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Clinical and Psychometric Validation of The Geriatric Depression Scale GDS For Portuguese Elders
Clinical and Psychometric Validation of The Geriatric Depression Scale GDS For Portuguese Elders
To cite this article: Margarida T. S. Pocinho PhD , Carlos Farate MD PhD , Carlos A. Dias MD
PhD , Tina T. Lee MD & Jerome A. Yesavage MD (2009) Clinical and Psychometric Validation of
the Geriatric Depression Scale (GDS) for Portuguese Elders, Clinical Gerontologist, 32:2, 223-236,
DOI: 10.1080/07317110802678680
Download by: [b-on: Biblioteca do conhecimento online UEvora] Date: 16 December 2017, At: 18:48
Clinical Gerontologist, 32:223–236, 2009
Copyright © Taylor & Francis Group, LLC
ISSN: 0731-7115 print/1545-2301 online
DOI: 10.1080/07317110802678680
This research is supported by grant AG 17824 from the National Institutes of Health, by
the Medical Research Service of the Veterans Affairs Palo Alto Health Care System, and by
the Department of Veterans Affairs Sierra-Pacific Mental Illness Research, Education, and
Clinical Center (MIRECC).
Address correspondence to Margarida T. S. Pocinho, Department of Exact Sciences, Biology,
and Engineering, Superior School of Health Technologies (ESTES), Coimbra, Portugal. E-mail:
margarida_pocinho@estescoimbra.pt
223
224 M. T. S. Pocinho et al.
INTRODUCTION
This complex clinical picture, plus the fact that psychiatric diagnoses
are based chiefly on the clinician’s subjective assessment of the patient’s
symptoms, explains the interest accorded to the development of an opera-
tive set of diagnostic measurable criteria based on internationally validated
structured clinical interviews (Evans & Mottram, 2000; Sinclair et al, 2001)
Furthermore, such a process can allow for the implementation of cross-
comparison and psychometric validation methods for data from interna-
tional studies. This is why Mcsweeney and Creer (1995) state that such
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The GDS has so far been translated and adapted into 26 languages,
including Brazilian (Zilenovski, 1991), Italian (Ferrario et al., 1990), and
Spanish (Perlado, 1987; González, 1988; González & Szurek, 1990; Montorio &
Izal, 1993).
In this paper, we will present data from the psychometric validity study
for the GDS Portuguese version. The field work for this study was under-
taken with a representative sample of Portuguese elders recruited from vari-
ous sites and residential settings. Additionally, this study evaluated the
suitability of the GDS in clinically assessing elders presenting with depressive
symptoms, in particular those suffering from moderate feelings of loneliness
linked to recurring suicidal ideation. This was the reason Alentejo was chosen
as the main study site. Alentejo has the highest suicide rate among the eld-
erly in Portugal, and has also one of the higher suicide rates in Europe.
Although there has been a previous validation study for a Brazilian version
of GDS (Zilenovski, 1991) and even if this version seemed to fit reasonably
well with a Portuguese language adaptation of the original scale, there are
subtle linguistic (semantic and pragmatic) differences between natives from
both countries that can be particularly significant for an elderly population
group (especially for those living outside greater urban centers and having a
lesser education level).
On the other hand, there is also an ecological validity issue, based on
socio-cultural differences (social traditions, personal meaning and commu-
nitarian judgment of certain emotions or somatic complaints in the context
of specific affective-behavioral, moral, and religious patterns) between elders
living in a South American and a European country, despite historical roots
they might share.
Moreover, there is a growing body of literature recommending a tran-
scultural approach for the creation of psychometric instruments with clinical
and epidemiologic characteristics allowing its usefulness in multicentric
studies. This is definitely the case for GDS.
METHODS
recruited from elders inhabiting the Center and North regions of Portugal
(whose prevalence rates for suicide are lower); another subsample was con-
stituted by elderly patients carrying a diagnosis of depression who were fol-
lowed in private psychiatric practice; finally, elderly people from Alentejo
(the region with the higher prevalence rate for suicide) were the subjects
recruited for the last subsample.
The study began by the translation and back-translation of the scale’s items,
followed by initial pre-testing in a sample of 200 elderly people, age 65 to
92 years. Sixty-three percent (mean ± SD = 76.63 ± 6.44) of them (126 sub-
jects) were female, and 37% (n = 74) were male. Also, 62% of the subjects
enrolled in the pre-testing phase (n = 24 ) came from rural areas, whereas
38% (n = 76) lived in an urban environment.
Cut-off points were established based on the mean values obtained for the
general population sample (the 660 elders noted above, in the first proce-
dure of the third step). Notice that almost all of them (656 elders) fully
completed the questionnaire, and so that the age/gender distribution, as
well as the residential characteristics, were analogous to the whole popula-
tion sample (n = 660).
CLINICAL VALIDATION
This step served as the final assessment procedure for establishing norma-
tive values. The clinical validation of cut-off points derived from the statisti-
cal analysis was performed through diagnostic interviews conducted on a
subsample of 20 clinically depressed elderly patients (50% were men and
50% women; 30% were 65 to 74 years old; 50% were 75 to 84 years old, and
20% were age 85 years or more; almost equal groups were from urban and rural
areas) In this subsample, a depression diagnosis (according to ICD diagnostic
criteria) was confirmed for 14 of these patients, whereas 6 subjects had no
confirmed diagnosis.
RESULTS
From the results of the first pre-test (following item translation and retrover-
sion) conducted on the above mentioned sample of 200 elderly people, it
Geriatric Depression Scale for Portuguese Elders 229
was possible to conclude that 3 of the 30 items of the original scale (items
27, 29, and 30) showed no internal consistency and that their positive corre-
lation with each one of the scale’s dimensions was always less than .3 (eval-
uated by means of Cronbach’s alpha and factorial analysis, respectively).
Concurrent Validity
After this first pre-test, the concurrent validity analysis of the GDS was then
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performed using the Hamilton Rating Scale for Depression. The result of this
analysis revealed a correlation score of .83 among the 30 elderly people
assessed, a value that indicates a high Pearson correlation coefficient
(Bryman & Cramer, 1993; Pestana & Gajeiro, 2000).
Factorial Validity
Since current mathematical thinking about statistics does not consider factor
analysis using the principal component method to be the most appropriate
procedure for dealing with dichotomous scales of measure, the Bartlett
spherecity test and the Kaiser-Meyer-Olkin (KMO) test were performed in
this study. The Bartlett test revealed a .000 level of significance (p < .05) and
a KMO value of .932, indicating that factor analysis seemed to be highly
adjusted to GDS scores.
After defining the type of analytic procedure to use it was then impor-
tant to decide on the most suitable method to perform it. Based on calcula-
tion of the anti-image matrix (where sample adjustment values—MSA
[Measures of Sampling Adequacy] inscribed on the diagonal were rather
high whilst their anti-image was low) principal component analysis was
chosen (Table 1).
Reliability
TEMPORAL CONSISTENCY—TEST-RETEST
Factors
1 2 3
GDS 1 .766
GDS 7 .752
GDS 9 .737
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GDS 19 .667
GDS 15 .643
GDS 10 .634
GDS 3 .613
GDS 5 .606
GDS 17 .551 .337
GDS 16 .551 .404
GDS 22 .435 .314
GDS 21 .422 .376
GDS 2 .391 .380
GDS 24 .649
GDS 11 .648
GDS 25 .621
GDS 6 .321 .604
GDS 13 .571
GDS 8 .492 .362
GDS 4 .476 .480
GDS 18 .477
GDS 20 .674
GDS 28 .572
GDS 14 .550
GDS 12 .545
GDS 26 .532
GDS 23 .363 .409
Note: Output criteria was selected in such a way
that correlations <.3 were not considered.
The global reliability study revealed rather high reliability (α =. 906; K-R = .907).
INTER-RATER RELIABILITY—TEST-RETEST
One can see that inter-rater results are concordant (p > .05). Since a
Lambda value of .961 is a good indicator (values close to zero indicate dif-
ferences) GDS demonstrated good stability, allowing it to be administrated
by different raters without significant effect on the results.
Another concordance assessment test is Cohen’s kappa. According to
Pestana & Gajeiro (2000) the level of observed concordance is most accu-
rately measured by Cohen’s Kappa. After establishing the initial normative
data the results were divided by the cut-off point 10, and a Kappa calcula-
tion was then performed. Results are shown in Table 3.
GDS shows a quite high concordance value between the two assess-
ments (0.87), regardless of who administers the scale.
After performing all the statistical analysis discussed above, a 27-item
final version of the GDS was developed (items of GDS Portuguese language
version are listed in the Appendix).
Normative Values
The GDS mean score for our sample was 9.6. However, this score decreased to
4.9 when three conditions were observed: 1) good family relationship; 2)
age under 74 years; 3) absence of polypharmacy. Conversely mean depres-
sion scores increase considerably (up to 15.9) whenever family relationship
Retest
Absence Presence
of depression of depression Total
Test
Absence of depression 23 2 25
Presence of depression 1 19 20
Total 24 21 45
Value Asymp. SE Approx. T
Agreement: Kappa 0.866 0.075 5.813***
N of Valid Cases 45
*** P < .0001.
232 M. T. S. Pocinho et al.
was bad or of a poor affective quality, when age was greater than 74 years,
or when polypharmacy was present.
Discriminant Analysis
To establish cut-off points based on mean values obtained for the study
sample, a presentation of more than 10 symptoms (mean value, 9.6) was
used as the cut-off point between absence and presence of depression.
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Using this cut-off point, 4 out of 10 of the elders in the study (40.2%) were
considered positive for depression.
To further verify the accuracy of our psychometric hypothesis, a
discriminant function analysis test was performed. In fact, assuming an
equal probability for absence or presence of depression among the elderly,
a theoretical cut-off point of 10 out of 27 symptoms does not statistically
mean depression is clinically present. Nevertheless, such a speculative
assumption was insufficient to validate our hypothesis. Further validation
was achieved through calculation of results obtained against group size
(meaning a .598 probability of not having depression and a .402 probability
of having depression). Results are displayed in Table 4.
Assuming that 59.8% of the subjects were not depressed, while 40.2%
were depressed, discriminant analysis revealed that 96.3% of the sample
was correctly assessed. The statistical cut-off point was then established by
calculating the contingency between predictive group values and global
GDS values. The results of the discriminant analysis indicate a predictive
cut-off point of 11 of 27 symptoms. However, in order to achieve the most
coherent decision possible, these results were compared with clinically vali-
dated cut-off points.
Clinical Validation
To accomplish such a task, GDS was administrated to elderly patients by a
psychiatrist in private practice who performed a diagnostic interview using
Absence Presence
Cohort of depression of depression Total
Presence Absence
of depression of depression Total
GDS
Presence of Depression 14 1 15
(>11 symptoms)
Absence of Depression 0 5 5
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(≤ 11 symptoms)
Total 14 6 20
PE IC− IC+
S 100% 1 1
E 83% 0.5 1
VPP (PPV) 93% 0.8 1
VPN (PNV) 100% 1 1
FP 17% 0 0.3
FN 0% 0 0
A 95% 0.9 1
• The first procedure was the one proposed by Fisher. Using this procedure,
scores obtained in the GDS were calculated using Fisher’s formula1 in order to
determine the scale’s cut-off point (P)2. A cut-off point of 11 was obtained.3
• The second procedure comes from epidemiologic studies and can be
applied whenever there is need for clinical confirmation of dimensional
diagnostic data generated by psychometric instruments.
CONCLUSION
The Portuguese language version of the GDS (with its 27-item scale struc-
ture) has high psychometric accuracy as a screening instrument to detect
234 M. T. S. Pocinho et al.
depressive disorder among elders, both in the general and clinical popula-
tion settings. Based on the data obtained in this study regarding its factorial
structure, internal and temporal consistencies, and its inter-rater reliability,
the GDS appears to be a highly valid and reliable test for use in screening
Portuguese elders for depression.
The normative values identified in this study strongly suggest that the
identification of 11 or more symptoms out of 27 in this version of the GDS
constitute a robust criterion for the identification of depressive disorder
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among the elderly attending primary care facilities in Portugal. These find-
ings indicate that the GDS can be a very useful screen, especially since
depressive disorders are considered to be a priority public health problem
by the World Health organization (WHO).
NOTES
(x1 + s 1 )+ (x2 − s2 )
1. P =
2
2. In the utilization of this formula we must bear in mind that c1 < c2 ; so in this case c1 = median
value for general population individuals and c 2 = median value for depressed individuals.
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