title: The Psychometric Properties of the Center for Epidemiologic Studies Depression Scale in Chinese Primary Care Patients: Factor Structure, Construct Validity, Reliability, Sensitivity and Responsiveness.
abstract: BACKGROUND
  The Center for Epidemiologic Studies Depression Scale (CES-D) is a commonly used instrument to measure depressive symptomatology. Despite this, the evidence for its psychometric properties remains poorly established in Chinese populations. The aim of this study was to validate the use of the CES-D in Chinese primary care patients by examining factor structure, construct validity, reliability, sensitivity and responsiveness.
  
  
  RESULTS
  The psychometric properties were assessed amongst a sample of 3686 Chinese adult primary care patients in Hong Kong. Three competing factor structure models were examined using confirmatory factor analysis. The original CES-D four-structure model had adequate fit, however the data was better fit into a bi-factor model. For the internal construct validity, corrected item-total correlations were 0.4 for most items. The convergent validity was assessed by examining the correlations between the CES-D, the Patient Health Questionnaire 9 (PHQ-9) and the Short Form-12 Health Survey (version 2) Mental Component Summary (SF-12 v2 MCS). The CES-D had a strong correlation with the PHQ-9 (coefficient: 0.78) and SF-12 v2 MCS (coefficient: -0.75). Internal consistency was assessed by McDonald's omega hierarchical (ωH). The ωH value for the general depression factor was 0.855. The ωH values for "somatic", "depressed affect", "positive affect" and "interpersonal problems" were 0.434, 0.038, 0.738 and 0.730, respectively. For the two-week test-retest reliability, the intraclass correlation coefficient was 0.91. The CES-D was sensitive in detecting differences between known groups, with the AUC >0.7. Internal responsiveness of the CES-D to detect positive and negative changes was satisfactory (with p value <0.01 and all effect size statistics >0.2). The CES-D was externally responsive, with the AUC>0.7.
  
  
  CONCLUSIONS
  The CES-D appears to be a valid, reliable, sensitive and responsive instrument for screening and monitoring depressive symptoms in adult Chinese primary care patients. In its original four-factor and bi-factor structure, the CES-D is supported for cross-cultural comparisons of depression in multi-center studies.
authors.affiliation: Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong.
authors.forename: Weng Yee
authors.initials: WY
authors.lastname: Chin
authors.affiliation: School of Nursing, The University of Hong Kong, 4/F, William M.W. Mong Block, 21 Sassoon Road, Pok Fu Lam, Hong Kong.
authors.forename: Edmond P H
authors.initials: EP
authors.lastname: Choi
authors.affiliation: Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong.
authors.forename: Kit T Y
authors.initials: KT
authors.lastname: Chan
authors.affiliation: Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong.
authors.forename: Carlos K H
authors.initials: CK
authors.lastname: Wong
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D019540:Area Under Curve; D003466:Cultural Characteristics; D003863:Depression / Q000175:diagnosis* / Q000453:epidemiology*; D005260:Female; D006723:Hong Kong; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000592:standards; D011594:Psychometrics / Q000379:methods*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012923:Social Class; D011795:Surveys and Questionnaires; D055815:Young Adult