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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 36  |  Issue : 3  |  Page : 180-183

Evaluation of center for epidemiological studies depression scale-10 (Malayalam Shorter Version) for depression among people living with HIV/AIDS


1 Department of Psychiatry, Sapthagiri Institute of Medical Sciences, Bengaluru, Karnataka, India
2 Department of Community Medicine, Government Medical College, Thrissur, Kerala, India
3 Department of Dermatology and Venereology, Government Medical College, Kozhikode, Kerala, India
4 Department of Psychiatry, Government Medical College, Thrissur, Kerala, India

Date of Submission31-Oct-2019
Date of Decision18-Jun-2020
Date of Acceptance08-Jul-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Sharanabasappa Algoodkar
Department of Psychiatry, Sapthagiri Institute of Medical Sciences, Bengaluru - 560 090, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_109_19

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  Abstract 


Background: Depression and other neuropsychiatric illnesses are common in people living with human immunodeficiency virus/acquired immunodeficiency syndrome (PLWHIV) because of its physical and mental health consequences. In this study, depression status has been evaluated and validated using the Center for Epidemiological Studies Depression scale (CES-D-10) Malayalam shorter version. Objective: The objective of the study was to study the outcome of CES-D-10 (Malayalam shorter version) in the screening of depression in PLWHIV and to evaluate its sensitivity and specificity. Patients and Methods: A cross-sectional survey of 100 PLWHIV patients was conducted at the antiretroviral treatment (ART) Centre, Government Medical College Chest Hospital, Thrissur, Kerala. Patients meeting the study criteria were subjected to a self-reported questionnaire which includes CES-D-10 with a cutoff score of 4. The depressive symptoms were evaluated using the International Classification of Diseases-10th version classification of mental and behavioral disorders. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and false-positive rate (FPR) and false-negative rate (FNR) were calculated to assess the performance of the CES-D-10 Malayalam version. Further, receiver operating characteristic (ROC) curve was used to evaluate the criterion validity. Results: In this study, for a cutoff score of 4 and above, the sensitivity, specificity, PPV, NPV, FPR, and FNR were found to be 86.66%, 91.43%, 81.25%, 94.12%, 8.57%, and 13.3%, respectively. The ROC curve was significant, with an area of 0.916. Conclusions: Thus, the 10-item shorter version of CES-D-10 (Malayalam shorter version) is a valuable tool for screening depressive symptoms among the PLWHIV.

Keywords: Center for Epidemiological Studies Depression scale-10, depression, Malayalam version, PLWHIV, validation


How to cite this article:
Algoodkar S, Rejani P P, Kidangazhiathmana A, Shaji K S. Evaluation of center for epidemiological studies depression scale-10 (Malayalam Shorter Version) for depression among people living with HIV/AIDS. Indian J Soc Psychiatry 2020;36:180-3

How to cite this URL:
Algoodkar S, Rejani P P, Kidangazhiathmana A, Shaji K S. Evaluation of center for epidemiological studies depression scale-10 (Malayalam Shorter Version) for depression among people living with HIV/AIDS. Indian J Soc Psychiatry [serial online] 2020 [cited 2023 Feb 6];36:180-3. Available from: https://www.indjsp.org/text.asp?2020/36/3/180/296252




  Introduction Top


Infection due to human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a predominant cause of mortality and burden in middle-and low-income countries.[1] Globally, India has the third largest HIV epidemic, with almost 2.1 million affected individuals. The prevalence of HIV among adults aged between 15 and 49 years is reported to be 0.2%.[2] The outcome of antiretroviral therapy (ART) initiatives conducted in India as per the WHO recommendations has led to a substantial decline in the mortality rate of people living with HIV/AIDS (PLWHIV). However, there is more attention on the comorbidities seen in PLWHIV.[3] Mental health disorders, specifically depression, is the most common comorbid condition seen in PLWHIV.[4] The prevalence of depression among Indian PLWHIV has been reported to be around 40%.[5] We found depression in 30% of our patients who were clinically stable PLWHIV on antiretroviral therapy.[6]

Many rating scales such as Hamilton Depression Rating Scale, Self-reporting Beck Depressive Inventory, Montgomery–Asberg Depression Rating Scale, and Center for Epidemiological Studies Depression Scale (CES-D) have been employed to assess the severity of depression in various disease conditions.[7],[8],[9] The CES-D is a widely used tool for assessing depression in primary care settings.[10] The CES-D is a 20-item self-reporting instrument widely used to evaluate depression and has high sensitivity and reliability.[11],[12] Further, the CES-D scale is also used in HIV-positive patients, specifically in high HIV-burden settings.[13],[14],[15] The CES-D has high internal consistency, estimated using coefficient alpha, and is reported as 0.85 for the general population (healthy) and 0.90 in patient samples.[10]

One study from India had used the 20-item version of the CES-D to evaluate depression in PLWHIV.[16] The 20-item measurement tool is lengthy and time consuming, and thus may not be useful in busy clinical settings. The CES-D-10 item scale was derived from the original CES-D-20 and has displayed high internal consistency (alpha = 0.8) and good specificity (81% to 93%) and sensitivity (79% to 100%) when using a cutoff score ≥4.[17] A recent study indicates that sensitivity, specificity, and positive predictive value (PPV) of CES-D-10 are reported to be 91%, 92%, and 92%, respectively, in HIV patients.[18] Studies also indicate that depression scales such as CES-D may be affected by the language of the content used, thus changing the content into the local language might also affect the outcome of the test. In this backdrop, the present study was done to assess the outcome of CES-D-10 (Malayalam shorter version) in the screening of depression and also to evaluate its sensitivity and specificity using the International Classification of Diseases-10th version (ICD-10) diagnosis of depression as a standard in clinically stable PLWHIV who were on ART.


  Patients and Methods Top


Participants

This cross-sectional study was conducted at the ART Centre, Government Medical College Chest Hospital, Thrissur, Kerala, to estimate the prevalence of depression among people with HIV/AIDS on antiretroviral therapy.

After careful screening of 100 PLWHIV by a trained clinician in psychiatry and ART, with the help of an ART counselor and a pharmacist, patients meeting the study criteria, that is, those who were on ART therapy for >2 years and attending the ART center with CD4 count >400 cells/mm3 and patients with drug adherence rate >95% with no significant opportunistic infections in the last 1 year were included in the study. Approval for the study was granted by the Ethical Committee Board of Government Medical College, Thrissur. Further, informed consent duly signed by the patients enrolled in the study was also obtained. The study was conducted for 2 years between April 2011 and August 2013.

Tools

In the present study, we used the Malayalam translated version of CES-D-10 developed in our department using standard procedure for translation, which was used in earlier studies in our department with a cutoff score of 4.[19] CES-D, a short self-reporting scale containing 10 items, in Malayalam language, was used to screen for depression. We used a cutoff score of 4 as suggested by earlier studies (Irvine et al., 1999). A symptom checklist based on the ICD-10 (the ICD-10 Classification of Mental and Behavioral Disorders) was also used to elicit symptoms suggestive of a depressive episode. A diagnosis of depressive episode was made after clinical evaluation using the ICD-10 diagnostic criteria (WHO, 2007).

Statistical analysis

The Epi Info is statistical software for epidemiology developed by Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (US) was used for data analysis. The sensitivity, specificity, PPV, negative predictive value (NPV), false-positive rate (FPR), and false-negative rate (FNR) were calculated to assess the performance of CES-D Malayalam shorter version. Further, receiver operating characteristic (ROC) curve was drawn to evaluate the validity of CES-D Malayalam shorter version depression scale.


  Results Top


In this study, 100 patients who met the study criteria were enrolled. Most of the patients were aged between 10 and 49 years (89%). There was a male predominance (65% of male patients) in the sample. On CES-D-10, 10-item rating scale, of the 100 patients, 36 (36%) patients responded yes to item number one, 28 (28%) patients to item number 2, 19 (19%) to item number 3, 71 (71%) to item 4, 14 (14%) to item 5, 13 (13%) to item 6, 40 (40%) to item 7, 60 (60%) to item 8, 11 (11%) to item 9, and 5 (5%) to item 10. The sensitivity, specificity, PPV, and NPV of the Malayalam shorter version (10-item scale) of CES-D were calculated using the ICD-10 diagnosis of depression as the gold standard. We found the sensitivity and specificity to be 86.66% and 91.43% and the PPV and NPV to be 81.25% and 94.12%, respectively, when a cutoff score of 4 and above was used. Meanwhile, the FPR and FNR were found to be 8.57% and 13.3%, respectively. The results are displayed in [Table 1].
Table 1: Sensitivity and specificity of Center for Epidemiological Studies Depression Scale with a cutoff score of 4 and above

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Further, the ROC curve for CES-D (shorter form), Malayalam version, displayed as a useful tool for screening depression with an area of 0.916 and found to be statistically significant (P <0.001). The data are shown in [Figure 1].
Figure 1: Receiver operating characteristic curve for the Center for Epidemiological Studies Depression scale (shorter form). Receiver operating characteristic curve shows that the Center for Epidemiological Studies Depression scale shorter version (10-item scale) is a useful tool for screening depression (area = 0.916 and P<0.001)

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  Discussion Top


Depression in PLWHIV imposes a major burden and also affects their quality of life.[17] We found the prevalence of depression to be 30% in the same sample, and factors such as female gender, lack of family support, and HIV-positive status of the spouse were found to be associated with depression.[6]

The CES-D is one of the most widely used screening methods to spot depression-related symptoms among the general population.[9] The shorter version contains ten items.[18] Previous studies indicate that CES-D-10 is a reliable and valid measure for assessing symptoms of depression with good specificity and sensitivity.[19]

In our study, we have used CES-D-10 Malayalam shorter version with a cutoff score of 4 and above. Our results support the findings of Irwin et al.,[16] With a cutoff score of 4 and above, which showed that the sensitivity of the 10-item CES-D was 97%; specificity, 84%; and PPV, 85%. Moreover, our findings are comparable with those of another study using the Malayalam shorter version of CES-D-10 with a cutoff score of 4, which showed a sensitivity of 97.7% and a specificity of 79.1% for depression.[20] We found the PPV and NPV to be higher while using a cutoff score of 4. The maximum PPV obtained in this study was 81.25%, which is comparatively lower than that obtained in the study byZhang et al. where the PPV value was 92%.[21]

The ROC curves based on our study suggest that the CES-D-10 is an adequate screening tool to identify PLWHA at risk of depression. The area under the curve for ROC values were all above the minimum value of 0.75, which is considered clinically significant (Fan et al., 2006).[22]

Although other rating scales such as Patient Health Questionnaire (PHQ-9) is a simple one, CES-D-10 also has similar efficacy as compared to PHQ-9. A study from South Africa for validation of the CES-D-10 scale with a sample size of 944 showed comparable results for CES-D-10 and PHQ-9. Patients from various centers showed an overall prevalence of 31%. The CES-D-10 had acceptable internal consistency across samples (α = 0.69–0.89) and adequate concurrent validity, when compared to the PHQ-9.[23] Another study evaluated psychometric properties of the PHQ-9, the CES-D-10, and the 8-item Patient-Reported Outcomes Measurement Information System on 455 patients with multiple sclerosis. Overall, scores on all the three scales demonstrated essential unidimensionality and had acceptable inter-item reliability and convergent/discriminant validity.[24]


  Conclusions Top


We found the CES-D-10 scale (Malayalam shorter version) to be having a sensitivity of 86.6% and a specificity of 91.6%, a PPV of 81.25%, and a NPV of 94.12% when a cutoff score of 4 or more was used to identify depression. The CES-D (shorter version) thus is a useful screening tool for the assessment of depression in clinical settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO. HIV/AIDS and Mental Health: Report by the Secretariat. Geneva: WHO; 2009.  Back to cited text no. 1
    
2.
UNAIDS. 'AIDSinfo', 2018. Available from: https://aidsinfo.unaids.org/. [Last accessed on 2019 Oct 31].  Back to cited text no. 2
    
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Algoodkar S, Kidangazhiathmana A, Rejani PP, Shaji KS. Prevalence and factors associated with depression among clinically stable people living with HIV/AIDS on antiretroviral therapy. Indian J Psychol Med 2017;39:789-93.  Back to cited text no. 6
[PUBMED]  [Full text]  
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Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.  Back to cited text no. 7
    
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Moullec G, Maïano C, Morin AJ, Monthuy-Blanc J, Rosello L, Ninot G. A very short visual analog form of the Center for Epidemiologic Studies Depression Scale (CES-D) for the idiographic measurement of depression. J Affect Disord 2011;128:220-34.  Back to cited text no. 10
    
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Vilagut G, Forero CG, Barbaglia G, Alonso J. Screening for depression in the general population with the center for epidemiologic studies depression (CES-D): A systematic review with meta-analysis. PLoS One 2016;11:e0155431.  Back to cited text no. 11
    
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Privado J, Garrido J. Factorial structure of the Spanish center for epidemiologic studies depression scales in HIV patients. Community Ment Health J 2013;49:492-7.  Back to cited text no. 12
    
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Chishinga N, Kinyanda E, Weiss HA, Patel V, Ayles H, Seedat S. Validation of brief screening tools for depressive and alcohol use disorders among TB and HIV patients in primary care in Zambia. BMC Psychiatry 2013;11:75.  Back to cited text no. 13
    
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Natamba BK, Achan J, Arbach A, Oyok TO, Ghosh S, Mehta S, et al. Reliability and validity of the center for epidemiologic studies-depression scale in screening for depression among HIV-infected and -uninfected pregnant women attending antenatal services in northern Uganda: A cross-sectional study. BMC Psychiatry 2014;14:303.  Back to cited text no. 14
    
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Bhatia MS, Munjal S. Prevalence of depression in people living with HIV/AIDS undergoing ART and factors associated with it. J Clin Diag Res 2014;8:1-4.  Back to cited text no. 15
    
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Irwin M, Artin KH, Oxman MN. Screening for depression in the older adult: Criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D). Arch Intern Med 1999;159:1701-4.  Back to cited text no. 16
    
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Chandra PS, Desai G, Ranjan S. HIV & psychiatric disorders. Indian J Med Res 2005;121:451-67.  Back to cited text no. 17
    
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Miller WC, Anton HA, Townson AF. Measurement properties of the CESD scale among individuals with spinal cord injury. Spinal Cord 2008;46:287-92.  Back to cited text no. 18
    
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Björgvinsson T, Kertz SJ, Bigda-Peyton JS, McCoy KL, Aderka IM. Psychometric properties of the CES-D-10 in a psychiatric sample. Assessment 2013;20:429-36.  Back to cited text no. 19
    
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Kumar S, Nakulan A, Thoppil SP, Parassery RP, Kunnukattil SS. Screening for depression among community-dwelling elders: Usefulness of the center for epidemiologic studies depression scale. Indian J Psychol Med 2016;38:483-5.  Back to cited text no. 20
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Zhang W, O'Brien N, Forrest JI, Salters KA, Patterson TL, Montaner JS, et al. Validating a shortened depression scale (10 item CES-D) among HIV-positive people in British Columbia, Canada. PLoS One 2012;7:e40793.  Back to cited text no. 21
    
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Fan J, Upadhye S, Worster A. Understanding receiver operating characteristic (ROC) curves. Can Assoc Emerg Physicians 2006;8:19-20.  Back to cited text no. 22
    
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Baron EC, Davies T, Lund C. Validation of the 10-item Center for Epidemiological Studies Depression Scale (CES-D-10) in Zulu, Xhosa and Afrikaans populations in South Africa. BMC Psychiatry 2017;17:6.  Back to cited text no. 23
    
24.
Amtmann D, Kim J, Chung H, Bamer AM, Askew RL, Wu S, et al. Comparing CESD-10, PHQ-9, and PROMIS depression instruments in individuals with multiple sclerosis. Rehabil Psychol 2014;59:2209.  Back to cited text no. 24
    


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