The CES-D in Chinese American women: Construct validity, diagnostic validity for major depression, and cultural response bias
Introduction
The Center for Epidemiological Studies Depression Scale (CES-D) is a self-report scale designed to measure symptoms of depression in community populations (Radloff, 1977, Radloff and Locke, 2008). Like most epidemiological instruments for depression that are developed in Western cultural settings using North American or European populations (Jenkins et al, 1991), development of the CES-D was originally based on a predominately white American population (Radloff, 1977, Weissman et al., 1977, Roberts and Vernon, 1983). The CES-D has been increasingly used for cross-cultural studies and comparisons between ethnic groups to identify probable clinical depression. This is understandable, as scales are efficient and economical. However, CES-D cut-off scores for depression are not validated for most ethnic groups. If an instrument has differential validity, then population needs can be distorted and biased comparisons made between groups (Crockett et al., 2005). Cross-cultural research shows mixed results on the diagnostic validity of the CES-D (Roberts, 1981, Guarnaccia et al., 1990, Roberts et al., 1990). Moreover, evidence is accumulating that ethnicity, culture and acculturation can create response bias to CES-D items (Ying, 1989, Callahan and Wolinsky, 1994, Iwata and Buku, 2002, Jang et al., 2005, Yang and Jones, 2007). More data are needed to close the gap between what little is known about CES-D validity in ethnic groups and its expanding use in cross-ethnic epidemiology.
CES-D function can differ not only between ethnic groups, but also within group by gender. CES-D diagnostic sensitivity for major depression varies by gender in Taiwanese adolescents (Yang et al. 2004). The CES-D has lower specificity for identifying major depression in Hispanic American women than men (Cho et al., 1993). CES-D items have shown differential bias (Stommel et al., 1993) and validity (Ross and Mirowsky, 1984) between mainstream American men and women. Women are more likely to endorse the “crying spells” item than men (Yang and Jones, 2007). Degrees of gender difference vary across cultural and ethnic groups (Fugita and Crittenden, 1990, Greenberger et al., 2000).
Although Chinese Americans are the largest Asian American group (Barnes and Bennett, 2002), numbering over 3.5 million (U.S. Census Bureau, 2007), only two previous studies analyze CES-D functioning in Chinese Americans: Kuo (1984) combined convenience and probability sampling for face-to-face interviews with 122 Chinese American men and women. Ying (1988) drew a probability sample of 360 Chinese American men and women from telephone listings. Both studies report CES-D internal reliability and factor structure. Despite the lack of information on CES-D construct validity and diagnostic validity in Chinese Americans, the scale is used for comparisons with other ethnic groups. For example, the Study of Women's Health Across the Nation compares rates at which white, African American, Hispanic, Japanese and Chinese American women have CES-D scores of 16 or higher to identify rates of clinically significant depression (Bromberger et al., 2004).
In this paper, we describe how the CES-D functioned in a community, probability sample of Chinese American women in terms of: diagnostic validity for major depression; construct validity; internal reliability; response bias; and scores. Our data originate from a study with the primary aim of examining associations between intimate partner violence and major depression in Chinese American women (Hicks and Li, 2003). The CES-D was included for planned, further analysis of relationships between CES-D depressive symptoms, health status, life events (including partner violence), and major depression. We use this unusually rich dataset on Chinese American women to analyze CES-D construct validity using self-perceived general health, social support and stressful life events. The study's joint administration of the CES-D and the Composite International Diagnostic Interview (CIDI) (WHO, 1997) allows us to report for the first time CES-D diagnostic validity for major depression in a Chinese American population. This provides new, preliminary information on the CES-D's usefulness as a screening tool for depression in Chinese Americans.
Section snippets
Subjects
The Boston Census was used to compile the sampling frame in order to avoid the bias of telephone surveys against immigrants, the poor, and non-English-speakers (Straus and Gelles, 1990, Pinn and Chunko, 1997). Boston neighborhoods range from impoverished to wealthy and include Chinatown and student dormitories. Because the census did not identify ethnicity, households with first or last Chinese-sounding names were identified according to Choi et al. (1993) and the research team. A list was
Sample characteristics
Of 1848 screened households, 323 were eligible for inclusion. Of 323 women selected for recruitment, 181 were interviewed, giving a response rate of 56%. Eighteen percent of selected women refused directly. No interview was done in 26% because we could not gain access for recruitment or because a relative refused on her behalf. The CES-D was completed by 168 subjects. Mean age was 34 years (S.D. =12). Mean household income was $49,196 (reported range $0 to $468,000). Table 1 gives
Comparison to other studies
We found the CES-D to have high internal consistency, as found in white Americans and other ethnic Chinese (Radloff, 1977, Ying, 1988, Lin, 1989, Greenberger et al., 2000). Twenty-six percent of our Chinese American sample scored above the cut-off score of 16 that is routinely used for potential clinical depression (Radloff, 1977), similar to 24% of San Franciscan Chinese Americans (Ying, 1988) and significantly more than Radloff's (1977) 19% of white Americans (P < 0.05). We found good CES-D
Acknowledgments
This study was funded by a Young Investigator Award to Dr. Hicks from the National Alliance for Research on Schizophrenia and Depression while she was an Instructor at the Department of Social Medicine, Harvard Medical School. Thanks to Professor Arthur Kleinman for his mentorship and to Professor Byron Good, who suggested including the CES-D in the study.
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