Validation of the 10-item Centre for Epidemiological Studies Depression Scale (CES-D-10) in Zulu, Xhosa and Afrikaans populations in South Africa

Emily Claire Baron, Thandi Davies, Crick Lund

The 10-item Centre for Epidemiological Studies Depression Scale (CES-D-10) is a depression screening tool that has been used in the South African National Income Dynamics Study (NIDS), a national household panel study. This screening tool has not yet been validated in South Africa. This study aimed to establish the reliability and validity of the CES-D-10 in Zulu, Xhosa and Afrikaans. The CES-D-10's psychometric properties were also compared to the Patient Health Questionnaire (PHQ-9), a depression screening tool already validated in South Africa. Stratified random samples of Xhosa, Afrikaans and Zulu-speaking participants aged 15 years or older (N = 944) were recruited from Cape Town Metro and Ethekwini districts. Face-to-face interviews included socio-demographic questions, the CES-D-10, Patient Health Questionnaire (PHQ-9), and WHO Disability Assessment Schedule 2.0 (WHODAS). Major depression was determined using the Mini International Neuropsychiatric Interview. All instruments were translated and back-translated to English. Construct validity was examined using exploratory factor analysis with varimax rotation. Receiver Operating Characteristics (ROC) curves were used to investigate the CES-D-10 and PHQ-9's criterion validity, and compared using the DeLong method. Overall, 6.6, 18.0 and 6.9% of the Zulu, Afrikaans and Xhosa samples were diagnosed with depression, respectively. The CES-D-10 had acceptable internal consistency across samples (α = 0.69-0.89), and adequate concurrent validity, when compared to the PHQ-9 and WHODAS. The CES-D-10 area under the Receiver Operator Characteristic curve was good to excellent: 0.81 (95% CI 0.71-0.90) for Zulu, 0.93 (95% CI 0.90-0.96) for Afrikaans, and 0.94 (95% CI 0.89-0.99) for Xhosa. A cut-off of 12, 11 and 13 for Zulu, Afrikaans and Xhosa, respectively, generated the most balanced sensitivity, specificity and positive predictive value (Zulu: 71.4, 72.6% and 16.1%; Afrikaans: 84.6%, 84.0%, 53.7%; Xhosa: 81.0%, 95.0%, 54.8%). These were slightly higher than those generated for the PHQ-9. The CES-D-10 and PHQ-9 otherwise performed similarly across samples. The CES-D-10 is a valid, reliable screening tool for depression in Zulu, Xhosa and coloured Afrikaans populations.