Screening for depression in a hepatitis C population: the
reliability and validity of the Center for Epidemiologic Studies
Depression Scale (CES-D).
Author(s): Clark, Cinda H.

Mahoney, Jane S.

Clark, David J.

Eriksen, Lillian R.
Source: Journal of Advanced Nursing; Nov2002, Vol. 40 Issue 3,
p361, 9p
Document Type: Article
Subject(s): HEPATITIS C -- Patients

DEPRESSION, Mental
Abstract: Rationale. Depression is reported as a serious adverse
event of antiviral therapy used to treat patients with hepatitis C
(Hepatitis C Virus); therefore, there is a need to identify a reliable and valid
measure of depressive symptoms for this population. Aims. To determine
reliability, construct validity and predictive validity of the Center
for Epidemiological Studies Depression Scale (CES-D) in a hepatitis C
(Hepatitis C Virus) population. Ethical issues. Study reviewed/approved by the
University Institutional Review Board and informed consent obtained.
Methods. Longitudinal design testing psychometric properties of the
CES-D prior to treatment and 4 and 24 weeks postinitiation of treatment.
Reliability was tested using Cronbach's coefficient ?. Construct
validity was tested, prior to therapy, using principal components
factoring with varimax rotation. Predictive validity was tested using
repeated measures analysis of variance (ANOVA) of CES-D scores at 4 and
24 weeks postinitiation of treatment. Results. Non-probability sample,
116 adult Hepatitis C Virus patients [62 (53%) males and 54 (47%) females].
Reliability (Cronbach's ?) = 0·88 pretreatment, 0·89 week 4 and 0·90
week 24. Construct validity testing revealed four factors: negative
affect; positive affect; somatic; and depressed affect/somatic.
Exception for two items, 'felt sad' and 'couldn't get going', all items
loaded distinctly with correlation coefficients in the range of
0·51-0·84. Predictive validity testing revealed a statistically
significant effect over time (P<0·001) in the direction predicted
(pretreatment x = 13·97; post 4 weeks x = 19·54 and 24 weeks x = 19·97).
Conclusions. The CES-D is a reliable and valid instrument to screen for
depressive symptoms in Hepatitis C Virus patients. The instrument detected the
predicted increase in depression associated with Hepatitis C Virus. Examination of the
sensitivity and specificity is needed to determine the most accurate
cut-off score. [ABSTRACT FROM AUTHOR]
Full Text Word Count: 5745
ISSN: 03092402
Accession Number: 7522410
 
Persistent Link to this Article:
http://search.epnet.com/direct.asp?an=7522410&db=afh
 
Cut and Paste: <A
href="http://search.epnet.com/direct.asp?an=7522410&db=afh">Screening
for depression in a hepatitis C population: the reliability and validity
of the Center for Epidemiologic Studies Depression Scale (CES-D).</A>
 
Database: Academic Search Elite
Section METHODOLOGICAL ISSUES IN NURSING RESEARCH
Screening for depression in a hepatitis C population: the reliability
and validity of the Center for Epidemiologic Studies Depression Scale
(CES-D)



Rationale. Depression is reported as a serious adverse event of
antiviral therapy used to treat patients with hepatitis C (Hepatitis C Virus);
therefore, there is a need to identify a reliable and valid measure of
depressive symptoms for this population.

Aims. To determine reliability, construct validity and predictive
validity of the Center for Epidemiological Studies Depression Scale
(CES-D) in a hepatitis C (Hepatitis C Virus) population.

Ethical issues. Study reviewed/approved by the University Institutional
Review Board and informed consent obtained.

Methods. Longitudinal design testing psychometric properties of the
CES-D prior to treatment and 4 and 24 weeks postinitiation of treatment.
Reliability was tested using Cronbach's coefficient ?. Construct
validity was tested, prior to therapy, using principal components
factoring with varimax rotation. Predictive validity was tested using
repeated measures analysis of variance (ANOVA) of CES-D scores at 4 and
24 weeks postinitiation of treatment.

Results. Non-probability sample, 116 adult Hepatitis C Virus patients [62 (53%) males
and 54 (47%) females]. Reliability (Cronbach's ?) = 0·88 pretreatment,
0·89 week 4 and 0·90 week 24. Construct validity testing revealed four
factors: negative affect; positive affect; somatic; and depressed
affect/somatic. Exception for two items, 'felt sad' and 'couldn't get
going', all items loaded distinctly with correlation coefficients in the
range of 0·51-0·84. Predictive validity testing revealed a statistically
significant effect over time (P<0·001) in the direction predicted
(pretreatment x = 13·97; post 4 weeks x = 19·54 and 24 weeks x = 19·97).

Conclusions. The CES-D is a reliable and valid instrument to screen for
depressive symptoms in Hepatitis C Virus patients. The instrument detected the
predicted increase in depression associated with Hepatitis C Virus. Examination of the
sensitivity and specificity is needed to determine the most accurate
cut-off score.

Keywords: hepatitis C, depression, Center for Epidemiological Studies
Depression Scale, psychometric testing, depression screening, antiviral
therapy, interferon, ribavirin, validity, reliability


Purpose


The purpose of this study was to determine the reliability, construct
validity and predictive validity of the Center for Epidemiological
Studies Depression Scale (CES-D) in a hepatitis C (Hepatitis C Virus)-infected
population. The investigators hypothesized the CES-D to be reliable and
valid, and that subjects would show significant increases in CES-D
scores following initiation of interferon a-2b (INF?-2b) plus ribavirin
(RBV).


Background


It is estimated that four million people in the United States of America
(USA) are currently infected with the hepatitis C virus (Hepatitis C Virus).
Approximately 30 000-35 000 new acute Hepatitis C Virus infections occur each year,
25-30% of which are diagnosed.

Hepatitis C Virus is responsible for an estimated 8000-10 000 deaths per year, and the
rate is expected to triple in 20-30 years if effective treatment is not
found (National Institute of Health 1997). Hepatitis C Virus research has been
primarily biological in nature with the major focus on pharmacological
treatment. Little attention has been given to the neurobehavioural
manifestations of the disease and the side-effects of its treatment,
specifically, depression. Depression is a reported side-effect of
interferon alpha plus ribavirin, the antiviral therapy of choice in
treating Hepatitis C Virus (Dusheiko 1997, Costa 1999, Fontana 2000, Bonaccoro et al.
2001). The most severe consequence of depression is suicide. Suicidal
ideations, suicide attempts, and successful suicides have been reported
as adverse events of antiviral treatment regimens for Hepatitis C Virus patients
(Janssen et al. 1994, Heeringa et al. 1998, Rifflet et al. 1998).
Additionally, Dwight et al. (2000) reported that functional disability
and fatigue were more strongly associated with depression severity than
with severity of hepatic disease. The presence of depression may
increase the risk for patient noncompliance with antiviral therapy
(Maddrey 1999), and has been reported as a reason for discontinuation of
therapy (Hakozaki et al. 1995, Miyaoka et al. 1999), thus leading to
antiviral failure.

According to expert consensus panel guidelines (Rush et al. 1993), when
major depressive disorder co-occurs with a major medical condition, it
should be considered an independent condition and treated. Treatment may
include enhancing or optimizing the treatment of the medical disorder as
well as treating the depression specifically. Successful treatment
relies upon early detection and diagnosis. Nurses and other healthcare
providers need reliable and valid methods to screen for depressive
symptoms in this population in order to identify at-risk patients and to
make appropriate psychiatric referrals (Wright 2000). A reliable and
valid measure of depressive symptoms is also needed for use in research
to determine the incidence, prevalence, and risk factors associated with
depression in this population. Reports of these epidemiologic aspects
are lacking in the literature and are required in order to understand
the scope of the problem. Furthermore, this information is needed in
order to design intervention trials focused on depression in
Hepatitis C Virus-infected patients leading to the development of best intervention
strategies.

The criteria for a major depressive episode includes: (a) at least a
2-week period of depressed mood or anhedonia (loss of interest in
activities most of the day); and (b) at least four of the following
symptoms: weight loss or weight gain; insomnia or hypersomnia;
psychomotor agitation or retardation; fatigue or loss of energy;
feelings of worthlessness or guilt; diminished ability to concentrate;
and suicidal thoughts, plans, or attempts (American Psychiatric
Association 2000, p. 356). Clinicians have voiced concern that somatic
symptoms associated with Hepatitis C Virus are also symptoms of depression. For
example, Hepatitis C Virus patients present with fatigue with and without antiviral
therapy. Such symptom overlap requires psychometric testing of
instruments in the Hepatitis C Virus population in order to guide interpretation of
scores. Accurate interpretation of depression scores depends upon the
reliability and validity of the instruments in the study population
(Nunnally & Bernstein 1994). Although no other studies have reported the
reliability and validity of a depression inventory in a Hepatitis C Virus population,
a preliminary cross sectional pilot study of Hepatitis C Virus-infected patients, at
various stages of treatment, was conducted to examine the reliability
and validity of the CES-D in a Hepatitis C Virus population. The analysis revealed
internal consistency reliability of 0·89. Testing of construct validity
using principle-axis factoring with varimax rotation revealed four
factors: depressive affect; somatic; interpersonal; and positive affect
(Clark et al. 1999). The current study expanded this analysis with an
added focus of evaluating the CES-D in a large group of subjects over
time, pretreatment and at two time points during treatment with
antiviral agents.

 

The study


Design and methods


The psychometric properties of the CES-D were studied using a
longitudinal design with a population of Hepatitis C Virus infected patients being
treated in one of three Hepatitis C Virus clinics.

Sample

Patients diagnosed with chronic active Hepatitis C Virus using polymer chain reaction
laboratory analysis were referred into the Hepatitis C clinic for
further evaluation and possible treatment with antiviral therapies. From
January 1999 to January 2001, all patients (n = 121) who were
prescreened and considered appropriate candidates for standard antiviral
therapy (NIH 1997) by their Hepatitis C Virus health care provider were invited to
participate in this study. A nonprobability sample of 116 adult patients
(96% participation rate; 4% rate of refusal) with chronic active Hepatitis C Virus
compensated liver disease, no uncontrolled concomitant physiologic
illness and able to read English participated.

Principal component factoring with varimax rotation was used to test the
construct validity of the CES-D. Factor analysis is based on
correlational statistical approaches and as such the standard error of
the correlations within the correlation matrix are related to sample
size. Thus larger sample size numbers (five to ten per variable) are
preferred for factor analytic studies (Gorsuch 1983). This formula would
indicate the need for a sample size of about 100-200 for the analysis in
this study. If fewer numbers are used then statistical tests are
required. According to Gorsuch, the Bartlett's Test is a powerful test
of the significance of the correlation matrix; therefore, it was used in
this study to ensure an adequate sample size. Also, as noted by Gorsuch,
when the communalities are high, there is less error present.
Communalities represent the variance of a variable that is shared with
the factors being extracted by the factor analysis. Thus, communalities
were also examined to provide support for the sample size.

Treatment for all subjects included a combination of subcutaneously
administered interferon a-2b 3 MIU three times per week plus ribavirin
1000 mg or 1200 mg, depending on body weight (< 165 or ? 165 lbs,
respectively), in divided daily doses over 6 months. The sample
consisted of 62 (53%) males and 54 (47%) females, 21 years of age or
older (median age of 46 years with age range of 27-63 years). Ethnic
distribution of the sample was 50% Caucasian, 27% African-American, 23%
Hispanic and 7% Vietnamese. Sixty-two (53%) were privately insured
subjects and 54 (47%) were part of a publicly funded indigent care
health care programme.

Setting

Three University affiliated out-patient hepatitis C clinics located in a
major medical centre in a large metropolitan city in south-east Texas
served as the settings for the study. Two of the sites were subspecialty
medical outpatient clinics associated with a tax-supported public
authority providing health care to residents regardless of ability to
pay, and the third site was a subspecialty medical outpatient clinic
associated with a private, not-for-profit hospital system.

Instrumentation

CES-D. The CES-D is a self-report measure of depressive symptoms
composed of a 20 item, four-point Likert scale (response range 0-3)
(Radloff 1977). Items were derived from several previously validated
depression scales (Dahlstrom & Welsh 1960, Beck et al. 1961, Zung 1965)
to correspond with major components of symptoms of depression identified
through literature review and psychometric studies. The components
included depressed mood, feelings of guilt and worthlessness, feelings
of helplessness, psychomotor retardation, loss of appetite, and sleep
disturbance (Radloff 1977). The CES-D assesses the frequency/duration of
depressive symptoms over the past week. Four items were worded in a
positive direction in order to disrupt the tendency toward a response
set. The range of total scores is from 0 to 60 with higher scores
indicating greater distress. Scores of 16 or greater are suggestive of
depressive symptoms and referral for further depression evaluation and
treatment may be needed (Radloff 1977).

The Cronbach's coefficient ? for reliability for the instrument has been
reported at 0·84, 0·85, 0·90 (Radloff 1977), 0·90 and 0·93
(Verdier-Taillefer et al. 2001) and 0·85 (Hann et al. 1999). Radloff
(1977) tested the CES-D in contrasted groups and found significantly
higher scores between psychiatric patients and a community sample,
respectively. The CES-D has been used extensively for screening of
depression in community and medical settings (Berkman et al. 1986,
Blazer et al. 1991, Davidson et al. 1994, Wassertheil-Smoller et al.
1996, Beekman et al. 1997, Lewinsohn et al. 1997, Schaeffer et al. 1999,
Lyon & Munro 2001, Savetsky et al. 2001). However, there are studies
that report a few differences in either the factor structure or the
cut-off scores. Earlier studies of subjects with psychiatric and medical
disorders, sensitivity reports ranged between 77·8 and 100% with
specificity ranging between 82 and 90% (Weissman et al. 1977, Parik et
al. 1988, Somervell et al. 1993, Beekman et al. 1997). Based on the
sensitivity and specificity measures, other studies have recommended a
higher cut-off score be used in select medical populations (Zich et al.
1990, Wilson-Schaeffer et al. 1999, Thomas et al. 2001). In testing the
CES-D in a population of older adults, Callahan and Wolinsky (1994)
found the factor structure was supported when five items were removed
from the analysis. In another study, a confirmatory factor analysis
replicated the factor structure in a frail elderly population and also
confirmed a higher order factor (Davidson et al. 1994).

The CES-D was chosen for this study over other depression inventories
because it was developed for use in the community rather than a
psychiatric population, and the wording of the CES-D is more concise
than other available instruments. While the CES-D has been used
extensively in other populations to screen for depression, there has
been no reported psychometric testing or use in a hepatitis population,
including Hepatitis C Virus. The CES-D has good reliability and validity in various
populations but may need some minor modification depending on the
specific population being studied. Thus, it is essential to test the
function of the CES-D in the population of Hepatitis C Virus-infected patients before
using it to assess and monitor changes in depressive symptoms.

Ethical considerations

This study protocol was reviewed and approved by The University of Texas
Health Science Center at Houston Committee for the Protection of Human
Subjects prior to study initiation. During the first scheduled office
visit to the hepatitis C clinic, the patient was invited to participate
in this study. Verbal informed consent was obtained in a private room by
the principal investigator or the research assistant. Confidentiality
was protected through utilization of identification numbers in
combination with subject's initials. After informed consent was
obtained, each subject was assigned a study number used in combination
with the subject's initials to maintain subject confidentiality.

As subjects were enrolled in this study, an enrolment log was maintained
and used as a checklist for collecting CES-D responses at prespecified
time points. Prior to routine clinic visits, the principal investigator
or a trained research assistant provided the CES-D and a demographic
form (clinical site, age, gender and ethnicity) to each patient in a
private room. CES-D data was collected from subjects (a) prior to the
first dose of antiviral medications, (b) 4 weeks after initiation of
combination antiviral therapy, and (c) after 24 weeks of combination
antiviral therapy. The times were identified based on previous clinical
trials, pilot data (Clark et al. 1999), and anecdotal evidence from
clinical experience. Clinical visits were routinely scheduled at these
times. Collecting data at these intervals allowed for baseline
information (pretreatment) as well as the ability to capture
measurements early during antiviral therapy (4 weeks postinitiation of
treatment) and at the end of treatment (24 weeks postinitiation of
treatment). Demographic data and data obtained from individual responses
to each CES-D item were entered into a computer based spreadsheet. The
CES-D total score was calculated using MS Excel/Office 98. Item response
and total scores were entered into SPSS 10 in order to test the
reliability and validity of the instrument.

Statistical analysis

The reliability of an instrument refers to the extent to which an
instrument is internally consistent, that is, the instrument's
components measure the same thing. Internal consistency is required, but
not adequate, for construct validity (Nunnally & Bernstein 1994). In
this study reliability was tested using Cronbach's coefficient ? as a
measure of internal consistency.

Validity means the ability of an instrument to measure what it intends
to measure. Construct validity is concerned with the structural
component that describes the properties of the measure in terms of how
constructs interrelate. The structural components are described in terms
of factors containing items with a correlation greater than 0·4
(Nunnally & Bernstein 1994). In this study, construct validity was
tested using principal component factor analysis with varimax rotation.
Radloff (1977) used principal component factor analysis in the original
development of the CES-D to identify the instrument's structure. Varimax
rotates the identified components to provide the best interpretation of
the factors (Nunnally & Bernstein 1994). For this study, the underlying
structure of the CES-D was examined in Hepatitis C Virus-infected patients prior to
treatment and compared with the structure of the instrument as described
by Radloff (1977). Predictive validity is concerned with the
instrument's ability to predict a predetermined behaviour external to
the measuring instrument itself (Nunnally & Bernstein 1994). Following
construct validity testing, the predictive validity of the instrument
was tested using repeated measures analysis of variance (ANOVA) in order
to test the research hypothesis that depressive symptoms scores would
significantly increase following initiation of antiviral therapy.


Results


The internal consistency reliability of the CES-D was estimated at each
of the three measurement times (pretreatment, 4 and 24 weeks
postinitiation of treatment). The Cronbach's coefficient a was 0·88 at
pretreatment, 0·89 at 4 weeks postinitiation of treatment, and 0·90 at
24 weeks postinitiation of treatment. These results are consistent with
those reported by Radloff (1977).

The Bartlett's Test result for this sample of 116 was P < 0·001,
indicating that even with this smaller sample size, there is a
significant correlation matrix from which to derive a principle
components analysis. The communalities in sample for the current study
ranged from a low of 0·54 to a high of 0·81 indicating relatively high
communalities. In addition the CES-D has been previously tested during
the original development and with subjects with other illnesses. The
evidence from previous testing of the CES-D and the statistical test
results of the Bartlett and the higher communalities indicate that the
sample size was adequate for the reliability and validity testing
proposed.

The analysis revealed four factors explaining 65% of the variance:
negative affect; positive affect; somatic; and depressed affect/somatic
(Table 1). With the exception of two items ('felt sad' and 'couldn't get
going'), all items related distinctly into one of the four factors with
correlation coefficients greater than 0·5. For the purpose of
psychometric testing, 'felt sad' and 'couldn't get going' were dropped
from the instrument. Factors found in this study were compared with the
original factors reported by Radloff (1977) in Table 2. In the original
psychometric testing of the CES-D, Radloff identified a four-factor
structure: depressed affect, positive affect, somatic, and
interpersonal. In this study, the CES-D items revealed a somewhat
different structure. While four factors emerged, the interpersonal
factor reported by Radloff (1977) related distinctly into a factor
containing three depressed affect items and one somatic item. The
positive affect factor was repeated in this study. Three somatic items
related distinctly into the somatic factor as compared with seven items
reported by Radloff (1977). The fourth factor was composed of two
depressed affect items and two somatic items; thus the name depressed
affect/somatic.

The hypothesized difference in CES-D scores from predrug treatment to 4
weeks posttreatment and again at 24 weeks posttreatment, was tested
using repeated measures ANOVA with an alpha of 0·05 (Table 3). There was
no interaction effect related to the clinic site at which the treatments
were administered. The pretreatment CES-D mean was 13·97; the
post-4-week CES-D mean was 19·54 and the 24-week CES-D mean was 19·97
(Table 4). The main effect of time was statistically significant (Table
5) and in the direction predicted between pretreatment and after both 4
weeks of treatment and 24 weeks of treatment (P < 0·001). There was no
statistically significant difference between the week 4 and week 24
CES-D scores.


Discussion


The results of this study suggest that the CES-D is a useful depressive
symptom-screening tool for Hepatitis C Virus infected patients. It has internal
consistency reliability as well as construct and predictive validity.
Construct validity relies upon the identification of a factor structure
that is logical and is supported by theoretical reasoning. The analytic
results found in this study partially support the factor structure
reported in tests of the original instrument (Radloff 1977); however,
differences were expected and found. Radloff (1977) tested the
instrument in a community sample as compared with a sample of
Hepatitis C Virus-infected patients in this study. For example, patients with Hepatitis C Virus
infection often present with fatigue, a symptom of depression, as a
consequence of both the disease and the treatment.

The observation that items 'felt sad' and 'couldn't get going' did not
load distinctly into a factor, suggested that the items should be
deleted from the instrument when screening for depression in an Hepatitis C Virus
population. It is interesting to note that the items were related to
depressed affect and a somatic item related to fatigue. However, this
finding should be viewed with caution. Future research should include
examining the sensitivity and specificity of the CES-D in Hepatitis C Virus-infected
patients with and without the inclusion of the items 'felt sad' and
'couldn't get going.' This research is needed to determine the most
appropriate cut-off score for screening for depressive symptoms in the
Hepatitis C Virus-infected population.

In this study, all of the interpersonal items were related to several
depressed affect items forming the negative affect factor. The
relationship of a depressed affect and disrupted or impaired
interpersonal relationships is consistent with what Beck (1971)
described as a negative conception of the self and a negative
interpretation of life's experiences. Beck described a cognitive triad
that consisted of a negative view of self, others, and the future. A
possible explanation for the association of some depressed affect items
with interpersonal items is that patients with Hepatitis C Virus infection may be
ostracized by family, friends, and coworkers. Such ostracism may be the
result of fear of contracting the virus or because of bias against the
lifestyles often associated with Hepatitis C Virus infection such as illegal drug use
and sexual promiscuity. Another explanation may be that patients with
Hepatitis C Virus feel so sick that they are not able maintain satisfying
participation in interpersonal relationships.

In addition to the reliability and validity of the instrument, the CES-D
has the advantages of being a self-administered tool with relatively few
items. Administration of the instrument prior to initiation of treatment
provides important baseline information. The CES-D can be given at
regularly scheduled intervals providing important clinical outcome
evaluation data.


Implications for practice


Competent nursing practice relies, in part, upon the nurse's
comprehensive assessment of the patient, which includes an evaluation of
the psychosocial domain of health. One of the major psychosocial issues
associated with the care of Hepatitis C Virus-infected patients is related to
co-occurring depressive symptoms. Given that depression is a frequently
reported side-effect that is often dose limiting in Hepatitis C Virus patients
receiving antiviral therapy, efforts towards prevention and early
recognition and intervention are needed to maximize treatment efficacy.
A national expert consensus panel has recommended incorporating the use
of self-report depression instruments as a low cost, convenient, and
valuable case-finding way to identify patients who are experiencing
depressive symptoms (Rush et al. 1993). Wright (2000) noted that nurses
who work with Hepatitis C Virus-infected patients have faced a challenge in
recognizing and intervening with these symptoms. This is partially due
to the lack of a reported reliable and valid measure of depression in
this patient population.

The results of this study suggest that nurses and other healthcare
providers should incorporate the CES-D in treatment protocols as a
screening tool for depressive symptoms. Screening should be conducted
prior to initiation of treatment and at regularly scheduled intervals
throughout antiviral treatment in order to evaluate the impact of the
treatment on this important area of well-being.

It is critical to note that the CES-D is to be used for screening, not
for diagnostic purposes. Patients should be told that the scores on the
CES-D reflect a need for evaluation and do not necessarily mean they
have major depression. When there is an indication of high depressive
symptoms, the patient must be assessed further for suicidality by
probing for suicidal thoughts, plans, means, and intent. The CES-D
scores and a suicidal evaluation provide critical information needed to
make the best clinical decision related to the acuity of the
presentation leading to treatment and referral. In the event that high
depressive scores (? 16) are reported or that the patient describes
suicidal ideations, a psychiatric referral is indicated.


Implications for future research


Future research should include an examination of the sensitivity and
specificity of the instrument in a Hepatitis C Virus infected population in order to
determine accurately the most appropriate cut-off point. Future research
should also include qualitative studies focused on the illness
experience of persons living with Hepatitis C Virus infection. Studies focusing on the
patient's experience would provide insight into the psychosocial
consequences of living with Hepatitis C Virus infection. It would be important to
examine the illness narratives of patients with triangulation of CES-D
responses. This would provide useful information needed to better
understand how patients explain the burden of depression, successful
coping strategies, and the unique features associated with living with
depression and Hepatitis C Virus infection.


Study limitations


The sample size is somewhat small, but adequate for determining
construct validity and internal consistency and reliability. Findings of
this study might be strengthened by replication of the study in other
geographical regions. Furthermore, in order to participate in this
study, participants had to be able to speak and read English; therefore,
the findings can only be generalized to an English-speaking population.


Conclusion


Nurses and other healthcare providers need to recognize the seriousness
of co-occurring depression in Hepatitis C Virus-infected patients. The CES-D provides
a reliable and valid measure to screen for depressive symptoms in this
population. Based on Radloff (1977), a score of 16 or greater indicates
the need for referral to psychiatric services.

Correspondence: Cinda Clark, Division of Gastroenterology, Hepatology,
and Nutrition, University of Texas Houston HSC, School of Medicine, 6431
Fannin, Suite 4.234, Houston, TX 77030, USA. E-mail:
cinda.h.clark@uth.tmc.edu


Table 1 Factor loadings and explained variance of Center for
Epidemiologic Studies-Depression Scale with hepatitis C virus patients
prior to treatment
 

Legend for Chart:

B - Negative effect
C - Positive effect
D - Somatic
E - Depressed effect/somatic

              A                        B              C
                                       D              E

People disliked me                0·84    0·15
                                  -              0·14

Couldn't shake off blues          0·77    0·17
                                  0·21    0·27

Crying spells                     0·77    -
                                  0·15    -

Life a failure                    0·72    0·15
                                  -              0·15

Felt depressed                    0·61    0·36
                                  0·25    0·35

People unfriendly                 0·60    0·18
                                  0·16    0·27

Bothered by things                0·51

I was happy                       0·21    0·75
                                  0·33    0·11

Felt hopeful                      0·15    0·74
                                  0·18    -

Enjoyed life                      0·23    0·73
                                  0·15    0·27

Jusnbsp;         0·15    0·27

Just as good as others            -              0·72
                                  -              0·13

Poor appetite                     -              -
                                  0·81    -

Everything an effort to do        0·20    -
                                  0·71    0·14

Keep mind on what doing           0·33    -
                                  0·64    0·21

Felt lonely                       0·40    0·20
                                  -              0·70

Talked less                       0·12    -
                                  -              0·68

Felt fearful                      0·23    -
                                  -              0·67

Restless sleep                    -              -
                                  0·50    0·60

% explained variance: Total 65    24             23
                                  9              9

Table 2 Comparison of factors identified in this study and Radloff
(1977)


Legend for Chart:

A - Negative effect
B - Positive effect
C - Somatic
D - Depressed effect/somatic

  A                                         B
         C                                  D

Current study

Bothered by things (S)                   Good as others (P)
    Poor appetite (S)                    Fearful (D)

Couldn't shake off the blues (D)         Felt hopeful (P)
    Keep mind on what I was doing (S)    Restless sleep (S)

Felt depressed (D)                       Happy (P)
    Everything an effort to do (S)       Talked less (S)

Like a failure (I)                       Enjoyed life (P)
                                         Felt lonely (D)

People unfriendly (I)

Crying spells (D)

People disliked me (I)

Depressed affect                         Positive effect
    Somatic                              Interpersonal

Radloff, L.S. (1977)

Couldn't shake off the blues             Just as good as others
    Bothered by things                   Like a failure

Felt depressed                           Felt hopeful
    Poor appetite                        Unfriendly

Fearful                                  Happy
    Keep my mind on what doing           People disliked me

Felt lonely                              Enjoyed life
    Everything an effort to do

Crying spells
    Restless sleep

Felt sad
    Talked less
    Couldn't get going

D, depressed effect; P, positive effect; S, somatic; I,
interpersonal-factors reported by Radloff (1977). Shaded areas
are consistent with the original factor structure reported by
Radloff (1977).

Table 3 Center for Epidemiologic Studies-Depression Scale scores pre and
posttreatment


Legend for Chart:

A - Time of treatment
B - Mean
C - Standard error
D - Confidence interval 95% lower bound-upper bound

   A               B               C
                                   D

Pre-treatment   13·974    0·907
                                 12·177-15·771

4 weeks post    19·543    0·977
                                 17·607-21·479

24 weeks post   19·966    1·053
                                 17·880-22·051

Table 4 Repeated measures analysis of variance


Legend for Chart:

A - Source of variance
B - Type III sum of squares
C - d.f.
D - Mean square
E - F
F - Significance
G - Partial Eta squared
H - Observed power

    A            B                  C        D
                 E                           F
                 G                           H

Intercept    110602·345      1    110602·345
             451·438              0·000
             0·797                1·000

Error        28174·989     115    245·000

Table 5 Significant pairwise comparisons of Center for Epidemiologic
Studies-Depression Scale scores over time


Legend for Chart:

A - Time
B - Mean difference
C - Standard error
D - Significance
E - 95% Confidence interval for difference Lower bound-upper
    bound

         A                 B               C
                           D               E

Pre-treat, 4 weeks    5·569    0·967
                      0·000    3·220-7·918

Pre-treat, 24 weeks   5·991    0·990
                      0·000    3·585-8·398

References


American Psychiatric Association (2000) Diagnostic and Statistical
Manual of Mental Disorders, 4th edn. American Psychiatric Publishing,
Washington, DC.

Beck A.T. (1971) Cognition, affect, and psychopathology. Archives of
General Psychiatry 24, 495-500.

Beck A.T., Ward C.H. & Mendelson M. (1961) An inventory for measuring
depression. Archives of General Psychiatry 4, 861-871.

Beekman A.T., Deeg D.J., Van Limbeek J., Braam A.W., De Vries M.Z. & van
Tilburg W. (1997) Criterion validity of the Center for Epidemiologic
Studies Depression Scale (CES-D): results from a community-based sample
of older subjects in The Netherlands. Psychology and Medicine 27,
231-235.

Berkman L.F., Berkman C.S. & Kasl S. (1986) Depressive symptoms in
relation to physical health and functioning in the elderly. American
Journal of Epidemology 124, 372-388.

Blazer D., Burchett B., Service C. & George L. (1991) The association of
age and depression among the elderly: an epidemiologic exploration.
Journal of Gerontology 46, 210-215.

Bonaccoro S., Puzella A., Marino V., Pasquini M., Biondi M., Artini M.,
Almerighi C., Levrero M., Egyed B., Bosmans E., Meltzer H.Y. & Maes M.
(2001) Immunotherapy with interferon-alpha in patients affected by
chronic hepatitis C induces an intercorrelated stimulation of the
cytokine network and an increase in depressive and anxiety symptoms.
Psychiatry Research 105, 45-55.

Callahan C.M. & Wolinsky F.D. (1994) The effect of gender and race on
the measurement properties of the CES-D in older adults. Medical Care
32, 341-356.

Clark C., Mahoney J., Eriksen L. & Ghalib R. (1999) Validation of the
Center for Epidemiologic Studies Depression Scale (CES-D) in hepatitis C
patients. Hepatology 30, 816A.

Costa M.A. (1999) Hepatitis C. Current Treatment Options in
Gastroenterology 2, 481-490.

Dahlstrom W.G. & Welsh G.S. (1960) An MMPI Handbook. University of
Minnesota Press, Minneapolis, MN.

Davidson H., Feldman P.H. & Crawford S. (1994) Measuring depressive
symptoms in the frail elderly. Journal of Gerontology 49, P159-P164.

Dusheiko G. (1997) Side effects of alpha interferon in chronic hepatitis
C. Hepatology 26(3 Suppl. 1), 112S-121S.

Dwight M., Kowdley K.V., Russo J.E., Ciechanowski P.S., Larson A.M. &
Katon W.J. (2000) Depression, fatigue, and functional disability in
patients with chronic hepatitis C. Journal of Psychosomatic Research 49,
311-317.

Fontana R.J. (2000) Neuropsychiatric toxicity of antiviral treatment in
chronic hepatitis C. Digestive Diseases 18, 107-116.

Gorsuch R.L. (1983) Factor Analysis, 2nd edn. Lawrence Erlbaum
Associates Publishers, Hillsdale, NJ.

Hakozaki Y., Shirahama T., Katou M., Nakagawa K., Oba K. & Mitamura K.
(1995) A controlled study to determine the optimal dose regimen of
interferon-alpha 2b in chronic hepatitis C. American Journal of
Gastroenterology 90, 1246-1249.

Hann D., Winter K. & Jacobsen P. (1999) Measurement of depressive
symptoms in cancer patients: evaluation of the Center for
Epidemiological Studies Depression scale (CES-D). Journal of
Psychosomatic Research 46, 437-443.

Heeringa M., Honkoop P., de Man R.A., Feenstr J. & Smits C.M. (1998)
Major psychiatric side effects of interferon alpha-2b. Ned Tijdschr
Geneenskd 142, 1618-1621.

Janssen H.L., Brouwer J.T., van der Mast R.C. & Schalm S.W. (1994)
Suicide associated with alfa-interferon therapy for chronic viral
hepatitis. Journal of Hepatolology 21, 241-243.

Lewinsohn P.M., Seeley J.R., Roberts R.E. & Allen N.B. (1997) Center for
Epidemiologic Studies Depression Scale (CES-D) as a screening instrument
for depression among community-residing older adults. Psychology and
Aging 12, 277-287.

Lyon D.E. & Munro C. (2001) Disease severity and symptoms of depression
in black Americans infected with HIV. Applied Nursing Research 14, 3-10.

Maddrey W.C. (1999) Safety of combination interferon alfa-2b/ribavirin
therapy in chronic hepatitis C -relapse and treatment-naive patients.
Seminars in Liver Disease 19(Suppl. 1), 67-75.

Miyaoka H., Otsubo T., Kamijima K., Ishii M., Onuki M. & Mitamura K.
(1999) Depression from interferon therapy in patients with hepatitis C.
American Journal of Psychiatry 156, 1120.

National Institute of Health (NIH) (1997) Consensus statement:
Management of Hepatitis C. Continuing Medical Education 15, 1 41.

Nunnally J.C. & Bernstein I.H. (1994) Psychometric Theory, 3rd edn.
McGraw-Hill Inc, New York.

Parik R.M., Eden D.T., Price T.R. & Robinson R.G. (1988) The sensitivity
and specificity of the Center for Epidemiologic Studies Depression Scale
in screening for post-stroke depression. International Journal of
Psychiatry and Medicine 18, 169-181.

Radloff L.S. (1977) The CES-D scale: a self-report depression scale for
research in the general population. Applied Psychological Measurement 1,
385-401.

Rifflet H., Vuillemin E., Oberti F., Duverger P., Laine P., Garre J.B. &
Cales P. (1998) Suicidal impulses in patients with chronic viral
hepatitis C during or after therapy with interferon alpha.
Gastroenterologic Clinical Biology 22, 353-357.

Rush A.J., Golden W.E., Hall G.W., Herrera M., Houston A., Kathol R.G.,
Katon W., Matchett C.L., Petty F., Schulberg H.C., Smith G.R. & Stuart
G.W. (1993) Depression in Primary Care: Vol. 1. Detection and Prevention
(AHCPR Publication no. PHS 93-0550). Department of Human Services,
Rockville, MD.

Savetsky J.B., Sullivan L.M., Clark J., Stein M.D. & Samet J.H. (2001)
Evolution of depressive symptoms in human immunodeficiency
virus-infected patients entering primary care. Journal of Nervous and
Mental Disorders 189, 76-83.

Schaeffer J.J., Gill K.M., Burchinal M., Kramer K.D., Nash K., Orringer
E. & Strawhorn D. (1999) Depression, disease, severity, and sickle cell
disease. Journal of Behavioral Medicine 22, 115-126.

Somervell P.D., Beals J., Kinzie J.D., Boehnien J., Leung P. & Manson
S.M. (1993) Criterion validity of the Center for Epidemiologic Studies
Depression Scale in a population sample from an American Indian village.
Psychiatric Research 47, 255-266.

Thomas J.L., Jones G.N., Scarinci I.C., Mehan D.J. & Brantley P.J.
(2001) International Journal of Psychiatry and Medicine 31, 25-40.

Verdier-Taillefer M., Gourlet V., Fuhrer R. & Alperovitch A. (2001)
Psychometric properties of the Center for Epidemiologic
Studies-Depression scale in multiple sclerosis. Nueroepidemiology 20,
262-267.

Wassertheil-Smoller S., Applegate W.B., Berge K., Chang C.J., Davis
B.R., Grimm R., Kostis J., Pressel S. & Schron E. (1996) Change in
depression as a precursor of cardiovascular events. SHEP Cooperative
Research Group. Archives of Internal Medicine 156, 553-561.

Weissman M.M., Sholomskas D., Pottenger M., Prusoff B.A. & Locke B.Z.
(1977) Assessing depressive symptoms in five psychiatric populations: a
validation study. American Journal of Epidemiology 106, 203-214.

Wilson-Schaeffer J.J., Gil K.M., Burchinal M., Kramer K.D., Nash K.B.,
Orringer E. & Strayhorn D. (1999) Depression, disease severity, and
sickle cell disease. Journal of Behavioral Medicine 22, 115-126.

Wright I.A. (2000) Monitoring depression in patients undergoing
alpha-interferon and ribavirin therapy for hepatitis C. Gastroenterology
Nursing 23, 275-280.

Zich J.M., Attkisson C.C. & Greenfield T.K. (1990) Screening for
depression in primary care clinics: the CES-D and the BDI. International
Journal of Psychiatry and Medicine 20, 259-277.

Zung W.W. (1965) A self-rating depression scale. Archives of General
Psychiatry 12, 63-70.

Submitted for publication 5 June 2002

Accepted for publication 30 July 2002

~~~~~~~~

By Cinda H. Clark, DSN RN CNS-M-S, Assistant Professor of Medicine,
Division of Gastroenterology, Hepatology and Nutrition, School of
Medicine, University of Texas Health Science Center at Houston, Houston,
Texas, USA; Jane S. Mahoney, DSN RN CNS-P/MH, CS, Assistant Professor of
Nursing, School of Nursing, University of Texas Health Science Center at
Houston, Houston, Texas, USA; David J. Clark, BS Psychology, Senior
Research Assistant, School of Medicine, University of Texas Health
Science Center at Houston, Houston, Texas, USA and Lillian R. Eriksen,
DSN RN, Associate Professor of Nursing, School of Nursing, University of
Texas Health Science Center at Houston, Houston, Texas, USA

  _____ 

Copyright of Journal of Advanced Nursing is the property of Blackwell
Publishing Limited and its content may not be copied or emailed to
multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email
articles for individual use.
Source: Journal of Advanced Nursing, Nov2002, Vol. 40 Issue 3, p361, 9p
Item: 7522410