Original article
Psychometric properties of the Center for Epidemiologic Studies Depression Scale (CES-D) in French clinical and nonclinical adultsPropriétés psychométriques du Center for Epidemiologic Studies Depression Scale (CES-D) sur un échantillon français d’adultes cliniques et non-cliniques

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Abstract

Background

Previous research on the Center for Epidemiologic Studies Depression Scale (CES-D) has five main limitations. First, no study provided evidence of the factorial equivalence of this instrument across samples of depressive and community participants. Second, only one study included systematic tests of measurement invariance based on confirmatory factor analyses (CFA), and this study did not consider the higher-order factor structure of depression, although it is the CES-D global scale score that is most often used in the context of epidemiological studies. Third, few studies investigated the screening properties of the CES-D in non-English-language samples and their results were inconsistent. Fourth, although the French version of the CES-D has been used in several previous studies, it has never been systematically validated among community and/or depressed adults. Finally, very few studies have taken into account the ordered-categorical nature of the CES-D answer scale. The purpose of the study reported herein was therefore to examine the construct validity (i.e., factorial, reliability, measurement invariance, latent mean invariance, convergence, and screening properties) of the CES-D in a French sample of depressed patients and community adults.

Methods

A total sample of 469 participants, comprising 163 clinically depressed patients and 306 community adults, was involved in this study. The factorial validity, and the measurement and latent mean invariance of the CES-D across gender and clinical status, were verified through CFAs based on ordered-categorical items. Correlation and receiver operator characteristic curves were also used to test the convergent validity and screening properties of the CES-D.

Results

The present results: (i) provided support for the factor validity and reliability of a second-order measurement model of depression based on responses to the CES-D items; (ii) revealed the full measurement invariance of the first- and second-order measurement models across gender; (iii) showed the partial strict measurement invariance (four uniquenesses had to be freely estimated, but the factor variance–covariance matrix also proved fully invariant) of the first-order factor model and the complete measurement invariance of the second-order model across patients and community adults; (iv) revealed a lack of latent mean invariance across gender and across clinical and community subsamples (with women and patients reporting higher scores on all subscales and on the full scale); (v) confirmed the convergent validity of the CES-D with measures of depression, self-esteem, anxiety, and hopelessness; and (vi) demonstrated the efficacy of the screening properties of this instrument among clinical and nonclinical adults.

Conclusion

This instrument may be useful for assessing depressive symptoms or for the screening of depressive disorders in the context of epidemiological studies targeting French patients and community men and women with a background similar to those from the present study.

Résumé

Position du problème

Les études antérieures sur le Center for Epidemiologic Studies Depression Scale (CES-D) comportent cinq principales limites. Premièrement, aucune étude n’est parvenue à mettre en évidence l’équivalence factorielle de cet instrument auprès d’adultes de la population générale et dépressifs. Deuxièmement, à notre connaissance, une seule étude a eu recours à des tests systématiques d’invariance en employant des analyses factorielles confirmatoires (AFC), et elle n’inclut pas la structure de second-ordre de la dépression, alors que le score global du CES-D est très souvent utilisé dans le contexte d’études épidémiologiques. Troisièmement, peu d’études ont étudié les propriétés de dépistage du CES-D auprès d’échantillons non-anglophones et leurs résultats sont inconsistants. Quatrièmement, bien que la version française du CES-D ait préalablement été utilisée dans plusieurs études, elle n’a jamais été systématiquement validée auprès d’adultes de la population générale et/ou dépressifs. Finalement, peu d’études antérieures ont considéré la nature catégorielle ordonnée des réponses au CES-D. L’objectif de cette étude est d’examiner la validité de construit (i.e. factorielle ; fidélité ; invariance de la mesure ; invariance de moyenne latente ; concomitante ; propriétés de dépistage) du CES-D français auprès d’un échantillon de patients dépressifs et d’adultes de la population générale.

Méthode

Un échantillon total de 469 participants, comprenant 163 patients adultes dépressifs, et un échantillon de 306 adultes de la population générale, ont été inclus dans cette étude. La validité factorielle, ainsi que l’invariance de la mesure et de la moyenne latente du CES-D – selon le genre et le statut clinique – ont été vérifiées à l’aide d’AFC pour items catégoriels ordonnés. Les corrélations et les courbes caractéristiques de fonctionnement du récepteur ont été utilisées, afin de tester la validité concomitante et les propriétés discriminantes du CES-D.

Résultats

Les résultats : (i) démontrent la validité factorielle et la fidélité du modèle de mesure de second ordre de la dépression sur la base des réponses aux items du CES-D ; (ii) révèlent l’invariance complète du modèle de mesure de premier et de second-ordre en fonction du genre et une absence d’invariance des moyennes latentes selon le genre (les femmes rapportent des scores significativement plus élevés sur l’ensemble des échelles) ; (iii) montrent une invariance partielle stricte du modèle de mesure de premier ordre (quatre résidus ont dus être librement estimés mais la matrice de variance-covariance factorielle s’est avérée complètement invariante) et l’invariance complète du modèle de mesure de second ordre entre les patients et les adultes de population générale ; (iv) révèlent l’absence d’invariance des moyennes latentes de premier et de second ordre en fonction du genre et du statut clinique des participants (les femmes et les patients présentant des scores plus élevés sur les sous-échelles et l’échelle globale du CES-D) ; (v) confirment la validité concomitante du CES-D avec des mesures de dépression, d’estime de soi, d’anxiété et de désespoir ; (vi) démontrent l’efficacité des propriétés de dépistage de cet instrument auprès d’adultes dépressifs et non-dépressifs.

Conclusion

Cet instrument peut être utile pour évaluer les symptômes dépressifs, ou dépister les troubles dépressifs majeurs dans le contexte d’études épidémiologique ciblant des populations françaises d’hommes et de femmes dépressifs ou de la population générale présentant des caractéristiques semblables à l’échantillon de la présente étude.

Section snippets

The present study

The goal of the present study was to further investigate the reliability, validity, measurement invariance, and appropriate cut-off scores of the CES-D, based on a CFA approach. The main CFA model that will be tested hypothesized a priori that the answers to the CES-D could be explained by four first-order factors (DA, PA, SC, and IR), which in turn would load on a single second-order factor representing depression. This model will be compared to various alternative models previously reported

Participants and procedures

A total of 469 participants were involved in this study (65.7% females) with a mean age of 40.7 years (standard deviation [SD], 16.2; range, 18–89 years). This sample comprised a first subsample of 306 community adults (59.5% females) not currently suffering from a major depressive episode (MDE) or any mental disorder, with a mean age of 35.4 years (SD, 14.3; range, 18–82 years). The second subsample consisted of 163 patients (77.3% females) with a mean age of 50.6 years (SD, 15.1; range, 19–89

Stage 1. Factor validity and reliability of the CES-D models

Six a priori CFA models from the available literature [1], [28], [45] were examined for the CES-D scores: (i) a one-factor model (Model 1); (ii) a two-factor model (Model 2, combining PA and IR in a single factor and combining DA and SC in a second factor); (iii) two different three-factor models (Model 3a, combining PA-DA in a single factor; Model 3b, combining DA and SC in a single factor); (iv) the a priori CES-D four-factor model (Model 4); and (v) the a priori CES-D four-factor model with

Discussion

These findings demonstrate that, in the total sample, the hypothesized second-order factor model satisfactorily fit the data, providing a better fit than the alternative models. These results confirm those from previous studies [9], [13], [22], [24], [26], [27], [28]. Further analyses also confirmed that the various CES-D subscales had adequate internal consistency coefficients (ω = .83–.96).

In the gender-based comparisons, the results show that the CES-D measurement model was fully invariant, up

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

Acknowledgments

The authors thank Valery Balestra-Depont, Cécile Mantrant, Sylvie Gossery, and Muriel Wybo for their contribution to the organization of the study, as well as Pablo Sillon for his assistance. Completion of this study was also made possible by the dedication of the personnel of each participating centre: Clinic la Costière (Gérard Marro, Georges Benichou, Jean-Pierre Dany, Patrick Ferrer, Richard Moriano, Alain Salimpour, Jean-Charles Struelens), Clinic Saint-Luc (Claude Capdeville, Sophie

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    Since all three contributed equally to the preparation of this paper, the order of appearance of the first, second, and third authors (A.J.S.M., G.M., and C.M.) was determined at random: they should all be considered first authors.

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