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Screening for Adolescent Depression:

A Comparison of Depression Scales
Robert Robert

Journal of The American Academy of Child and Adolescent Psychiatry

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 Screening for Adolescent Depression: A Comparison of Depression Scales

ROBERT E. ROBERTS , PH.D. , PETER M . LEWINSOHN , PH.D . , AND JOHN R . SEELEY , B .S.

Abstract. The ability of two depression scales, the Center for Epidemiologic Studies Depression Scale
(CES-D) and the BeckDepression Inventory (BOI), to identify cases of DSM-Il/-R majordepression and dysthymia
wasinvestigated in a large, community sample of highschool students. Receiver operating characteristics analyses
indicated thatdifferent caseness criteria should be usedfor boys and girls for boththe CES-D and the BDI. Internal
consistency-reliability and sensitivity and specificity for detecting current episodes of current depression and dys-
thymiawereadequate andcomparable to those found with adult samples, but boththeCES-D and the BDIgenerated
many false positives. Multiple screening using the " serial" strategy increased positive predictive powersubstantially
for both the CES-D and the BDI, whereas using the "parallel" strategy had very little effect on the efficacy of
thetwo screeners. The results indicate that neither the BOI nor theCES-D should be usedby themselves as methods
for case ascertainment in eitherepidemiological or experimental studies, although the BOIdoes function somewhat
better than the CES-D as a screener. J . Am . Acad. Child Adolesc . Psychiat ry, 1991 , 30, I:58-66. Key Words:
adolescent depression, screening scales, reliability, validity , epidemiology.

An understanding of childhood and adolescent depression
has been hampered, in part, by a lack of well-established
techniques for case ascertainment in child and adolescent
populations . To date, there are no widely accepted proce-
dures for measuring psychopathology among youth (Edel-
brock and Costello, 1988). The resulting diversity in meas-
urement strategies greatly attenuates the ability to generalize
about findings across studies. While there have been at-
tempts to achieve a greater consensus regarding the assess-
ment of psychopathology in children (American Academy
of Child and Adolescent Psychiatry, 1987; Rutter et aI. ,
1988), the research literature remains fragmented .
Case ascertainment in psychiatric research historically has
been accomplished using one of two approaches--dinical
or nonclinical. Nonclinical (i.e., nondiagnostic) measures
have been used extensively with both patient and community
populations because they are more economical and easier
to use than diagnostic assessments (Seiler, 1973; Costello
and Angold 1988) . With the increasing recognition of the
efficiency of two-stage case identification procedures in psy-
chological and psychiatric research (Lewinsohn and Teri ,
1982 ; Kendall et aI. , 1987) and particularly in epidemio-
logical studies (Cooper and Morgan, 1973; Shrout and Fleiss,
1981; Dohrenwend and Dohrenwend, 1982), there has been
a trend toward combining both assessment strategies into a
two-stage procedure. Nonclinical measures, usually in the
form of brief symptom checklists, are used as Stage 1 be-
cause they provide a fast , economical method of partitioning
Accepted July 31. 1990 .
From the Social Psychiatry Research Group . The University of
Texas Health Science Center at Houston (Dr. Rob erts) and the Oregon
Research Institute (Dr . Roberts, Dr . Lewinsohn, and Mr. Seeley) .
This work has been supported in part by research grant No. MH40501
from the National Institute of Mental Health to Dr. Lewinsohn. The
authors would like to acknowledge the contributions made to the proj-
ect by Linda Sherman . Sandy Jeffs . and Ginny Osteen .
Reprint requests should be addressed to Dr . Roberts, Sch ool of
Public Health , The University of Texas Health Science Center at
Houston , P . O. Box 20186, Houston . Texas 77225 .
0890-8567/9113001-0058$02.00/0© 1991 bytheAmerican Academy
of Child and Adolescent Psychiatry.
the study population into presumed well (negative results
on screening examinations) and ill (positive results on
screening examinations) groups . The second group then typ-
ically is administered the second stage, using procedures to
establish a psychiatric diagnosis . Increasingly, those pro-
cedures include structured interview schedules administered
by either clinicians or lay interviewers (American Academy
of Child and Adolescent Psychiatry, 1987; Edelbrock and
Costello , 1988) .
However, in spite of the increasing use of two-stage
screening procedures in epidemiological research, there re-
main questions about the methods of assessment used in
both stages. For example, there are few data on the rela-
tionship between symptom scales or checklists and struc-
tured or unstructured diagnostic instruments (Roberts et aI.,
1989) . As a result , very little is known about the utility of
brief psychiatric symptom scales as first-stage screening
instruments. In particular, there is little evidence on the
concordance between screening scales and diagnostic pro-
cedures when two-stage case identification is used in studies
of children and adolescents.
The purpose of this report is to pre sent data on the op-
erating characteristics of two widely used depression scales,
the Center for Epidemiologic Studies Depression Scale
(CES-D) and the Beck Depression Inventory (BDI) . These
scales were developed for use with adults, but in the present
study they are used with high school-aged adolescents. The
focus of this report is on the reliability (internal consistency
and test-retest), sensitivity, specificity, prevalence of
depression using alternative caseness criteria, concordance
between the CES-D and BDI, and the incremental utility of
using multiple screening . The data presented are taken from
a large-scale, longitudinal study of the epidemiology of
adolescent depression, the Oregon Adolescent Depression
Project (OADP) (Lewinsohn et aI., 1988).
CES-D and BDI
The CES-D was developed by researchers at the Center"
for Epidemiologic Studies at the National Institute of Mental
Health to measure depressive symptoms among adults in

58 J .Am.Acad. Child Adolesc .Psychiatry,30:1.January 1991


community surveys. The scale has been used in a number
of such surveys, including Kansas City , Missouri , 'and
Washington County, Maryland (Comstock and Helsing,
1976; Radloff, 1977), Alameda County, California (Rob-
erts, 1980), Los Angeles County, California (Frerichs et
aI., 1981), and in the National Health and Nutrition Ex-
amination Survey (Sayetta and Johnson, 1980), among oth-
ers. Specifically, the scale was "designed to measure the
current level of depressive symptomatology, with emphasis
on the affective component, depressed mood" (Radloff,
1977, p. 385).
The CES-D Scale may be either self- or interviewer-
administered and consists of 20 items. In the present study,
the scale was self-administered. The time frame for re-
porting symptoms is the past week. Subjects were asked to
indicate how frequently in the past week they experienced
a particular symptom: "rarely or none of the time" (scored
0); " some or a little of the time" (scored I); " occasionally
or a moderate amount of time" (scored 2); and "most or
all of the time" (scored 3). Scores range from 0 to 60.
The reliability and validity of the scale with adults have
been assessed with clinic populations (Craig and Van Natta,
1973; Weissman et aI., 1977) and with respondents from a
number of community studies (for example , Comstock and
Helsing, 1976; Radloff , 1977; Roberts , 1980; Lewinsohn
and Teri , 1982). Fewer studies of adolescents have used the
CES-D. Available evidence from the studies suggests that
the operating characteristics of the scale are similar in adult
and adolescent populations (Schoenbach et aI. , 1982; Tolor
and Murphy , 1985; Doerfler et aI., 1988; Roberts et aI.,
1990). Internal consistency reliability is generally in the 0.8
to 0.9 range and test-retest stability is 0.5 to 0.6 over follow-
up periods, ranging from several weeks to several months.
In addition, the structure of the 20 items has been shown
to be nearly identical for adults and adolescents (Roberts et
aI., 1990). Using the standard " caseness" criterion of a
score equal to or greater than 16, between 16% and 20%
of adults score as cases , compared to 40% to 50% of ad-
olescents.
To the authors' knowledge , no study has been published
examining the concordance of the CES-D with clinical di-
agnoses of depression using either Research Diagnostic Cri-
teria (RDC) or DSM-III criteria with adolescents. The results
of research on adults have been equivocal concerning the
efficacy of the CES-D in detecting clinical depression (Rob-
erts et aI., 1989), with some authors suggesting the scale
is an acceptable brief screener and others arguing that it is
not.
The BD! contains 21 items that assess cognitive , behav-
ioral, affective, and somatic components of depression . One
of the more widely used measures of depressive symptoms
(Kendall et a!., 1987), the BD! has been shown to differ-
entiate among nondepressed, moderately depressed, and se-
verely depressed adults (Beck et aI. , 1961; Beck, 1967) and
to possess good psychometric properties (Beck, 1967; Wil-
liams et aI. , 1972; Beck and Beamesderfer , 1974).
Each question provides for a response of 0 to 3. A zero
response means the depressive symptom is not present; a 1
means the symptom is present, a 2 means the symptom is
J .Am .Acad. Child Ado/es c . Psychiatry, 30: 1, Janua ry 1991
SCREENING FOR ADOLESCENT DEPRESSION
moderate , and a 3 means the symptom is severe. The total
BD! score is the sum of the individual items; total BD!
scores can range from 0 to 63. Cutoff points developed by
Beck for the total BD! are: 0 to 9, nondepressed; 10 to 15,
mild depression; 16 to 23, moderate depression; 24 or more,
severe depression. A total BDI score of 16 or more has
been recommended as a cutoff score for major depressive
disorder. The BD! has been used in over 200 studies , in-
cluding adolescents (Albert and Beck , 1975; Teri , 1982;
Kaplan et al. 1984), and validity studies have been done
with adults (Beck , 1967), college age students (Bumberry
et aI., 1978) and adolescent s (Strober et aI. , 1981).
Research with adolescents indicates good internal con-
sistency reliability (0.8 to 0.9) and test-retest reiiability
(Strober et aI., 1981; Teri, 1982). In addition, the structure
of the 21 items is similar for both adults and adolescent s
(Teri, 1982). There have been no community-based studies
examining how effectively the BD! identifies cases of clin-
ical depression. In a study of adolescent psychiatric patients ,
scores of 16 on the BDI correctly classified 81% of those
with major depressive disorder with a false positive rate of
14% and false negative rate of 5% (Strober et aI. , 1981).
The Schedule for Affective Disorders and Schizophrenia
(SADS) was used to make RDC diagnoses of depression .
In summary , available data suggest that the CES-D and
the BDI have reasonably good psychometric properties; that
is, they are equally reliable with adolescents and adults and
appear to manifest the same dimensional (factor) structure
with both adolescents and adults . On the other hand , the
proportion of adolescents scoring as depressed on the
CES-D is greater than for adults (Roberts et aI., 1990), but
the opposite has been reported for adolescents using the BD!
(Teri, 1982). In addition, there is little information con-
cerning the degree of concordance of these scales with in-
dependently derived clinical diagnose s of depressive dis-
order. Thus, there appears to be evidence for the content,
concurrent , and construct validity of the scales, but the
question of their criterion validity is unresolved (Costello
and Angold, 1988). In other words, it is not known how
well they predict (screen for) clinical depression in adoles-
cents.
Method
Sample
The population for these studies was the total enrollment
(approximately 10,200) of nine senior high schools (grades
9 to 12) in two urban and three rural communities located
in West Central Oregon. Completed T 1 sample size was
1,710, and the completed T I to T 2 panel is projected to be
between 1,500 and 1,600 students . Cohort I, for which data
collection began in 1987, had about 350 subjects; Cohort 2
(1988) had about 860 subjects and Cohort 3 (1989) about
500 subjects.
The following sampling strategy was used: (1) Parents of
all students, with the exception of those who were contacted
in a previous year, were sent a letter describing the project
and an attached decline card; (2) students whose parents did
not return the decline card (a passive consent procedure)
constituted the sampling frame; and (3) a sampling fraction
59
ROBERTS ET AL.

of 10% was used for Cohort 1 and 18.5% for Cohort 2, TABLE I . Selected Characteristics of Oregon Adolescent
with the exception of two of the rural high schools. For Depression Project Sample (N = 1,704)
these schools the sampling frame was increased to 22% in Age
order to have an equal proportion from rural and urban Mean 16.6
schools in the final sample. The sampling fraction in Cohort SD 1.2
3 was 20% and was limited to the two largest school districts < 15(%) 10.6
(six schools). Sampling was in proportion to (a) the size of 15 25.1
16 26.5
the school, (b) size of grade within the school, and (c) gender
17 24.8
within the grade.
ｾ 18 13.1
The selected students and their parents received two let- Gender (%)
ters, the first welcoming them to the study and a second Male 47 .1
informing them that they would receive a phone call within Female 52.9
the next few days. The caller attempted to schedule the Grade (%)
adolescent for an interview. Participants who did not have 9 20.7
phones were asked to contact the institute. If there was no 10 25.6
response, a member of the staff was sent to the adolescent's II 25.5
school and/or to their home to explain the project and sched- 12 28.1
Repeated grade (%) 12.3
ule interviews at the Oregon Research Institute.
Ethnic status (%)
Assessment of Psychopathology White 91.1
Nonwhite 8.9
A diagnostic interview was conducted with each adoles- Black .9
cent using the Schedule for Affective Disorders and Schiz- Hispanic 2.5
ophrenia for School-Age Children , (K-SADS) (Puig-Antich American Indian 2.2
and Chambers, 1983; Chambers et aI., 1985), a semi-struc- Asian 1.9 .
tured diagnostic interview. The version of the K-SADS used Other 1.3
combines features of the epidemiological version (K- Average household size
SADS-E) (Orvaschel et aI., 1982) and the K-SADS-P Mean 3.0
SD 1.5
(current episode) . With the assistance of Professor Puig-
Parental status of household (%)
Antich, an interview schedule was developed that uses the
Two parent figures 71.3
K-SADS-E strategy to assess past episodes and the K-SADS- Both natural parents 53.0
P strategy to assess current episodes and that also incor- Number of siblings
porates the symptom severity ratings from the K-SADS-P Natural siblings
for all episodes, past or present. Interviewers also determine Mean 1.8
the "worst" episode experienced by the subject. These in- SD 1.4
terviews provided information on the presence of specific Total (including step)
symptoms for a reliable diagnosis of depression and other Mean 2.4
psychiatric disorders using DSM-IlI-R criteria. Following SD 2.0
the procedures developed by Endicott et al. (1981), inter- Moved during past year (%) 24.0
Proportion of parents completing
viewers completed a 14-item version of the Hamilton 4 or more years of college (%)
Depression Rating Scale (Hamilton, 1960) using depression Fathers 42.8
items in the K-SADS-E. Each adolescent also completed a Mothers 30.1
screening instrument twice, once concurrently with the di-
agnostic interview and the second time approximately I
week later. This instrument contained the CES-D , the BDI,
and items on anxiety , suicide ideation, conduct problems, 0.001. A significant difference was also found for SES, F
and one item asking adolescents to rate their degree of (1,2023) = 96.95, p < 0.001; the mean SES for decliners
depression during the past week. (42.2) was slightly lower than that of participants (48.2).
However, despite the significant difference, both of these
Response Rate means represent the middle class .
Approximately 61% of those students selected partici- Reasons were also recorded for the decline. Nearly 70%
pated in the study. Each time a family declined, the minimal ' indicated that the adolescent was not interested; 12% of
information of key demographic variables was obtained. them were interested but were overruled by their parents ;
Differences between participants and nonparticipants were 12% of the families thought the assessment was too per-
minimal. There were no differences in the gender of the sonal. The rest were made up of a variety of other reasons ,
head of the household or family size (one-versus two-par- including being too shy, too busy, etc. There was a slight
ent). Seniors (67%) were significantly more likely to par- relationship between the grade of the participant and the
ticipate than freshmen (59%), X2 (3,2571) = 10.45, p < reason given for declining participation, X2 (9,938) =
0.05, and females (68%) were significantly more likely to 21.421, p < 0.05. Parents of teens in the earlier grades
participate than males (60%) X2 (1,2575) = 17.30, p < were more likely to overrule their teens' interest than were

60 J. Am. Acad. Child Adolesc. Psychiatry, 30: 1,January 1991

 SCREENING FOR ADOLESCENT DEPRESSION

parents of teens in the later grades. Teens in the later grades TABLE 2. Operating Characteristics of BDl and CES-D
were more likely to decline because they were not interested. BD! CES-D
As can be seen in Table I, the OADP sample is predom-
Reliability
inantly white and middle class. In terms of family size and Ol 0.88 0.89
structure as well as geographic mobility, the sample is fairly '(T,-T2 ) 0.67 0.61
typical. The sample is distributed rather evenly across the 'Hamilton 0.50 0.48
four high school grade levels and is reasonably balanced by Distribution of scores
gender, with a slight preponderance of females. X 7.17 16.98
SD 7.50 10.65
Data Collection Mode 0.0 10
Trained monitors supervised the completion of question- range 0-53 0-57
Prevalence (%)
naires by adolescents and answered questions, etc . Once
8D!
the questionnaires were completed, monitors reviewed them ｾＱｏ 27.7
and the answer sheets for omissions, illegal responses, etc. ｾ 16 13.1
to obtain correct data from the adolescents, For the diag- ｾ 24 4.0
nostic assessments, all interviewers (N = 27) were highly CES-D
trained and experienced. Many had advanced degrees in ｾ 16 48.0
clinical or counseling psychology or social work. Upon ｾ 21 31.4
completion of training, all were required to demonstrate a ｾ 31 12.1
minimum Kappa of 0.80 across all symptoms for at least
two consecutive training interviews and demonstrate a min-
imum kappa of 0.80 using a videotape of an interview with
an adolescent with evidence of psychopathology. Almost hibited: (1) adequate reliability, (2) moderate to high cor-
all clinical assessments were videotaped, and a 12% sample relation with the CES-D , (3) relatively low correlation with
of these was assessed by one of two reliability interviewers a measure of response style, and (4) only moderate corre-
(the most experienced). Discrepancies in symptoms and/or lations with other measures used. This latter criterion was
diagnoses were reviewed by the interviewer supervisor and included to reduce redundancy .
resolved through discussions with the reliability interviewer. Results
Within 1 to 2 weeks of the interview, all K-SADS-E forms
were systematically reviewed , comparing the case report Operating Characteristics of the Screeners
with-the interview schedule. To minimize drift, weekly dis- Data on the operating characteristics of the BDI and the
cussion sessions were held between the supervisor and in- CES-D are presented in Table 2. Internal consistency and
terviewers to review the K-SADS, DSM-III-R , and discuss test-retest reliability of the two scales are quite similar and
problems encountered, etc . These procedures resulted in the acceptable. Concurrent validity, as measured by correlation
maintenance of acceptable reliability throughout the data with Hamilton scores, also is acceptable and virtually iden-
collection . Based on 223 subjects for whom reliability data tical for the two scales. The distribution of scores, however,
were available, the Kappa for a current episode of major is considerably different. Adolescents score much higher on
depression was 0 .95 (SE = 0.04), based on 11 "true" the CES-D than on the BDI , even though the scoring (0,
cases of DSM-III-R major depression (only one ' case was 1, 2, 3) and total scores (60, 63) of the two scales are almost
misdiagnosed) . identical. The mean scores were 7.17 for the BDI and 16.98
for the CES-D . In terms of prevalence data, these same
Measures of Risk Factors trends are observable. Using the criteria recommended by
The array of risk factor measures in the study were drawn Barnes and Prosen (1985), 48% of the adolescents were at
from six broad conceptual domains: (1) status attributes , (2) least mildly depressed, 31.4% were at least moderately de-
health, (3) stressful events, (4) cognitive style, (5) response pressed , and 12.1 % were severely depressed on the
style, and (6) social interactions. CES-D. When the criteria recommended by Shaw et al.
During Year I of the project, considerable time was spent (1985) were used, 27.7% were at least mildly depressed,
in the development of scales for the psychosocial risk factors 13.1% were at least moderately depressed, and 4% were
hypothesized to be important for adolescent depression. The severely depressed on the BDI. There were significant gen-
goal was to include risk factors shown to be related to der differences on both scales . The mean BDI scores were
depression among adults or strongly hypothesized to be 6.49 for males and 7.78 for females (p < 0.001). The mean
uniquely important to depression among adolescents. This CES-D scores were 15.70 for males and 18.12 for females
was felt to be necessary because most of these measures (p < 0.001). However, if only the "severely depressed"
had not been developed with adolescent populations, and categories are compared, a different pattern emerges. For
their psychometric properties with this age group were un- the BDI, the proportion scoring as severely depressed was
known. Consequently, four pilot studies involving over 2,000 3.6 for males and 4.3 for females (NS); whereas for the
high school students during the first year of the project were CES-D, the proportion was 8.6 for males and 15.3 for
sequentially conducted. The CES-D was included in each females (p < 0 .001) .
pilot. Measures were retained in the core study if they ex- In order to evaluate the sensitivity (true positive rate) and

J .Am.Acad. Child Adolesc.Psychiatry, 30 :1, January 1991 61

ROBERTS ET AL.

specificity (true negative rate) of the CES-D and BDl at TABLE 3. Comparative Ability of BD! and CES-D to Detect Cases
various cutoff points, receiver operating characteristic (ROC) of DSM-III-R Psychiatric Disorder
analysis was employed. ROC analysis has been demon- BDI CES-D
strated as a useful technique for providing comprehensive Current Past Current Past
indices of diagnostic performance (e.g., Murphy et al., 1987;
Major depression
Mossman and Somoza, 1989; Hsiao et al., 1989). By cal- 2.5 16.0
Base rate 2.5 16.0
culating the area under the ROC curve (AUC) , it is possible Sensitivity 83.7 38.4 83.7 39.5
to compare performances of different diagnostic tests (Han- Specificity 80.9 83.2 75.2 76.8
ley and McNeil, 1982). Shown in Figure 1 are the ROC Kappa 0.14 0.20 0.11 0.13
curves for the CES-D and BDI by gender. As can be seen, PPP 10.2 30.4 08.0 24.5
all four curves are sufficiently above the random ROC (line NPP 99.5 87.6 99.4 86.9
of no information). However, a marked difference emerges Dysthmia
when the BDI curve for males versus the other three curves Base rate 0.5 2.8 0.5 2.8
is compared. The AUCs for male BDI and CES-D curves Sensitivity 88.9 44.7 77.8 48.9
Specificity 79.6 79.9 74.0 74.4
are 0.93 (SE = 0.046) and 0.87 (SE = 0.062), respec-
Kappa 0.03 0.06 0.02 0.05
tively. For females, the AUCs for the CES-D and BDl are 1.6 5.1
PPP 2.3 5.9
identical: 0.83 (SE = 0.043). In sum, the AUC indices NPP 99.9 98.1 99.8 98.1
suggest good diagnostic performance for both the CES-D All affective
and the BDI and better performance for males than females Base rate 3.2 17.8 3.2 17.8
on the BDI. Optimal cutoff scores that maximize the area Sensitivity 83.3 37.3 85.2 39.3
under the curve for each of the ROC curves have been Specificity 81.3 83.7 75.6 77.3
circled. Kappa 0.18 0.20 0.13 0.14
Data on the comparative ability of the CES-D and BDl PPP 12.7 33.1 10.3 27.3
to detect clinically diagnosable cases of DSM -III-R disorders NPP 99.3 86.1 99.4 88.5
are presented in Table 3. Based on the ROC analyses, the Any disorder
Base rate 9.7 29.2 9.7 29.2
optimal CES-D caseness criterion is 24 for females, 22 for Sensitivity 52.7 28.7 54.5 34.0
males, and 24 for the total sample. For the BDl, it is 11 Specificity 82.7 85.2 76.7 79.5
for females, 15 for males, and 11 for the total sample. Kappa 0.23 0.15 0.18 0.14
When the data in Table 3 are examined, several findings PPP 24.6 44.4 20.1 40.7
are noteworthy. First, sensitivity and specificity are both NPP 94.2 74.3 94.0 74.4
reasonably good for current episodes of major depression Note: PPP = positive predictive power. NPP = negative predictive
and dysthymia for the CES-D and the BDI. For past epi- power.
sodes, specificity remains high, but sensitivity declines sub-
stantially, suggesting that the time referents (past week) in
the two scales have observable empirical consequences.
Second, the Kappa values across all diagnostic categories
examined, both time referents (current and past) and both
1.0
1 - - - 7 - - -:;:;;;--- - -.:::::::;;;;;;:::::::= ---/1
r...
ｾ Ｍ .•. •..• ...•.... / .... : scales, are exceedingly low, in some instances only slightly
j better than chance. This is largely a function of the low
base rates for the current prevalence of major depression
0.8
and dysthymia (Meehl and Rosen, 1955). Still, these find-
s.; ings indicate that there is little chance-corrected agreement
:;:;
'iii between CES-D and BDI "caseness" and that determined
c:
ｾ 0.6 by the K-SADS-E and DSM-III-R criteria. The positive pre-
Ql dictive power (PPP) is low for the CES-D and the BDl for
1ii
II: both major depression and dysthymia. By contrast, negative
ｾ
Ql
BOI, Males
predictive power (NPP) is high for current episodes of major
'iii
o
0.4 ) BOI, Females depression and dysthymia.
o,
Q, CES-O, Males

I=-
::J CES-O, Females Use of Multiple Screeners
! ,I Lineof No Information
As part of the design, the screening instruments were

.:
0.2
administered twice. Of the 1,710 subjects, 1,604 completed
both screening questionnaires within a mean interval of 9.6
days (SD = 10.8, mode = 7). The efficacy of multiple
ｯＮＭﾥｾＬｪ
0.0 0.2 0.4 0.6 0.8 1.0
screens was examined using both "serial" and "parallel"
False-Posltlvs Rate (1·Speciflcity)
strategies. In the former, a subject must have positive results
on both screens to be a putative case; in the latter, the subject
FIG. 1. Receiver operating characteristic curves depicting the Beck
Depression Inventory and Center for Epidemiologic Studies Depres- can be a case if the results are positive on either screen. For
sion scales by gender. Optimal cutoff points are circled. those completing the questionnaires within 31 days (N =

62 J.Am. Acad. Child Adolesc. Psychiatry, 30:1, January 1991

 SCREENING FOR ADOLESCENT DEPRESSION

TABLE 4. The Effects of Multiple Screens on the Ability of the BDI and CES-D to Detect Cases of DSM-/ll-R Major Depression
CES-D BDI
Females Males Total Females Males Total
Serial screens
Sensitivity 63.60 84.60 62.50 63.60 61.50 69.50
Specificity 90.80 92.70 92.50 87.40 96.00 89.30
PPP 21.90 17.70 21.00 17.10 22.20 16.50
NPP 98.40 99.70 98.90 98.30 99.30 99.00
Kappa 0.28 0.27 0.29 0.22 0.31 0.23
Parallel screens
Sensitivity 90.90 92. 30 89. 10 87.90 92.30 91.30
Specificity 70.70 73.70 74.40 72.30 86.00 74.20
PPP 11.20 6.10 9.60 11.50 10.90 9.70
NPP 99.50 99.80 99.60 99.30 99.80 99.60
Kappa 0.14 0.08 0.13 0.14 0.17 0.13
Note: PPP = positive predictive power. NPP = negative predictive power.

1,562), dual administration had a discernible effect. For
current major depression, serial screening increased Kappa
values from 0.13 to 0.29 and from 0.18 to 0.23 , and the
PPP increased from 12.7 to 21.0 and from 10.3 to 16.3 for
the CES-D and the BDI, respectively. The effects of parallel
screening were negligible (Table 4).
Concordance between the Two Screeners
The performance of the CES-D and the BDI as screening
instruments for adolescent depression was examined addi-
tionally by studying the degree to which they agreed with
each other. First, subjects were cross-classified in terms of
whether they were a case or a noncase, using the caseness
criteria described above. For the overall sample, there was
an 82.4 % agreement between the two scales on caseness
(69.5% noncases, 12.9% cases). Virtually all of the mis-
classification for males was attributable to the CES-D clas-
sifying them as cases (14.1%), compared with the BDI
(2.7 %). For females, the misclassification rates were sim-
ilar; 9.5% for the CES-D and 8.9% for the BD!.
Extending this line of analysis, all subjects with a current
diagnosis of major depression or dysthymia were selected
and the concordance of the BDI and CES-D in their ability
to detect these cases was examined. The concordance was
reasonably good. For all subjects, the two scales agreed on
87.8% (77 .6% true positives, 10.2% false negatives); Kappa
was 0.55. For males, the two scales agreed on 92.8% (85.7%
true positives, 7.1% false negatives); Kappa was 0.63. For
females, agreement was 85.7% (74.3% true positives, 11.4%
false negatives); Kappa was 0.53 . In these analyses, the
CES-D and the BDI disagreed only 7% of the time for males,
contrasted with 14% for females.
The correlation between the BDI and CES-D was 0.70,
approaching the upper limit defined by their respective re-
liabilities.
The question of whether subsets of the items in the BDI
and CES-D might function as well or nearly as well as brief
screeners as the full scales was also examined . For this, a
series of multiple regression analyses with clinical diagnosis
as the criterion was used. Based on these analyses (results
not shown), four of the BDI items yielded a multiple regres-
sion of 0.31 (compared with r = 0.26 for the total scale).
The items were "feel sad," "blame myself, " "cry, " and
" no appetite." Four items from the CES-D also were iden-
tified as the optimal subset, with a multiple regression of
0. 28 (compared with r = 0.25 for the total scale). The
items were " felt depressed, " " poor appetite ," " felt sad, "
and "could not get going." As can be seen in Table 5,
based on ROC-derived optimal cutting points, there is little
loss in efficiency in using the four-item versions of either
the BDI or the CES-D (Table 3). There is a slight erosion
of Kappa values, but the values of NPP and PPP are virtually
unchanged.
Discussion
The internal consistency reliability of both the CES-D
and BDI was high (0.88 and 0.89), which is comparable to
what has been reported in studies of adults (Gotlib and Cane ,
1989). The test-retest stability was less impressive (0.61
and 0.67), suggesting that considerable mobility occurred
during the l-month follow-up interval (the range was 1 week
to 1 month). It is not possible to determine from the data
how much change was attributable to real change or to the
unreliability of the BDI or the CES-D . Gotlib and Cane
(1989) have suggested that test-retest reliability might not
be particularly relevant in those instances in which temporal
stability is not assumed to be inherent in the construct being
assessed (e.g., state levels of depressed affect). Even so,
test-retest reliabilities in the range of 0.6 suggest that re-
sponses to items in the BDI and CES-D may be relatively
volatile and may serve to attenuate the ability of the scales
to identify putative cases of clinical depression.
Prevalence (unweighted) of DSM-III-R major depression
was 2.5 % (SE = 0.4) for current episodes and 18.5% (SE
= 0.9) for past episodes. For dysthymia, the rates were
0.5% (0.2) and 3.3% (0.6). When the BDI was used, the
unweighted prevalence of serious depression was 4.0 % (SE
= 0.5); for the CES-D it was 12.1 % (SE = 0.8). The
prevalence of mild-to-severe depression was 27.7% (1.1)
for the BDI and 48.0% (1.2) for the CES-D . Even when
the most stringent definitions of caseness were used , more
adolescents were classified as " depressed" using these two

J.Am . Acad. Child Ado/esc. Psychiat ry , 30:1, January 1991 63

ROBERTS ET AL.
TABLE 5. Efficacy of Four-Item Versions of BDI and CES-D to Detect Cases of DSM-III-R Depression
CES-D
Multiple Regression Items Females Males
Cutpoint 8.00 6.00
Sensitivity 77.10 85.70
Specificity 81.90 73.50
PPP 14.70 5.40
NPP 98.90 99.70
Kappa 0.193 0.071
% Depressed via cutpoint 25 20.40 27.50
Note: PPP = positive predictive power. NPP = negative predictive power.
scales (particularly, the CES-D) than using the K-SADS and
DSM-III-R criteria.
The prevalence rate for the BDI (4%) for severe depres-
sion is similar to that reported by Teri (1982); but the rate
for moderate depression (9%) is lower than she reported
(33%). Kaplan et al. (1984) used the BDl with junior and
senior high school students and reported 22% exhibited mild-
to-severe symptoms of depression. The prevalence rate of
48%, using the traditional score of 16+ on the CES-D, is
comparable to that found in pilot studies (Roberts et aI.,
1990) and that reported by Schoenbach et al. (1982) and
by Doerfler et al. (1988), but it is much higher than that
reported by Wells et al. (1987).
The results of the ROC analyses suggest that different
caseness criteria should be used for adolescent males and
females. The scores that maximized sensitivity and speci-
ficity of the BDl were 11 for females and 15 for males. For
the CES-D, the scores were 24 for females and 22 for males.
It is not certain why the gender ratio for the two scales is
reversed. However, an examination of the distribution of
the BDI scores revealed that the males had a more skewed
distribution, with proportionately more having either very
low or very high scores. However, this difference does not
appear to be large enough to account for the observed pat-
tern.
The data in the current study also show that both the
CES-D and the BDI are relatively good at identifying true
positives (the false-negative rate is low in most cases) for
major depression and dysthymia. For this adolescent sam-
ple, however, these particular scales are not as good at
detecting true negatives (the false-positive rate is very high).
Similar results have been reported by many investigators.
Thus, Breslau (1985) in a sample of mothers of chronically
ill children, Roberts et al. (1989) in a tri-ethnic sample of
psychiatric patients, and Lewinsohn and Teri (1982) re-
ported that the positives from the screening instruments
included many persons with no diagnosed disorder or with
disorders other than depression. These observations are il-
lustrated by examining the positive and negative predictive
power values in Table 3. The positive predictive power
values are much lower than are the negative predictive power
values for each diagnostic group examined. It is clear that
neither the CES-D nor the BDl, when used by themselves,
generate adequate nosological information for epidemio-
logical or experimental studies.
With the data in the present study the question of whether
64
BDI
Total Females Males Total
6.00 4.00 4.00 4.00
85.70 76.50 92.90 81.30
69.40 75.80 79.60 77.60
7.70 11.10 7.60 9.60
99.40 98.80 99.80 99.30
0.092 0.136 0.111 0.127
32.20 26.10 21.60 24.00
the repeated use of the screening instruments could enhance
the efficacy of the screeners was addressed. It had been the
expectation that the serial strategy, by requiring that a sub-
ject have positive results on both screens and consequently
be more likely to have met the DSM-IlI-R duration criterion,
would result in an increase in PPP. Conversely, it was the
expectation that the parallel strategy-by requiring that to
be classified as negative, a subject had to have low results
at both screens-would enhance the NPP.
To the authors' knowledge, the multiple screening pro-
cedure in which one or more screening instruments are given
simultaneously or successively has been used in psychiatric
research only in one previous study; namely, that by Lew-
insohn and Teri (1982). In that study, it was found that PPP
of the CES-D, using the conventional 16+ cutoff, could
be enhanced from 34% to 40% with the serial strategy. In
that study, neither the simultaneous nor the successive strat-
egy was able to enhance the NPP because the negative
predictive power was already extremely high.
In the present study, comparable results were obtained;
namely, the serial strategy was able to enhance PPP and the
parallel was not able to enhance NPP again because it was
so high to begin with.
A particularly informative result was the finding that very
brief versions of both the BDI and the CES-D can be used
to screen for clinical depression with no dramatic attenuation
in screening efficiency. Similar findings have been reported
on adult samples by Shrout and Yager (1989). On a practical
note, however, both scales in their original form already
are brief (20 and 21 items) and require only 4 to 5 minutes
to complete on average.
The objective in this paper was to assess the utility of
using the CES-D and the BDI to screen for depression in a
community-based sample of adolescents. Based on these
results, the recommendation concerning the use of these
scales in multistage case-identification procedures is equiv-
ocal. On the one hand, both scales have good reliability and
appear to operate equally well with adults and adolescents,
and they have been widely used in numerous research con-
texts. Also, as in previous studies with adults (Lewinsohn
and Teri, 1982; Roberts et aI., 1989), their ability to detect
putative nosological cases of clinical depression in adoles-
cents is less than impressive. For example, using the optimal
caseness criteria identified in the ROC analyses, the number
of adolescents to be screened in our Stage 2 procedure could
have been reduced, i.e., the K-SADS interview, by 79%
J.Am.Acad. Child Adolesc. Psychiatry, 30:1, January 1991

using the BDI and 74% using the CES-D Stage 1. These
gains appear impressive, since the cost of the clinical as-
sessment needed in the second stage is substantial. On the
other hand, 16% (false negatives) of the DSM-III-R cases
of major depression and dysthymia would have been missed,
and clinical assessments would have been conducted with
8.3 times the actual number of true clinical cases with the
CES-D and 6.4 times the actual number with the BD!. Such
a high rate of false positives has both economic and mental
health policy implications. The most direct economic im-
pact, of course, is the substantial increase in cost required
to provide clinical assessments for large numbers of people
who will have negative results at Stage 2.
Of the two scales, which is preferable? Pending cross-
validation, the authors' choice is the BDl. Although neither
scale provides an efficient and cost-effective procedure for
identifying DSM-III-R cases of major depression or dysthy-
mia, the BDI identifies proportionately fewer (27%) false
positives than the CES-D. In addition, the prevalence of
severe depression at 4% was much closer to the point prev-
alence of 3.0% for major depression and dysthymia than
the 12.1% for the CES-D. Furthermore, the proportion of
adolescents, adults, and children classified as severely de-
pressed using the BDI are much more similar than with the
CES-D (Teri, 1982).
In general, it can be assumed, as is typically the case in
such studies, that the diagnoses made by clinicians constitute
a "gold standard" vis-a-vis ascertainment of depression.
Clearly, this is not the case. There is certainly error in the
diagnostic criterion that has been used. One consequence is
that part of the low concordance between the CES-D, the
BDI, and the clinical diagnosis undoubtedly is attributable
to error in the latter as well as the former.
Another possible reason for the weakness of the CES-D
and the BDI as first-stage screening instruments may be
inherent in the construct "depression." The CES-D and
BDI were intended to measure syndromal depression (i.e.,
the symptoms of depression) and not nosological depres-
sion, the presence or absence of an episode of depression
as variously defined by the RDC, DSM-III, DSM-III-R, and
eventually DSM-IV Ｈｾ･ｮ､｡ｬ et al., 1987). Since syndromal
depression accompanies so many other psychiatric and med-
ical conditions, it may be inevitable that to the extent that
a screener measures only depression symptoms there will
be many false positives. Perhaps this problem can be alle-
viated by designing a second screening instrument for those
who screen with positive results on the first screen. The
purpose of the second screen would be to discriminate be-
tween true and false positives.
However, Gotlib and Cane (1989) suggest that the prob-
lem may be due at least in part to the screening instruments.
They conducted a content analysis of the items contained
in eight of the most widely used self-report measures of
depression using DSM-III criteria and concluded that the
BDI and the CES-D should be the scales of choice. Even
so, Gotlib and Cane identified a sizeable proportion of the
items in each scale that do not reference the phenomenology
of depression. In fact, they concluded that only 12 of the
21 BDI items and 10 of the CES-D items specifically meas-
J.Am.Acad. Child Adolesc. Psychiatry, 30:1, January 1991
SCREENING FOR ADOLESCENT DEPRESSION
ured depressive symptomatology.
Roberts et al. (1989) also have noted that scales such as
the CES-D do not explicitly operationalize DSM-III criteria
for major depression or dysthymia. They argue that further
reliance on existing depression screening measures, even
modified versions (Riskind et al., 1987), has little to rec-
ommend it. They suggest a more productive line of inquiry
will involve the development of scales or checklists that
explicitly use items or symptom queries to operationalize
categories in the diagnostic classification system with which
they are to be compared. If the goal is to detect possible
cases of DSM-III depression in either treatment or com-
munity settings, then screening measures should reflect DSM-
III diagnostic criteria for major depression and/or dysthymia
(see Shrout and Yager, 1989). (A strategy that appears
promising in this regard has been described by Zimmerman
and Coryell, 1987.) To the extent that a screening instrument
departs from this set of criteria, they argue, it will suffer
from unacceptably low levels of efficiency in detecting
"true" cases of clinical depression.
If more efficient screening instruments are to be devel-
oped, greater attention will have to be given to the criterion-
related validity of the items chosen (Costello and Angold,
1988; Shrout and Yager, 1989). The critical issue is not the
reliability of the instrument nor its correlation with other,
similar scales. The litmus test of a screening instrument is
its ability to correctly identify cases and noncases, and in
this regard, current technology leaves much to be desired.
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