INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL.

12: 2125 (1997)

A SPANISH VERSION OF THE GERIATRIC DEPRESSION SCALE IN MEXICAN-AMERICAN ELDERS

Professor, University of Maryland, USA Associate Professor, Department of Family Practice, University of Texas Health Science Center at San Antonio, USA
DAVID V. ESPINO F.M. BAKER

ABSTRACT
Objective. The purpose of this study was to establish the sensitivity of a Spanish translation of the 15-item Geriatric Depression Scale (GDS-S) in a sample of 41 elderly Mexican-American psychiatric patients with a diagnosis of depressive disorders. Method. Utilizing the reverse translation technique and bilingual Mexican-American psychiatrists as evaluators, patients with DSM-III-R diagnoses of aective disorder who were sequential admissions to an inpatient psychiatric unit were enrolled in the study. The GDS-S was administered by trained interviewers within 24 weeks of admission to 28 patients with major depressive disorder (MDD) and 13 patients with other depressive disorders (ODD). No other screening instruments for depressive symptoms were used. Results. Using the original cut-scores of GDS, the sensitivity was 39% in patients with MDD and 77% in patients with ODD. When a revised cut-score of 4 and above was identied as reective of depressive symptoms, the sensitivity improved to 75% for patients with MDD and 85% for patients with ODD. Because there were no true negatives, specicity was not determined. Conclusions. The GDS-S may have limited value in screening community-resident Mexican-American elders for depressive symptoms unless they have signicant medical problems which limit their function and are associated with a dysthymic disorder. Screening instruments for depression which include neurovegetative or somatic items may be a better choice in this population.
KEY WORDS Geriatric

Depression Scale; Spanish; survey

Hispanic Americans comprise 8% of the total population of the United States (National Center for Health Statistics, 1991). Cuellar notes that Hispanic Americans are a heterogeneous population which includes various national, ethnic and racial groups (Cuellar, 1990). Mexican Americans comprise the largest group of Hispanic Americans (Cuellar, 1990; Jimenez and de Figueiredo, 1991). Persons over age 65 are a rapidly increasing segment of this population; 4.2% of Mexican Americans are age 65 and older (Angel and Hogan, 1991). Mexican-American elders have a higher prevalence of hypertension, obesity, diabetes mellitus
*Address for correspondence: Dr F. M. Baker, Department of Psychiatry, University of Maryland School of Medicine, 645 Redwood Street, Baltimore, Maryland 21201-1549, USA CCC 08856230/97/01002105 # 1997 by John Wiley & Sons, Ltd.

and cardiovascular disease in comparison to white Americans (Espino, 1990; Espino et al., 1991; Task Force on Black and Minority Health, 1985). The morbidity associated with medical illness as well as chronic disease has been shown to increase the risk for the development of a major depressive disorder (Cassem, 1988; Ruegg et al., 1988; Alexopoulos et al., 1988; Rosenthal et al., 1987). A few studies have addressed the presence of psychiatric symptoms and disorders among Mexican Americans of mixed age. Kemp et al. used a modication of the Comprehensive Assessment and Referral Evaluation (CARE) items in a probability sample of 700 Hispanic elders in Los Angeles County (Kemp et al., 1987). Twentysix per cent of this sample met the criteria of the Diagnostic and Statistical Manual, Third EditionRevised (DSM-III-R) for depression and
Received 30 November 1992 Accepted 8 December 1994

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F. M. BAKER AND D. V. ESPINO

dysphoria (American Psychiatric Association, 1987) that was strongly correlated with medical disability and with dementia. In patients without these associated disorders only 5.5% were found to have depressive illness. Data from the Los Angeles site of the Epidemiologic Catchment Area Survey (Burnam et al., 1987) reported a signicantly higher prevalence rate of phobic disorder among Mexican-American women age 40 and older compared to other agesex groups. Other investigators (Mendes de Leon and Markides, 1988) found comparatively low levels of depressive symptoms, particularly among males, using the Center for Epidemiologic Studies Depression Scale (CES-D) to screen 1074 Mexican Americans of three generations. In a triracial study of adult patients (Mexican American, African American and white Americans), the Diagnostic Interview Schedule (DIS) was used to establish the presence of depression or anxiety. In 14.3% of women over age 65 depression or anxiety was found (Hoppe et al., 1989). Garcia and Marks (1989) analyzed data from the Hispanic Health and Nutrition Examination Survey collected between 1982 and 1984 in ve southwestern states. A total of 3084 MexicanAmerican adults between the ages of 20 and 74 were interviewed with the CES-D. These authors found that persistent hopelessness about the future, lack of enjoyment of life and feelings of self-deprecation were more prevalent among Mexican Americans than white Americans. Persons with less adaptation to American culture were found to have a higher prevalence of these symptoms. In this study, the overall CES-D scores across all ages and between sexes were lower than reported in other studies. Only 17% of women and 7.4% of men had scores of 16 or higher (usual threshold for depressive symptoms). These authors cautioned that internalized cultural values and perceived sanctions could inuence responses to specic items on the CES-D and warned that these should be interpreted with caution. Given the studies that demonstrate the presence of depressive symptoms and conditions that increase the risk for depressive symptoms among Mexican-American elders, a screening instrument dierent from the CES-D to identify the presence of depressive symptoms among Mexican-American elders was sought. The 15-item Geriatric Depression Scale (GDS) was developed (Yesavage and Brink, 1983) from the initial 30-item GDS (Sheikh and Yesavage, 1986) to provide such a screening

instrument to assess depressive symptoms in older populations. Somatic complaints and neurovegetative changes were deleted from the GDS because these items could be positive in the elderly on the basis of normal age-related changes as well as due to medical illnesses and the eects of prescribed medications. We report on a study that assessed the reliability and validity of a Spanish translation of the 15-item GDS (GDS-S) in a sample of Mexican-American elders with established DSM-III-R diagnoses of aective disorder. METHODOLOGY Awareness of and sensitivity to specic cultural denitions of illness and treatment are crucial concerns in the studies involving persons of varying cultures (Baker, 1990). Cultural factors can inuence the threshold of symptoms that result in the seeking of health care and the specic individual (traditional healer curandero) or physician approached for treatment (Baker, 1990; Espino et al., 1991; Martinez, 1988). In order to minimize the potential for cross-cultural eects, consecutively admitted Mexican-American elderly patients hospitalized on an inpatient psychiatric unit with predominantly Mexican-American bilingual sta were recruited for this study. Psychiatric diagnoses of Mexican-American elders were made based upon a clinical interview of the patient and the patient's family members and a review of the patient's medical records to establish the specic DSM-III-R diagnoses/diagnoses present. All diagnoses were made by bilingual Mexican-American psychiatrists who had worked for several years with Mexican-American elders in San Antonio, Texas, and who were aware of the cultural context of the older patient as well as their non-verbal behavior. The reverse translation of the GDS-S developed for this study was based on the input of community-resident elders as well as Mexican-American physicians who were natives of San Antonio. A Spanish translation of the 15-item GDS was administered to the consenting Mexican-American elders with diagnoses of aective disorder by volunteers from the San Antonio chapter of the American Association of Retired Persons (AARP). These AARP members were community-resident, Mexican-American elders who received specic training in the administration of the GDS-S. Interrater reliability was established at 94%.

THE SPANISH GERIATRIC DEPRESSION SCALE

23

RESULTS The study sample was composed of 41 patients: 23 men and 18 women. The median age was 74 with a range of 6298 years (Table 1). The sample was divided into two groups: patients with a DSM-III-R diagnosis of major depressive disorder (N 28; 68%) and patients with other DSM-III-R depressive disorders (N 13; 32%). In the group of patients with major depressive disorder (MDD), 18 patients (44%) had a delusional depression and six of these (33%) had a recurrent aective illness. In the group of patients with other depressive disorders (ODD), six patients of the 13 (46%) had a diagnosis of organic mood disorder due to stroke, hypothyroidism, B12 deciency or Parkinson's disease. Three of the 13 (23%) had a diagnosis of dysthymic disorder. Two patients (15%) had a major depressive disorder with panic attacks and two patients (15%) had a diagnosis of bipolar disorder, depressed. The most frequently reported medical problems were non-insulin dependent diabetes (N 11; 27%), hypertension cardiovascular disease (N 11; 27%), chronic obstructive pulmonary disease (N 6; 15%) and cerebrovascular accidents (N 5; 12%). The most frequently prescribed medications were antidepressants (nortriptyline: N 23; 56%, desipramine: N 5; 12%, amitriptyline: N 4; 10%), antipsychotics (haloperidol: N 15; 37%, perphenazine: N 4; 10%, thioridazine: N 2; 5%), antianxiety agents (lorazepam: N 5; 12%) and others (N 4; 10%). Twenty-four per cent of the sample (N 10) had their medication changed (usually during the fourth to sixth week of hospitalization) due to non-response to an antidepressant. Five patients (10%) were changed from nortriptyline to desipramine and two patients (5%) from doxepine and amitriptyline to trazodone and nortriptyline, respectively. In this sample, the total GDS-S score ranged from 1 through 14. Using the original cut-scores (05 normal; 610 mildly suggestive of depression; 1115 strongly suggestive of depression (Table 2)), 39% of the MDD group (11 of 28) screened positive for depression symptoms. Seventy-seven per cent (10 of 13) of the ODD group screened positive for depressive symptoms. The dierence between the MDD and ODD groups was greater than a p value of 0.10, but the dierence was not statistically signicant at the 0.5 level (12 2.8273; df 1). Because there were no true negatives in our study design, specicity was

Table 1. AgeGender Distribution of the Sample

Age group 6064 6574 7584 8599 Totals N 2 9 9 3 23 Men % 9 39 39 13 56 Women N % 1 9 5 3 18 5 50 28 17 44 Total N % 3 18 14 6 41 7 44 34 15 100

Table 2. Comparison of results of total scores of GDS-Soriginal threshold. Scores of 6 and above suggestive of depressive symptoms
05 Normal N Major 17 Depressive Disorders Other 3 Depressive Disorders Totals 20 % 61 010 1115 Totals Mildly Strongly suggestive of suggestive of depression depression N % N % N % 9 32 2 7 28 100

23

62

15

13 100

49

17

41

10

41 100

Table 3. Comparison of results of total scores of GDS-Srevised threshold. Scores of 4 and above suggestive of depressive symptoms
03 Normal N Major Depressive Disorders Other Depressive Disorders Totals 7 % 25 GDS-S Scores 415 Suggestive of depression N % 21 75 Totals N 28 % 100

15

11

85

13

100

22

32

78

41

100

not calculated. Using a revised threshold of scores of 4 or higher suggestive of depression (Table 3), 75% of the MDD (21 of 28) and 85% of the ODD group (11 of 13) screened positive for depressive symptoms. The dierence between the groups was not statistically signicant (12 0.1614; df 1).

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F. M. BAKER AND D. V. ESPINO

When the frequency of positive response to individual items was assessed, 76% (N 31) of the sample reported having dropped many of their activities and interests. Seventy-one per cent of the sample (N 29) stated that they preferred to stay at home. Sixty-three per cent of the sample (N 26) stated that they thought that most people were better o than they were. Fifty-one per cent of the sample (N 21) reported that they were often bored and that they felt that their lives were empty. DISCUSSION Although there are limitations to this study, there are specic strengths. This is one of the few studies that has used a screening instrument for depression in a sample of Mexican-American elders with known DSM-III-R psychiatric diagnoses in order to assess its reliability. Our research design was developed to minimize the eect of cross-cultural miscommunication by choosing a site with bilingual Mexican-American sta with bilingual Mexican-American psychiatrists. Thus, understanding the cultural nuances and non-verbal communication of the Mexican-American elder was optimized. The prevalences of medical illnesses were similar in the MDD and ODD group, with non-insulin dependent diabetes mellitus present equally in each group. The ODD patients had greater functional disability due to medical illnesses (eg severe osteoarthritis, nephropathy and neuromuscular esophageal dysfunction). Among patients with MDD who screened negative on the GDS-S with the original scores, three patients had malignancies and one patient had severe lung disease. The better sensitivity of the GDS-S in the ODD group may reect the secondary dysthymia associated with medical illness (Blazer et al., 1987). The recent review of depression associated with Parkinson's disease was found to be dierent from the depression of MDD. Guilt, self-blame, or feelings of failure or punishment were not seen in depression associated with Parkinson's disease. The pattern of increased levels of dysphoria and pessimism about the future, irritability, sadness and suicidal ideation seen in depressed Parkinsonian patients is similar to the pattern of depressive symptoms reported by these Mexican-American elders. Further studies will be necessary to conrm that among Mexican-American elders, elders with depressive symptoms in the context of medical

illness will screen positive on the GDS-S in contrast to Mexican-American elders with only MDD. It is possible that the spectrum of depressive illness is a crucial consideration. Mexican-American elders with severe depression (MDD) in this sample reported a decrease in activities and interests, a preference to stay at home and that they were worse o than other people. The GDS-S in its design eliminated questions related to somatic complaints. Given the suggested dierence in sensitivity between the MDD and the ODD groups, it would be of interest to establish whether the MDD group reported more somatic symptoms than the ODD or manifested another presentation of depressive illness not assessed by the GDS-S questions. Perhaps, the observed depressive illness is closer to the model of depression hypothesized for Parkinson's disease. Our ndings suggest that among Mexican-American elders depressive illness is a complex process requiring further clarication, with specic attention to those with and without medical illnesses which limit functional status. ACKNOWLEDGEMENTS The authors wish to acknowledge the outstanding contribution made to this study by Mr Dennis Fabrizio in his role as research assistant. The success of our project was due in a signicant manner to his eorts. The study was supported in part by the South Texas Health Research Center Grant #15 and by NIMH #2 K07 MH000816-02. REFERENCES
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