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Center for Epidemiologic Studies Depression Scale (CES-D)
L. S. Radloff and B. Z. Locke
Modified From: Rush J, et al: Psychiatric Measures, APA, Washington, DC, 2000.
GOALS
The Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff 1977) was
developed to measure symptoms of depression in community populations. At the time of
its development, researchers were interested in the health correlates of depressive
symptoms and in tracking changes in severity of symptoms over time. The scale has also
been used in many studies as a screen for the presence of depressive illness. Items were
selected to represent the major components of depression on the basis of the clinical
literature and factor analytic studies. Components include depressed mood, feelings of
worthlessness, feelings of hopelessness, loss of appetite, poor concentration, and sleep
disturbance. The scale does not include items for increased appetite or sleep, anhedonia,
psychomotor agitation or retardation, guilt, or suicidal thoughts.
DESCRIPTION
The scale is a composite of 20 items selected mainly from the following sources: the
Zung Self-Rating Depression Scale (Zung SDS), the Beck Depression Inventory (BDI),
the Raskin Scale, a depression checklist developed by E. A. Gardner (unpublished
manuscript, 1968), and the Minnesota Multiphasic Personality Inventory Depression
Scale (MMPI-D). Four of the items are worded in a positive direction to control for
response bias. Subjects are asked to rate each item on a scale from 0 to 3 on the basis of
“how often you have felt this way during the past week”: 0 = rarely or none of the time
(less than 1 day), 1 = some or a little of the time (1–2 days), 2 = occasionally or a
moderate amount of time (3–4 days), and 4 = most or all of the time (5–7 days). Sample
items are provided in Example 24 –2. CES-D scores range from 0 to 60; higher scores
indicate more severe depressive symptoms. Total severity is calculated by reversing
scores for items 4, 8, 12, and 16 (the items that control for response bias), then summing
all of the scores. A score of 16 or higher was identified in early studies as identifying
subjects with depressive illness.
PRACTICAL ISSUES
It takes approximately 5 minutes to complete the CES-D. The scale appears in several
publications, including Weissman et al. (1977). The scale has been published in its
entirety in Radloff (1977) and is available from
National Institutes of Health
Epidemiology Branch
5600 Fishers Lane
Rockville, MD 20857
The reliability and validity of the CES-D have been tested in African American, Asian
American, French, Greek, Hispanic, Japanese, and Yugoslavian populations (Naughton
and Wiklund 1993). The CES-D has been translated into several languages, including
Chinese (Cantonese and Mandarin), French, Greek, Japanese, and Spanish.
PSYCHOMETRIC PROPERTIES
Reliability
Internal consistency as measured by Cronbach’s alpha is high across a variety of
populations (generally around 0.85 in community samples and 0.90 in psychiatric
samples). Split-half reliability is also high, ranging from 0.77 to 0.92. Test-retest
reliability studies ranging over 2–8 weeks show moderate correlations (r = 0.51–0.67),
which is desirable for a test of symptoms that are expected to show change over time.
Studies of African American versus Anglo-American versus Mexican American
respondents showed no differences in measures of internal consistency reliability
(Roberts 1980).
Validity
In samples of outpatients with depression, alcoholism, drug addiction, or schizophrenia,
correlation coefficients (r) between CES-D scores and Symptom Checklist –90 (SCL-90)
Depression subscale scores were high, ranging from 0.73 to 0.89. Correlations with the
Hamilton Rating Scale for Depression (Ham-D) scores were variable and ranged from
0.49 for patients with acute depression to 0.85 for patients with schizophrenia.
Correlations with the Raskin Scale were also variable, ranging from 0.28 for patients with
acute depression to 0.79 for patients with schizophrenia (Weissman et al. 1977).
Studies of elderly patients report only fair agreement between scores on the CES-D and
the short form of the Geriatric Depression Scale (GDS) (Gerety et al. 1994) and a
correlation (r) of 0.69 between the CES-D and the Zung SDS (DeForge and Sobal 1988).
In a sample of 406 psychiatric outpatients, CES-D scores were higher in currently
depressed patients than in other patient groups (Weissman et al. 1977). Mean CES-D
scores for various patient groups were 38.10 for acute depression (n = 148 and SD =
9.01), 14.85 for depression in remission (n = 87 and SD = 10.06), 22.97 for alcohol
dependence (n = 61 and SD = 13.58), 17.05 for drug dependence (n = 60 and SD =
10.69), and 12.98 for schizophrenia (n = 50 and SD = 12.94) In a primary care sample (N
= 53), Fechner-Bates et al. (1994) reported that a chi-square test that compared DSM-IIIR categories of mild, moderate, and severe depression with and without psychotic
features against CES-D scores above or below a cutoff score of 16 was not significant.
Analysis of variance (ANOVA) tests for overall differences in severity of CES-D scores
across the three DSM groups showed a significant difference between the mild and
severe depression groups but not between moderate and mild or between moderate and
severe groups. In a sample of 35 acutely depressed patients treated with medication,
patients who were judged to be recovered by clinicians at the end of the study showed a
mean decrease in CES-D scores of 20 points, whereas nonresponders or partial
responders showed a decrease of 12 points (Weissman et al. 1977). In a study of the
utility of the CES-D in discriminating depression in 406 psychiatric outpatients with a
range of psychiatric diagnoses, Weissman et al. (1977) used a CES-D cutoff score of 16
to define case status. As expected, the CES-D showed a high sensitivity (99%) for acute
primary depression and for depression in patients with alcohol dependence (94%) and
schizophrenia (93%). Sensitivity was lower in patients with drug dependence (74%).
Specificity, however, was low in patients whose depression had remitted (56%) and in
those with drug dependence (59%) and somewhat higher in those with alcohol
dependence (84%) and schizophrenia (86%). The authors concluded that the scale’s
performance in differentiating primary depressions from those that occur in association
with other disorders was less than optimal. In a community study of 720 subjects, Boyd
et al. (1982) found that sensitivity for major depression as determined by Research
Diagnostic Criteria (RDC) was low (64%) but specificity was high (94%) at a cutoff
score of 16. However, the positive predictive value for major depressive disorder was
only 33%. False-negative results were attributed to subjects who answered positively in
the Schedule for Affective Disorders and Schizophrenia (SADS) interview but negatively
on the questionnaire. False-positive diagnoses were produced in subjects who showed
CES-D symptoms associated with anxiety, drug abuse, phobias, panic, or somatization
disorder. The results from a large follow-up study of 310 mothers of handicapped
children are consistent with these findings. In examining the diagnoses obtained from the
Diagnostic Interview Schedule (DIS) of those who scored ³16 on the CES-D, Breslau
(1985) found sensitivity of 87.5% and specificity of 73% for current major depression but
also found that the sensitivity was 80% and the specificity was 73% when the target
diagnosis was changed to generalized anxiety disorder. When subjects qualifying for both
diagnoses were removed, sensitivity was 75% for major depression and 67% for
generalized anxiety disorder. In 528 community subjects, Roberts and Vernon (1983)
found that the CES-D yielded a false-positive rate of 16.6% and a false-negative rate of
40% for major depression as determined by RDC. The efficacy of the scale was not
improved substantially when diagnosis was expanded to include minor depression or the
depressive personality. Similarly, Myers and Weissman (1980) found a false-positive rate
of 6.1% and a false-negative rate of 36.4% in a sample of 515 community respondents.
Thus, the major community studies performed do not support the use of the CES-D alone
as a screen for clinical depressions. In a sample of 425 primary medical care patients,
Fechner-Bates et al. (1994) compared CES-D scores at or above 16 with DSM-III-R
diagnoses obtained from the Structured Clinical Interview for DSM-III-R Axis I
Disorders (SCID-I). The CES-D was significantly related to a diagnosis of major
depression but also to other Axis I diagnoses. For major depression, sensitivity was
79.5% and specificity was 71.1%. The positive predictive value was 27.9%. Adding
subjects with bipolar disorder increased the positive predictive value to 31.3%. Of the
subjects with elevated CES-D scores, 72.1% did not meet criteria for major depression,
and a fifth of the depressed subjects scored below the CES-D cut point. The authors
conclude that the CES-D should be considered a measure of general distress.
CLINICAL UTILITY
Although the CES-D was developed to measure the severity of depressive symptoms in
community samples and shows internal and test-retest reliability, validity studies suggest
that the measure is not specific for depression. In this way, the CES-D is similar to
several other self- report depression scales used as first-stage screening devices in general
community or primary care studies. Indeed, validity data obtained with the CES-D are
comparable to those obtained with the BDI and the Zung SDS when they are used as
first-stage screening devices. Thus, although the scale was developed to assess depression
in community surveys, studies do not support its use in undiagnosed populations without
a follow-up interview.
REFERENCES AND SUGGESTED READINGS
Boyd JH, Weissman MM, Thompson WD, et al: Screening for depression in a
community sample: understanding the discrepancies between depression symptom and
diagnostic scales. Arch Gen Psychiatry 39:1195–1200, 1982
Breslau N: Depressive symptoms, major depression, and generalized anxiety: a
comparison of self-reports on CES-D and results from diagnostic interviews. Psychiatry
Res 15:219–229, 1985
Craig TJ, Van Natta PA: Influence of demographic characteristics on two measures of
depressive symptoms. Arch Gen Psychiatry 36:149–154, 1979
DeForge BR, Sobal J: Self-report depression scales in the elderly: the relationship
between the CES-D and the Zung. Int J Psychiatry Med 18:325–328, 1988
Fechner-Bates S, Coyne JC, Schwenk TL: The relationship of self-reported distress to
depressive disorders and other psychopthology. J Consult Clin Psychol 62:550–559, 1994
Gerety MB, Williams JW Jr, Mulrow CD, et al: Performance of case-finding tools for
depression in the nursing home: influence of clinical and functional characteristics and
selection of optimal threshold scores. J Am Geriatr Soc 42:1103–1109, 1994
Husaini BA, Neff JA, Harrington JB, et al: Depression in rural communities: validating
the CES-D scale. Journal of Community Psychology 8:20–27, 1980
Myers JK, Weissman MM: Use of a self-report symptom scale to detect depression in a
community sample. Am J Psychiatry 137:1081–1084, 1980
Naughton MJ, Wiklund I: A critical review of dimension-specific measures of healthrelated quality of life in cross-cultural research. Qual Life Res 2:397–432, 1993
Radloff LS: The CES-D Scale: a self-report depression scale for research in the general
population. Applied Psychological Measurement 1:385–401, 1977
Roberts RE: Reliability of the CES-D in different ethnic contexts. Psychiatry Res 2:125–
134, 1980
Roberts RE, Vernon SW: The Center for Epidemiologic Studies Depression Scale: its use
in a community sample. Am J Psychiatry 140:41–46, 1983
Weissman MM, Sholomskas D, Pottenger M, et al: Assessing depressive symptoms in
five psychiatric populations: a validation study. Am J Epidemiol 106:203–214, 1977
CENTER FOR EPIDEMIOLOGIC STUDIES—DEPRESSION SCALE
Circle the number of each statement which best describes how often you felt or behaved this
way – DURING THE PAST WEEK.
Rarely or
none of the
time (less
than 1 day)
Some or a
little of the
time (1-2
days)
Occasionally or Most or all
a moderate
of the time
amount of the
(5-7 days)
time (3-4 days)
During the past week:
0
1
2
3
1) I was bothered by things
that usually don’t bother me
0
1
2
3
2) I did not feel like eating;
my appetite was poor
0
1
2
3
3) I felt that I could not shake
off the blues even with help
from my family and friends
0
1
2
3
4) I felt that I was just as good
as other people
0
1
2
3
5) I had trouble keeping my
mind on what I was doing
0
1
2
3
6) I felt depressed
0
1
2
3
7) I felt that everything I did
was an effort
0
1
2
3
8) I felt hopeful about the
future
0
1
2
3
9) I thought my life had been
a failure
0
1
2
3
10) I felt fearful
0
1
2
3
11) My sleep was restless
0
1
2
3
12) I was happy
0
1
2
3
13) I talked less than usual
0
1
2
3
14) I felt lonely
0
1
2
3
15) People were unfriendly
0
1
2
3
16) I enjoyed life
0
1
2
3
17) I had crying spells
0
1
2
3
18) I felt sad
0
1
2
3
19) I felt that people disliked
me
0
1
2
3
20) I could not get “going”
0
1
2
3