Psychometric validation of the Center for Epidemiological Studies Depression Scale in Head and Neck Cancer patients

Highlights

• Scale shows strong reliability via internal consistency Cronbach’s alpha and validity.

• Exploratory factor analysis revealed a 3 factor solution as opposed to a 4 factor solution.

• Test retest reliability suggests caution while evaluating for change in depressive symptoms over time.

Abstract

Objective

The Center for Epidemiological Studies Depression Scale (CES-D) is a 20-item tool developed to screen for depression in the general population. To psychometrically evaluate and validate the CES-D scale for use in head and neck cancer (HNC) patients.

Methods

The CES-D was applied to 130 subjects at onset of radiation treatment and 3-months following treatment. Analysis was conducted via face and content validity using two expert raters, internal consistency was applied using Cronbach's alpha, test retest reliability comparing baseline to 3-month application, concurrent validity was performed against the FACT-H&N and Pain Disability Index, construct validity was conducted via exploratory factor analysis.

Results

The sample was predominantly male receiving chemo radiation. Face validity was strong (α = 0.85). Significant difference was found in the mean score between depressed (CES-D cut point ≥ 16) vs. non-depressed (t = −15.84, p = .00) (95% CI = −17.18, −13.33). Internal consistency of the scale was high (α = 0.84). Test retest reliability (p < .001) showed moderate-strong correlations (0.51), however was not sensitive to change in this sample across the study time period. Concurrent validity was strong (r = −0.77, 0.51). Factor analysis at baseline explained 54.92% of variance, with 3 distinct factors; depressed affect, somatic/retarded activity, and positive affect. In contrast to general populations, the factor 'disturbed interpersonal skill' was not retained.

Conclusion

Results confirm the reliability and validity of the CES-D as a measure of depression in HNC populations. Proposed cut off scores remain stable but scale responsiveness suggests caution when evaluating change over time in this population.

Introduction

Depression is a common complication in patients with cancer [1]. Studies have shown that patients with head and neck cancer (HNC) experience higher rates of depression than other groups with an incidence of 15–50% as compared to 15–25% in other cancers [2]. Depression associated with cancer treatment in HNC patients has also been shown to contribute to lower quality of life, high levels of fatigue, low motivation, and higher suicide rates [2]. Early detection of depression and treatment would facilitate better treatment outcomes and quality of life [3]. Currently there are numerous screening tools available to detect depression, however few have been validated for specific use with HNC populations.

The Center for Epidemiological Studies Depression Scale (CES-D) is a tool developed by L.S. Radloff in 1977 to screen for depressive symptomology (depressed mood) in the general population [4]. Currently, the CES-D has demonstrated strong psychometric properties in prior research and is widely utilized as a measure of depression across different populations [5], [6]. This 20-item scale covers four major symptoms of depression including depressed affect, positive affect, somatic and retarded activity, and disturbed interpersonal relationship [4]. Within the scale, items are scored on a 4 - point Likert scale based on the past week’s experiences, resulting in a total score ranging from 0 to 60 with higher scores indicating more symptoms of depression [4]. Inferences and scores from any measurement tool are dependent upon population characteristics and can affect a scale's dimensionality [7]. Given this, disease specific validation is necessary as groups may differ on the underlying construct, effecting the degree to which score inferences and use can be generalized. While the CES-D is considered a robust measure of depression it needs to be psychometrically validated for use in HNC patients.

Given the considerable burden of depression in HNC patients and the lack of a population specific measure for this outcome, we aimed to explore the performance of the CES-D for use with HNC patient samples.