptoms of PD and potentially
decreases the overlap of
depression and PD. However,
there is a reliance on the
caregiver determining if
symptoms are secondary to PD or
depression and this can be
difficult. There are no clear
guidelines as to how a caregiver
should determine if, for example,
a patient is not sleeping because
of PD or depression. These are
difficult distinctions for an
experienced clinician to make and
the CSDD leaves these decisions
to the judgment of caregivers.
3. There is no formal definition of
the caregiver and it is therefore
possible that the rater could rely
on multiple caregivers.
4. The CCSD is not designed for PD
and there are a number of
“depressive symptoms” which
overlap with PD (e.g.,
retardation). The guidelines and
questions should be scripted to
make the scale more specific to
PD.
5. The interviewer for the CCSD has
to have some sophistication in
assessing psychiatric symptoms
and will need training in this area.
A nonclinical research technician
would not be able to complete the
scale without considerable
training. This would also be a
difficult scale for neurologists
and general physicians to
complete accurately without some
psychiatric expertise or training.
6. The scale is not appropriate for
postal surverys.
7. The scale was primarily
developed for patients with
dementia, and has not been
properly assessed for its
psychometric properties in
nondemented patients.
Which type of study is this scale very suitable Considering the above limitations, the
for and which one is it unsuitable (screening,
prevalence, aetiological (e.g. case-control or
genetic), treatment trial of PD or depression
medication, correlation with biological
markers or other scales, e.g. of parkinsonism,
clinical practice for diagnosis/screening). List
all
Please include copy of scale version assessed
CSDD could be a valuable tool in
diagnosing dPD in patients with
comorbid dementia. Treatment studies
should be conducted to assess the
validity in PD patients and trials should
start by assessing the appropriate cut-off
scores for diagnosing depression. Future
trials could include assessing the
sensitivity of the scale to change and
adapting the scale to PD motor
symptoms (e.g., distinguishing agitation
from dyskinesia).
References
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell scale for depression in
dementia. Biol Psychiatry. 1988; 23:271–284.
Alexopoulos GS. Abrams RC. Young RC. Shamoian CA. Use of the Cornell scale in
nondemented patients. Journal of the American Geriatrics Society. 36(3):230-6, 1988
Mar.
Amuk T. Karadag F. Oguzhanoglu N. Oguzhanoglu A. Reliability and validity of the
Cornell Scale for Depression in Dementia in an elderly Turkish population. Turk
Psikiyatri Dergisi. 14(4):263-71, 2003.
Agrell B. Dehlin O. Comparison of six depression rating scales in geriatric stroke
patients. Stroke. 20(9):1190-4, 1989.
Ballard CG. Patel A. Solis M. Lowe K. Wilcock G. A one-year follow-up study of
depression in dementia sufferers. British Journal of Psychiatry. 168(3):287-91, 1996
Ballard CG. O'Brien JT. Swann AG. Thompson P. Neill D. McKeith IG. The natural
history of psychosis and depression in dementia with Lewy bodies and Alzheimer's
disease: persistence and new cases over 1 year of follow-up. Journal of Clinical
Psychiatry. 62(1):46-9, 2001 Jan.
Burn DJ. Rowan EN. Minett T. Sanders J. Myint P. Richardson J. Thomas A. Newby J.
Reid J. O'Brien JT. McKeith IG. Extrapyramidal features in Parkinson's disease with and
without dementia and dementia with Lewy bodies: A cross-sectional comparative study.
Movement Disorders. 18(8):884-9, 2003.
Camus V. Schmitt L. Ousset PJ. Micas M. Depression and dementia: contribution to the
French validation of 2 depression scales: the Cornell Scale for Depression in Dementia
and the Dementia Mood Assessment Scale. Encephale. 21(3):201-8, 1995..
Greenberg L. Lantz MS. Likourezos A. Burack OR. Chichin E. Carter J. Screening for
depression in nursing home palliative care patients. Journal of Geriatric Psychiatry &
Neurology. 17(4):212-8, 2004.
Harwood DG. Ownby RL. Barker WW. Duara R. The factor structure of the Cornell
Scale for Depression in Dementia among probable Alzheimer's disease patients.
American Journal of Geriatric Psychiatry. 6(3):212-20, 1998.
Harwood DG. Barker WW. Ownby RL. Bravo M. Aguero H. Duara R. Depressive
symptoms in Alzheimer's disease. An examination among community-dwelling Cuban
American patients. American Journal of Geriatric Psychiatry. 8(1):84-91, 2000.
Herrmann M. Freyholdt U. Fuchs G. Wallesch CW. Coping with chronic neurological
impairment: a contrastive analysis of Parkinson's disease and stroke. Disability &
Rehabilitation. 19(1):6-12, 1997 Jan.
Kurlowicz LH. Evans LK. Strumpf NE. Maislin G. A psychometric evaluation of the
Cornell Scale for Depression in Dementia in a frail, nursing home population. American
Journal of Geriatric Psychiatry. 10(5):600-8, 2002.
Lam CK. Lim PP. Low BL. Ng LL. Chiam PC. Sahadevan S. Depression in dementia: a
comparative and validation study of four brief scales in the elderly Chinese. International
Journal of Geriatric Psychiatry. 19(5):422-8, 2004.
Logsdon RG, Teri L. Depression in Alzheimer's disease patients: caregivers as surrogate
reporters. J Am Geriatr Soc.43:150–155, 1995.
Muller-Thomsen T. Arlt S. Mann U. Mass R. Ganzer S. Detecting depression in
Alzheimer's disease: evaluation of four different scales. Archives of Clinical
Neuropsychology. 20(2):271-6, 2005.
Ownby RL. Harwood DG. Acevedo A. Barker W. Duara R. Factor structure of the
Cornell Scale for Depression in Dementia for Anglo and Hispanic patients with dementia.
American Journal of Geriatric Psychiatry. 9(3):217-24, 2001.
Pujol J. De Azpiazu P. Salamero M. Cuevas R. Depressive symptoms in dementia. The
Cornell scale: validation of the Spanish version. Revista de Neurologia. 33(4):397-8,
2001.
Sharp LK, Lipsky M. Screening for depression across the lifespan: a review of measures
for use in primary care settings. Am Family Physician 66(6): 1001-1008, 2002.
Schreiner AS. Hayakawa H. Morimoto T. Kakuma T. Screening for late life depression:
cut-off scores for the Geriatric Depression Scale and the Cornell Scale for Depression in
Dementia among Japanese subjects. International Journal of Geriatric Psychiatry.
18(6):498-505, 2003.
Steinberg M. Munro CA. Samus Q. V Rabins P. Brandt J. Lyketsos CG. Patient
predictors of response to treatment of depression in Alzheimer's disease: the DIADS
study. International Journal of Geriatric Psychiatry. 19(2):144-50, 2004.
Teri L. Gibbons LE. McCurry SM. Logsdon RG. Buchner DM. Barlow WE. Kukull WA.
LaCroix AZ. McCormick W. Larson EB. Exercise plus behavioral management in
patients with Alzheimer disease: a randomized controlled trial. JAMA. 290(15):2015-22,
2003.
van Weert JC. van Dulmen AM. Spreeuwenberg PM. Ribbe MW. Bensing JM.
Behavioral and mood effects of snoezelen integrated into 24-hour dementia care. Journal
of the American Geriatrics Society. 53(1):24-33, 2005.
Vida S. Des Rosiers P. Carrier L. Gauthier S. Depression in Alzheimer's disease: receiver
operating characteristic analysis of the Cornell Scale for Depression in Dementia and the
Hamilton Depression Scale.Journal of Geriatric Psychiatry & Neurology. 7(3):159-62,
1994.
Scale: Name
UPDRS part I
Are there several versions of the scale?
If so, which one has been assessed?
The UPDRS is currently being revised:
(comments on suggested preliminary New
UPDRS part I in brackets and blue; there is
however no finalized version yet)
This is part I (Mentation and Behaviour and
Mood section) of the Unified Parkinson’s
Disease Rating Scale, which has four parts.
Part II is ADL, part III motor and part IV
(physical) complications.
It comprises 4 screening items: Intellectual
Impairment, Thought disorder, Depression and
Motivation/Initiative. The structure adheres to
the rest of the UPDRS I-III with 5 answer
options (0 normal to 4 severe), but frequency
is also incorporated in some items.
(In the New UPDRS, there will still be four
parts but divided into Non-Motor Aspects of
Experiences of Daily Living, Motor Aspects
of Experiences of Daily Living, Motor
Examination and Motor Complications. Nonmotor Aspects of Experiences of Daily Living
will have two parts, one which is observercompleted and one which is patientcompleted. It is likely that the first part will
include items on depressed mood, anxious
mood and apathy, and the second part items on
sleep and fatigue. The answer options will be
more consistent with each other and severity
rating of depressed and anxious mood will be
rated based on ability to carry out daily
activities and interactions and not include
physical signs of depression or suicidality
(which are present in the current version). For
each observer-rated question, instructions for
the rater and an instruction to the patient are
provided. An appendix will include scales for
non-motor aspects of PD, including
depression, that are “recommended” (i.e.
validated in PD). This appendix will be
updated regularly and will be available online.
The results of our review of rating scales will
provide the baseline for this appendix with
regard to depression.)
Originally clinician-rated. Experience in
diagnosis of depression is not required
Description of scale
(content,
number of items and subscales,
number of answer options (severity or
frequency or both)
Rater: Patient or caregiver or clinician.
If clinician-rated, training for
application required?
Copyright or public domain?
How can the scale can be obtained
(address or website)?
(personal judgement), and a self-rated version
has been validated (Louis et al, 1996), see
appendix.
(In the New UPDRS, this section is planned to
have one observer-rated and one self-rated part
to reduce completion time for the whole
scale.)
The scale is in the public domain and available
from the MDS website
(http://www.mdvu.org/library/ratingscales/pd/)
(The New UPDRS will also be available on
the MDS website).
Scale properties
Please provide references for all statements or note if this is your personal judgement
Content
Face validity?
Due to its brevity relatively poor.
Only one question on depression,
although the other questions overlap
with mood-congruent delusions (Q2:
thought disorder), loss of interest
(Q4: Motivation/initiative) and
cognition (but not concentration)
(Q1: intellectual impairment). The
question on depression simply
defines depression as feelings of
sadness or guilt greater than normal
or “depression”, with physical
symptoms in more severe depression
and suicidality in the most severe
rating.
(personal judgement)
(In the New UPDRS no physical or
cognitive aspects of depression or
suicidality are enquired about. When
rating depression, raters are
instructed to consider low mood,
sadness, hopelessness, feelings of
emptiness or loss of enjoyment and
their duration over the past week and
to rate their interference with the
patient’s ability to carry out daily
routines and engage in social
interactions.
Is loss of pleasure included?
No. Loss of interest is included as
part of an answer option which also
includes physical aspects of
depression; it is also asked in
question 4 (motivation)
(yes, see question above, but
anhedonia is merged with sad mood
in one question. Thus, answers to this
question may not provide
unambiguous answers about the
presence of anhedonia.)
Is the scale heavily weighted towards one aspect
It concentrates on feelings of
of depression? If so, which?
sadness, and loss of interest is mixed
with apathy in question 4.
(no questions on physical aspects of
depression or suicidality)
Does it exclude an important aspect of
depression? If so, which
Compatible with DSM IV or other depression
criteria (compare content to DSM IV, if formally
assessed see also criterion validity below)?
Includes items on anxiety, psychosis and
cognition as a result of depression?
No question on loss of pleasure. It
does not include some physical and
behavioural symptoms of depression,
such as fatigue, cognitive symptoms
such as concentration difficulties and
mood-congruent delusions, affective
symptoms such as feelings of
worthlessness.
(the new UPDRS question on
depressed mood will include loss of
enjoyment but excludes physical
aspects of depression from the rating
of depressed mood; some of these are
covered as separate questions
elsewhere, e.g. sleep, fatigue,
cognition, hallucinations, but there
are no questions on worthlessness,
sexual function and suicidality)
Loss of interest only included in
moderate rating (3), no question on
loss of enjoyment. Psychomotor
retardation or agitation, fatigue,
feelings of worthlessness not
included. Time frame one week not
two weeks. No change to normal
mood required. No increase in sleep,
weight or appetite included.
(time frame one week not two weeks;
no change to normal mood required.
loss of enjoyment included; separate
questions on depressed mood,
cognitive impairment, insomnia and
fatigue; change of weight or appetite,
behavioural change, worthlessness or
guilt, thoughts of suicide or death not
included)
Psychosis and memory loss are rated
in separate questions and not as part
of the symptomatology of
depression. Delusions are only rated
as most severe form of psychosis
(concentrates on visual
hallucinations); cognitive
impairment, which is also rated as a
separate entity rates memory and
executive function, not
concentration. Anxiety not included
(ditto, but additional question on
Which areas are not covered?
Number/percentage of items that overlap with
symptoms of
Parkinsonism (energy, sleep, fatigue,
appetite, psychomotor retardation/agitation)
Cognitive impairment (slowness of
thinking, clarity of thinking, attention,
concentration)
Apathy (loss of interest, loss of initiative)
What is the time frame/is the time frame
appropriate (e.g. “during the past week”)?
anxiety)
As above
Insomnia, anorexia, weight loss (all
in the one depression question, rating
3)
(In New UPDRS: these are rated in
separate questions)
None, as intellectual impairment
question only addresses memory and
frontal lobe function
(In New UPDRS: cognitive slowing
and ability to pay attention in
question 1 (cognition) but not as part
of depression mood rating)
2: In question on depression: loss of
interest; separate question on
motivation
(In New UPDRS: separate question
on apathy)
Past week; yes
(personal judgement)
(ditto)
Use
Was it designed to measure severity or to
screen for depression?
Is there a cut-off score for diagnosis of
depression (in depression without PD)?
Is this appropriate in depression with PD
(dPD)?
If not, why?
Has a different cut-off score for dPD been
suggested, and if so, is there evidence to
support it?
Has it been used to measure severity or to
screen for depression (in depression without
PD and dPD)?
Designed as an indicator for depression
as part of the overall assessment of all
aspect of PD. A critique of the UPDRS
stated: “Section I is conceptually
different from parts II and III, and as a
screening assessment for the presence of
depression, dementia or psychosis, it
cannot be used as an adequate severity
measure of any of these behaviours. In
cases of interventions, targeting such
non-motor problems of PD, specific
additional scales are generally used. An
appendix to the UPDRS with a series of
recommended scales for more detailed
measurement of all screening questions
would enhance consistency of data
collection among researchers. At present,
such appendices do not exist.”
(New UPDRS: all questions in the nonmotor experiences part of the New
UPDRS are designed as screening
questions. Any study that aims to
specifically diagnose of measure severity
of any non-motor symptoms (including
depression) should use one of the scale
recommended in the appendix)
No, but 0 indicates no depression and 1
periods of non-sustained sadness; thus 2
indicates sustained depression (>1 week)
(No, but 0 is no depression, 1 depressed
mood not sustained more than 1 day, and
2 is depression mood not interfering with
any activities, so 3 is depression
interfering with daily activities and social
interactions)
Only applicable to patients with PD
(ditto)
No studies found.
(n.a.)
Acceptability
Length
Very short
(Slightly longer but still very short; other
non-motor experiences will also be part
of part I, e.g. urinary symptoms)
Ambiguities in instructions to patient/rater
There are several concepts combined in
Ambiguities in rating anchors
one question on depression, which
introduces ambiguity in the completion,
e.g. “sustained depression with vegetative
symptoms and suicidal thoughts or
intent”
Similarly, in the question on motivation,
assertiveness, loss of interest, motivation
and initiative are combined
(In the New UPDRS, this is avoided and
only duration and interference with daily
activities and social interactions is rated.)
Appropriateness of questions for PD
Appropriate as designed specifically for
population
PD
(ditto)
Applicability across PD and depression
All stages
disease stages mild – moderate – severe?
(ditto)
Can it be used for “on” and “off” and has this Not done; most questions relate to longer
been done?
and more sustained symptoms
In the assessment of the self-rated
version, subjects were asked to rate their
symptoms separately while “on” and
while “off,” but only 10% experienced
off periods, and only on data were
analyzed (Louis et al, 1996).
(ditto)
Clear instructions to raters
Several ambiguities as mentioned above
(Avoided in the New UPDRS)
Clinimetric/psychometric properties
Metric flaws (floor and ceiling effects, score
distributions)?
Not applicable for one question. Not
tested for total UPDRS part I. However,
the scaling of all 4 questions appears
questionable. E.g it is not clear what the
interval between scores is and whether
there is a clear progression from 1 to 4.
(The New UPDRS is based on degree
of interference with daily activities and
social functioning.)
Reliability (internal consistency, interrater,
In non-depressed patients with PD:
test-retest) of total or sub-scales and of
interrater reliability: only moderate
individual items
(relative ranges RR 10-15) for the
depression item (ĸ 0.60) and high (RR
5-10) for the other 3 items (ĸ 0.710.80), none very high (RR<5)
(Martinez-Martin et al, 1994)
Patient-rating (Louis et al, 1996): The
concordance rates (i.e., percentage
agreement) between patients and
observers for the four questions were
0.82 –0.9 with 0.9 for the depression
question (maximum 1.0), and the kappa
values were between 0.68 and 0.77 with
0.77 (95%CI 0.51, 1.0) for the
depression question.
Test-retest: ICC 0.74 (fair to good) for
overall UPDRS part I; however only
fair for individual items: intellectual
impairment (ĸ 0.50),
motivation/initiative (ĸ 0.57),
depression ĸ 0.65 thought disorder ĸ
0.63 (Siderowf et al, 2002)
No data on internal consistency of part I
only, but poor rs within total UPDRS
N.a.
Validity: assessed – not assessed, good – not good (references); please also comment on
sample sizes
In depression without PD
Face or content validity
Criterion validity (compared to goldN.a.
standard, e.g.
DSM IV (SCID, SCAN, systematic
interviews) or
other criteria for diagnosis)
Construct validity (correlations with
N.a.
other
convergent scales and divergent scales
(which?);
factor analysis)
Valid in ethnically and culturally
different
populations?
Valid in both genders and at all ages?
Valid in patients with dementia or
significant
cognitive impairment?
In depression in PD (dPD)
Face or content validity
Criterion validity (compared to goldstandard,
e.g. DSM IV (SCID, SCAN, systematic
interviews) or other criteria for
diagnosis)
Construct validity (correlations with
other
convergent scales and divergent scales
(which?);
factor analysis)
Valid in ethnically and culturally
different
populations?
Valid in both genders and at all ages?
Valid in patients with dementia or
significant
cognitive impairment?
N.a.
N.a.
N.a.
Relatively poor due to brevity
Not tested
Not tested/not applicable to one
question
Not tested
Not tested
Not tested; in the study of the self-rated
version, four (13.3%) of 30 subjects had
mild cognitive
impairment (modified Mini-Mental
State score <49) but would not have
met DSM IV criteria for
dementia. “Two of these required the
help of a proxy in filling out the
UPDRS.” (Louis et al, 1996)
Are you aware of any correlations of the scale
with biological markers?
In patients without PD
In patients with PD
Demonstrated to be sensitive to change
(change over time or to treatment)
In patients without PD
In patients with PD
Has the minimal clinically important change
and minimal clinically relevant incremental
difference been assessed?
In patients without PD
In patients with PD
Has this scale been assessed or used in
patients with PD? What are the clini- or
psychometric properties in this population?
Has the scale been translated and validated in
other languages?
Overall impression
Advantages and disadvantages
Which type of study is this scale very suitable
for and which one is it unsuitable (screening,
prevalence, aetiological (e.g. case-control or
genetic), treatment trial of PD or depression
medication, correlation with biological
markers or other scales, e.g. of parkinsonism,
clinical practice for diagnosis/screening). List
No
The total UPDRS part I has been shown
to be sensitivity to change in some
studies of antiparkinsonian drugs (with
possibly antidepressant properties)
(Allain et al, 1991).
No
As above
Used in many languages. Although there
are no validated versions, the whole
scale has been used worldwide. The
study by Martinez-Martin et al (1994)
was performed in Spanish patients.
Advantages: short, specifically designed
for patients with PD
Disadvantages: Poor face validity, poor
content validity, not tested in clinical
studies, clinimetric properties unknown,
ambiguities
(New UPDRS: unfinished, but should
avoid ambiguities and overlap with
symptoms of PD; however, poor content
validity, only designed as screening
question. Does not adequately screen for
the DSM-IV or ICD-10 criteria for major
depression. Some features of depression
are assessed in separate questions as they
may occur independently from
depression.
Only suitable as screening tool to direct
towards use of specific depression scales
(ditto)
all
References
Allain H, Cougnard J, Neukirch HC. Selegiline in de novo parkinsonian patients: the
French selegiline multicenter trial (FSMT). Acta Neurol Scand Suppl. 1991;136:73-8.
Drapier S, Raoul S, Drapier D, Leray E, Lallement F, Rivier I, Sauleau P, Lajat Y, Edan
G, Verin M. Only physical aspects of quality of life are significantly improved by
bilateral subthalamic stimulation in Parkinson's disease. J Neurol. 2005 Mar 23; [Epub
ahead of print]
Louis ED, Lynch T, Marder K, et al. Reliability of patient completion of the historical
section of the Uni.ed Parkinson’s disease Rating Scale. Mov Disord 1996;11:185–192.
Martinez-Martin P, Gil-Nagel A, Gracia LM, Gomez JB, Martinez-Sarries J, Bermejo F.
Unified Parkinson's Disease Rating Scale characteristics and structure. The Cooperative
Multicentric Group. Mov Disord. 1994;9:76-83.
Movement Disorder Society Task Force on Rating Scales for Parkinson's Disease. The
Unified Parkinson's Disease Rating Scale (UPDRS): status and recommendations. Mov
Disord. 2003;18:738-50.
Siderowf A, McDermott M, Kieburtz K, Blindauer K, Plumb S, Shoulson I; Parkinson
Study Group. Test-retest reliability of the unified Parkinson's disease rating scale in
patients with early Parkinson's disease: results from a multicenter clinical trial.Mov
Disord. 2002;17:758-63.
Centre for Epidemiologic Studies Depression Scale
Richard G Brown PhD and Sergio Starkstein MD PhD
Scale:
Are there several versions of the scale?
If so, which one has been assessed?
Description of scale
(content,
number of items and subscales,
number of answer options (severity or
frequency or both)
Centre for Epidemiologic Studies Depression Scale
(CES-D)
The primary version and the one reviewed is the 20
item scale [Radloff 1977]. A variety of short-forms
have been developed that vary in the number of items
(8 or 10) and the number of response options (2-4).
The 10-item form (CESD-10) retains the same scoring
as the original and was developed for use in older
adults [Andresen et al. 1994], with similar
psychometric properties.
A revised CES-D (The CESD-Revised)
The 20-item CES-D was developed as a screening
instrument for community based studies. Its primary
use has remained in the area of psychiatric
epidemiology although it has found some wider use in
the study of depression in patients with medical
conditions.
The CES-D measures depression symptoms over the
past seven days. The response values are a 4-point
Likert scale, with a range of 0-3. Each symptom is
rated from 0 ‘rarely or none of the time (less than one
day)’ to 3 ‘most or all of the time (5-7 days)’. The
instructions do not indicate that a symptom has to be
continuously present to be rated. Thus a symptom may
be rated if it occurs for only some of the time during
the day.
Four of the 20 items are positively worded and the
scoring needs to be reversed. The scale provides a
single score. A high score (maximum 60) indicates
more severe depression.
Rater: Patient or caregiver or clinician.
If clinician-rated, training for
application required?
The CES-D is designed for self-completion. However,
has been used (and validated) in several administration
formats including face-to-face interview (where the
interviewer simply reads out the items and records to
scored response), telephone interview as well as selfreport. The CESD-Revised is also available in a webbased version with both text and voice-based item
administration (http://www.mdlogix.com/cesdr.htm).
Clinical experience is not required for its use.
Copyright or public domain?
Public domain.
How can the scale can be obtained
(address or website)?
The scale is included in the original publication and
freely available via the web. The CESD-Revised is
available online at http://www.mdlogix.com/cesdr.htm
Scale properties
Please provide references for all statements or note if this is your personal judgement
Content
Face validity?
The scale was developed from items of existing
depression rating scales including the Zung
Depression Scale [Zung 1965], the Beck
Depression Inventory [Beck and Beamesderfer
1974], a scale developed by Raskin [Raskin et
al. 1967] and the Minnesota Multiphasic
Personality Inventory [Hathaway and McKinley
1940].The scale inherits some face validity
from these scales.
Is loss of pleasure included?
Yes – single question on ‘enjoying life’
Is the scale heavily weighted towards one
Predominanty psychological symptoms with
aspect of depression? If so, which?
some somatic.
Does it exclude an important aspect of
Loss of interest is not assessed. No assessment
depression? If so, which
of suicidal behaviour or ideation.
Compatible with DSM IV or other depression
criteria (compare content to DSM IV, if
formally assessed see also criterion validity
below)?
Includes items on anxiety, psychosis and
cognition as a result of depression?
Which areas are not covered?
Number/percentage of items that overlap with
symptoms of Parkinsonism (energy, sleep,
fatigue, appetite, psychomotor
retardation/agitation)
Cognitive impairment (slowness of thinking,
clarity of thinking, attention, memory,
concentration)
Apathy (loss of interest, loss of initiative)
What is the time frame/is the time frame
appropriate (e.g. “during the past week”)?
Are the symptoms of Recurrent Brief
Depressive Disorder captured?
It was developed as a screening measure and
not as a diagnostic tool. The 20-item CES-D
was developed before DSM-III and did not seek
to assess all symptoms included within the
definition of Major Depressive Disorder. Its
content and time frame are even more distant
from DSM-IV. The revised version (CESD-R),
although still primarily intended to be a
screening tool, has saught to remedy this issue
and has both content and time-frame consistent
with DSM-IV.
Cognition assessed only partially. Anxiety
assessed by question on fearfulness. Delusional
beliefs not assessed.
Loss of interest, anergia, libido, tedium vitae
and suicidality, weight loss, reverse vegetative
symptoms, guilt, emotional blunting, diurnal
variation, delusions
6/20– sleep problems, decreased appetite,
concentration problems, talking less, problems
“getting going”, increased effort
1 item on on concentration
No assessed
During the past week (2 weeks for the CESDRevised)
Not captured
Use
Was it designed to measure severity or to screen
for depression?
Is there a cut-off score for diagnosis of
depression (in depression without PD)?
Originally designed as a screening test for
depression in non-clinical populations,
although it is widely used as an index of
severity.
A cut-off score of 16 or more is most widely
used to define a depressive ‘case’. This would
represent someone who has reported at least 6
items to be frequently present over the course
of the past week.
Is this appropriate in depression with PD (dPD)?
If not, why?
The cut-off has not been assessed in dPD.
However, although not designed as a
diagnostic instrument, and with only a poor
fit to DSM-IV content and time frame, the
CES-D performs reasonably well in
distinguishing depressed from non-depressed
individuals in similar populations (see
Criterion validity below).
Although the standard cut-off score is widely
used and appears to have good properties,
some studies have suggested that found the
higher cut-off score (27) to perform between
when screening medical patients [Zich et al.
1990]. The optimum cut-off score would
probably need to be demonstrated for
individual patient groups.
Has a different cut-off score for dPD been
suggested, and if so, is there evidence to support
it?
Has it been used to measure severity or to screen
for depression (in depression without PD and
dPD)?
No
Acceptability
Length
Ambiguities in instructions to patient/rater
Ambiguities in rating anchors
Very widespread use in diverse populations.
A Medline search limited to older adults
(65+) revealed 766 published papers. It has
been little used to measure dPD.
Acceptable
The CES-D’s widespread use is many
hundreds of published studies is an indication
of its acceptability in a wide range of clinical
and non-clinical settings, in different
populations, age groups and cultures. The
language of the items is straightforward and
simple, avoiding jargon or phrases that would
prove difficult for groups with cognitive
impairment or poor education. There have
been numerous studies evaluating the scale in
low-income, poorly educated populations.
While these have revealed problems with
some individual items of the scale, overall the
CES-D appears to perform well in such
groups. It has been suggested that the 4-point
rating system may be confusing for some
older adults [Kohout et al. 1993], and simpler
‘yes/no’ short-forms have been developed
and its excellent psychometric properties as a
screening instrument demonstrated [Irwin et
al. 1999].
Appropriateness of questions for PD population
The CES-D appears acceptable for use in PD
in terms of the language and format.
The absence of questions on libido may make
it more acceptable to older adults who
frequently find such questions difficult to
answer.
Applicability across PD and depression disease
stages mild – moderate – severe?
The scale is unlikely to be significantly
contaminated by non-depressive indicators of
disease progression and may be useful across
the range of disease severities.
It’s time frame makes it unsuitable for the
assessment of short-term mood fluctuations.
Clear instructions to raters
Primarily self-report
Clinimetric/psychometric properties
Metric flaws (floor and ceiling effects, score
distributions)?
As a screening instrument it is better at
detection depression than in discriminating
between severities of depressive disorder
(see below)
Reliability (internal consistency, inter-rater, testAmong community samples it shows internal
retest) of total or sub-scales and of individual
consistency in the range 0.8-0.9 across a
items
range of groups varying in age, gender and
race. Test-retest reliability (from periods
from 2 weeks to one year) in the range 0.40.7 [Radloff1977;Devins et al. 1988].
Comparisons of different modes of
administration (e.g. face-to-face interview
versus telephone interview) show good
comparability [Aneshensel et al. 1982].
Validity: assessed – not assessed, good – not good (references); please also comment on sample
sizes
In depression without PD
Face or content validity
Poor (although addressed in CESD-Revised)
Criterion validity (compared to gold-standard,
Although not designed as a diagnostic
e.g. DSM IV (SCID, SCAN, systematic
instrument, and with only a poor fit to DSMinterviews) or other criteria for diagnosis)
IV content and time frame, the CES-D
performs reasonably well in distinguishing
depressed from non-depressed individuals.
In a large-scale community study in older
adults [Beekman et al. 1997] the scale
identified Major Depression with a
sensitivity of 1.0 and a specificity of 0.88.
False positives were more likely among
elderly with physical illness, cognitive
decline or anxiety.
Even in these groups, however, the scale has
acceptable performance. In an evaluation of
stroke patients [Parikh et al. 1988], a cut-off
of 16 identified depression with a specificity
of 0.90 and sensitivity of 0.86. In a further
study of medically ill older adults [Schein
and Koenig 1997] applying the cut-off of 16
distinguished patients with and without
DSM-IV Major Depression with a sensitivity
of 0.90 and specificity of 0.84. The scale was
less suitable for distinguishing between
Major Depression and Minor Depression,
where the standard cut-off had unacceptable
specificity (0.38). A higher cut-off (27) had
good specificity, but at the expense of low
sensitivity. Once again, the reinforces the
scales primary use as a screening instrument,
although its also suggests that it may lack
utility in distinguishing between gradations
of severity within the clinical range.
Although the standard cut-off score is widely
used and appears to have good properties,
some studies have suggested that found the
higher cut-off score (27) to perform between
when screening medical patients [Zich,
Attkisson, and Greenfield1990]. The
optimum cut-off score would probably need
to be demonstrated for individual patient
groups.
Construct validity (correlations with other
convergent scales and divergent scales (which?);
factor analysis)
Valid in ethnically and culturally different
populations?
Numerous factor analyses have been
undertaken on various populations. Most,
although not all, have reported 4 factors that
can typically be labelled depressed affect,
positive affect, somatic symptoms and
retarded activity [Radloff1977;Devins,
Orme, Costello, Binik, Frizzell, Stam, and
Pullin1988;Sheehan et al. 1995]. The
detailed factor structure shows some
differences across different languages,
cultures and populations, although such
variation is unlikely to be restricted to the
CES-D
The scale has been employed across an
extremely wide range of languages and
cultures. The scale has been translated into
all western and eastern European languages.
Valid in both genders and at all ages?
Valid in patients with dementia or significant
cognitive impairment?
In depression in PD (dPD)
Face or content validity
Criterion validity (compared to gold-standard,
DSM IV (SCID, SCAN, systematic interviews)
other criteria for diagnosis)
Construct validity (correlations with other
convergent scales and divergent scales (which?);
It is also available in middle eastern
languages including Arabic, Turkish and
Hebrew. Studies have also been published
using the scale in many other countries
including Japan, Korea, China, Thailand, Sri
Lanka, Indonesia, Begal and India.
Studies that have examined the properties of
the scale in these different populations has
generally found the instrument to be
acceptable. Some cross-cultural variation has
been reported in the scales measurement of
positive affect, where differences in
expression have been reported between
western and eastern cultures [Iwata et al.
2002]. detailed studies have also revealed
problems with the reliability and validity in
certain items in some cultures and subgroups,
although this probably does not affect the
overall performance of the scale as a
screening instrument. As an example, one
study identified that Turkish and Moroccan
women (but not men) have problems with
some of the interpersonal question [Spijker et
al. 2004]. Within North America, few
differences have been found between
different ethnic groups [Roberts 1980],
although endorsement of the interpersonal
items are elevanted in African-Americans
compared to white respondants [Cole et al.
2000]. It is likely that any depression
instrument will have similar problems at the
level of individual items
There is wide-ranging evidence in the
published literature supports the utility,
reliability and validity of the scale in both
genders and across the age spectrum. Itemlevel analyses suggest some variations, such
as women being more likely to endorse the
item on crying than men[Cole, Kawachi,
Maller, and Berkman2000]. Once again, such
effects are unlikely to be restricted to the
CES-D.
Yes in mild dmentia. Can also be used
validly with informant report [Logsdon and
Teri 1995]
Adequate
Not assessed
Not assessed
factor analysis)
Valid in ethnically and culturally different
populations?
Valid in both genders and at all ages?
Valid in patients with dementia or significant
cognitive impairment?
Are you aware of any correlations of the scale
with biological markers?
In patients without PD
In patients with PD
Demonstrated to be sensitive to change (change
over time or to treatment)
In patients without PD
In patients with PD
Has the minimal clinically important change and
minimal clinically relevant incremental
difference been assessed?
In patients without PD
In patients with PD
Has this scale been assessed or used in patients
with PD? What are the clini- or psychometric
properties in this population?
Has the scale been translated and validated in
other languages?
Overall impression
Advantages and disadvantages
Not assessed
Not assessed
Not assessed
Yes (Brouwer et al., 2005; Isogawa et al.,
2005; Muck-Seler et al., 2002; Neumeister et
al., 2004; Rafter, 2001).
Yes (Hoogendijk et al., 1998)
(Frochtengarten et al., 1987; Kostic et al.,
1990; Kostic et al., 1996; Mellers et al.,
1995).
The CESD is not typically used as an
outcome measure in clinical trials.
In a prospective study of dopamine agonists
and their association with sleep problems and
quality of life [Happe and Berger 2001].
Mean CES-D score remained stable over 12
months in patients continuosly prescribed a
dopamine agonist or commenced on an
agonist, but showed a significant worsening
in depression and reduced quality of life in
patients where agonist treatment was
withdrawn
No assessed
The scale has been used only rarely. In
addition to the study described above, it was
used to assess depressive symptomatology in
a study of hallucination [Fenelon et al. 2000]
where higher levels of depression were
reported in hallucinators than nonhallucinators. In another study, associations
were reported between the severity of
depression and fatigue [Lou et al. 2001].
Yes – translated and validated in most
European, Middle Eastern and Asian
languages.
Advantages
The CES-D has much to recommend as a
screening instrument for depression in older
adults in with physical illness in community
studies or primary care settings. Better
performance and utility may be achieved
with its alternative short-forms. Nevertheless,
its item content suggests that its primary
value would be in as a screening instrument
for dysphoric mood. The lack of content
relating to loss of interest/anhedonia would
have some advantage in studies seeking to
assess dysphoria independently of apathy.
Disadvantages
Does not fit well with DSM-IV/ICD-10
criteria for depression, and it is not a
diagnostic tool. The CESD-Revised may
correct these shortcomings, but this version
of scale has not yet been adequately
evaluated.
The primary disadvantage of the CESD for
use in PD is the lack of evidence of its
psychometric properties in the condition.
Although it is possible to generalise findings
from other conditions such as stroke, until
such evidence is available for PD, if chosen
the CES-D should probably be used with
caution and alongside other better
characterised scales.
Which type of study is this scale very suitable for
and which one is it unsuitable (screening,
prevalence, aetiological (e.g. case-control or
genetic), treatment trial of PD or depression
medication, correlation with biological markers
or other scales, e.g. of parkinsonism, clinical
practice for diagnosis/screening). List all
The CESD would be most appropriate for the
its primary purpose as a screening tool in
large scale studies, where alternative modes
of administration may be required. Evidence
from comparable population may be used as
evidence for reliability and validity in this
setting.
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