Tag Archives: depression

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: http://cesd-r.com/

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.


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.