Screening Tests for Depression in
Older Black vs. White Patients
P.M. Baker, M.D., M.P.H., Susall A. Veil;' B.A.
Juli Fried,nan, RA., CY1lthia Wiley, MA., P.C...R
ThirtJI-nine psychiatricpatients age 50 clnci olclerlvith cliagnoses
of ,lepressioll participafetlln a s/ucl)J of the reliability ofscreening ins/rll1nenls in the iclentification ofclepressioll. All patients
hacl a ,liagnosis of affective clisorcler cOl1firnlecl b)J a SCID
il1tervielv. ForlJ,-nine percent of the clapressetl patients lvere
black, 51% luere 70-92 years old, 77% llJere UJOlnen, Cl11{151%
lvere lVic/olvecl. \flhen the Centerfor Epiclenliologic Stllclies-Depression Scale (CES-D) lvas aclnzinisterecl to these clepressect
palien/s, its sensiJivilJ' in black patients lvas 71% ancl in lvhile
patients lvas 85%. 111e sensitivity of the Geriatric Depression
Scale (GDS) was 53% in black patients anel 65% in lvhite
patients. The CES-D lvas significantly be//er than the GDS in the
icientification ofclepressive SYll1ptonls in this sClIl1ple. 171ese clata
suggest that the CES-D anti the CDS 111ay not be equal!)J effective
in iclelltifying ciepression. cl1non.g olcler A111erican black and
lvhile patients. Further sttlclies lvith larger sa111ples of SCIDcliagnosecl, clepresseel, olcier black ancllvhitepatients are neet/ecl
to conflrnz these fin clings. (Anlerican Journal of Geriatric Psychiatry 1995; 3:43-51)

T

he prevalence of depression in older
persons has been found to val)' depending on the population being surveyed.
Anlong cOlnmunity resident older persons,
the Epidemiologic Catchment Area sUlVey
found that 20/0-4% of cOlumunity residents
age 65 years and older had a major depressive disorder. 1-3 Although 150/0-60% of comn1unity resident older persons in the United
States and in England reported depressive
sytnptoms;t-7 these reports of depressive
symptolTIS were not consistent with a de-

pressive disorder. In contrast, studies of
medically ill older persons have reported
rates of major depressive disorder of 20%
and 25% in medical inpatients8-l0 and up to
30% among some samples of atnbulatory
Ineclical clinic patients. ll112
Although some investigators have studied mixed populations that have included
black and Hispanic-American older people,I}-15 the majority of older persons studied have been white. With the increasing
proportion of minority elderly patients that

Received May 2, 1994; revised July 8 t 1994; accepted July 19, 1994. FrOfil the Departnlent of Psychiatry, University

of Maryland School of Medicine. Address correspondence to Dr. Baker at the Department of Psychiatry, University
of Matyland School of Medicine, 645 Red\vood St., Baltimore t MD 21201-1549.

Copyright © 1995 Anlcrican Association for Geriatric Psychiatry
THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

43

Screening Tests/or Depression
will be present in the next 30 years,16 it will
be i1nportant to be able to identify psychiatric symptoms and psychiatric disorders
among these individuals. 17,JR
The presentation of depression LliTIong
black patients has been reported to differ
from that of white patients. An emphasis on
somatic complaints and spontaneous reports of how religion helps them to cope (in
contrast to reports of depressed mood and
guilty ruminations) were found in SaIne
depressed black patients. 19,20 Another study
found that depressed, hypertensive black
Alnerican men had higher ratings on scales
measuring hostility and irritability.21 Although some screening instrllInents for
depressive illness assess somatic COlnplaints,22-24 hostility and irritability are not
included in nl0st screening instruments for
depressive sympt0111s. The presentation of
depressive disorder alnong older, black
Alnericans has not been studied in detail.
In a recently published paper, Mitchell
et a1. 25 reported on a san1ple of 868 eastern
North Carolina, cOlnlllunity resident older
persons who were screened with the 15itelll Geriatric Depression Scale (GDS). This
sa111ple included 277 black All1ericans, 32°1'0
of the san1ple. Factor analysis suggested
three separate dinlensions in the GDS~ life
satisfaction, withdrawal, and general depressive affect. In this North Carolina sample, decreased capacity to walk and drive a
car (Instrumental Activities of Daily Living
[IADL)) and decreased education had a consistent negative effect in each of the separate din1ensions. C01111llUnity residents with
1110re linlitations in IADL were less satisfied
with their lives, were 1110re withdrawn, and
repol1ed l1l0re general depressive affect.
The less educated and those with literacy
problenls also reported 1110re depressive
affect. Social support, found to be a lnodifier of limitations of IADL in prior studies,
was not found to an1eliorate increased limitations of IADL in this sall1ple. Although
increased social support and religiosity have
previously been shown to rnodify life strain
and physical health outcomes, this was not
44

found here. As Activities of Daily Living
(ADL) limitations increased in residents
who believed in religious intervention in
illness (i.e., that prayer could cure illness;
religious miracles did occur), the general
depressive affect di111ension of the GDS
increased. In-depth inteIViews of 200 subjects revealed that people with limitations in
ADL (ability to eat, dress, stoop to pick up
an object, walk up and clown a flight of
stairs, move a heavy object like a living
r00111 chair) blamed theInselves when the
religious intervention that they believed
would cure them did not. 25 Thus, religiosity
in this sample was associated with increased dysphoria.
When the GDS was Llsed to screen one
sample of COnlJ11Unity resident, black older
people (mean age, 77 years) in San Antonio,
TX, it was found to be less effective than the
reference standard, a psychiatric evaluation,
in identifying those patients with depressive
synlptoms or depressive disorder. 26 In this
San Antonio sample, the sensitivity of the
GDS was 35% and its specificity was 1000/0.
This contrasts with the reported sensitivity
of 840/0 and specificity of 95% by the developers of the GDS. 27 Older black Atnericans
denied depressive symptoms, stating rather
that their faith kept thenl frOll1 feeling depressed. Those subjects with clinical depression spontaneollsly reported having "a
problem" or "trouble, but said that their
faith prevented theln from feeling sad, blue,
or "down" because "God wouldn't give Ine
1110re than I could bear." These black subjects did not spontaneollsly cOlnplain of
depressed o10od or the absence of pleasure
and did not report guilty rluuinations.
If the presentation of depressive disorder and the manifestation of depressive
sYlnptoll1s were different in older black
Alnericans, the current group of screening
instrull1ents nlay not be effective in identifying depressive synlpt0111S in these patients. This study was undertaken to identify
the ll1QSt effective existing screening instnlInent for depressive sylnptoms anl0ng older
black and white Americans.
U

VOLUME 3 • NUMBER 1 • \VINTER 1995

Bakeretal.

This article reports on the effectiveness
of the Center for Epidemiologic Studies-Depression Scale (CES-D) and the GDS in
identifying depressive sylnptOJns in black
and white patients with established depressive disorders. We will also consider the
association of functional level and social
support with the presence of depressive
synlptoms in this sample.

MEmODS
Psychiatric patients with DSM-III-R diagnoses of affective disorders-depressed and
diagnoses of delnentia were recruited for
the study.2H Persons age 50 and older adnlitted to a 16-bed, geriatric psychiatry inpatient
unit of a university teaching hospital and a
conl111unity Jllental health center between
July 1, 1992 and December 31, 1993 with the
criterion diagnoses were referred by their
therapists. Each patient was contacted by a
111enlber of the research tealn, an appoint111ent was scheduled, and infornled consent
was obtained.
Diagnoses of affective illness were confirnled by the adIninistration of the Structured Clinical Intelview for the Diagnostic
and Statistical Manual-3rd Edition (SCID).29
All consenting patients with a SCID diagnosis of affective disorder and a DSM-III-R
diagnosis of dementia were adtnitted to the
sUldy.
All patients received an admission
screening battery that consisted of the Short
Psychiatric Evaluation Schedule (SPES)t 30
the Physical Self-Maintenance Scale
(PSMS),3 1 the IADL,32 and the Lubben Social
Network Scale. 33 These were adIninistered
to determine each patient's functional level
and current social support system. The
screening battery consisted of the 20-item
CES-D,3'i the 15-itenl GDS t 35,36 the Mini-Mental State Exanlination (MMSE),37 and the
ShOlt Portable Mental Status Questionnaire
(SPMSQ).3H The SPMSQ and the MMSE were
used as screening instruments for the assessnlent of cognitive dysfunction and the
THE MIEIUCAN JOURNAL OF GERIATRIC PSYCHIATRY

GDS and the CES-D were used to screen for
the presence of depressive sytnptoll1s.
The GDS was selected because of its
ease of adtninistration (forced-choice, yesor-no response) and administration time of
approxitnately 5 Ininutes. It has been used
for atnbulatory, conlmunity residents age 55
and older,15.36 as well as in studies of nursing
hOlne residents. 14,39 There are scarce data on
the use of the GDS anlong older, black
Americans. 15 ,25,26 In contrast, the CES-D has
been used to screen several sanlples of
cOlnn1unity resident t black Americans age
50 and older.((Q These studies of mixed-aged
sanlples of black subjects were completed
in cities and counties from Florida County,
FL, to Los Angeles, CA. By use of threshold
scores varying froln 16 to 25 as evidence of
the presence of depressive sympt01l1S, rates
of depressive synlptolns ranging from 12.8%
to 29°;6 were reported by the five studies of
c0111munity resident satnples. These instruments were selected to nlaintain cOlnparability with the published literature, and their
usual threshold scores were used in this
study.
This article reports on comparisons of
the GDS and the CES-D in the identification
of depressive synlpt01l1S in psychiatric patients with SCID-confirmed depressive disorders.

RESULTS
Thirty-nine patients age 50 years and older
with diagnoses of depression consented to
participate in this study. Of the 39 patients
with depressive disorders, 51 % (12 = 20)
were between the ages of 70 and 99 years,
and 77% (n = 30) were W01l1en (Table 1).
Forty-nine percent (n = 19) of depressed
patients were black. Twenty-seven percent
of depressed patients (n = 10) were psychiatric outpatients from the community Inental
health center. There was no statistically significant difference in age between the older
black and white subjects (X2U) = 0.23; P =
0.634; Table 1). Psychiatric inpatients and

45

Screening Tests for Depression

outpatients had an average of two 111edical
problems, and all were receiving treatment
for their depressive disorder at the tinle of
participation in the study. Psychiatric inpatients were approached to participate in the
study an average of 2 weeks into their
hospitalization, depending on the severity
of their depressive disorder (range: 4-23
days). Fifty-one percent (11. = 20) of the total
sample were widowed. There was no statistically significant difference in lnarital statlls
(Table 2) between the two racial groups
(Fisher's exact test, two-tailed, P= 0.41).
More WOlnen (n = 17) than Inen (n = 3)
were widowed (Fisher's exact test, twotailed, P = 0.02).
The Inedian reported education for the
depressed patients was 9 years, with a range
of 1 year to 21 years (Ph.D.). The current
median reading level \vas 8 years, with a
range of 4 years through > 8th grade.
T\venty-seven percent of depressed patients
(n = 8) were reading below their reported
education level: six black women, one
white tnan, and one white wonlan. These

patients were reading at a median of four
grades below their reported education
level.
Eighty-five percent of patients with an
affective disorder (n = 33) had major depressive disorder. Of the remaining patients
with an affective disorder, 8% (11 = 3) had
bipolar disorder, depressed and 30/0 were
diagnosed schizoaffective, depressed (n =
1). Five percent of depressed patients had
an acljustnlent disorder with depressed
nlood (n = 2).
Seventy-four percent of depressed patients (29/39) had CES-D scores of 16 or
higher, the usual cut-point for the presence
of depressive sylnptolns (Table 3). Only
fifty-six percent of depressed patients (n =
22) had GDS scores of 6 or higher, the usual
cut-point for the presence of depressive
symptoll1S for the GDS. Thus, the sensitivity
of the CES-D for all depressed patients was
740/0, contrasted with a sensitivity of 56% for
the GDS. Because the sample consisted
only of depressed patients, specificity could
not be estinlated.

TABLE 1. Comparison of age and race for total sample of depressed patients,,, (%) (N = 39)

Black
10 (26)

50-69

Total Sample

White

9(23)

Age

19 (49)

70-99

9 (23)

11 (28)

20 (51)

Total

19 (49)

20 (51)

39 (100)

X2(11 = 0.2271; P= 0.634 (NS).
Race and gender distribution of the sample, " (%)
Black \VOnlen

15 (38.5)

4 (10.0)

Black Incn
\"(Ihite ,voluen

15 (38.5)

\'(Ihite 111cn

5 (13.0)
39 (100)

Total
TABLE 2.

Marital status by race,:' II (%)
Black

White

Total Sample

4 (10)

3 ( 8)

7 (18)

Single

15 (38)

17 (44)

32 (82)

Total

19 (48)

20 (52)

39 (100)

Ivlarricd

;l

Fisher's Exact Test t t\vo-tailed = 0,41 (NS).

46

VOl.UME

3 • NUMBER 1 • \VINTER 1995

Bakeret aJ.

Table 3 shows CES-D and GDS score
differences by racial group. Only 12 of 19
depressed black patients had CES-D scores
of 16 or higher, screening positive for depression. This gave a sensitivity of 63°h.
When the two patients with a diagnosis of
adjustment disorder with depressed 11100d
(a nli1d depressive disorder) were deleted
froll1 the black subsanlple of 17, the sensitivity of the CES-D improved to 71% (Table
3.) Seventeen of the 20 depressed, older
white patients had CES-D scores of 16 or
higher, a sensitivity of 850/0.
By use of the reported threshold score
of 6 or higher on the GOS as evidence of
depressive synlpt0111S, only 9 of 19 depressed black patients were identified as
having depressive syJnptonlS, a sensitivity
of 47°,.1). In contrast, 13 of 20 depressed
white patients had GDS scores of 6 or
higher, a sensitivity of 650/0 (Table 3). Thus,
the GDS (56% ) was 1110re effective than
chance (500/0) in identifying depressive

symptoms in the total salnple. Among depressed older white patients, the sensitivity
of 65% was at a less-than-desirable level for
a screening instrunlent) and in black depressed patients, it was only 47 % • In contrast, the CES-D was a more effective
screening instnunent for depressive symptoms in both older black (with a sensitivity
of 710/0) and older white patients (sensitivity
of 850/0) in this sanlple.
The CES-D and the GDS were COll1pared in their effectiveness in the identification of depressive synlptolns (Table 4),
using McNenlur's test. The CES-D was 1110re
effective in the identification of depressive
syn1ptoll1S in clinically depressed patients
than was the GOS (P= 0.008). Seven depressed patients identified by the CES-D
were Inissed by the GDS, whereas the GDS
identified no patients missed by the CES-D.
Because increasing inlpairn1ent in level
of functioning is correlated with an increased report of depressive synlptoms in

TABLE 3. Comparative sensitivities of the CES·D and GDS among older dcpressed3 patients, II
CES-D

Depressed

Black
\Vhite
Tot:tl

Sensitivity

CES-D+

19 (17)

12 (12)

630/0 (71°1'0)

20

17

850/0

39 (37)

29 (29)

GDS+

740/0 (780/0)

9
13
22

GDS
Sensitivity
47%

65%
56%

J\'ole: CES-D+ = depressed patients \vith Center for Epidenliologic Studies Depression Scale (CES-D) score ~ 16.

GDS+ = depressed patients \vith IS-itcln Geriatric Depression Scale (GDS) score

~

6.

black patients \vith a diagnosis of adjustnlcnt disorder \Vilh depressed nlood, a (nUder depressive
disorder, \vere renloved fronl the IlDepressed" category, a nc\v total of 17 subjects and u sensitivity of 71 % for
the CES-D resulted.)
U Diagnosis of depression based on SCID intervic\v.

(\X'hen

t\VO

TABLE 4. Comparlsona of Center for Epidemiologic Studies Depression Scale (CES-D) scores and
15-item Geriatric Depression Scale (GDS) score categories for the total sample (N 39)
J:I

CES-D Score-

0-15

CES..D Score+
16-60

10

7

17

0

22

22

10

29

39

Total

GDS score-

O-S

GDS score+

6-15

Total

a McNenlur's test of paired associates, p;:: 0.008.

THE AMERICAN JOUUNAL OF GERIATRIC PSYCHIATRY

47

Screening Tests for Depression
the literature,I.10,25 particularly anl0ng older
black patients, the CES-D scores and the
GDS scores were correlated with the IADL
scale score and the PSMS scale scores.
There was no statistically significant relationship observed for the CES-D and IADL
scores (Fisher's exact test, two-tailed; P =
0.212) or between CES-D scores and PSMS
scores (Fisher's exact test, two-tailed; P =
0.438). The correlation between IADL scale
scores and GDS scores of 6 or higher was
not statistically significant (Fisher's exact
test, two-tailed; P= 1.000) nor was that between PSMS scores and positive GDS scores
<X 211) = 2.408; P= 0.121).
There was no significant association
between positive CES-D scores and Lubben
Social Network Scale scores of 20 and less
(at-risk social networks [Fisher's exact test,
two-tailed; p= 1.000D. When GDS scores
were cotuparecl with the scores on the
Lubben Social Network Scale, a sinlilar absence of association was found (X2111 =
0.011; p= 0.917).
When the scores of the CES-D were
c0l11pared with the repolted educational
attainnlent of the sanlple education of S 9
years was associated with a positive CES-D
score CX 2131 == 8.769; p= 0.033). An analysis
of educational attaintnent and GDS scores
found no association (X 2131 = 5.364; P =
0.147).
When the scores of the SPES of PfeiffetJO were cOlnpared with the CES-D scores,
a positive SPES score indicating the presence of psychiatric synlptonls and enl0tional turnl0il (scores of 5 or higher) was
associated with a positive CES-D score
(Fisher's exact test, two-tailed; P < 0.0001).
A significant positive relationship was also
found between SPES scores and GDS scores
2
(X 1i1 = 4.821; P= 0.028).
t

t

DISCUSSION
The results of this preIinlinary study 1l1USt
be viewed with caution because of our srnall
sanlple size. I-Iowevef, even with the snlall
48

sample size t a statistically significant (P =
0.008) difference was observed between the
CES-D and the GDS in the correct identification of depressed patients as having
sytnptonls of depression. Only the CES-D
denl0nstrated acceptable levels ofsensitivity
in both black and white patients.
These preliminary results suggest that
the 20-item CES-D instrument would be
preferable to use as a screening instrument
for depressive symptolTIs in a sample comprising older black and white patients. Although the sensitivity in older black patients
is 1110dest (71%), it is significantly better
than the 47% of the GDS in this limited
sa111ple of older, black depressed patients.
The sensitivity of the CES-D (85%) in older
white patients is robust. The 65% sensitivity
of the GDS in older, white depressed patients is less than desirable for a screening
instrull1ent. The CES-D may be a 1110re effective screening instru111ent for both black
and white Anlerican patients because it includes itenlS on sleep disturbance C'My
sleep was restless."), hypervigilance (UPeopIe were unfriendly. n and "I felt that people
disliked Ine."), and crying (UI had clying
spells.") that were 1110re likely to be reported by depressed black patients in this
s31nple. A detailed c0111parison of itell1S that
were 1110re frequently endorsed by both
black and white depressed psychiatric patients is in process.
Originally developed to screen C01111nlloity resident elderly for the presence of
depressive sytnptolTIs,35,36 the GDS has been
used in nledically ill patients}j and nursing
haole residents39 \vith ll1ixed results. Because 270/0 of this sanlple were psychiatric
outpatient residents in the C0I11111unity, our
results suggest that for use in both psychiatric outpatients and inpatients with depressive synlptonls, the GDS tnay not be reliable
in identifying the presence of depressive
SYI11ptOll1S; this is a finding consistent with
,
prior stlldies. 11 ,15.3 j
A relationship between increased ill1pairnlent in functional level and an increased report of depressive Sy1l1ptOll1S was
VOLUME

3 • NUrvlBEH 1 • \VINTER 1995

Bakeret al.

not observed in this sample. This contrasts
with findings in the existing literature. 1,10.25
These psychiatric patients' level of functioning was less inlpaired, however, than the
sample of nlfal elderly people described by
Mitchell et a1. 25
Although 420/0 of the salnple (11 = 16)
had social network scores that placed them
at risk, there was no correlation between an
at-risk social network and screening positive for depression with either the CES-D or
the GDS. Because of our slnall sall1ple size,
additional studies with a larger sanlple size
are indicated.
The association between lower educational level and the report of depressive
sYlnptoms in this sanlple confirll1s this finding of prior investigators 13 ,25 and 111ay be
confounded by the consequences of lower
educational attain111ent, that is, lower Iifetirne earned inC0111e and poorer health,
housing, and diet. The discrepancy between repolted education and current reading level ll1akes this finding of particular
concern because these older people will
have further difficulty in negotiating billpaying, cOll1pleting Medicare and Social Security forn18, and providing informed
consent The inlplications of these results
have been discussed in a separate paper:11
The detection of the presence of depressive sytUpt0l11S anl0ng cOffilnunity resident and medically ill older people is of
crucial concern because of the resulting
tllorbidity that ll1ay be associated with depressive sympt0I11s. The ability to screen
both black and white older persons for the
presence of depressive synlpta111s would
facilitate the early diagnosis of depressive
syn1ptonls and enable physicians to refer
those patients for psychiatric evaluation to
establish the specific disorderCs) present
and reC0111111end appropriate treatment. 2,20,21
In a follow-up to the results of this snldy, 66
older, black 111edical clinic patients were
screened with the CES-D. 1"hirty-two percent screened positive for the presence of
depressive synlpt0111S, and 11°;'0 had an affective disorder, according to the DSM-III-R
THE AlvIERICAN JOURNAL OF GEIUATRIC PSYCHIATRY

checklist. Differences in verbal and nonverbal behaviors between older, depressed
black and white patients were identified. 42
The statistically significant correlation
between positive scores on the SPES and
positive scores on the CES-D and GOS suggests the pOSSibility of using the SPES as
either an alternative screening instnl111ent or
an adjunctive screening instnlluent with the
CES-D to confinn the presence of significant
intrapsychic distress. Further studies with
the SPES in nonpsychiatric, older populations are needed to establish the extent of
it~ usefulness.
Because of their ll1ultiple, chronic tnedical problen1s and increasing nU111bers,
older black An1ericans are at an ever-increasing risk for the developluent of depressive sytnptolns. These 111edical problell1s
often result fronl 111ininlal health care in
earlier years because of segregated health
facilities and lower incolnes,18,37 poor diet,
and increased risk for accidents and exposure to environn1ental toxins~ Because the
changing den10graphic profile of the older
United States population projects a significant increase in nonwhite groups over the
next 30 years,I6 we need to pay increased
attention to establishing and developing effective 111ethods of screening for the presence of depressive sYlnptoll1s and cognitive
inlpairnlent in different ethnic populations.
We encourage other investigators to assess
the effectiveness of various screening instfull1ents for depression in populations of
"ethnic" older people, that is, black At11erican, A111erican Indian and Alaska Native,
Asian-A111erican and Pacific Islander, and
I-Iispanic-All1erican older persons. We encourage other investigators to C01l1pare the
CES-D and GDS instru111ents in sanlples of
older patients with SCID-confirnled depressive disorders.

771e authors acknolvleclge the support provicleel bJJ the At/entCiI Disorclers of the Aging
Research BrCl11Ch of the National Institute oj
Mental J-[ecllth through Grant 2K07
A1/-J00816-02.

49

Screening Testsfor Depression
These data were presented at the Seven.th AunuCiI Meeting ofthe A111erican Asso-

ciation. for Geriatric Psychiatly in Tal11jJa,
FL on Februaly 19, 1994.

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2. Dlazer DG: Affective disorders in late life, in Geri~ltric Psychiatry. Edited by Busse E\X', Blazer DG.
\Vashington, DC, Anlcrican Psychiatric Press, 1989,
pp 369-401
3. \Veissman MM, Klennan GL: Depression: current
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International Journal of Geriatric Psychiatry (in
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