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VALIDATING THE CENTER FOR EPIDEMIOLOGICAL STUDIES DEPRESSION
SCALE (CES-D) FOR USE AMONG OLDER ADULTS IN NEPAL
SUJAN LAL SHRESTHA
A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF ARTS
UNIVERSITY OF FLORIDA
Sujan L. Shrestha
Many thanks go to Amy Pienta, for her endless support and expert guidance
throughout my undergraduate and graduate training at the University of Florida. I am
especially thankful to Tanya Koropeckyj-Cox for her support and guidance throughout
my graduate training at the University of Florida. I am also very grateful to Terry Mills
for serving on my committee.
TABLE OF CONTENTS
A C K N O W L E D G M E N T S .................................................................... ......... .............. iii
LIST OF TABLES ......... ... ..................... ........ .......... ...........vi
ABSTRACT .............. ..................... .......... .............. vii
1 IN TRODU CTION ................................................. ...... .................
2 B A C K G R O U N D .................... .... ................................ ........ ........ .......... .. ....
D expression and A ge .................. .......................................... .. ...... .. ...
D expression and G ender............. ........................................................ ................ .8
D expression and Physical D disability ........................................ ......................... 9
3 M ETHOD S ..................................... ................................. ........... 10
M easurem ent of D expression .................................................................... ... ............... 11
M easurement of Chronic Disease Status .............. ............................................. 12
M easurem ent of Self-Rated H health ........................................ ........................ 12
Measurement of Functional Limitations ......................................... ...............12
Measurement of Sociodemographic Characteristics ...............................................13
A nalytic P lan ................................................................... 13
4 R E SU L T S ................................................................................................................... 14
Characteristics of the CES-D Scale ............... .......... ..................... ............... 15
Properties of the Short-Form CES-D Scale ........................... .............................. 17
Correlates of D expression Scale.............................................................. ............... 19
M ean Score of C E S-D ................................................... ................................. 20
OLS Regressions of D expression Scale ............................................ ............... 22
5 DISCUSSION ..................................... ........... .......... .......... 25
L IST O F R E F E R E N C E S ........................................................................ ..................... 34
B IO G R A PH IC A L SK E T C H ...................................................................... ..................39
LIST OF TABLES
1 Descriptive Sample Characteristics of Older Adults Living in the Chitwan Valley
(n = 9 6 ) ...................................... ................................................... 1 5
2 Percentage and Mean number of Symptoms for CES-D Scale of Older Adults
Living in the Chitwan Valley (n=96) ............ ............................... ............... 16
3 Scale Properties of the short-form CES-D Scale of Older Adults Living in the
Chitw an V alley (n=96) ............................................... .. ...... .. ............ 18
4 Bivariate Correlation between the CES-D7 and Age, Sex, Activities of Daily
Living (ADL), Self-Rated Health, Positive Affect (CES-D5), and Negative
Affect (CES-D2) of Older Adults Living in Chitwan (n=96).............................19
5 Mean number of Depressive Symptoms by Gender, Age, and Self-Rated Health
of Older Adults Living in Chitwan (n=96).................................. ..................21
6 OLS Regression Models of Greater Depressive Symptoms (CES-10, CES-D7,
CES-D5, and CES-D2) for Older Adults Living in Chitwan (n=96) .......................23
Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Arts
VALIDATING THE CENTER FOR EPIDEMIOLOGICAL STUDIES DEPRESSION
SCALE (CES-D) FOR USE AMONG OLDER ADULTS IN NEPAL
Sujan Lal Shrestha
Chair: Tanya Koropeckyj-Cox
Cochair: Amy Pienta
Major Department: Sociology
The aim of this study is to examine the validity of the Center for Epidemiologic
Studies Depression Scale (CES-D) for use in Nepal and to examine the prevalence of
depressive symptomatology and associated factors among a convenience sample of older
adults living in the Chitwan Valley region of Nepal. Study participants included 96
people aged 55 years and older interviewed in 1998. Depressive symptoms were
measured by respondent's score on a modified 10-item CES-D scale translated to
Nepalese and derived from the original 20-item CES-D scale. The reliability and factor
structure of the short-form CES-D scale were examined using principal-components
factor analysis. The relationships among age, sex, self-rated health, activities of daily
limitation (ADL), and depression were also examined. Principal-components factor
analysis revealed two independent factors of depressive symptoms, related to "depressed
mood" (negative affect) and "feeling well" (both positive affect and somatic symptoms).
Together, the feeling well and negative affect factors accounted for 54.2 percent of the
total variance. Cronbach's alpha indicated satisfactory reliability for seven items together
(.72). Principal-component analysis led to the conclusion that the items "did you feel
lonely," "did you feel interested in things," and "did you feel that you could 'get going"'
did not correlate well with the other items and CES-D scale. Higher CES-D scores were
significantly associated with being young-old versus old-old, having more limitations
with activities of daily living (ADL), and having poorer self-rated health. The
relationship between CES-D and self-rated health was no longer statistically significant
after controlling for demographic factors and ADL limitations. Interestingly, the somatic
items -- "everything you did was an effort," "sleep well," and "a lot of energy" -- were
more highly correlated with positive affect than with negative affect measures, which
may reflect the positive orientation in the Nepalese translation. Unexpected findings were
the link between depression and younger age and the lack of statistically significant
relation between sex and depression; further investigation is needed to better understand
the measurement and occurrence of depressive symptoms among older adults in Nepal.
Declining fertility and improvements in health status and longevity suggest that
the aging population will continue to increase in the poorest countries of Asia and Africa.
Over the last several decades, many of the poorest countries in the world have undergone
substantial economic growth and great changes in social conditions. With the fall of
infant and child mortality rates and increase in adult survival, noncommunicable diseases
have emerged as important causes of death associated with aging in the poorest regions of
the world (Murray & Lopez, 1996). Together, these changes will likely have
consequences for the mental health of the elderly living in Asia and other regions that are
undergoing rapid social change. Therefore, there is growing recognition of the
importance of mental health problems in developing countries (Murray & Lopez, 1996).
Murray and Lopez (1996) report in their study, Global Burden of Disease, that mental
disorders are among the most serious in the world, and their burden will increase over the
In Nepal, mental health is a largely neglected because of social stigma, inadequate
infrastructure resources including as personnel and health facilities, and a virtual absence
of formal mental health services in rural areas, where the vast majority of the population
live. In addition, there has been very little research in Nepal directed at understanding
mental health issues. Under these circumstances, it will be helpful to first examine the
validity of the depression scale and to document the impact of the mental disorder on age,
gender and physical disability.
While global population aging has led to new research activities throughout the
world, there are many countries, including Nepal, for which only limited health and aging
data are available. We know little about mental health and do not have equivalent
measures for research in Nepal as well as other Asian countries. Mental health problems
go undetected in Nepal, therefore we know very little about mental health status of the
elderly. The purpose of this study is to (1) to evaluate the validity of a Nepalese version
of the CES-D scale for measuring depressive symptoms among older adults in Nepal;
and (2) to describe overall mental health status of a sample of older Nepalese.
Specifically, I examine data from the Chitwan Valley Family Study of Nepal. The current
study addresses the following specific research questions:
1. Are underlying factors of the 10- Item CES-D scale relevant and significant in a
Nepalese older adult population?
2. How are age, gender, and health factors related to depressive symptoms among
older adults in the Nepalese context?
Depression has been defined as an unpleasant feeling of sadness and/or dejection
marked by difficulties in sleeping, concentrating and acting (Turner et al., 1995).
Depression often arises from stress and strain, making it an excellent indicator of well
being (Turner et al., 1995). Depression is probably the single most studied aspect of
mental health, and it has practical, clinical, and scholarly implications. Unfortunately
little is known about the prevalence of depression and other indicators of mental health in
poorer, rapidly changing nations such as those countries in Asia, Africa, and some parts
of Latin America.
A growing number of epidemiological studies are examining the relationship
between population aging and psychological well being in such nations. These studies
commonly rely on self-report, standardized instruments which measure psychiatric
symptomatology in non-clinical populations (Beals et al. 1991). There are numerous
benefits in employing self-report, standardized instruments, as they can be easily
administered to large groups, can be readily scored, and may allow for statistical
comparison between ethnic population groups. A weakness of using standardized
measurement, however, is in the assumption that concepts and expression of
psychological disorders are uniform across cultural groups. This may be an ethnocentric
assumption when considering diverse cultural groups (Marsella et al. 1985).
One of the most frequently used standardized measures of depression is the Center
for Epidemiology Studies on Depression (CES-D), a self-administered instrument
consisting of 20 items that is designed to measure the level of depressive
symptomatology in community populations (Radloff, 1977). Although the CES-D was
designed primarily to measure depression symptoms, (e.g., feel blue, feel depressed), it
also measures self-esteem and social withdrawal (e.g., lonely, sad, fearful, a failure,
feeling bothered, talking less, feeling that people are unfriendly, and feeling disliked).
In Radloff s (1977) original study, the CES-D was administered to African- and
European-Americans in the United States. In Western samples, four factors are typically
differentiated: (a) depressive mood (feeling blue, depressed, lonely, sad, fearful, a
failure); (b) positive affect (happy, feeling as good as others, enjoy life, hopeful); (c)
somatic symptoms (feeling bothered, losing sleep, keeping ones mind on problem, using
too much effort and (d) interpersonal problems (feeling disliked, feeling that people are
unfriendly) (Radloff, 1977). While Thorson and Powell (1993) obtained a five-factor
solution for an adult sample, other studies have repeated Radloffs (1977) four-factor
solution (Clark et al. 1981; Golding & Aneshensel 1989), including a study using a
Korean version of the CES-D (Noh et al. 1992).
Several studies of culturally diverse samples have questioned the assumption of
universality regarding concepts of psychological disorders, thereby challenging the
validity of using standardized measures among non-Western populations. For example,
research findings on depressive disorders suggest that non-western groups may report
more somatic symptoms than Western groups (Marsella et al., 1985). The importance of
the somatic component has also been found among the Chinese (Cheung, 1986;
Kleinman & Kleinman, 1985), Filipinos (Crittenden et al., 1992) and Vietnamese
(Flaskerud and Soldevilla 1986). Researchers have established that the CES-D has
acceptable validity for use with Nepalese adult samples (Tausig et al., 2003) as well as
Korean and Chinese samples (Lin, 1989), although significant variations have been found
in the psychometric properties of the translated scale. Factor analysis results for Chinese
and Japanese American adults obtained a three factor solution in which depressive mood
and somatic symptoms were combined in a single factor (Kuo 1984; Ying 1988). Factor
analyses for Korean and Filipino Americans in Kuo's (1984) study also supported a
strong relation between depressed mood and somatic symptoms and found only two
unique factors. However, no study has reported the construct validity of the CES-D in
Nepal for use with the older adult population.
Nepal is a densely populated, landlocked, Himalayan nation located between India
and China with a total population size of around 24 million (CBS, Nepal, 2001).
Population aging, typically accelerated by declining birth rates and declining mortality,
has just begun in Nepal. Currently only 3.5 percent of the population is over the age of 65
(U.S Bureau of the Census, 2000). Only 4 percent of the population lives in urban areas
and farming is the major occupation. Just over 38 percent of the population is literate, and
most (56.6 percent) are economically active. Although there is no universal public
pension in Nepal, older adults (age 65+) are less likely to be economically active than the
general population though 26% of elderly are economically active.
Nepal is one of the world's most economically depressed nations and is a non-
Western, very traditional society (Watkins, Regmi, & Alfon, 1989). Nonetheless, there
has been a push in Nepal toward greater economic development and closer links to the
West (Pigg, 1992). It is still difficult to speculate whether such ideological and economic
moves will affect the traditionalism of the Nepalese people. Because of a possible
combination ofNepal's traditionalism and changing national characteristics, it is difficult
to predict how Nepalese depression scores will compare to those observed in the United
States, other Western nations, and other Asian nations.
The Nepalese do not typically use mental health services for the treatment of
depression, and mental health professionals are used only for problems of severe
psychoses. The general public's attitudes towards mental illness are fear and rejection. A
mentally ill person is often considered to have been born under a "bad day" or as
suffering the consequences of his/her ancestors' misdeeds in their previous lives. Mental
illness brings shame on the whole family. It affects one's social status in society, and it
also affects the marriage opportunities of the family members. According to a report from
U.S. Department of Health and Human Services (2001), Asian people in general are
reluctant to talk about mental health issues because there is disgrace associated with
revealing mental health problems. Thus it may be difficult to detect depression in Nepal
because of the extreme social stigma it carries. It is for this reason that measures of
mental health may not translate well in the Nepalese context. There are known difficulties
in applying Western diagnostic criteria or symptoms scales to both minority populations
and cross culture populations (Kleinman & Good, 1985).
In summary, to establish the validity of the CES-D for use with older adults in
Nepal, I conduct factor analyses is and results compared to studies described above. To
further assess the validity of the sub-components and the overall measures of depression,
I examine correlations among characteristics commonly associated with depression and
with the measures evolving from this analysis. Lastly, I examine the relationship between
depression and health, age, and gender that have been reported in other studies.
Depression and Age
Depressive symptoms, which are more common in old age than in middle age
(Kessler et al., 1992), are associated with serious negative outcomes such as increased
risk of a depressive disorder (Beekman et al., 1997). Increased depressive symptoms in
later life are associated with high rates of illness and disability among older people
(Berkman et al., 1986). A recent survey conducted in Nepal finds a U-shaped profile of
depression by age, with middle aged adults feeling less depressed than younger and older
adults, and CES-D depression symptoms increasing with old age (Tausig et al., 2003).
Somatic symptoms, such as sleep or appetite disturbances and reduced energy can be
expected to increase as a result of depression, illness or both. Somatic symptoms alone
however, do not account for increased depression among the elderly. Rather both
depressive symptoms and somatic symptoms have been found to increase with advancing
age (Kessler et al., 1992). Many somatic symptoms of depression are also commonly
found in nondepressed older individuals who are physically ill. Thus, the association
between increasing age and depression has been shown inconsistently in the literature. A
pan-European study found only a modest association between increasing age and
depressive symptoms after the age of 65 (Prince et al., 1999), though a community study
demonstrated an association between age and depressive symptoms after controlling for a
number of socio-economic and health related variables (Blazer et al., 1991). Therefore, I
expect that increased age and greater depressive symptoms will be correlated and
depression will be more prevalent among older adults in Nepal.
Depression and Gender
Studies of depression in later life have also shown that depression is more common
among women than men (Kennedy et al., 1989). Several studies have found clear gender
differences in the prevalence of depressive disorders (Meltzer et al., 1995) with women
being much more likely to report depressive symptoms than men. Across many nations,
cultures, and ethnic groups, women typically encounter as much as twice the levels of
depression as compared to men (Nolen-Hoeksema, 1987). Furthermore, several studies
have indicated that females tend to score higher on levels of depressive symptoms
(Kessler et al., 1994; McGrath et al., 1990). The evidence suggests that differences in
rates of depression are largely a consequence of difference in the performance of roles.
Many studies suggest that family, marital, and other interpersonal factors serve as a
primary basis for these differences (Vanfossen, 1981; Billings & Moos, 1984).
Furthermore, Nolen-Hoeksema (2001) offers the explanation that women have less power
and status than men in most societies; they experience certain traumas and also
experience lack of respect and constrained choices.
In Nepal, I expect that the disadvantaged social position of women and its
consequences for their physical and mental health would also be reflected in higher rates
of depressive symptoms among older Nepalese women. Women's overall health status is
very poor as reflected in their lower life expectancy than men's, partly due to
experiencing one of the highest maternal mortality rates in the World (Country by
Country: Nepal, 1996). Women's poor health is influenced by social factors such as low
level of education and illiteracy, heavy work burdens, early marriage, and high fertility.
Women's inequality further increases exposure to risks, such as social and physical
violence, and also affects their power to manage their own lives, to cope with such risks,
and thus, to influence their own health. A previous study in Nepal, however, from Tausig
et al. (2003) found that being female is not related to higher levels of depression; the
current study tests whether the relationship between depression and gender is found
specifically among older adults.
Depression and Physical Disability
Finally, many cross-sectional studies have confirmed that depressed older persons
have more physical disabilities than their non-depressed peers (Broadhead et al., 1990;
Wells et al. 1989). Several longitudinal studies have also found evidence for a negative
effect of depression on physical disability over time (Turner, & Noh, 1988; Gallo et al.,
1997). The psychiatric and medical literatures abound in evidence of the high prevalence
of depression among individuals with physical health problems (Green & Austin, 1993;
Fielding, 1991; Wells et al., 1991). A review of studies indicates that individuals who
suffer from chronic illness, particularly illness that obstructs their daily functioning, are
especially susceptible to problems with depression and this relationship has been reported
across cultures (Ormel et al., 1994). The Mental Illness and Disability among Elder in
Developing Countries: the Case ofNepal, Subedi and colleagues (2004) also found that
higher rates of disability are associated with depression. Thus, it is hypothesized that
physical health and depression will be highly related in Nepal as well.
Data for this study were obtained from a convenience sample of older adults living
in the Chitwan Valley of Nepal. The Western Chitwan Valley in South-Central Nepal is a
wide flat valley situated in the Himalayan foothills at approximately 450 feet above sea
level. The majority of people in this study area are farmers whose domestic economy is
based on agricultural production. Chitwan is about 150 miles south of the capital city of
Kathmandu. The research team began collecting data in the Fall of 1998. The overall goal
of the pilot data collection efforts was to gather information about mental and physical
health among older adults in Nepal in order to establish validity for a set of measures of
mental and physical health measures. Following successful strategies used by William
Axinn's research team in the same study area, a set of measures that were meaningful for
a previously unstudied population of older adults was selected using a combination of
ethnographic field research methods and semi-structured interviews with older adults
living in the Chitwan Valley of Nepal (see Axinn, Pearce, & Dirgh, 1999). From these
data, the research team was able to identify salient dimensions of mental and physical
health for the daily living of the elderly living in the Chitwan Valley. The survey
interview obtained demographic, psychological functioning, physical functioning, self
related health, and chronic disease conditions from those people aged 55 and above. Each
item in the questionnaire was translated into Nepali and then retranslated into English to
ensure accuracy. The translation was done by both U.S. and Nepali researchers who were
well-trained in both languages. Individual interviews were conducted through face-to-
face surveys with 96 older adults residing in the Chitwan Valley. Respondents were
selected using a convenience sampling with older adults aged 55 and older.
Measurement of Depression
The Center for Epidemiology Studies of Depression (CES-D) scale was translated
and adapted to measure depressive symptoms. Radloff (1977) discusses in detail the
properties of the scale and its appropriateness for use with community residence adults.
Depressive symptoms were measured in the Nepalese sample by the respondent's score
on a 10-item scale that was derived from the original 20-items of the CES-D. A shortened
10-item CES-D was used and is composed of four negatively and six positively worded
items. The participants were asked about 10 depressive symptoms that they might have
experienced in the seven-day period preceding the interview. Each item references
whether feelings such as loneliness and happiness have occurred, with responses coded
dichotomously for "yes = 1" having a symptom or "no = 0" if they have not. Specifically,
the respondents were asked to rate the following: Much of the time during past week did
you. (1) feel depressed, (2) feel that everything you did was an effort much of time, (3)
sleep well, (4) happy, (5) feel lonely, (6) feel interested in things, (7) enjoy life, (8) feel
sad, (9) feel that you could "get going," and (10) have a lot of energy. Items worded
positively (sleep well, happy, feel interesting things, get going, and lot of energy) were
reverse coded before analysis, so that higher scores indicated higher depressive
symptoms (See Table 2). The scores were then summed to obtain total scores ranging
from 0 to 10. The score indicates the total number of symptoms reported for the past
week. The internal consistency coefficients for the summed, 10-item CES-D scale are
satisfactory, with a reliability coefficient of .65.
Measurement of Chronic Disease Status
A measure of chronic disease status was also developed. Respondents were first
asked whether they had ever been to a doctor. Of the 96 respondents, only 87 respondents
had visited a doctor in their lifetime. Of those reporting they had been to a doctor, they
were then asked "Has a doctor ever told you that you have... hypertension, diabetes,
stroke, or heart disease... yes or no?" The total number of chronic diseases was summed
into a single index of comorbidity.
Measurement of Self-Rated Health
Respondents were asked to rate their health in general on a five-point Likert scale.
They were asked, "Overall, would you say your health is excellent, very good, good, fair,
or poor?" This item is included as a measure of self-rated health in our analyses. Self-
rated health is treated as a dichotomous variable, in the analyses: (1) good health equal to
excellent, very good and good, and (0) poor health equal to fair and poor.
Measurement of Functional Limitations
Physical functioning was measured through a variety of function-specific indicators
referencing limitations of lower body mobility, large muscle strength, upper body
mobility, and the activities of daily living. Lower body mobility problems refer to any
difficulty walking (across the room, a block, or a mile) or difficulty climbing stairs (one
or several flights). Any reported difficulty with reaching arms above the head, picking up
a dime from a table, or lifting a heavy object (10-pound bag of groceries) is defined as an
upper body mobility limitation. Large muscle strength problems reference any difficulty
sitting for a length of time, rising from a sitting position, or kneeling, stooping, and
pushing/pulling large objects. Finally, persons who report any difficulty with one or more
of the following items-- eating, bathing, dressing, or getting in and out of the bed-- are
classified as having activities of daily living limitation.
The total number of activities of daily living (ADL) limitations was summed to
obtain a score for each individual, based on responses to the following questions: do you
have any problem (1) eating without help, (2) bathing without help, (3) dressing without
help, and (4) getting in and out of the bed without help? Responses were recorded as "yes
= 1" having any difficulty or "no = 0."
Measurement of Sociodemographic Characteristics
Age is measured in years from two questions asking respondents to report their age
or the year they were born. Gender is constructed based on the interviewer's observation
and coded male (=0) or female (=1).
A factor analysis of the items from the CES-D is conducted to explore the
psychometric properties of the translated depression measure and to examine
relationships with other key variables. Bivariate analyses include examining the zero-
order correlations between the sub-components and summary measures of depressive
symptoms and other variables, including age, gender, and measures of health. Other
bivariate analyses include means comparisons of the sub-components and total
depression index as they related to gender, age, and health status, with the t-test for
statistical significance is calculated. Finally, OLS regression models including all of the
independent variables (age, gender, and health) are estimated for each of the sub-
components and the overall indicator of depression.
Sociodemographic statistics are presented in Table 1 for the sample of older
Nepalese living in Chitwan Valley. The sample ranged in age from 55 to 87 with a mean
age of 66. Just less than half of the sample was comprised of women (46.1%). Also,
reported in Table 1 are indicators of the overall health of the sample. Out of the 96
respondents, only 87 respondents had ever visited a doctor. Those who had visited a
doctor were asked a series of questions to elicit the prevalence of doctor-diagnosed health
problems. Heart disease and hypertension were the most common chronic disease
conditions with 30.1% and 22.9 % of elderly reporting they had been diagnosed as having
heart disease or hypertension, respectively. The comorbidity index, constructed from
these disease status indicators by summing the number of reported chronic conditions,
exhibited a range of 0 to 3 conditions among the elderly adults in sample. On average,
respondents reported having about one chronic illness (0.6, SD = 0.8). More than 55
percent (55.8%) of elderly people reported they had one of the difficulties with activities
of daily living (ADL). An index of the severity of ADL limitation was constructed based
on any reported difficulty with one or more of the following items- eating, bathing,
dressing, or getting in and out of the bed. The summed number of reported ADL
limitation conditions exhibited a range of 0 to 7 limitations among the elderly adults in
sample. On average, respondents reported having about two ADL limitations (1.8, SD =
Table 1: Descriptive Sample Characteristics of Older Adults Living in the Chitwan
S.D min max n
Age (mean in years) 66.0 7.7 55 87 96
Female (%) 46.1 96
Any ADL Limitations (%)
Severity of ADL Limitation (mean)
Very Good (%)
Chronic Disease Status A
Heart Disease (%)
Comorbidity Index (mean # condition)
2.2 0 7 96
0.8 0 3 78
A Calculated for those who have visited a doctor (n=87), with a series of questions that
asked...have you ever been examined by a health professional such as doctor or a nurse?
Self-rated health indicates an individual's view of his or her general health status.
Only 12.6% of adults over the age of 55 rated their health as poor. However, only 4.9%
reported their health as excellent. Functional limitations were also frequently reported
among the elderly of the sample.
Characteristics of the CES-D Scale
Table 2 shows the frequency of CES-D symptoms. The most commonly reported
symptoms were feeling that everything they did was an effort (70.8%) and feeling
depressed (63.5%). About half of the respondents reported feeling sad (54.2%), feeling
interested in things (51%), or that they could get going (50%).
Table 2: Percentage and Mean number of Symptoms for CES-D Scale of Older Adults
Living in the Chitwan Valley (n=96)
Short-form CES-D Scale Items Percentage Reporting "Yes"
Everything effort 70.2
Felt depressed 63.5
Feel sad 54.2
Feel interesting in things 51.0
Get going 50.0
Enjoy life 45.8
Feel lonely 42.7
Sleep well 39.6
A lot of energy 39.6
CES-D All 10 items (mean #symptoms):
Standard Deviation 2.4
Depressive symptoms were measured as dichotomous responses (1 = yes, 0 = no) to the
following questions, referring to the past week:
Did you feel depressed much of the time during the past week?
Did you feel that everything you did was as effort...?
+ Did you sleep well...?
+ Were you happy...?
Did you feel lonely...?
+ Did you feel interested...?
+ Did you enjoy life...?
Did you feel sad...?
+ Did you feel that you could "get going"...?
+ Did you have a lot of energy...?
+ = Items that are reverse coded.
Looking at the other symptoms, 45.8 percent of older adults reported that they
enjoyed life, 42.7 percent felt lonely, 40.6 percent felt happy, and 39.6 percent reported
that they had a lot of energy and had slept well much of the time during the past week.
The total mean number of depressive symptoms created from these CES-D items by
summing the number of reported depressive conditions, revealed a range from 0 to 10
conditions among the elderly in sample. The mean number of depressive symptoms
reported was 4.98.
Properties of the Short-Form CES-D Scale
Table 3 presents data on the reliability and factor structure of the short-form (10-
item) CES-D scale, based on exploratory analysis of these data, using the principal-
components methods. Principal-components factor analysis supports two relatively
independent factors of the CESD-7, which relate to "depressed mood" (negative affect)
and "feeling well" (both positive affect and somatic symptoms). One consists of five
items connected to feeling well (sleep well, enjoy life, a lot of energy, everything effort,
and happy) and another factor consists of two items related to negative affect (felt
depressed, and sad). Together, feeling well and negative affect factors accounted for 54.2
percent of the total variance in the sample.
For this study, using an eigenvalue greater than or equal to 1.0 indicates any factors
that hold at least as much total variance as contained in a single item (Kim & Mueller,
1977). A factor loading of 0.40 was used to retain an item in a factor, even though in
exploratory analysis, after factors are rotated, loadings of 0.30 or higher are generally
acceptable. This study revealed that both the feeling well and negative affect factors have
eigenvalues greater than 1.0, with eigenvalues of 2.697 and 1.095, respectively. Both
feeling well and negative affect items were found to have higher than the minimum of a
0.40 factor loading.
Table 3: Scale Properties of the short-form CES-D Scale of Older Adults Living in the
Chitwan Valley (n=96)
Patterns of Factor Loadings:
Feeling Well Negative Affect
Sleep Well .75
Enjoy Life .70
A Lot of Energy .69
Everything Effort .58
(Eigenvalue = 2.697)
Felt Depressed .81
Feel Sad .70
(Eigenvalue = 1.095)
Reliability (Cronbach's alpha):
CESD-10 items .65
CES-D 7 items: .72
Positive affect (5 items): .73
Negative affect: (2 items): .41
*Note: The 3 items that do not load into factors.
Several studies have used factor analysis to develop CES-D subscales (Clark et al.,
1981; Liang et al., 1989). Based on the exploratory factor analyses, two factors
interpreted as feeling well and negative or depressed mood are constructed by summing
CES-D items to each of two subscales retained by the factor analysis (shown in Table 3).
The two sub-factors were also summed to create a single measure of CES-D using the
underlying 7-items that were retained by the factor analysis. Cronbach's alpha measures
indicate satisfactory reliability for the 7-item scores (.72) and for feeling well (.73).
Reliabilities were higher for the feeling well (.73) subscale than for the negative affect
subscale (.41). Many previous studies indicated that the Cronbach's alpha scores of the
short form CES-D scale are expected to be lower than the full scale.
Principal-component factor analysis showed that the items "did you feel lonely,"
"did you feel interested in things," and "did you feel that you could 'get going'" were not
correlated well with other CES-D items and scale. Deleting items that did not load clearly
substantially improved subscale reliabilities; therefore these three items were dropped
from further analysis and only seven of the ten items were used in subsequent analyses.
Correlates of Depression Scale
Table 4 present correlations between all CES-D measures (CESD-7-item, feeling
well and negative affect) and independent variables. Age is correlated with activities of
daily living limitation and is statistically significant at the 0.01 level. CESD-7 score and
negative affect score were statistically significantly and negatively correlated with age.
Sex was not significantly associated with any of the CES-D scores.
Table 4: Bivariate Correlation between the CES-D7 and Age, Sex, Activities of Daily
Living (ADL), Self-Rated Health, Positive Affect (CES-D5), and Negative
Affect (CES-D2) of Older Adults Living in Chitwan (n=96)
AGE SEX ADL HLTH DEP7 DEP5
ADL .326** .161
HLTH .008 -.142 .128
DEP7 -.210* -.096 .355** .216*
DEP5 -.165 -.062 .353** .260* .938**
DEP2 -.207* -.126 .190 .021 .660** .358**
**. Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2 -tailed).
ADL = Activities of Daily Activities Limitation
HLTH = Self-rated Health
DEP7 = Short-form Depression Scale (Total)
DEP5 = Positive Affect
DEP2 = Negative Affect
Activities of daily living limitations and self-rated health were statistically
significantly and positively correlated with CES-D scores (CESD-7, and feeling well).
The CESD-7 scores were statistically significantly and positively correlated with both the
feeling well and negative affect depression subscales. Finally, feeling well is also
statistically significantly and positively correlated with the negative affect depression
Mean Score of CES-D
The mean scores for the CESD-7, feeling well and negative affect are presented by
gender, age and self-rated health in Table 5. Though other studies have found that women
usually report higher depression, the opposite appears to be true in this pilot sample. For
all three CES-D measures, men reported higher CES-D mean scores than women, but
these differences were not statistically significant. Normally, older persons have higher
CES-D scores than younger persons, but this study finds a relationship in the opposite
direction. Overall, the CESD-7 and negative affect scores are higher among the young
old (4.0 and 1.3, respectively) than the old old (3.1 and 1.0). These differences are
statistically significant. The young old also report higher levels of feeling well than the
old old (2.7 and 2.1 respectively), but this is not a statistically significant difference.
The self-rated health differences in average depression scores are statistically
significant with CES-D (7-item) and feeling well. In other research, poorer health is
associated with higher CES-D scores. The current analyses also find such a relationship
with the 7-item CES-D and the feeling well subscale, with mean scores for the CES-D- 7
of 2.9 for those in good health and 3.9 for those with poor health, and mean scores for
feeling well-being of 1.8 for those in good health and 2.7 for those older adults in poor
health. However, there is no statistically significant relationship between negative affect
score (2 items) and self-rated health; respondents with poorer health reported only
slightly higher negative affect (1.2) compared to those in good health (1.1).
Table 5: Mean number of Depressive Symptoms by Gender, Age, and Self-Rated Health
of Older Adults Living in Chitwan (n=96)
CES-D (mean # symptoms)
Young old (55-65)
Old old (66-87)
Good (Excellent, very good, good)
Poor (fair, poor)
Positive Affect (mean # symptoms)
Young old (55-65)
Old old (65-87)
Good (Excellent, very good, good)
Poor (fair, poor)
Negative Affect (mean # symptoms)
Young old (55-65)
Old old (66-87)
Good (Excellent, very good, good)
Poor (Fair, poor)
p-value = 0.357
p-value = 0.042*
p-value = 0.036*
p-value = 0.555
p-value = 0.011*
p-value = 0.228
p-value = 0.045*
* P-value = <.05
OLS Regressions of Depression Scale
Table 6 includes the results from four different OLS regres5 sion models that
analyzed the effects of age, sex, activities of daily living limitations (ADL), and self-rated
health on each of the four depression measures (10-item, 7-item, feeling well, and
negative affect). The first model indicates that there are significant relationships between
depression (10-item) and age, sex, activities of daily limitation, and self-rated health,
explaining 25 percent of the variability in depression.
Looking at the relationship between age and depression (CESD-10), the value of p
is less than 0.05, which is statistically significant. This result indicates that the young old
are more depressed than the old old after controlling for gender, activities of daily living
limitations, and self-rated health. There is also a positive relationship between activities
of daily living limitations and depression (10-item), statistically significant at the 0.001
level. As would be expected, higher rates of activities of daily living limitation are related
to higher levels of depression among the older people.
The second model indicates that there are significant relationships between
depression (7-item) and age, gender, activities of daily limitation, and self-rated health.
The F-value is higher than the previous model, 8.028, and the R-square is increased to
0.27. Again, the relationship between age and depression (CESD-7) is statistically
significant after controlling for gender, activities of daily living limitations and self-rated
health. Old old adults report less depression even after other factors are controlled. A
positive relationship between activities of daily living limitation and depression (7-item)
is also found (p<.001). As one might expect, higher depressive symptoms were reported
by those with poorer performance of activities of daily living.
Table 6: OLS Regression Models of Greater Depressive Symptoms (CES-10, CES-D7,
CES-D5, and CES-D2) for Older Adults Living in Chitwan (n=96)
Variable CES-D10 CES-D7 CES-D5 CES-D2
Age -.258* -.340* -.302* -.262*
(.472) (.403) (.021) (.163)
Gender (female=l) -.072 -.100 -.056 -.149
(.466) (.398) (.323) (.161)
ADL Limitations .490** .470** .445** .303**
(.063) (.053) (.043) (.022)
Self-rated Health .116 .120 .171 -.045
(.476) (.408) (.332) (.165)
Intercept 1.202 0.248 -0.278 0.526
R-squared .254 .270 .253 .125
F 7.397 8.028 7.379 3.095
P <.0001 <.0001 <.0001 <.05
CES-D10 = Short Form Center for Epidemiologic Studies-Depression Scale.
CES-D7 = 7-item CES-D Scale
CES-D5 = Positive affect
CES-D2 = Negative affect
*P <.05; **P <.001
The third and fourth models also indicate that there are significant relationships
between the depression subscales (feeling well and negative affect) and age, sex,
activities of daily limitation, and self-rated health. The F-values, 7.379 and 3.095, are
somewhat lower but still statistically significant (p<0.0001 and <.05, respectively). The
R-squares are 0.253 and 0.125, with less variability explained in the 2-item subscale of
Age is significantly related to both feeling well and negative affect. There is also
positive and significant correlation between activities of daily living limitation and the
two factors of depression, feeling well and negative affect. The direction of these effects
is the same as in the above models.
Looking at all four models, there is no statistically significant relationship between
sex and depression after controlling for the other variables. There is also no statistically
significant relationship between self-rated health and depression once age, sex, and
activities of daily living limitations are controlled for in the models. Recall that before
controlling for age, sex, and activities of daily living limitations, there were statistically
significantly and positively relationships between self-rated health and depression
(CESD-7, and positive affect).
The need for culturally appropriate depression measures has been widely
recognized in the literature whenever researchers study individuals from population
where English is not their primary language. Unfortunately, most depression instruments
have been developed and tested with populations in more highly developed nations. The
development of culturally appropriate depression measures is important in developing
countries because it would provide an instrument that would permit comparisons across
societies. The goal of this study was to conduct an exploratory factor analysis in an
attempt to define the reliability of the CES-D in a sample of older adults living in
Chitwan Valley, Nepal. Exploratory factor analysis revealed two relatively independent
factors of the CESD-7, which were related to depressed mood (negative affect) and
feeling well (positive affect and somatic symptom). A similar two-factor model (positive
and negative affect) was identified in previous research using the short-form CES-D scale
in a Chinese population (Boey, 1999).
The CES-D short-form has satisfactory reliability for this study although only 7-
items were retained. The reliability of the CES-D in this study compares favorably to
those found for the AHEAD samples (Asset and Health Dynamics among the Oldest Old)
by Mills and Henretta (2001) as well as by Boey (1999) for the mental health status of
old old in Hong Kong. The "feeling well" sub-scale also has satisfactory reliability for
this study. However, the negative affect sub-scale with only two items has a Cronbach's
alpha of only 0.41. It is interesting to note that the items "everything you did was an
effort," "sleep well," and "a lot of energy" were found in the feeling well depression
category. This result was consistent with Edman et al. (1999), which reported that the
"everything you did was an effort" item loaded on positive affect factors where effort
may be viewed as a positive purpose.
Cross-cultural studies of depression among Asian populations have emphasized an
Asian tendency for depressive mood and somatic symptoms to combine in a single factor
(Kuo 1984; Ying 1988). The current results, however, do not support a strong connection
between depressive mood and somatic symptoms. This apparent contradiction may be a
result of the translation of original CES-D measures into Nepali. Two of the translated
somatic symptoms -- sleep well and have a lot of energy -- are translated for this study as
positively phrased questions during the interview. A literal translation from the original
CES-D measures into Nepali is difficult; respondents might have understood retaining the
original negative orientation of these items differently if translation were available. For
example, there is no exact Nepalese word for restless sleep. It would be very difficult,
especially for older people, to understand the meaning behind the exact phrase of restless
sleep in Nepali. Nonetheless, the positive rewording that was chosen during the
translation may have failed to capture this dimension of depression. Future research
might consider alternative wordings of this question.
Principal component analysis for the short-form CESD-7 did not reveal separate
somatic and interpersonal components of the original CES-D to be important in this pilot
sample. Exploratory items showed that the items "did you feel lonely," "did you feel
interested in things," and "did you feel that you could 'get going'" did not correlate well
with other items or the CES-D scale as a whole. The lack of correlation of these three
items with other items in this scale might be result of difficulty in understanding the
questions in Nepalese version.
Further, in adapting a measure initially developed in a Western Society, culture-
specific cautions should be taken because expression of depression in Nepalese culture
may be different. As shown in the result of Nepalese sample, the item "did you feel
lonely" may be somewhat problematic for this cultural comparison, because the original
CES-D scale is based on the assumption that depressed persons tend to stay alone or feel
isolated. However this may not necessarily be true in Nepalese culture. Where the
majority of the older adults are living with their families, they are contributing to their
families by helping with household tasks. Therefore, feeling lonely likely has different
meaning with that in U.S. society, whose elders usually have an independent living
The CES-D scores for the 7-items scales are highly correlated with feeling well and
negative feeling, with correlation coefficients ofr = 0.94 and r = 0.66, respectively. These
high correlations suggest that the sub-scales are valid underlying factors of depression
more generally. These validation analyses demonstrate that the seven-item short-form
CES-D, which is based on the Western concept of depression, can be a reasonably valid
measure of some aspects of depression among older adults in Nepal.
Finally, factor analysis further indicates that Nepalese older adults are more likely
to endorse having slept well, having a lot of energy and that everything is an effort in the
feeling well category, but are less likely to endorse not being able to "get going" in the
feeling well category. These findings suggest that emotional expression, including
responses about somatic symptoms, may vary across different societies and cultures, thus
complicating efforts to compare population mean scores of depression using scales such
as the CESD.
With regard to relationships between sociodemographic characteristics and various
measures of depression (CESD-7, feeling well, and negative affect), the results indicate
that gender is not related to depression. This finding is not consistent with many studies
on gender differences in depressive symptoms. Many studies have found higher
depression scores in women than men (Kennedy et al., 1989, Kessler et al., and, 1994;
McGrath et al., 1990). This finding is consistent with a recent study by Tausig and
colleagues (2003) in Nepal, which reported lower depression scores or CES-D depressive
symptoms in women than men. Other studies found no significant difference in
depressive symptoms between genders in Nepal (Subedi et al 2004) as well as in Mexico
(Aranda et al., 2001). This study's findings regarding the relationship between sex and
the CES-D scale scores calls for further examination of mental health and gender in
Nepal and other developing countries.
Somewhat surprisingly, the young old scored higher number of depressive means
score than the old old in all three measures of depression (CESD-7, feeling well and
negative affect). There is also significant relationship between depression (CESD-7, and
negative affect) and age. This finding is at odds with numerous studies that have found
higher depression scores among the oldest adults (Kessler et al, 1992). However, a close
look at the literature reveals that when depression scores are examined across age groups,
inconsistent results have been reported. In some studies the depression scores increase
with age (Kessler et al., 1992; Beekman et al., 1995), in others the scores decrease
(Henderson, et al, 1998) or no age differences are found (Mirowsky & Ross, 1992). Eaton
and Kessler (1981) also reported in a large community sample that individuals over age
65 show lower levels of depression than those in younger age groups. These
contradictory results appear to derive from differences in the age composition of the
samples studied. A study by Tausig et al. (2004) reported that there is a U-shaped profile
of depression and age, with the highest depression in the young and old in Nepal.
Because the present study focuses on age differences among older adults and does not
compare to younger adults, this may explain the puzzling findings with regard to age.
Also, mortality risk, even among older adults, is extraordinarily high in Nepal which
means that those surviving to old old age may be a highly select group.
The possible explanation of the results of this study in gender may be partly
attributable to the relatively small sample size. Perhaps the sample size was not large
enough to detect a statistical difference in level of depressive symptoms, or there may
have been a nonrandom sampling bias in this convenience sample that yielded a much
different group than that found in other studies. The unexpected results in depression
symptoms could reflect a sampling bias whereby women and old old adults with less
depressive symptoms might be more likely to engage in an interview than men and the
young old in the community. Differences in social support may be another important
factor in the study of depressive symptoms in both Nepalese men and women, though it is
unclear which domains or context of social support (family, relatives, occupational,
income, and so forth) are predictive of depression in Nepalese men compared to women.
There is substantial evidence on the relationship of social support to both physical and
mental health (Dean, & Lin, 1977). Finally, this result may reflect cultural differences in
the expression of depressive symptoms in Nepalese men and women. All of these
possibilities argue for closer examination of depression and gender in Nepal using
random, representative samples, more sensitive and varied measures of mental health
symptoms, and broader measures of other possible correlates of depression among older
men and women. Furthermore, the CES-D version that we used contained only short-
form CES-D items and two response categories. Despite the high correlation (r = .94)
found between the short-form of CES-D modified scale, it is possible though not likely,
that use of the regular version of the CES-D would have resulted in significantly higher
scores and greater variation in the scores. Future research should also compare the current
measures of depressive symptoms with other mental health measures, including the
Diagnostic and Statistical Manual (DSM)-R-III checklist. This approach would allow for
a more thorough assessment of the validity and reliability of the depression scale in Nepal
and whether it's cultural and conceptual relevance in this population.
Replication of this study's results with different samples and with different scales is
essential. Further research is required to determine whether the observed absence of a
gender effect is an artifact of the measures and sample used here or if it is in fact real.
Finally, given the differences in sub-scales according to age and self-rated health, future
research of the CES-D scale might gain more accurate information by looking at the sub-
scales separately when examining age and self-rated health. Kohout et al., (1993)
indicated that short forms of CES-D scale have been developed to ease the response
burden on older adults. Overall, this short-form of CES-D scale is important in the
Nepalese context where the literacy rate is very low and where the discussion and
measurement of mental health symptoms is culturally unusual. Only 53 percent of people
are literate (CBS, Nepal, 2001).
On the other hand, the abbreviated scales may miss important aspects of how
mental health concerns and well-being are expressed and evaluated in this population. To
fully understand the mental health of older people, first we need to identify the salient
features of depression and other factors. Future studies need be done using qualitative
methods to give a clearer picture of how people define depression, what they think about
depression, how family members and other people think about mental health, and which
factors play an important role in Nepal. Once we identify the expression of depression in
Nepal, we then need to re-construct and validate a measure of depression that can be used
in survey. This strategy will also guide word phrasing that will be used in questions. The
assertion that mental illness represents a significant portion of the illness burden in
developing countries makes it important for researchers to determine the extent of illness
and the factors and causal pathways underlying difference in mental health and well-
being. Such information is essential because these health problems are often ignored in
large populations living in developing countries.
This study demonstrates that depression is a significant problem among older adults
who have limitations in activities of daily living (ADL). This finding is consistent with
many studies that found higher depression scores associated with poor performance of
physical disability (Subedi et al. 2004; Gallo et al. 1997; Broadhead et al. 1990).
Berkman et al. (1986) also stated that a major contributing factor to increased depressive
symptoms in later life is the high prevalence of disability among older people. However,
like other cross-sectional studies this study does not provide a clear causal direction--
whether poor performance of activities of daily living is a cause of depression or
depression is a cause of poor performance of activities of daily living. This fundamental
link and how it operates, however, calls for further examination, because as Simon et al.
(1999) have noted, depressed persons have higher physical symptoms world-wide, across
cultures. It is important to also note that depression was found to be unrelated to self-
rated health once other demographic factors were accounted for. This result suggests that
the positive, bivariate relationship between self-rated health and depression may be
explained by age and activities of daily living (ADL) limitation rather than by self-rated
health itself. However, concerns about the measurement of self-rated health in this survey
calls for caution in interpreting the results.
In conclusion, the purpose of this study is to evaluate the validity of measures of
depression (CES-D) scale and to describe an important aspect of mental health status of a
sample of older Nepalese. This study is an important step in establishing the validity of
the CES-D for use in detecting depression level among older adults in Nepal. It is also an
important step toward determining the prevalence of physical disability and overall health
status and how they are associated with higher risk of depression in the Nepalese older
adult population. However, it is difficult to generalize from the present results because
respondents were not randomly selected from the population. There are some additional
limitations in this study. The analytic sample size is small, consisting of only 96
respondents. Future research would benefit from the use of respondents who are
representative of overall sample. Additionally, it would have been ideal to have greater
information about other sociodemographic characteristics of the sample that are known to
correlate with psychological well-being in later life -- such as fertility history, social
support, occupation, education, living arrangement, socioeconomic status and marital
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Prior to receiving his Master of Arts degree in sociology, Sujan Lal Shrestha earned
his Bachelor of Arts degree in sociology at the University of Florida. Concurrent to
earning his Master of Arts degree, he was a research trainee at the Institute on Aging.
After completing his master's degree, Sujan began his Ph.D. coursework at the
University of Florida at Gainesville in the Department of Sociology.