Abstract
ObjectiveWe aimed to collect and meta-analyse the existing evidence regarding the performance of the Center for Epidemiologic Studies Depression (CES-D) for detecting depression in general population and primary care settings.MethodSystematic literature search in PubMed and PsychINFO. Eligible studies were: a) validation studies of screening questionnaires with information on the accuracy of the CES-D; b) samples from general populations or primary care settings; c) standardized diagnostic interviews following standard classification systems used as gold standard; and d) English or Spanish language of publication. Pooled sensitivity, specificity, likelihood ratios and diagnostic odds ratio were estimated for several cut-off points using bivariate mixed effects models for each threshold. The summary receiver operating characteristic curve was estimated with Rutter and Gatsonis mixed effects models; area under the curve was calculated. Quality of the studies was assessed with the QUADAS tool. Causes of heterogeneity were evaluated with the Rutter and Gatsonis mixed effects model including each covariate at a time.Results28 studies (10,617 participants) met eligibility criteria. The median prevalence of Major Depression was 8.8% (IQ range from 3.8% to 12.6%). The overall area under the curve was 0.87. At the cut-off 16, sensitivity was 0.87 (95% CI: 0.82–0.92), specificity 0.70 (95% CI: 0.65–0.75), and DOR 16.2 (95% CI: 10.49–25.10). Better trade-offs between sensitivity and specificity were observed (Sensitivity = 0.83, Specificity = 0.78, diagnostic odds ratio = 16.64) for cut-off 20. None of the variables assessed as possible sources of heterogeneity was found to be statistically significant.ConclusionThe CES-D has acceptable screening accuracy in the general population or primary care settings, but it should not be used as an isolated diagnostic measure of depression. Depending on the test objectives, the cut-off 20 may be more adequate than the value of 16, which is typically recommended.
Highlights
Major Depression ranks amongst the most burdensome health conditions, both at individual and population levels [1,2,3]
At the cut-off 16, sensitivity was 0.87, specificity 0.70, and Diagnostic Odds Ratio (DOR) 16.2
The positive likelihood ratio was LR+ = 2.94, the negative likelihood ratio was LR- = 0.18, and the resulting DOR was 16.2
Summary
Major Depression ranks amongst the most burdensome health conditions, both at individual and population levels [1,2,3] It is the most frequent mood disorder, with a lifetime prevalence that has been reported to range from 7% to 21% [4]. It is estimated that about 50% of depressed patients are incorrectly identified by general practitioners in routine unassisted diagnosis of depression [7], and that only a limited proportion of cases receive adequate treatment [8;9] Given these figures, systematic screening has been advocated as a means for improving detection, treatment and outcomes of depression, and to facilitate follow-up of patients’ progress [10;11]. There is an increasing need for evidence about the accuracy (the ability to discriminate between people with the disorder and those without it) of different assessment methods
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