Translation, cultural verification and formal validation of the Centre for Epidemiologic Studies Depression Scale – Revised (CESD-R) for young people in Indonesia

Mental health problems among young people are a major public health concern in every country. Worldwide, it is estimated that about one in five adolescents experience a mental health problem annually, but rates are higher in low- and middle-income than in high-income countries. Modelled estimates available from the Global Burden of Disease 2015 study show that mental disorder peaks during adolescence in Indonesia, with these disorders contributing 15 per cent of the total disease burden experienced by this age group.

Reliable and valid psychometric instruments for early detection and to establish population burden and distribution within communities are crucial for effective clinical and public health responses. Most instruments to detect symptoms of mental disorders have been developed and their psychometric properties established in high-income, English-speaking countries. When applied in low- and middle-income countries to groups who speak languages other than English, have a diversity in emotional lexicons or differing familiarity with test-taking, these instruments cannot be assumed to have the same cut-off points to detect clinically significant symptoms or other psychometric properties as among those in the original populations. It is therefore essential to establish the reliability and validity of any psychometric instrument before its use in a new setting. To date, there is no locally validated instrument for screening for common mental disorders among young people in Indonesia. This project aimed to provide a reliable and valid instrument for screening for common mental disorders among young people in Indonesia.

Method

This nested sub-study had two inter-linked components. Component one was the translation, cultural verification and pilot-testing of the Centre for Epidemiologic Studies Depression Scale Revised (CESD-R) and the Kessler Psychological Distress Scale – 10 items (K10). We used a formal, documented, multi-stage method to translate and culturally verify the CESD-R and K10 for Indonesia. Component two was a formal validation study to establish the local psychometric properties of these two scales among young people in Indonesia. The formal validation study was integrated into Project 4 data collection in the Jakarta schools. About 720 young people in Jakarta contributed data to Project 4 by completing a detailed self-report questionnaire that included the CESD-R and K10 Indonesian versions. We randomly selected a sub-sample of 196 students from those who had completed the questionnaires and invited them to complete brief individual diagnostic psychiatric interviews. The diagnostic MINI International Neuropsychiatric Interview for Children and Adolescents modules for major depressive episode, dysthymia, panic disorder, separation anxiety disorder and generalized anxiety disorder were administered by supervised Universitas Indonesia trainees in child and adolescent psychiatry or clinical psychology.

Findings

The translated and culturally verified scales were found to be comprehensible, and meaningful to young people in Jakarta. The data revealed that the Indonesian versions of the CESD-R, K10, and the K6 (a subset of 6 items of K10) have good internal consistency. The CESD-R and the K10/K6 demonstrated good discriminant capacity to detect depression or any depressive or anxiety disorder among 16-18 year old Indonesian adolescents.

This study indicates that the CESD-R is a useful tool for screening for depression and both the K10 and K6 are useful for screening for any depressive or anxiety disorder among Indonesian adolescents. Depression and anxiety disorders commonly co-occur. These mental health problems share most risk factors. They should be addressed simultaneously, especially in primary health care. The K10 and K6 were designed to detect psychological distress as an indicator of either or both depression and anxiety. The results of this study suggest that both the K10 and K6 can be used to screen for any depressive or anxiety disorders, each with high sensitivity and specificity. The K6 is preferable for use in primary health care because it is shorter and has similar good psychometric properties. The CESD-R was constructed to screen for depression only. It is longer than the K10/K6. We would not suggest CESD-R for use in primary health care but for programs or epidemiological studies that focus on depression among Indonesian adolescents.

The research has translated and culturally verified the CESD-R and the K10 and formally validated these tools against the Mini International Neuropsychiatric Interview for Children and Adolescents, a gold-standard structured diagnostic interview, among 196 young people in Jakarta. This is the first study to describe the performance and identify the optimal cut-off points of the CESD-R, K10 and K6 to detect depressive and anxiety disorders among adolescents in Indonesia. The data revealed that these scales have good internal consistency and discriminant ability to detect depression or any depression or anxiety disorders among 16- to 18-year-old Indonesian adolescents. This indicates that the CESD-R Indonesian version is a comprehensible and sensitive tool for screening for depression, and both the K10 and K6 Indonesian versions are comprehensible and sensitive tools for screening for any depression or anxiety disorder among young people in Indonesia.

Outputs

• News article: How we can help detect depression in our teens

Article

• Tran TD, Kaligis F, Wiguna T, Willenberg L, Nguyen HTM, Le M, Luchters S, Azzopardi P, Fisher J (2019), Screening for depressive and anxiety disorders among adolescents in Indonesia: Formal validation of the centre for epidemiologic studies depression scale – revised and the Kessler psychological distress scale. Journal of Affective Studies, 246, 189-184.