Handbook of Assessment in Clinical Gerontology

2007;21:17-30.

Assessment of Depression and Bereavement in Older Adults

Barry A. Edelstein¹, Lisa W. Drozdick²Caroline M. Ciliberti¹

¹ Department of Psychology, West Virginia University Morgantown, WV, USA

² Clinical Assessment, Pearson, San Antonio, TX, USA

Abstract

This chapter provides an overview of conceptual, diagnostic, and practical issues associated with the assessment of late life depression and bereavement in older adults. Commonly used assessment instruments are reviewed, followed by case studies illustrating the complexity of assessing older adults who present with symptoms of depression, complicated bereavement, or both. The need for multidimensional and multi-method assessment, and consideration of the importance of cultural factors are emphasized. Shortcomings of the current DSM-IV diagnostic criteria for depression are noted in light of the age-related differences in symptom experience and presentation.

This chapter addresses the assessment of older adult depression and bereavement. The assessment of depression in older adults can be complicated due to age-related differences in the presentation of depression, comorbid medical and mental health problems, and age-related changes in cognitive functioning. Moreover, available assessment instruments may have less utility with older adults, either because they were developed with younger adults, or because they were developed to meet diagnostic criteria that may not be appropriate for older adults (see Jeste, Blazer, & First, 2005). Consequently, clinicians may be failing to identify depression adequately in older adults and to identify and treat older adults with subsyndromal or minor depression, which involves considerable disability but is not formally recognized as a clinical disorder.

This chapter addresses both depression and bereavement because loss is often a significant contributor to and risk factor for depression, and adults face increasing losses as they move through older adulthood. Depression is a normal response to a significant loss. The depression can last for a considerable amount of time and be functionally debilitating. Bereavement is one of the more significant risk factors for the first onset of depression and recurrent depression in older adults (Bruce, 2002). In light of the clinical significance of bereavement, its increasing likelihood over the lifespan, and the paucity of assessment literature addressing the topic, we have included the assessment of bereavement in this discussion of late-life depression assessment.

Epidemiology of late-life depression

Symptoms of depression tend to be approximately as prevalent in late life as in mid-life (Blazer, 2003). The frequency of depressive symptoms among the oldest old appears higher than among younger adults, although factors other than age (e.g., greater proportion of women, increased cognitive impairment, lower socioeconomic status, greater physical disability) may account for the difference (Blazer, 2003). The prevalence of clinically significant symptoms of depression ranges from 8–16% among community-dwelling older adults (Blazer, 2003). The prevalence of major depression in community-dwelling older adults ranges from approximately 1–4% (Beekman, Copeland, & Prince, 1999). Prevalence estimates for minor depression among community-dwelling older adults range from approximately 4–13%, with the highest estimate found in the Netherlands (Beekman et al., 1995). With minor and major depression combined, Steffens, Fisher, Langa, Potter, and Plassman (2009) found an overall prevalence of 11.19%, with the prevalence being similar for community-dwelling older men and women.

Prevalence estimates of major depression vary across settings, with increases in prevalence as one moves from outpatient to inpatient settings. The prevalence of major depression among older adults seen in primary care settings ranges from 5–10% (Lyness et al., 2002; Schulberg et al., 1998). Among hospitalized older adults, prevalence rates of major depression range from 10–12% (Blazer, 1994; Koenig, Meador, Cohen, & Blazer, 1988). Prevalence estimates for major depression among long-term care residents are even higher, ranging from 12.4% to 14.4% (Parmalee, Katz, & Lawton, 1989; Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001).

These epidemiological findings must be tempered by the questionable adequacy of our current diagnostic system for older adults (see discussion below) and the finding of different relations between age and depression across studies. Researchers have noted varied relations between age and depression, including negative linear, curvilinear, and positive linear relations (Nguyen & Zonderman, 2006). Nguyen and Zonderman suggest that the differences in relations can be attributed, in part, to the nature of the assessment measures employed. Measures of depressive symptoms reveal a negative linear relation or positive curvilinear relation. Such relations suggest fewer symptoms of depression as one ages, or increased symptoms among younger and older adults when compared with an intermediate age group. The authors note that when diagnostic measures of major depression are used, there tends to be a positive linear or negative curvilinear relation between age and depression. Thus, major depression increases with age, or is lower among younger and older groups when compared with an intermediate age group.

Conceptual approaches to assessment

The assessment paradigm employed by the clinician determines the assessment methods and instruments employed, the questions addressed, and the integration and use of the assessment results (Edelstein, Martin, & Koven, 2003; Edelstein & Koven, in press). Haynes and O'Brien (2000) have defined an assessment paradigm as a set of principles, beliefs, values, hypotheses, and methods advocated in an assessment discipline or by its adherents (p. 10). Two conceptually distinct paradigms are the traditional (e.g., trait-oriented, psychodynamic) and the behavioral (e.g., behavior–analytic, cognitive–behavioral). One can distinguish between traditional and behavioral paradigms through an examination of how each explains or accounts for behavior. More traditional approaches tend to emphasize an individual's dispositional characteristics (see Mischel, 1968) or hypothetical constructs (e.g., anxiety, depression), which are inferred from the individual's self-reports and observed behavior (Edelstein, Woodhead, Bower, & Lowery, 2006). Such approaches to psychopathology often include exploration of an individual's feelings or affective states.

Behavioral approaches tend to be more contextual and emphasize descriptions of environmental conditions under which the behavior of interest is more or less likely to occur. A behavioral account of an individual's behavior involves a description of the conditions under which the behavior occurs (see Edelstein & Koven, in press). More emphasis is placed on the variables controlling the behavior of interest, and less emphasis is placed on characteristics of the individual. It is important to note that behavioral approaches do not discount the role of cognitions or private events; however, they do not consider cognitions to have causal efficacy. Cognitions are treated as any other behavior, whether observable or not. For the purposes of the present discussion, emphasis is placed on behavioral assessment that relies primarily on direct observation of overt behaviors.

One might also distinguish between traditional and behavioral approaches by considering the distinction between nomothetic and idiographic approaches to personality assessment (see Allport, 1936). Traditional approaches are more closely aligned with a nomothetic approach, which involves an examination of the commonalities among individuals. This approach underlies classification systems such as the Diagnostic and Statistical Manual–Fourth Edition (DSM-IV) (American Psychiatric Association, 1994). In contrast, behavioral approaches are more similar to the idiographic approach, which is used to ascertain the uniqueness of an individual.

Traditional and behavioral approaches and instruments are often combined. For example, one might administer a self-report depression inventory and examine the individual item responses to gain an individualized understanding of the individual's mood. The total score on the instrument may also be compared with that of a normative sample to enable one to make a judgment about whether the individual's score is below or above a cutoff score that signals a clinical level of depression. Each approach has its strengths and weaknesses.

As one moves from cognitively intact to cognitively impaired older adults, one must rely more on the direct observation of behavior, because the self-reported experiences of depression become unreliable and/or invalid, and eventually unavailable as cognitive skills diminish. Nomothetic assessment instruments must now depend upon the inferences of clinicians based on direct observations of the older adult. Mood and other symptoms must now be inferred from overt behavior. The question of why an individual is reporting particular experiences and engaging in particular behaviors can no longer be answered by questioning that individual. The nomothetic and idiographic assessment methods tend to converge on the observation of behavior.

Definition and Diagnostic Issues

Jeste et al. (2005) cogently argued that age-appropriate diagnostic criteria are needed for the major DSM psychiatric diagnoses. This issue is particularly salient for the diagnosis of late-life depression, as older adults often present a different array or profile of symptoms than younger adults (Caine, Lyness, King, & Connors, 1994; Fiske & O'Riley, 2008). For example, older adults are less likely than younger adults to report suicidal ideation (Blazer, Bachar, & Hughes, 1987), guilt (Gallo, Rabins, & Anthony, 1999; Musetti et al., 1989; Wallace & Pfohl, 1995), and dysphoria (Gallo, Anthony, & Muthen, 1994; Gallo et al., 1999). In contrast, older adults are more likely than younger adults to report hopelessness and helplessness (Christensen et al., 1999), somatic symptoms (Gallo et al., 1994), psychomotor retardation (Gallo et al., 1994), weight loss (Blazer et al., 1987), and loss of appetite (Blazer et al., 1987).

The issue of whether somatic symptoms should be considered among the diagnostic criteria for depression among older adults has been somewhat controversial (see Norris, Snow-Turek, & Blankenship, 1995), in part because of the overlap of symptoms of physical disease and somatic symptoms of depression (e.g., low energy, sleep disturbance, diminished appetite and sexual drive). The frequency and severity of medical conditions increase with age and can lead to many of the somatic symptoms included in the diagnosis of depression (e.g., weight loss or gain, insomnia, fatigue). Moreover, depression is frequently comorbid with physical illness and cognitive dysfunction, both of which increase with age.

Several studies reported increased endorsement of somatic symptoms of depression with increasing age and suggest removing somatic symptoms from self-report measures of depression (e.g., Barefoot, Mortensen, Helms, Avlund, & Schroll, 2001; Berry, Storandt, & Coyne, 1984; Bolla-Wilson & Bleecker, 1989; Goldberg, Breckenridge, & Sheikh, 2003; Mahurin & Gatz, 1983). However, many studies suggest that removing somatic items from assessment instruments may result in decreased sensitivity to depression in older adults (Drayer et al., 2005; Kirmayer, 2001; Norris, Arnau, Bramson, & Meagher, 2004). Moreover, somatic symptoms cannot always be attributed to physical disease (Gatz & Hurwicz, 1990; Olin, Schneider, Eaton, Zemansky, & Pollock, 1992; Wagle, Ho, Wagle, & Berrios, 2000). There is evidence to suggest that while changes in appetite and sexual drive may not be indicative of depression among older adults, the remaining somatic symptoms are indicative (Nguyen & Zonderman, 2006; Norris et al., 2004). Clinicians should consider assessing somatic symptoms of depression, although caution should be used when interpreting results obtained in individuals for whom medical issues may be contributing to results.

Several other factors can complicate the assessment of late-life depression, including the onset of symptoms. The time of onset of the first depressive episode of major depression may be related to the nature of depression symptoms (Jeste et al., 2005). The symptoms of first-onset, late-life depression (after age 60) may be different from depression that occurs early in life (before age 60) and recurs in late life (Brodaty et al., 2001).

Older adults can experience symptoms of depression that do not meet criteria for a depression diagnosis, yet are associated with psychosocial and functional impairment similar to that associated with major depression (Beekman et al., 1995; Hybels, Blazer, & Pieper, 2001; Lavretsky, Kurbanyan, & Kumar, 2004). Various authors have argued that depression should be conceptualized along a continuum of severity (e.g., Rapaport et al., 2002), with major depressive disorder at one end, subsyndromal depression at the other end, and minor depression in the middle (e.g., Hybels et al., 2001; Lavretksy et al., 2004). Although subsyndromal depression is not currently classified, minor depression appears in the appendix of DSM-IV. Subthreshold depressions are of particular importance for older adults, as their prevalence increases with age (Judd, Schettler, & Akiskal, 2002). Moreover, in an examination of older primary care patients, Lyness, King, Cox, Yoediono, and Caine (1999) found that the prevalence of subsyndromal depression exceeded that of major depression, minor depression, and dysthymia.

There are two additional presentations of depression that do not meet criteria for major depression, dysthymia, or minor depression, and are thought to be more common in older adults. The first is termed depression without sadness, (Gallo, Rabins, Lyketsos, Tien, & Anthony, 1997) in which individuals present with symptoms of depression (e.g., hopelessness, worthlessness, thoughts of death or suicide) but do not report sadness or loss of interest or pleasure in formerly enjoyed activities. Even though these individuals fail to meet DSM-IV criteria for depression, they are at risk for functional disability, psychological distress, cognitive impairment, and death (Gallo & Rabins, 1999). Similarly, Newmann, Engel, and Jensen (1991) characterized a depletion syndrome with symptoms of loss of appetite, lack of interest, thoughts of dying, and hopelessness (see also Adams, 2001).

Olin, Katz, Meyers, Schneider, and Lebowitz (2002) have argued that the depression that occurs with Alzheimer's disease is different from other depressive disorders and have proposed provisional criteria for depression of Alzheimer's disease. They suggest that the depression observed with Alzheimer's patients is different from depression due to a general medical condition. The outcome of the authors’ proposal remains to be seen. Mayer et al. (2006) compared three rating scales for use as outcome measures in treatment trials of depression of Alzheimer's disease. The Cornell Scale for Depression in Dementia (CSDD) (Alexopoulos, Abrams, Young, & Shamoian, 1988), particularly the mood subscale, appeared to be the best choice for measuring the effects of treatment. The CSDD is discussed later in this chapter.

Multicultural Issues

The racial and ethnic diversity of older adults in the United States is expected to increase with the growing population (U.S. Census Bureau, 2008a), with minority populations expected to become the majority in 2042. This is particularly important to appreciate, as prevalence estimates of depression vary across racial and ethnic groups. Some authors (e.g., Mui, Burnette, & Chen, 2002) have argued that the prevalence data for some racial and ethnic groups are biased due to the low acceptability of measures used to report symptoms in minority populations, and various socio–cultural factors (e.g., tolerance of symptoms). Moreover, norms are often not available for racial and ethnic groups, and psychometric properties are often not available for racial and ethnic groups on assessment instruments that were developed with Caucasian samples. Moreover, there appear to be cross-cultural differences in the expression of depression symptoms (Futterman, Thompson, Gallagher-Thompson, & Ferris, 1997). For example, Japanese individuals tend to report interpersonal complaints, whereas Chinese individuals tend to present somatic symptoms (Krause & Liang, 1992). However, whether these cultural differences are exhibited through old age is unclear at this time. Readers are cautioned to carefully consider the available normative data for racially or ethnically diverse clients, to avoid stereotypes when considering culturally specific information in the assessment process. Interested readers are referred to Sue and Sue (2007), who provide helpful information on working with racially and ethnically diverse populations. Many of their suggestions are particularly useful for understanding perspectives on mental health care by first generation immigrants, and those who maintain a strong cultural identity.

Symptoms of depression vary between community-dwelling African American and non-African American individuals, including endorsement rates for less hope about the future, poor appetite, difficulty concentrating, requiring more effort for usual activities, less talking, feeling people were unfriendly, feeling disliked by others, and being more ‘bothered’ than usual (Blazer, Landerman, Hays, Simonsick, & Saunders, 1998). However, these authors found when such factors as education, income, cognitive impairment, chronic health problems, and disability were controlled, the differences across race/ethnic groups in somatic complaints and satisfaction were minimal. Rates of depression among older adult African American individuals tend to be lower than the rates for Caucasian older adults (Blazer, 2003). Results of the recent Aging, Demographics, and Memory Study (Steffens et al., 2009) revealed a prevalence of depression (minor and major combined) among African Americans that was one-third of the prevalence for Whites and Hispanics. With the exception of a greater number of somatic complaints by African American women, there appear to be no significant differences in the symptoms of depression as expressed by African American and Caucasian older adults (Myers et al., 2002).

The population of Hispanic individuals in the United States is large and diverse, suggesting that any attempt to generalize across Hispanic subgroups would be unwise. The largest Hispanic groups of older adults (65+), according to the U.S. Census Bureau (2006), are Mexican Americans (64%), Central and South Americans (13.1%), Puerto Rican Americans (9.0%), Cuban Americans (3.4%), Dominican Americans (2.8%), and other Hispanics (7.7%). The prevalence of depression among Hispanic Americans is relatively high. A study of depression among older Mexican Americans in the Sacramento area (Gonzalez, Haan, & Hinton, 2001) revealed a prevalence of 24.5% using a CES–D cutoff of 16 or more. The prevalence was higher among immigrants (30.4%) and less acculturated participants (36.1%). In comparison, the prevalence rate for U.S. born participants was 20.5%. In a recent examination of the Health and Retirement Study, Yang, Cazorla-Lancaster, and Jones (2008) found that Puerto Rican American older adults have a higher prevalence rate for major depression (19.3%) than other Hispanic individuals living in the United States; Cuban Americans had the next highest rate (11.7%), followed by Mexican Americans (8.2%).

The population of Asian individuals in the United States is also quite diverse, with level of acculturation playing a role in the prevalence of depression. In a study of acculturation stress and depression among Asian (i.e., Chinese, Korean, Indian, Filipino, Vietnamese, and Japanese) immigrant older adults, Mui and Kang (2006) found that higher acculturation stress was associated with higher depression levels. Similarly, a review by Kuo, Chong, and Joseph (2008) found that depression is prevalent among older adult Asian immigrants, and is linked to a variety of variables (e.g., gender, how long they have been an immigrant, English proficiency, acculturation, health status, social support).

A recent study of 2611 community-dwelling Chinese adults (Niti, Ng, Kua, Ho, & Tan, 2007) in Singapore, aged 55 and older, revealed a 13.3% prevalence of depressive symptoms based upon scores on a Chinese version of the Geriatric Depression Scale (Yesavage, Brink, & Rose, 1983). This rate is similar to the 12.5% rate reported in Hong Kong (Chi et al., 2005) and the 20.1% rate reported in Taiwan (Chiu, Chen, Huang, & Mau, 2005) using the Geriatric Depression Scale. Asian individuals are likely to hold a holistic view of the mind and body (Sue & Sue, 2007). A physical complaint is a culturally acceptable means of expressing an emotional disorder (Sue & Sue, 2007). This is consistent with the finding that somatic complaints are common among depressed Asian individuals (Parker, Cheah, & Roy, 2001).

Depression is a major concern among American Indian older adults (Greer, 2004). However, until recently, information regarding the prevalence of depression among American Indians remained insufficient because few studies had sufficient sample sizes, and some were conducted with nonrandom samples (Beals et al., 2005). Unfortunately, the most recent and carefully conducted epidemiological study of American Indians, the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP; Beals et al., 2005) failed to include individuals over the age of 54. Thus, adequate prevalence estimates for older adult American Indians remain unknown.

One must remember that there are considerable within-group and between-group cultural differences among racial and ethnic groups, and that degree of assimilation, educational experience, and acculturation can yield very different individual clinical presentations. One must be careful not to overgeneralize with regard to behavioral characteristics, cultural values, and the presentations of symptoms when working with an individual client.

Multi-method Assessment

No single method of assessment is consistently superior to any other. Each method (e.g., interviews, direct observation, self-reports, reports by others, psychophysiological recordings) has its strengths and shortcomings. Because of that, using multiple methods and sources of information has been strongly recommended in the assessment literature (e.g., Eid & Diener, 2006; Haynes & O'Brien, 2000) to ensure accurate, reliable, and valid information. This is particularly true when assessing individuals with cognitive impairment. One can avoid, to some degree, the shortcomings of any one method, and capture information unique to any one method, by employing multiple methods. For the sake of simplicity, we have focused on three general methods. The interested reader is referred to Eid and Diener (2006) for a more comprehensive treatment of multiple method measurement.

Self-Report

Self-report is arguably the most popular assessment method. The most commonly used assessment instrument, the clinical interview, employs self-report. It is also the method used for the multitude of questionnaires and inventories designed to examine various forms of psychopathology and cognitive functioning. Clinicians should be sensitive to the specific wording of the questions, question format, and question context, as these can influence self-reports of older adults (Schwarz, 1999; 2003). Older adults are more likely than younger adults to be cautious when responding, give more acquiescent responses, refuse to answer certain types of questions, and respond don't know (Edelstein, Woodhead, Bower & Lowery, 2006). Older adults may also minimize or deny symptoms (Blazer, 2009; Wong & Baden, 2001). The accuracy, reliability, and validity of older adult self-reports is mixed, suggesting that one should be cautious when using the self-report method and, when possible, utilize multiple methods.

There are limited findings which shed light on the adequacy of self-reported information that relates specifically to depression assessment. Older adult self-reports of insomnia, when compared with the results of polysomnography, have been good (e.g., Reite, Buysse, Reynolds, & Mendelson, 1995). In addition, self-reports of activities of daily living by older adults in outpatient settings are strongly related to performance measures (Sager et al., 1992); although the accuracy of estimates of functional ability are mixed (e.g., Rubenstein, Schairer, Wieland, & Kane, 1984; Sager et al., 1992). Among the factors that contribute to the adequacy of older adult self-reports are physical health and acute or chronic cognitive impairment. As one might expect, cognitively impaired older adults often have impaired memory, and are less likely to comprehend questions or the nature of information requested. Moreover, older adults in the earlier stages of dementia often deny memory impairment, and may also deny other symptoms (e.g., Larrabee & Crook, 1989). In contrast, older adults with mild to moderate dementia may offer reliable and valid self-reports when only recent memory is required (see Feher, Larrabee, & Crook, 1992).

Finally, when using self-report measures, it is important to determine the quality of their psychometric support. There are an increasing number of self-report instruments being developed with, and for use with, older adults (e.g., assertiveness, Northrop & Edelstein, 1998; worry, Wisocki, Handen, & Morse,1986; fear, Kogan & Edelstein, 2004; depression, Yesavage et al., 1983; anxiety, Pachana et al., 2007; suicide risk, Edelstein et al., in press). However, clinicians too often adopt self-report measures that were developed with younger adults, and utilize them with older adults without considering their psychometric properties and whether suitable normative data are available.

Report-By-Others

The report-by-other (e.g., spouse, caregiver, adult child) assessment method has many of the strengths and weaknesses of the self-report method. The principal shortcoming is that those reporting on an individual rarely have continuous access to the individual's behavior, both covert and overt. An advantage of including reports-by-other is that they often provide unique and converging information. Information obtained from multiple sources can provide a rich array of information across contexts and time. Reports-by-others become invaluable when assessing cognitively impaired individuals. As one gathers information from various individuals, it is important to remember that these reports are subject to the same potential problems of unreliability, invalidity, and inaccuracy as self-report and other assessment methods. The characteristics of the individual providing the report can influence the accuracy of the information obtained. For example, when Zanetti, Geroldi, Frisoni, Bianchetti, and Trabucchi (1999) compared caregiver reports of patients’ ADLs against direct measurement of the patients’ ADLs, they found that the accuracy of the caregiver reports varied as a function of the caregiver's depressive symptoms and burden level.

Direct Observation

Direct observation is an important source of information, regardless of the patient's level of physical, medical, and psychosocial functioning. One can begin to formulate hypotheses about an individual's functioning by merely watching that individual walk down a hallway, rise from a bed, or formulate a greeting as he or she is met for the first time. The psychomotor speed, characteristics of speech, frequency and duration of eye contact, quality of grooming, and many other characteristics can provide clues as to psychological functioning before the first words are spoken. Does the individual leave his or her bedroom or house? Does he or she continue to engage in once pleasurable activities? Does the individual remain in bed for long periods of time? The number of potentially relevant, observable behaviors is considerable. Direct observation is a source of convergent information that can be incorporated into a multi-method assessment.

Direct observation can be particularly useful when assessing cognitively impaired older adults, and those who are uncooperative with interviews. As with the other assessment methods, direct observation of behavior must be reliable, valid, and accurate. Discrepancies among reports of direct observations should be explored, and training to avoid such discrepancies should be provided if the setting permits (e.g., inpatient medical facilities, long-term care facilities). Techniques for systematically sampling and recording behaviors can easily be taught to hospital or nursing home staff, as well as family members. Observational methods can be tailored to the behavior of the individual and the demands of the caregivers and staff members. Ideally, a list of specific behaviors and symptoms can be provided, rather than asking staff or family members to watch out for symptoms of depression.

Multidimensional Assessment

Late-life depression is a multidimensional problem for older adults, whose health and cognitive, social, adaptive and psychological functioning collectively yield a complex assessment challenge that often requires the expertise of multiple disciplines (see Zeiss & Steffen, 1996). Such an approach to assessment is often termed comprehensive geriatric assessment (Rubenstein, 1995). Support for the assessment of these domains is found in the DSM-IV and in the nursing home assessment recommendation of the Omnibus Budget Reconciliation Act (1987). Multidimensional assessment can lead to improved diagnostic accuracy, more appropriate placement, improved functional status, more appropriate use of medications, improved coordination of services, and improved emotional status (Edelstein et al., 2003). A recent review of the comprehensive geriatric assessment literature (Ellis & Langhorne, 2005) also revealed that such assessments increase the chances of patients remaining at home and avoiding hospitalization.

We have confined our brief discussion of multidimensional assessment to a discussion of functioning in the following domains: adaptive functioning, health, cognitive functioning, and social support. The focus of this chapter is depression, which would fall under the domain of psychological functioning. A broader discussion is beyond the scope of this chapter.

Assessment of Adaptive Functioning

Adaptive functioning is usually defined by an individual's ability to perform activities of daily living (ADLs) (e.g., eating, dressing, bathing) and instrumental activities of daily living (IADLs) (e.g., meal preparation, money management). Numerous medical and psychological disorders, and physical disabilities, can diminish one's adaptive functioning (e.g., depression, dementia, diabetes, Parkinson's disease, chronic obstructive pulmonary disease). Depression can be particularly devastating on the ability to perform activities of daily living (e.g., Penninx, Leveille, Ferrucci, Van Eijk, & Guralnik, 1999). In addition, individuals whose daily activities are already compromised by disease or disability prior to experiencing depression are at increased risk of experiencing diminished adaptive behaviors with the presence of depression. This is particularly a problem for older adults as they transition from community residences or residential facilities to long-term care facilities (Achterberg, Pot, Kerkstra, & Ribbe, 2006).

The relation between depression and adaptive functioning can be reciprocal, as diminished adaptive behaviors can lead to depression (Blazer, Steffens, & Koenig, 2009). Several ADL and IADL assessment instruments are available, including the Katz Activities of Daily Living Scale (Katz, Downs, Cash, & Grotz, 1970), the Adult Functional Adaptive Behavior Scale (Spirrison & Pierce, 1992), the Texas Functional Living Scale (Cullum, Weiner, & Saine, 2009), and the Independent Living Scales (Loeb, 1996).

Assessment of Physical Health

Approximately 80% of older adults experience at least one chronic health problem, with 50% having two or more chronic conditions (He, Sengupta, Velkoff, & DeBarros, 2005). Moreover, approximately 20% of older adults suffer from at least one disability (He et al., 2005). The prevalence of major depression in primary care patients is 5–10%, and 11% for medical inpatients (Alexopoulos et al., 2002). The assessment of depression is complicated by the comorbidity of health problems: physical diseases can both accompany and present as depression. For example, hypothyroidism can initially present as depression (Fountoulakis, Iacovides, Grammaticos, St. Kaprinis, & Bech, 2004). Moreover, hypothyroidism and cerebrovascular disease can precede the diagnosis of late-life depression (Alexopoulos, 2005; Alexopoulos et al., 2002; Fountoulakis et al., 2004). Depression also can follow or result from other medical conditions, e.g., Alzheimer's disease, stroke, Parkinson's disease, myocardial infarctions, chronic obstructive pulmonary disease (Cummings & Victoroff, 1990; Rodin, Craven, & Littlefield, 1991; van Manen et al., 2002). One of the more challenging tasks in the assessment of late-life depression is deciphering the contributions of physical disease to the presentation of depression.

To further complicate the assessment, one must consider the potential contributions of medications taken by older adults. Older adults consume 34% of all prescription medications, and 30% of all over-the-counter medications, although they constitute only 12% of the U.S. population (Centers for Disease Control and Prevention, 2004; Hajjar, Cafiero, & Hanlon, 2007). Older adults take an average of two to five medications, and 20–40% of older adults take five or more medications (McLean & Le Couteur, 2004).

As one ages, one's body undergoes anatomical and physiological changes that affect drug pharmacokinetics (e.g., absorption, distribution, metabolism, excretion) and pharmacodynamics (e.g., effect of drug on its target site; Mangoni & Jackson, 2004). These changes often increase the sensitivity of the older adult to medications and the potential for adverse effects. In light of the number of medications taken by older adults, the task of sorting out potential drug interactions and adverse medication effects can be challenging. Perhaps more directly relevant to the assessment of depression are drugs that can produce depressive symptoms as side effects (see Patten & Love, 1994); for example, corticosterioids, sedatives, and drugs used to treat hypertension, elevated cholesterol, and asthma.

Assessment of Cognitive Functioning

The difficulty of distinguishing dementia from depression has long been recognized, and represents yet another assessment challenge (see Storandt & VandenBos, 1994). The difficulty stems from the overlapping symptoms of depression and dementia, and the fact that the two can coexist. An individual with depression can exhibit deficits in attention and concentration, which interfere with the learning of new information. Difficulty in retrieving information may also be impaired. Depressed individuals may also appear apathetic and withdrawn. The interested reader is referred to Kaszniak and Christensen (1994) for a discussion regarding the differentiation of dementia and depression. Moreover, there is increasing evidence of deficits in executive function in late-life depression (Alexopoulos, 2003; Elderkin-Thompson, Mintz, Haroon, Lavretsky, & Kumar, 2007). Some of these symptoms may improve once depressive symptoms abate (Butters et al., 2000). However, even if symptoms of cognitive impairment improve or remit, those who experience symptoms of cognitive impairment during a depressive episode are more likely to develop dementia in the future (Alexopoulos, Meyers, Young, & Mattis (1993).

The initial evaluation of an older adult whom one suspects is depressed or cognitively impaired should at least include screening for cognitive impairment. Several cognitive screening instruments are available, each with its strengths and weaknesses (see Cullen, O'Neill, Evans, Coen, & Lawlor, 2007, and Edelstein et al., 2008). Though the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975) is probably the most popular of the available screening instruments, there are several alternatives, some of which may be more sensitive to mild cognitive impairment than the MMSE; for example, the St. Louis University Mental Status Examination (SLUMS; Tariq, Tumosa, Chibnall, Perry, & Morley, 2006), and the Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005), which is available in more than 10 languages. If impairment is suggested by performance on a cognitive screening instrument, additional cognitive or neuropsychological assessment can be performed. The interested reader is referred to Woodford and George (2007) for a review of cognitive assessment methods.

Assessment of Social Support

A relation between social support and depression is well established in the literature (Barnett & Gotlib, 1988), although the direction of that relation has been questioned (Krause, Liang, & Yatomi, 1989). Although social support has the potential for buffering stress, consideration of both positive and negative social support is important. One should not presume that because someone has a relationship with another individual, that the sum of their social interactions is positive for that individual. Negative social support (see Rook, 1994) is positively related to depression among older adults (e.g., Pagel, Erdly, & Becker, 1987). When exploring social support, the number of individuals providing social support should be considered separately from the individual's satisfaction with support.

Depression Assessment Instruments

Many depression assessment instruments have been validated for use with older adults. When selecting instruments, appropriate normative data and adequate indications of reliability and validity are required; however, reliability estimates and diagnostic statistics (e.g., sensitivity) are highly dependent on sample characteristics. Larger samples, lengthier assessment instruments, greater score variability, and larger score ranges produce higher estimates of reliability. It is important to consider these factors when interpreting the results of studies and selecting a particular instrument to use with an individual.

Here we review only the depression assessment instruments most commonly used with older adults. While other instruments show promise, such as the Quick Inventory of Depressive Symptomatology (QIDS; Rush et al., 2003), there is limited research on their use in older adults and they are not discussed further in this chapter. Each of the following instruments is considered in terms of its psychometric properties and overall strengths and weaknesses. For a review of the validity of using depression instruments in older adults for diagnostic purposes, monitoring change, or rating severity, see Fiske and O'Riley (2008).

Self-Report Instruments

We have found self-report assessment instruments to be the most valuable objective assessment instruments, as they are often easy and quick to administer. However, it is important to note examinee characteristics (e.g., low educational attainment or compromised cognition may relate to difficulty comprehending and completing self-report measures) and the potential for response bias when interpreting results. For example, Burke, Houston, Boust, and Roccaforte (1989) found elevated rates of false-negative errors on the Geriatric Depression Scale (GDS) (Yesavage et al., 1983) in Alzheimer's patients. It is important to note that many of the instruments were administered orally to examinees, particularly to individuals with suspected cognitive impairment, difficulty completing the forms, or residing in nursing homes. In most cases the psychometric data obtained was similar to that obtained with individuals who self-completed the forms.

Beck Depression Inventory

Several versions of the Beck Depression Inventory are available. The Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) is the most well-researched depression self-report inventory with older adults. It is a 21-item, multiple-choice inventory employing Guttman scaling designed to assess the level of depression in adults. Each item is scored 0 to 3 points for a total score range of 0 to 63. The scale was developed as a quantitative measure of depression and was not originally intended as a diagnostic instrument (Kendall, Hollon, Beck, Hammen, & Ingram, 1987). Suggested score ranges for mild depression, moderate to severe depression, and severe depression are 10–19, 20–30, and 31 or higher, respectively (Kendall et al., 1987). A 13-item short form (Beck & Beck, 1972) is also available with score ranges of 5–7 for mild depression, 8–15 for moderate depression, and 16 or higher for severe depression. The full-scale BDI requires approximately 5–10 minutes to administer, whereas the short form requires approximately 5 minutes. Estimates of internal consistency for the full-scale and short-form BDI have been acceptable (0.82–0.91; Gallagher, 1986; Gallagher, Nies, & Thompson, 1982; Kim, Pilkonis, Frank, Thase, & Reynolds, 2002; Scogin, Beutler, Corbishley, & Hamblin, 1988) in both normal and depressed older adults. Estimates of test–retest reliability and concurrent validity have also been acceptable (0.77–0.90; Gallagher et al., 1982; Giordano et al., 2007; Scogin, 1994).

Using a cutoff of 10, the full-scale BDI demonstrated good sensitivity and specificity with older adult depressed outpatients (sensitivity = 100%, specificity = 96%; Olin et al., 1992), medical outpatients (sensitivity = 89%, specificity = 82%; Norris, Gallagher, Wilson, & Winograd, 1987), and medical inpatients (sensitivity = 83%, specificity = 65%; Rapp, Parisi, Walsh, & Wallace, 1988). A cutoff score of 17 yielded a sensitivity of 50% and specificity of 92%, suggesting that a cutoff of 10 would be the best score if one is screening for depression. Using discriminant function analysis to examine the classification accuracy of the BDI, Bentz and Hall (2008) obtained adequate sensitivity of 72.5% and specificity of 80.9% in an inpatient, mostly cognitively impaired, geriatric sample. The 13-item short form demonstrated good sensitivity (97%) and adequate specificity (77%) at a cutoff score of 5 (Scogin et al., 1988).

The BDI can be divided into psychological (1–0.4) and somatic items (15–21). Rapp and coauthors (1988) also found that using a cutoff score of 5 for the psychological items yielded better indices of sensitivity (75%) and specificity (92%) than when combined with the somatic items in medical inpatients. Scogin and associates (1988) obtained sensitivity and specificity estimates of 77% and 97%, respectively, using the cutoff score of 5 with non-patient older adults and a group diagnosed with major depression. These results reinforce the need to consider the influence of older adults’ somatic complaints when assessing depression, particularly among medical patients.

The BDI correlates moderately to highly with the Geriatric Depression Scale in various inpatient and community-dwelling older adult populations (Allen-Burge, Storandt, Kinscherf, & Rubin, 1994; Giordano et al., 2007; Snyder, Stanley, Novy, Averill, & Beck, 2000). Gallagher et al. (1982) found moderately high test–retest stability in older adult community volunteers and outpatients diagnosed with depression. However, Kendall and colleagues (1987) argue cogently for the use of multiple assessment periods, noting that in spite of the relatively high test–retest coefficients obtained with the BDI, over 50% of individuals scored above a defined cutoff change classification following retesting within hours, days, or one to four weeks. They argue that the overall stability of the measurement appears primarily due to scores from non-depressed subjects.

Among the positive features of the BDI are the fact that it has been evaluated frequently with generally positive outcomes and is brief, easily scored, and easily administered (Scogin, 1994). On the negative side, individuals with cognitive impairment may have difficulty completing the BDI, particularly the Guttman response scale (Edelstein et al., 2008). This difficulty is reflected by higher false positive rates in Alzheimer's patients (Wagle et al., 2000). Interestingly, these differences cannot be attributed to somatic symptoms. However, the somatic content of some items may complicate interpretation of scores, as the complaints can result from depression, physical disorders, or both. Olin et al. (1992) reported a high rate of difficulty by older adults in completing the BDI. Forty-six percent of community-dwelling older adults endorsed multiple responses on at least one item and 12% failed to complete at least one item. Depressed individuals were more likely to fail to complete at least one item correctly. Finally, Allen-Burge et al. (1994) reported gender differences in the BDI, with lower detection of depressive symptoms in men. Moreover, Jefferson, Powers, and Pope (2001) found that older women may be more hesitant to complete the BDI than other measures of depression. Overall, the BDI is a useful screening instrument for depression.

A second version of the Beck Depression Inventory (BDI–II; Beck, Steer, & Brown, 1996) included older adults in the normative sample and addressed many of the problems noted in the BDI. Although the number of items and response style remains the same as with the original version, the item content was modified to address all DSM-IV criteria for Major Depressive Disorder and rates behavior over the past two weeks. Senior et al. (2007) administered the BDI–II via telephone and obtained good reliability and validity with older adults diagnosed with generalized anxiety disorder. The BDI–II has good internal consistency in community-dwelling older adults (Norris et al., 2004; Segal, Coolidge, Cahill, & O'Riley, 2008), older cardiac patients (Low & Hubley, 2007), and women residing in retirement communities (Jefferson et al., 2001). The BDI–II has growing support in the research literature for use with older adults and is a useful update of the BDI for use with older adults.

In addition, the Beck Depression Inventory–Fast Screen for Medical Patients (BDI–FS; Beck, Steer, & Brown, 2000), previously known as the Beck Depression Inventory for Primary Care, is a 7-item scale that omits somatic items. It maintains the item structure from the BDI–II and rates items occurrence over the past two weeks. The BDI–FS demonstrated high sensitivity and specificity in older adults with health problems (Scheinthal, Steer, Giffen, & Beck, 2001), and adequate reliability in older adult post-stroke patients (0.75; Healey, Kneebone, Carroll, & Anderson, 2008) and geriatric outpatients (0.83; Scheinthal et al., 2001). A cutoff score of 4 produced a sensitivity of 100% and a specificity of 84% in an older adult outpatient population. The BDI–FS is a quick alternative to the full BDI or BDI–II. It shows potential for use with older adults, particularly those with medical conditions. However, further research is needed to fully recommend its use as a standard assessment of depression in older adults.

Geriatric Depression Scale

The Geriatric Depression Scale (see Appendix A) was developed specifically for use with older adults and contains 30 items. Each item is scored 0 to 1 for a total score range of 0 to 30. The GDS utilizes a simple yes–no item format, omits somatic items, and demonstrated utility when used over the telephone (Burke, Roccaforte, Wengel, Conley, & Potter, 1995). Recommended cutoffs for the full-scale version range from 10–16, with sensitivity and specificity varying in different subject populations (Fiske, Kasl-Godley, & Gatz, 1998; Harper, Kotik-Harper, & Kirby, 1990; Watson, Lewis, Kistler, Amick, & Boustani, 2004). Lower accuracy was found in healthy, highly-educated community-dwelling older adults (Watson et al., 2004). Reliability and validity evidence has been established for older, medically ill outpatients (Norris et al., 1987), non-cognitively impaired nursing home residents (Lesher, 1986; Smalbrugge, Jongenelis, Pot, Beekman, & Eefsting, 2008), older adults diagnosed with GAD (Snyder et al., 2000), and hospitalized older adults (Rapp et al., 1988). Kieffer and Reese (2002) analyzed reliability across 338 studies using the GDS and found a mean reliability of 0.85.

Evidence supporting the use of the GDS with cognitively impaired individuals is mixed, with Feher et al. (1992) finding it a valid measure of mild to moderate depressive symptoms in Alzheimer's patients with mild to moderate dementia; although some dementia patients disavow memory loss and tend to deny depressive symptoms on the GDS. This response bias could account for the less than desirable findings in some studies employing the GDS with dementia patients. Hyer and Blount (1984) found that the GDS discriminated between depressed and non-depressed older adult psychiatric patients, and had better sensitivity and specificity than the Zung Self-Rating Depression Scale (SDC) (Zung, 1965) and the Hamilton Rating Scale for Depression (HRSD) (Hamilton, 1960; 1967). Lichtenberg, Steiner, Marcopulos, and Tabscott (1992) found moderate sensitivity (82%) and specificity (86%) with dementia patients in a long-term care facility using the diagnosis of a psychiatrist as the criterion measure. Using discriminant function analysis to examine the classification accuracy of the GDS, Bentz and Hall (2008) obtained sensitivity of 82.6% and specificity of 81.3% in an inpatient, mostly cognitively impaired, geriatric sample.

Allen-Burge et al. (1994) reported gender effects on the GDS, with poorer detection of depression in males. In addition, Olin et al. (1992) reported a mild level of difficulty by older adults in completing the GDS. Eight percent of community-dwelling older adults endorsed both responses (yes and no) on at least one item and 14% failed to complete at least one item. Depressed individuals were more likely to fail to complete at least one item correctly.

Ott and Fogel (1992) found a moderately strong correlation (r = 0.77) between the GDS and the Cornell Scale for Depression in Dementia (CS; Alexopoulos et al., 1988) in patients with mild dementia (Mini-Mental State Exam [MMSE; Folstein et al., 1975] of 22 or less), but a weaker relationship between the two with increased cognitive impairment. Stiles and McGarrahan (1998), in their review of the GDS literature, present the cutoff scores associated with levels of sensitivity and specificity for virtually all GDS studies with older adults. Various cutoff scores have been suggested, varying to some extent by the sample population characteristics. Stiles and McGarrahan recommend cutoff scores of 11 for maximal sensitivity and 14 for higher specificity.

A 15-item short form of the GDS is also available (Lesher & Berryhill, 1994) with high internal consistency (r = 0.88). Lesher and Berryhill found a strong relation between scores on the long and short forms of the GDS (r = 0.89) and similar sensitivity and specificity with heterogeneous diagnostic groups. (See also Cwikel & Ritchie, 1988.) Baker and Miller (1991) found support for its sensitivity and specificity when used with medically ill skilled nursing home residents, whereas Burke, Roccaforte, and Wengel (1991) found less support when used with cognitively impaired individuals. Recommended cutoff scores vary from 5–7 (Almeida & Almeida, 1999; Haworth, Moniz-Cook, Clark, Wang, & Cleland, 2007; Lesher & Berryhill, 1994) in various older adult populations. Brown, Woods, and Storandt (2007) examined the factor structure of the GDS–15 in samples of non-demented, demented, and depressed older adults. A 2-factor model, including Life Satisfaction and General Depressive Affect factors, was stable across the non-demented and demented samples but only 1-factor was evident in the depressed older adults, suggesting that poor life satisfaction impacts scores on the GDS–15. Overall, the utility of the GDS appears to diminish with increases in cognitive impairment. Although the short form may be useful when time constraints or fatigue are issues, the longer form appears to be more reliable and valid (Stiles & McGarrahan, 1998).

The GDS appears to be a useful screening instrument for depression in older adults. It was developed for use with older adults, employs a yes–no format that is relatively easy to use with cognitively impaired older adults, and has been validated with a wide range of populations. On the less positive side, results with cognitively impaired populations have been mixed (Korner et al., 2006). As a practical measure, Stiles and McGarrahan (1998) offer the following approach to the use of the GDS in individuals suspected of cognitive impairment. Initially screen the older adult for cognitive impairment using the MMSE. If the MMSE score is less than 15, the GDS score is suspect and can be disregarded as unreliable. However, if the MMSE score is below 24, the GDS cutoff of 14 is suggested.

Center for Epidemiological Studies–Depression Scale

The Center for Epidemiological Studies–Depression Scale (CES–D; Radloff, 1977), designed for large-scale epidemiological studies in the general population, is a 20-item self-report inventory that can be completed in approximately 5 minutes. Each item is scored 0 to 3 on a Likert-type scale for frequency of symptoms in the last week, for a total score range of 0 to 60. It consistently demonstrates four factors: depressive affect, well-being, somatic symptoms, and interpersonal relations across multiple older adult samples (Hertzog, Van Alstine, Usala, Hultsch, & Dixon, 1990; O'Rourke, 2005; Williams et al., 2007), although some items cross factors across studies. The suggested cutoff for depression is a score of 16 or more. However, as seen in cutoff scores for all the measures, some studies suggest this may be too low for some older adult populations, producing too many false positives (Haringsma, Engels, Beekman, & Spinhoven, 2004; Himmelfarb & Murrell, 1983), and too high for detecting depression in healthy populations (Watson et al., 2004).

Split-half and coefficient alpha estimates of internal consistency (0.85 to 0.92) reported by Radloff were high across age, sex, geographic, and racial and ethnic subgroups. High reliabilities were also reported in community-dwelling older adults (0.82; Lewinsohn, Seeley, Roberts, & Allen, 1997), older medical inpatients (0.86; Schein & Koenig, 1997), and older adult caregivers (0.88; O'Rourke, 2005). High rates of false positives with the suggested cutoff score of 16 were reported by Schein and Koenig (1997) in medical patients. They suggest a two-stage approach to the use of the CES–D in this population to improve the diagnostic efficiency of the instrument. First, examinees must meet the minimum cutoff total score of 16. Second, the examinee must obtain a score of at least 4 on the depressed affect subscale.

A 10-item short form of the CES–D also has been used with a cutoff score of 10 or more (Andresen, Malmgren, Carter, & Patrick, 1994). Test–retest reliability was reasonably good (r = 0.71). Comparison of the CES–D–10 with the 20-item CES–D was quite favorable, resulting in only one misclassification using the CES–D–10. The strengths of the CES–D include its widespread use in epidemiological studies, the availability of norms based on a large representative sample (Himmelfarb & Murrell, 1983), its factor invariance across age groups, and its demonstrated reliability and sensitivity in older adults. A revision of the CES–D (Eaton, Smith, Ybarra, Muntaner, & Tein, 2004) has been developed to reflect changes in diagnostic criteria from the original version, but has not yet been validated in older adults.

Overall, the CES–D appears to be a good instrument for screening community-dwelling older adults. On the less positive side are its response format and low specificity in several studies (see Radloff & Teri, 1986). The response format requires frequency ratings of how often one experienced symptoms over the past week, which may be difficult and somewhat less reliable among individuals with cognitive impairments. Boutin-Foster (2008) reported differential responding patterns in different ethnic groups. Latinos obtained higher scores than African Americans and Caucasians in all domains, and were three times more likely to obtain scores at or above the cutoff score. Moreover, Kohout, Berkman, Evans, and Cornoni-Huntley (1993) reported that 10% of the older adults completing the CES–D failed to complete at least one item. Its low specificity at the cutoff of 16 (Boyd, Weissman, Thompson, & Myers, 1982; Myers & Weissman, 1980; Roberts & Vernon, 1983), using a diagnosis of major depression as a criterion, suggests that it is better suited as a screening than a diagnostic instrument.

Hospital Anxiety and Depression Scale

The Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983) is a 14-item measure designed to assess anxiety and depression symptoms in medical patients, with emphasis on reducing the impact of physical illness on the total score. The depression items tend to focus on the anhedonic symptoms of depression. Items are rated on a 4-point severity scale. The HADS produces two scales, one for anxiety (HADS–A) and one for depression (HADS–D), differentiating the two states. Scores of greater than or equal to 11 on either scale indicate a definitive case. Kenn, Wood, Kucyj, Wattis, and Cunane (1987) reported good differentiation of depressed and non-depressed older adults, and Haworth et al. (2007) found similar results in cardiac patients, although a lower cutoff score was used to minimize false negatives. The HADS–D correlates 0.72 with the GDS and 0.61 with the HRSD in Parkinson's patients (Mondolo et al., 2006), and 0.82 with the GDS–15 in older cardiac patients (Haworth et al., 2007). Mondolo et al. reported sensitivity and specificity with Parkinson's patients to be 100% and 95%, respectively.

Although initial studies suggest the HADS–D is a useful instrument to assess depression in older adults, Davies, Burn, McKenzie, Brothwell, and Wattis (1993) reported a high degree of false positives, with over a quarter of medical inpatients misclassified by the HADS–D. Moreover, Haworth et al. (2007) suggest the use of the GDS over the HADS–D due to the lower sensitivity and specificity of the HADS–D. Alternatively, Mondolo et al. (2006) found the HADS–D better at diagnosing depression than the GDS in Parkinson's patients. Overall, in light of the mixed psychometric evidence, the HADS–D is probably not the best choice for depression assessment instruments for older adults at this time. Further research may yield more support for the use of this scale in older adults.

Zung Self-Rating Depression Scale

The Zung Self-Rating Depression Scale (SDS) is a 20-item measure, with each item rated on a 4-point scale. It requires approximately 5–10 minutes to complete. Ranges for mild to moderate depression, moderate to severe depression, and severe depression are 50–59, 60–69, and over 70, respectively (Zung, 1967). Reliability with older adults appears to be low to moderate, which is most apparent among the oldest old (Kivela & Pahkala, 1986; McGarvey, Gallagher, Thompson, & Zelinski, 1982—cited in Fiske et al., 1998). Older adults tend to score higher than younger adults, possibly due to the somatic items on the scale (Berry et al., 1984). Kitchell, Barnes, Veith, Okimoto, and Raskind (1982) estimated the sensitivity and specificity with medically ill inpatients to be 58% and 87%, respectively. Somewhat better efficiency has been demonstrated with medical outpatients (sensitivity = 82%, specificity = 87%; Okimoto et al., 1982). Finally, age and sex differences have been suggested in the SDC factor structure (Kivela & Pahkala, 1986). Overall, in light of the evidence of its psychometric characteristics, the SDC is probably not the best choice for a depression assessment instrument for older adults at this time. Further research on its psychometric properties and norms may yield a more positive impression of this instrument.

Clinician Rating Scales

Clinician rating scales often require somewhat more time to complete than self-report instruments, but they offer the advantages of providing an objective perspective on the depressive symptoms and are particularly useful with older adults experiencing moderate to severe cognitive impairment. They are commonly used in clinical research. As with the self-report instruments, each of the instruments we review has its strengths and weaknesses.

Hamilton Rating Scale for Depression

The Hamilton Rating Scale for Depression (HRSD) has been considered the gold standard for assessing severity of depression and is widely used in research. The HRSD has several versions, with the number of items employed ranging from 17 to 28. The 17-item version is the most commonly used and contains somatic and suicidal ideation items, although it does not include all of the items that would be necessary for the diagnosis of a major depressive episode (e.g., sleep difficulties, weight gain). Each of the behaviorally anchored items is rated on either a 3- or 5-point scale and summed to obtain the total score. Scores greater than 24 are indicative of severe depression, and scores less than 7 are indicative of the absence of depression. It correlates moderately with the BDI (0.68) in community-dwelling older adults and more strongly with the GDS (0.84) in a mixed Danish geriatric sample (Korner et al., 2006).

Williams (1988) developed the Structured Interview Guide for the HRSD (SIGH–D) to address the problem of variability in inter-rater reliability resulting from the relatively unstructured nature of the original 17-item scale. The structured interview can be completed with the patient or a collateral source. Gilley et al. (1995) found low rates of symptom endorsement in Alzheimer's patients, suggesting that the use of collateral sources may be a more valid approach in this population. Even with the increased structure, reliability remained fair to poor for half of the items (Pachana, Gallagher-Thompson, & Thompson, 1994). Gallagher (1986) noted that approximately 20 training interviews were required to achieve acceptable reliability. In addition, Hammond (1998) found low internal reliability in geriatric medical inpatients and suggested that anxiety symptoms may confound results on the scale.

On a more positive note, Korner et al. (2006) reported an inter-rater reliability of 0.90 in a geriatric sample. In addition, Rapp, Smith, and Britt (1990) found the 17-item version of the HRSD to have good psychometric properties with older medical patients and Leentjens, Verhey, Lousberg, Spitsbergen, and Wilmink (2000) and Olden, Rosenfeld, Pessin, and Breitbart (2009) established good concurrent validity with DSM-IV criteria. The HRSD may be a good alternative for older adults who have difficulty completing self-report inventories. A new version of the HRSD was presented in Williams et al. (2008) with good psychometric support in an adult sample. More research is needed on its use in older adults before it can be recommended.

Geriatric Depression Rating Scale

The Geriatric Depression Rating Scale (GDRS) (Jamison & Scogin, 1992) is a 35-item clinician rating scale that contains 29 of the 30 GDS items plus six items with somatic content. The scale combines the format of the HRSD, for the purpose of obtaining severity ratings, with the content of the GDS, which de-emphasizes somatic content. Preliminary evidence of internal consistency is good (alpha = 0.92). Preliminary estimates of concurrent validity with hospitalized, outpatient, and community-dwelling older adults are also good, with moderate to strong correlations obtained between the GDRS and the HRSD (r = 0.83), BDI (r = 0.69), and GDS (r = 0.84). A cutoff score of 20 yielded 88% sensitivity and 82% specificity. The GDRS requires a trained interviewer and approximately 35 minutes to administer. An advantage of the GDRS over the HRSD is that it probably requires less experience and training to administer reliably (Scogin, 1994).

Geriatric Mental State Schedule–Depression Scale

The Geriatric Mental State Schedule–Depression Scale (GMSS–DS) (Ravindran, Welburn, & Copeland, 1994) is a 33-item, semi-structured interview that employs a 3-point rating scale for most items. The items were drawn from the Geriatric Mental State Schedule on the basis of their ability to discriminate between depressed and non-depressed older adults, and their sensitivity to change following pharmacological treatment. The scale is intended for rating symptomatological changes of depression. The authors have presented sound evidence of its internal consistency (alpha = 0.95; Spearman-Brown split half = 0.92). Moreover, strong correlations were demonstrated between GMSS–DS scores and scores on the BDI, HRSD, and clinician ratings of severity (r = 0.86, 0.91, and 0.84). A cutoff score of 18 yielded a sensitivity estimate of 97% and specificity estimate of 90% with regard to improvement following treatment (improved versus not improved).

In constructing the instrument, the authors included a large number of items because the frequency of different depressive symptoms appears to be more variable in older than younger adults. The large number of items could make this a particularly sensitive instrument for monitoring symptom change, although the large number of items may make it too cumbersome for use with medical populations (Davies et al., 1993). Some symptoms (e.g., guilt, pessimism, dissatisfaction) that have been shown to be sensitive to change in younger adults were not included because the symptoms appear to continue as residual symptoms in older adults following clinical improvement in depressive symptoms. While the initial psychometric characteristics appear very promising for the GMSS–DS as an index of change in depressive symptoms, the instrument could benefit from cross validation with different older populations.

Structured Interviews

Structured and semi-structured diagnostic interviews can be quite helpful to ensure reliable diagnoses for researchers. However, their utility for the practicing clinician is often limited because of the time and skills required to administer them reliably.

Structured Clinical Interview

The Structured Clinical Interview (SCID) (First, Spitzer, Gibbon, & Williams, 1997) for DSM-IV has not been evaluated in older adults, but is one of the best-known and best-accepted structured interviews. There is, however, little evidence that it is used frequently in clinical practice although it is widely used in research on depression in various populations (e.g., Haworth et al., 2007). Segal, Kabacoff, Hersen, VanHasslet, and Ryan (1995) found good inter-rater reliability for major depression in older adults with the DSM-III-R version of the SCID. In their discussion of the previous edition of the SCID for the DSM-III-R, Pachana and coauthors (1994) stated that they did not find it very useful as a diagnostic standard for depression among older adults, as it appears less sensitive than they had anticipated for identifying depressive disorders. In light of the apparent limited use, lengthy administration time, and limited information on the validity and utility