Quality of Life Research

, Volume 9, Issue 9, pp 1015–1029

The evaluation of the Center for Epidemiologic Studies Depression (CES-D) scale: Depressed and Positive Affect in cancer patients and healthy reference subjects

  • Maya J. Schroevers
  • Robbert Sanderman
  • Eric van Sonderen
  • Adelita V. Ranchor


This study examined the reliability and validity of a two-factor structure of the Center for Epidemiologic Studies Depression (CES-D) scale. The study was conducted in a large group of cancer patients (n = 475) and a matched reference group (n = 255). Both groups filled in a questionnaire at two points in time; patients 3 and 15 months after diagnosis. Factor analysis confirmed our hypothesis that the 16 negatively and four positively formulated items measure two relatively independent factors, i.e. Depressed Affect and Positive Affect. Therefore, these items should not be combined into an overall sumscore. In both groups, Depressed Affect proved to be a reliable and valid measure of depressive symptomatology, as indicated by its good internal consistency, its strong correlations with other measures of psychological distress and neuroticism, and its effectiveness in discriminating patients from the reference group on depressive symptomatology. In contrast, the validity of the Positive Affect factor could not be confirmed, since it was only weakly related to other measures of psychological distress and extraversion. Depressed and Positive Affect were about equally related to self-esteem, life satisfaction, and quality of life. These findings support the use of a sumscore based on the 16 negatively formulated CES-D items as a more valid measure of depressive symptomatology, in cancer patients and in healthy individuals from the general population.

Cancer Depression Positive Affect The Center for Epidemiologic Studies Depression(CES-D) scale 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Katon W, Sullivan MD. Depression and chronic medical illness. J Clin Psychiatry 1990; 51: 3–11.PubMedGoogle Scholar
  2. 2.
    McDaniel JS, Musselman DL, Porter MR, Reed DA, Nemeroff CB. Depression in patients with cancer. Diagnosis, biology, and treatment. Arch Gen Psychiatry 1995; 52: 89–99.PubMedGoogle Scholar
  3. 3.
    Ganz PA, Coscarelli A, Fred C, Kahn B, Polinsky ML, Petersen L. Breast cancer survivors: Psychosocial concerns and quality of life. Breast Cancer Res Treat 1996; 38: 183–199.PubMedCrossRefGoogle Scholar
  4. 4.
    Vinokur AD, Threatt BA, Vinokur KD, Satariano WA. The process of recovery from breast cancer for younger and older patients. Changes during the first year. Cancer 1990; 65: 1242–1254.PubMedCrossRefGoogle Scholar
  5. 5.
    Omne PM, Holmberg L, Burns T, Adami HO, Bergstrom R. Determinants of the psychosocial outcome after operation for breast cancer. Results of a prospective comparative interview study following mastectomy and breast conservation. Eur J Cancer 1992; 28A: 1062–1067.CrossRefGoogle Scholar
  6. 6.
    McDaniel JS, Nemeroff CB. Depression in the cancer patient: Diagnostic, biological, and treatment aspects. In: Chapman CR, Foley KM (eds), Current and Emerging Issues in Cancer Pain: Research and Practise. New York: Raven Press, 1993; 1–19.Google Scholar
  7. 7.
    DeFlorio M, Massie MJ. Review of depression in cancer: Gender differences. Depression 1995; 3: 66–80.Google Scholar
  8. 8.
    Ensel WM. Measuring depression: The CES-D scale. In: Lin N, Dean A, Ensel WM (eds), Social Support, Life Events, and Depression. Orlando: Academic Press Inc., 1986; 51–70.Google Scholar
  9. 9.
    Kaplan HI, Sadock BJ, Grebb JA. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry. Maryland, USA: Williams & Wilkins, 1994.Google Scholar
  10. 10.
    Spitzer RL, Williams JB, Gibbon M, First MB. Structured Depressed Outpatient Interview for DSM-III-R. Washington, DC: American Psychiatric Press, 1989.Google Scholar
  11. 11.
    Radloff LS. The CES-D Scale: A self-report depression scale for research in the general population. Appl Psychol Measur 1977; 1:385–401.Google Scholar
  12. 12.
    Vera M, Alegria M, Freeman D, Robles RR, Rios R, Rios CF. Depressive symptoms among Puerto Ricans: Island poor compared with residents of the New York City area. Am J Epidemiol 1991; 134: 502–510.PubMedGoogle Scholar
  13. 13.
    Hertzog C, Van Alstine J, Usala PD, et al. Measurement properties of the Center for Epidemiological Studies Depression Scale (CES-D) in older populations. Psychol Assessment 1990; 2: 64–72.CrossRefGoogle Scholar
  14. 14.
    Kessler RC, Foster C, Webster PS, House JS. The relationship between age and depressive symptoms in two national surveys. Psychol Aging 1992; 7: 119–126.PubMedCrossRefGoogle Scholar
  15. 15.
    Pasacreta JV. Depressive phenomena, physical symptom distress, and functional status among women with breast cancer. Nurs Res 1997; 46: 214–221.PubMedCrossRefGoogle Scholar
  16. 16.
    Kurtz ME, Given B, Kurtz JC, Given CW. The interaction of age, symptoms, and survival status on physical and mental health of patients with cancer and their families. Cancer 1994; 74: 2071–2078.PubMedCrossRefGoogle Scholar
  17. 17.
    Given CW, Given BA, Stommel M. The impact of age, treatment, and symptoms on the physical and mental health of cancer patients. Cancer 1994; 74: 2128–2138.PubMedCrossRefGoogle Scholar
  18. 18.
    Beck AT, Ward CH, Mendelson M, Mock JE, Erbaugh JK. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561–571.PubMedGoogle Scholar
  19. 19.
    Zung WWKA. A self rating depression scale. Arch Gen Psychiatry 1965; 12: 63–70.PubMedGoogle Scholar
  20. 20.
    Dahlstrom WG, Welsh GS. An MMPI Handbook. Minneapolis: University of Minnesota Press, 1960.Google Scholar
  21. 21.
    Raskin A, Chulterbrandt JS, Reating N, McKeon J. Replication of factors in psychopathology in interview, ward behavior and self report ratings of hospital depressives. J Nerv Ment Dis 1970; 198: 87–96.Google Scholar
  22. 22.
    Gardner EA. Development of a symptom checklist for the measurement of depression in a population. Unpublished manuscript (cited in: Ensel, 1986) 1968.Google Scholar
  23. 23.
    Beeber LS, Shea J, McCorkle R. The center for epidemiologic studies depression scale as a measure of depressive symptoms in newly diagnosed patients. J Psychosoc Oncol 1998; 16: 1–20.CrossRefGoogle Scholar
  24. 24.
    Callahan CM, Wolinsky FD. The effect of gender and race on the measurement properties of the CES-D in older adults. Med Care 1994; 32: 341–356.PubMedGoogle Scholar
  25. 25.
    Barlow JH, Wright CC. Dimensions of the Center of Epidemiological Studies-Depression Scale for people with arthritis from the UK. Psychol Rep 1998; 83: 915–919.PubMedCrossRefGoogle Scholar
  26. 26.
    Hann D, Winter K, Jacobsen P. Measurement of depressive symptoms in cancer patients: Evaluation of the center for epidemiological studies depression scale (CES-d). J Psy-chosom Res 1999; 46: 437–443.Google Scholar
  27. 27.
    Edman JL, Danko GP, Andrade N, McArdle JJ, Foster J, Glipa J. Factor structure of the CES-D (Center for Epidemiologic Studies Depression Scale) among Filipino-American adolescents. Soc Psychiatry Psychiatr Epidemiol 1999; 34: 211–215.PubMedCrossRefGoogle Scholar
  28. 28.
    Santor DA, Coyne JC. Shortening the CES-D to improve its ability to detect cases of depression. Psychol Assessment 1997; 9:233–243.CrossRefGoogle Scholar
  29. 29.
    Stommel M, Given BA, Given CW, Kalaian HA, Schulz R, McCorkle R. Gender bias in the measurement properties of the Center for Epidemiologic Studies Depression Scale (CES-D). Psychiatr Res 1993; 49: 239–250.CrossRefGoogle Scholar
  30. 30.
    Watson D, Clark LA. Measurement and mismeasurement of mood: Recurrent and emergent issues. J Pers Assess 1997; 68: 267–296.PubMedCrossRefGoogle Scholar
  31. 31.
    Russell JA, Carroll JM. On the bipolarity of positive and negative affect. PsyB 1999; 125: 3–30.Google Scholar
  32. 32.
    Watson D, Clark LA, Carey G. Positive and negative affectivity and their relation to anxiety and depressive disorders. J Abnorm Psychol 1988; 97: 346–353.PubMedCrossRefGoogle Scholar
  33. 33.
    Stein NL, Trabasso T, Liwag M. The Representation and Organization of Emotional Experience: Unfolding the Emotion Episode. In: Lewis M, Haviland JM (eds). New York: Guilford Press, 1993; 279–300.Google Scholar
  34. 34.
    Diener E, Emmons RA. The independence of positive and negative affect. JPSP 1984; 47: 1105–1117.Google Scholar
  35. 35.
    Diener E, Sandvik E, Pavot W. Happiness is the frequency, not the intensity, of positive versus negative affect. In: Strack F, Argyle MSN (eds), The Social Psychology of Subjective Well-being. Elmsford, NY: Pergamon, 1991; 119–139.Google Scholar
  36. 36.
    Ross CE, Van Willigen M. Education and the subjective quality of life. J Health Soc Behav 1997; 38: 275–297.PubMedCrossRefGoogle Scholar
  37. 37.
    Iwata N, Umesue M, Egashira K, et al. Can positive affect items be used to assess depressive disorders in the Japanese population? Psychol Med 1998; 28: 153–158.PubMedCrossRefGoogle Scholar
  38. 38.
    Meyer GJ, Shack JR. Structural convergence of mood and personality: Evidence for old and new directions. JPSP 1989; 57: 691–706.Google Scholar
  39. 39.
    DeNeve KM, Cooper H. The happy personality: A meta-analysis of 137 personality traits and subjective well-being. PsyB 1998; 124: 197–229.Google Scholar
  40. 40.
    Diener E. Subjective well-being and personality. In: Barone DF, Hersen M (eds), Advanced Personality. NY: Plenum Press, 1998; 311–334.Google Scholar
  41. 41.
    Morris T, Greer HS, White P. Psychological and social adjustment to mastectomy: A two-year follow-up study. Cancer 1977; 40: 2381–2387.PubMedCrossRefGoogle Scholar
  42. 42.
    Bloom JR, Spiegel D. The relationship of two dimensions of social support to the psychological well-being and social functioning of women with advanced breast cancer. Soc Sci Med 1984; 19: 831–837.PubMedCrossRefGoogle Scholar
  43. 43.
    Hobfall SE, Walfish S. Coping with a threat to life: A longitudinal study of self-concept, social support and psychological distress. Am J Community Psychol 1984; 12: 87–100.CrossRefGoogle Scholar
  44. 44.
    Greer S, Burgess C. A self-esteem measure for patients with cancer. Psychol Health 1987; 1: 327–340.Google Scholar
  45. 45.
    De Ruiter JH, De Haes JC, Tempelaar R. Cancer patients and their network: The meaning of the social network and social interactions for quality of life. Support Care Cancer 1993; 1: 152–155.PubMedCrossRefGoogle Scholar
  46. 46.
    VanderZee KI, Buunk BP, DeRuiter JH, Tempelaar R. Social comparison and the subjective well-being of cancer patients. Basic Appl Soc Psychol 1996; 18: 453–468.CrossRefGoogle Scholar
  47. 47.
    Bouma J, Ranchor AV, Sanderman R, Van Sonderen FLP. Het meten van symptomen van depressie met de CES-D. Een handleiding. Groningen: Noordelijk Centrum voor Gezondheidsvraagstukken, Rijksuniversiteit Groningen, 1995.Google Scholar
  48. 48.
    Spielberger CD, Gorsuch RL, Lushene RE. STAI Manual. Palo Alto, CA: Consulting Psychologists Press, 1970.Google Scholar
  49. 49.
    Kreitler S, Kreitler H, Chaitchik S, Shaked S, Shaked T. Psychological and medical predictors of disease course in breast cancer: A prospective study. Eur J Personality 1997; 11: 383–400.CrossRefGoogle Scholar
  50. 50.
    Spiegel D, Sands S, Koopman C. Pain and depression in patients with cancer. Cancer 1994; 74: 2570–2578.PubMedCrossRefGoogle Scholar
  51. 51.
    Weitzner MA, Meyers CA, Stuebing KK, Saleeba AK. Relationship between quality of life and mood in long-term survivors of breast cancer treated with mastectomy. Support Care Cancer 1997; 5: 241–248.PubMedCrossRefGoogle Scholar
  52. 52.
    Goldberg D, Williams P. User's Guide to the General Health Questionnaire. Windsor: NFR-Nelson, 1988.Google Scholar
  53. 53.
    Goldberg DP, Hillier VF. A scaled version of the General Health Questionnaire. Psychol Med 1979; 24: 18–26.Google Scholar
  54. 54.
    De Haes JC, Van Knippenberg FC, Neijt JP. Measuring psychological and physical distress in cancer patients: Structure and application of the Rotterdam Symptom Checklist. Br J Cancer 1990; 62: 1034–1038.PubMedGoogle Scholar
  55. 55.
    Eysenck HJ, Eysenck SBG. Manual of the Eysenck Personality Scales (EPS Adult). London: Hodder & Stoughton, 1991.Google Scholar
  56. 56.
    Sanderman R, Arrindell WA, Ranchor AV, Eysenck HJ, Eysenck SBG. The Measurement of Personality Using the Eysenck Personality Questionnaire (EPQ). A manual. Groningen: Northern Centre for Healthcare Research, 1995.Google Scholar
  57. 57.
    Rosenberg M. The measurement of self-esteem. In: Society and the Adolescent Self-image. New Jersey: Publisher Princeton, 1965; 16–36.Google Scholar
  58. 58.
    Van der Linden FJ, Dijkman TA, Roeder PJB. Schoolgaande jongeren, hun leefwereld en zelfbeleving. Nijmegen: Hoogveldt Instituut, 1983.Google Scholar
  59. 59.
    Arrindell WA, Meeuwesen L, Huyse FJ. The Satisfaction with Life Scale (SWLS): Psychometric properties in a non-psychiatric medical outpatients sample. Person individ Diff 1991; 12: 117–123.CrossRefGoogle Scholar
  60. 60.
    Kiers HAL. SCA: A Program for Simultaneous Components Analysis of Variables Measured in Two or More Populations. Groningen, The Netherlands: iec ProGamma, 1990.Google Scholar
  61. 61.
    Kathol RG, Mutgi A, Williams J, Clamon G, Noyes R. Diagnosis of major depression in cancer patients according to four sets of criteria. Am J Psychiatry 1990; 147: 1021–1024.PubMedGoogle Scholar
  62. 62.
    Kathol RG, Noyes R, Williams J, Mutgi A. Diagnosing depression in patients with medical illness. Psychosomatics 1990; 31: 434–440.PubMedGoogle Scholar
  63. 63.
    Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York: Springer, 1984.Google Scholar
  64. 64.
    Folkman S. Positive psychological states and coping with severe stress. Soc Sci Med 1997; 45: 1207–1221.PubMedCrossRefGoogle Scholar

Copyright information

© Kluwer Academic Publishers 2000

Authors and Affiliations

  • Maya J. Schroevers
    • 1
    • 2
  • Robbert Sanderman
    • 1
    • 2
    • 3
  • Eric van Sonderen
    • 1
    • 2
  • Adelita V. Ranchor
    • 1
    • 2
  1. 1.Northern Centre for Healthcare ResearchUniversity of GroningenGroningenThe Netherlands
  2. 2.Department of Health SciencesUniversity of GroningenGroningenThe Netherlands
  3. 3.Department of PsychologyUniversity of GroningenGroningenThe Netherlands

Personalised recommendations