Application of the Center for Epidemiologic Studies Depression Scale among first-visit psychiatric patients: a new approach to improve its performance

Background: Although the Center for Epidemiologic Studies Depression Scale (CES-D) is an internationally popular self-rating scale for depression both in community and clinical settings, extant literature concerning its validity has several shortcomings. The present paper aimed to overcome these problems. Methods: We applied newer assessment technology of receiver operating characteristics (ROC) analyses and stratum-specific likelihood ratios (SSLRs) and cross-validated the results in the 'training' and 'testing' data sets of 591 patients representing various clinical settings all over Japan. Results: The ROC analyses demonstrated that the CES-D had moderate convergent and discriminant validity to detect major depressive episodes among first-visit psychiatric patients. Selecting single optimal cutoffs, however, failed to arrive at consistent results across various settings. The efficacy of the instrument was most conveniently transportable into clinical practices when converted into SSLRs, which were 0.35 (95%CI: 0.25-0.49) for the score range 0-29, 2.3 (1.8-3.1) for the score range 30-49, and 11.7 (3.1-44.0) for the scores above 50. In addition, the SSLRs proved to be generalizable not only across various clinical settings in our sample but also across psychiatric, primary care and community samples in the published reports. Conclusion: Clinicians and clinical epidemiologists can apply the SSLRs of the CES-D to various settings to estimate the probability of suffering from a major depressive episode in a convenient and intuitive manner. (C) 1997 Elsevier Science B.V.