Monthly Archives: October 2014

Measuring Depression: The CES-D

In an earlier post I discussed methodology designed to create a measurement instrument which combines ethnographic and quantitative methods aimed at recognizing idioms of distress among individuals within a specific population. In today’s post I will discuss a measurement designed to work in various contexts to measure depression. This measure is called The Center for Epidemiologic Studies Depression Scale (CES-D). This scale was created in 1977 by Lenore Radloff. Radloff created the scale using items derived from previous depression scales. The items reflect components which were gleaned from studies of depression and include; depressed mood, feelings of hopelessness and helplessness, loss of appetite, sleep disturbance, and reduced psychomotor functioning. The CES-D uses a Likert scale ranging from 0 to 3, reflecting the frequency of occurrence of the items in the scale. There are 20 items in the scale, therefore the scores range from 0 to 60. A score of 16 or above is usually considered a marker for people who are at risk for clinical depression. Scores of 16 to 26 are usually considered indicative of mild depression and scores of 27 or more indicate major depression.

The scale has been used throughout the world and there have also been short form 10 item and 4 item scales developed. Of particular interest to me are short form versions of the scale which I intend to use in the Bribri village of Yorkin. Grzywacz et al. (2014) tested several versions of the 10 item CES-D among seven Mexican immigrant communities within the United States. They found consistent reliability of the scales among the various populations. Also of interest, Kim et al. (2011) found that Hispanics tend to endorse positive items in the scale more frequently than whites or blacks in the United States. Grzywacz et al. (2010) used the 4 item form among Latino farm workers in the U.S. and found a mean score of 6.17

To my knowledge there have been no studies published reporting the use of the scale among indigenous communities in Costa Rica and Panama, where the Bribri currently reside. It is my intention to use the scale in Yorkin and compare its results to a scale which I will develop using the methods previously described and published by Weaver and Kaiser (2014). By comparing the two scales I will be able to determine if what the Bribri are describing as “depresión” is the same as the concept of depression that the CES-D scale is measuring.

You can check out an online version of the scale here:

Below I have included the full 20 item scale.

Center for Epidemiologic Studies Depression Scale (CES-D), NIMH

Below is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way during the past week.

Rarely or none of the time (less than1 day ) Some or a little of the time (1-2 days)Occasionally or a moderate amount of time (3-4 days) Most or all of the time (5-7 days)

  1. I was bothered by things that usually don’t bother me.
  2. I did not feel like eating; my appetite was poor.
  3. I felt that I could not shake off the blues even with help from my family or friends.
  4. I felt I was just as good as other people.
  5. I had trouble keeping my mind on what I was doing.
  6. I felt depressed.
  7. I felt that everything I did was an effort.
  8. I felt hopeful about the future.
  9. I thought my life had been a failure.
  10. I felt fearful.
  11. My sleep was restless.
  12. I was happy.
  13. I talked less than usual.
  14. I felt lonely.
  15. People were unfriendly.
  16. I enjoyed life.
  17. I had crying spells.
  18. I felt sad.
  19. I felt that people dislike me.
  20. I could not get “going.”

SCORING: zero for answers in the first column, 1 for answers in the second column, 2 for answers in the third column, 3 for answers in the fourth column. The scoring of positive items is reversed. Possible range of scores is zero to 60, with the higher scores indicating the presence of more symptomatology.


“Depresión”: What does it mean?

During my stay in Yorkin this past summer, it was mentioned by one of the women that there used to be a lot of “depresión” in the village before they started their ecotourism project. My initial reaction was, “I wonder what exactly they mean by “depresión”?” And then I started thinking about administering the CES-D, which is a depression scale that has been used in many contexts internationally, in the community. I also knew that some way, somehow, I would have to get at exactly what they mean by “depresión” but I was a little unsure of how to do this.

After my presentation of my pre-dissertation research in Yorkin, our new faculty member in the department of anthropology here at the University of Alabama, Lesley Jo Weaver, turned me on to an article she had just had published (Weaver and Kaiser 2014) describing the methodology that I was looking for. In this article she describes how a researcher can accomplish two major agendas of psychological anthropology, the first being the comparison of mental health between sites using standard measurement tools and the second focusing on identifying locally specific ways of discussing mental illness. In this paper she lays out the methodology used in two research sites which identified local idioms of distress, developed a locally derived mental health scale, evaluated the scale, and contextualized the findings with ethnographic data.

The first phase of this methodology involves ethnography. In this phase field notes and interviews are coded for themes and terms used to describe mental health and the frequency of usage is recorded. Also as part of the ethnographic work, participants were asked to create free lists of symptoms and characteristics which accompany particular idioms of distress, for example in the case of the Bribri, depresión. From this ethnographic data a survey questionnaire can then be developed asking participants to rate on a Likert scale the accuracy and frequency of various terms used to describe an idiom of distress. From this data, a scale can be created which reflects local terminology and understanding of culturally salient mental health domains, again in the case of the people in Yorkin, depresión.

In the next phase, the locally derived scale can be administered along with a standard scale, for example the CES-D for measuring depression. Quantitative analysis can then be administered; examining correlations between the results of the two scales, checking for internal consistency using Cronbach’s alpha, and using principal components analysis to examine those factors in the scale which are most relevant.

The authors suggest “This research agenda respects culturally defined illnesses and acknowledges the contextuality of all illness experiences while still maintaining the comparative enterprise of cross-cultural psychiatry” (Weaver and Kaiser 2014:12). I foresee using this methodology in my research in phase 2, after using participant observation to learn about and describe their ecotourism project while also collecting hair samples which will be used to examine levels of cortisol (as a biomarker for stress) among community members.

Weaver & Kaiser 2014
Weaver & Kaiser 2014


The Bribri and the way of Siwa

Sometimes while searching frantically through the University libraries’ databases for peer-reviewed journal articles you find that pot of gold under the rainbow. I had a moment like that this morning; I had been searching for peer-reviewed articles which contain information concerning the recent history of the Bribri. This information has been extremely difficult to find. I have been patching together information I have found in websites and books, but I’ve been unhappy with either the sources of my material or the information contained therein. This morning my hard work paid off and I found an article written by Polly J. Posas entitled “Shocks and Bribri agriculture past and present.” In this article, which mostly focuses on Bribri agriculture, Posas includes data gleaned from editorials written at the University of Costa Rica and a couple of books written in Spanish which I have not been able to gain access to. This was exactly the information I was looking for and I delved into her article with renewed fervor.Talamanca

Posas begins by explaining that the amerindians located in the area of the Isthmus of Panama contain some of the oldest DNA groups in the Americas (Perego et al. 2012), suggesting that the modern-day populations are related to some of the first people to populate the Americas. The Bribri belong to this group. The Bribri and a related tribe, the Cabecar, both belong to the Chibchan language group and used to share common leaders and a cohesive political entity until geographic features contributed to their isolation, effectively splitting the groups around 300 years ago. This reminds me of a story I was told by Mole during my time in Yorkin. Mole described how their God Sibu created both the Bribri and the Cabecar, but they were split into two tribes by a great river. The Bribri and the Cabecar for the most part live on their two respective indigenous reserves which together comprise the Talamanca Indigenous Reserve, which was set aside in 1977 by the Costa Rican government. According to the 2011 Costa Rican census, there are close to 13,000 indigenous people living on reserves in the country with close to 8000 living on the Bribri Talamanca reserve. The Talamanca Indigenous Reserve is located within La Amistad Biosphere Reserve in the south east corner of the Limón province of Costa Rica.

The first written accounts of the Bribri come to us by way of the Spanish explorers. Fernandez, writing in 1908, mentions an account by Juan Vasquez de Coronado in which the explorer states that the women work alongside the men, even bearing arms and going to war. Coronado describes the land as being heavily populated and fertile, with an abundance of crops such as cotton, cacao, corn, and native fruits and plants. In fact, according to pollen analysis, corn has been produced in the area since at least 500 BC (Barrantes et al. 1990). This fact is reflected in the Bribri creation myth which states that the God Sibu created the Bribri and the Cabecar out of two kernels of corn.

At the beginning of the 20th century, the Bribri experienced severe disruption and upheaval when the United Fruit Company moved into the area. The company forcibly removed the Bribri from the Talamanca Valley and created large banana plantations in their place. The Bribri were forced to move up into the hills and mountains. Here the Bribri continued their subsistence agriculture but were hampered by the poor soil of the region combined with having to deal with steep slopes and torrential rainfall. Some Bribri moved back into the valley from the 1940s to the 1960s and worked as laborers for the United Fruit Company. Others who had stayed in the mountains often traveled to the valleys to work in the plantations, being away from their homes for months at a time. In 1978, the Bribri’s cacao orchards were decimated by monilia pod rot, which they now control through natural processes such as providing adequate space between trees. Soon after, petroleum prospecting came to their area and the Bribri were again disrupted by heavy machinery, dynamite blasts, and an introduction of a cash economy. The Bribri people were in conflict with the methods of extracting resources as part of the capitalistic economy. Their way of life, given to them by Sibu, revolved around taking care of their natural environment which was seen as being connected to their physical bodies and to Sibu. As Lisandro Diaz Diaz was quoted in Borge and Castillo 1997 “In order to protect the earth and all the marvelous things it contains, Sibu left the knowledge, our science called Siwa, which is expressed through stories, legends, and traditional practices. The Siwa contain spiritual teachings that have governed our relationship with nature… Sibu left us, the Bribri and the Cabecar, as guardians and protectors of the natural diversity. For thousands of years we have cared for our Mother Earth and for the next thousands of years we will continue caring with the same zeal as our elders… A profound interrelation between the society and nature has existed, thanks to this principle, we can still encounter the great natural diversity of Talamanca.”

It is in this context that I currently find the inhabitants of Yorkin. It is their strong connection to the natural environment which has urged them forward in creating through ecotourism a strategy to make their way in the modern world without relying on wage labor or non-sustaining, extractive economies based on plantain or banana monoculture. It is my sincere hope that I may in some way play a small role in aiding them in this process. I also hope to document their practice and share what they have learned and accomplished with other indigenous groups who are finding themselves in the same situation.


Behind Blue Eyes: No one knows what it’s like to feel these feelings…..

Recently I read an article by Carol Worthman of Emory University entitled “Emotions: You can feel the difference.” The article can be found as a chapter in the book “Biocultural approaches to the Emotions” which was published in 1999 and edited by Alexander Laban Hinton. As I read the article I was taken back to my first year as an undergraduate student sitting in a psychology class concerned with child development. In that class I was first exposed to the work of Jerome Kagan on temperament in infants and the work of Mary Ainsworth involving various types of attachment of children to their caregivers. The more recent work by Carol Worthman builds on these ideas and outlines a process in which an individual’s relationship to the environment is mediated by emotions and how the appraisal of this relationship has an effect on the individual’s mental and physical health. Ultimately, Worthman argues that emotions have a role in cognition and physical well-being.

Worthman begins with a description concerning what exactly emotions are and what they do. Emotions are involved in processing sensory information. Emotions influence the detection of stimuli and the amount of attention given to stimuli. Emotions are involved in learning, memory, and cognitive integration. Emotions also influence the cognitive drive of an individual, affecting motivation, organization, prioritization, and recruitment of cognitive structures. Emotions are also a signal to the self and to others. Emotions affect communication, relations, and self- representations. neuro-emotion

Emotion and the brain

Worthman introduces the ideas of Gregory Bateson, formed in 1958, concerning ethos and eidos. Ethos can be described as the affective-emotional landscape characterizing members of a culture. Contrary to this, eidos concerns the cognitive-propositional landscape characterizing working cultural logic of members of a culture. These ideas reflect a Western view of feeling and thinking being dichotomous or Cartesian. In this model, the two realms are mutually exclusive; as emotion increases cognition decreases, and as emotion decreases cognition increases. Worthman suggests that in addition to operating in this manner, there may also be a synergy between thinking and feeling. She suggests that emotions are crucial to preconscious processing wherein they direct attention, and are also involved in memory construction and retrieval.

Emotion influences what is remembered, how it is remembered, modulates the retrieval of information, and ultimately forms a “bridge to the unconscious.” Indeed, most processing of sensory information, including emotions, occurs in the unconscious and is therefore embodied outside of awareness.

Conscious vs. subconscious thinking

Worthman suggests that what becomes conscious is selective and it is emotion that shapes the selection. Consciousness is finite; the brain determines what to pay attention to and what to ignore or place in the background. Emotion plays a key role in selecting attention and prioritizing cognition. Emotions are integral to information processing. And finally both conscious and pre or unconscious information is embodied.


Worthman proposes a “dual embodiment schema” in which culture or the social context has an influence on the body through the process of embodiment and in return the body has an influence on the culture or social context leading again to various forms of embodiment. As Worthman states, “as culture shapes persons, persons shape culture.” The process of this embodiment depends on individual motivation, perception, behavior, and physical attributes. It is the individual’s interpretation of events, not the facts themselves, which constitutes lived experience.

Individual differences in emotional valence and interpretation of emotion can be described as the individual’s temperament. Jerome Kagan was a pioneer in the idea of temperament and described how reactive-inhibited infants are more easily excited, difficult to soothe, and less readily habituated.

Jerome Kagan on temperament

This has also been shown to be true in primates, particularly rhesus monkeys. In research conducted by Suomi (1991) high-reactive rhesus monkey infants were found to be more influenced by rearing conditions than low-reactive infants. High-reactive infants raised by “average mothers” were socially avoidant and low in dominance. Contrarily, low-reactive infants assumed immediate status no matter what were their rearing conditions. It has also been found that rearing conditions exert enduring effects on hormonal stress patterns (Higley et al. 1992).

In conclusion, individual reactivity can be a product of genetic inheritance or of early experience. Long-term effects of early experience may be exhibited only in certain situations. Effects of early experience depend on individual temperament through the interaction of reactivity and the environment. Variation in affective responsiveness influences how information is perceived, evaluated, and acted upon. These ideas constitute a psycho behavioral and biological link. They also illustrate the importance of the individual’s personal makeup and the context or social environment. A person’s inherited genetic biology influences temperament, which in turn influences emotion and how the individual interacts with the environment, which in turn influences mental and physical health, with all aspects combining in a circular feedback loop. I have included a chart created by Worthman below, which was created a few years after the article under discussion. In my opinion, the chart goes a long way towards illustrating these ideas in a visual format.



Culture Specific Terms for Mental Health

During my time volunteering as a guide for the Estibrawpa project in the Bribri village of Yorkin, Costa Rica, the women explained that they started the project to address illness in the community. The first type of illnesses they mentioned came about as a result of the men working with pesticides and fertilizers on plantain and banana plantations. In particular they noted skin and respiratory ailments. The second form of illness they described as “depresión.” As a medical anthropologist I am acutely aware that this term may mean something totally different in this context than how it is understood in the Western medical model. The DSM-IV TR describes a major depressive episode as a period of at least two weeks in duration in which occurs a depressed mood or the loss of interest or pleasure in activities. The individual must also experience at least four additional symptoms that include changes in appetite or weight, sleep, or psychomotor activity, along with decreased energy, feelings of worthlessness or guilt, difficulty thinking or concentrating, or recurrent thoughts of death or suicidal ideation. However, much research in Latin America has shown that there are other cultural terms used to signify similar illness and distress among those populations.

One such research project conducted by Susan Weller and colleagues (2008) found links between the cultural terms susto and nervios and the Western medical formulation of depression. Susto and nervios can both be considered culture bound syndromes, which the DSM defines as “locality specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category.” Weller found that among her study sample of Mexicans, those who had reported experiencing nervios or susto also reported higher levels of perceived stress and depression. In fact, they suggest that those reporting a period of nervios in the past were 20 times more likely to experience depression.

So, what exactly are the experiences of nervios and susto? Nervios has been described as a chronic situation involving persistent emotional distress with symptoms that include crying, difficulty sleeping, sadness, hopelessness, and being quick to anger. It is more common among women and marginalized members of a population. Susto is often also described as “soul loss.” It is often understood to be caused by sudden fright in which the soul leaves the body. Symptoms include listlessness, restless sleep, debilitation, depression, and indifference related to personal hygiene and dress.

So where does this leave me in determining what is meant by the people in Yorkin by the term “depresión?” To determine this, I can begin by asking which symptoms are related to this term. I can then also ask if there are other terms used within their culture to describe this distress. In this manner, I can determine the specific explanatory model which the women are referring to when they use this term to describe the distress they were feeling. I will also ask if they have heard of the terms nervios and susto and whether or not they use them to describe specific experiences with distress. To determine whether or not the distress they were experiencing can be compared to the Western model of depression, I can use an established instrument, for example the CES-D, to determine if the items in the scale accurately describe their experience of distress. To also add validity to the measuring instrument, correlations can be examined between those reporting “depresión” and their resulting score on the established depression scale.

Ultimately, what is most important to me is the cluster of symptoms which they consider when describing their distress as “depresión.” Also, I would like to determine whether or not they use other terms to describe this distress and why or how they have decided to use the term “depresión” when describing this distress to myself and other visitors. Stay tuned for more on methods concerning how to develop locally derived mental health scales as I review a new article by Weaver and Kaiser.