Center for Epidemiological Studies-Depression Scale: Evaluation of a New Cutoff Score for Women Living with HIV.

Major Depressive Disorder (MDD) is one of the most burdensome mental health conditions among adults in the United States, with a lifetime prevalence of 7%, accounting for 3.7% of all US disability-adjusted life years. Among persons living with HIV (PLWH), the lifetime prevalence rates of depression are two to three times higher, at estimates ‡20%. In addition, PLWH diagnosed with depression are less likely to be adherent to antiretroviral therapy (ART) and thus are at a significantly higher risk of death. The Center for Epidemiological Studies-Depression (CES-D) scale is a well-established 20-item measure that was developed for the screening of cognitive, affective, and somatic symptoms of depression involving women with and without breast cancer. Cutoff scores are used to indicate clinically relevant symptoms and suggest a need for further assessment using a diagnostic tool. Optimal cutoff scores should be established to maximize detecting true illness and minimize false positives. The established clinical cutoff indicating clinical depression when using the CES-D is ‡16. However, higher cutoff scores have shown better balance between sensitivity and specificity among chronically ill, female, and vulnerable populations. Among low-income women in primary care, a 16-point cutoff score had high sensitivity (0.95) and specificity (0.70); however, two-thirds of those screened positive for depression did not meet criteria for MDD [positive predictive value (PPV) = 0.28]. A cutoff score of 34 had high specificity (0.95) and a higher predictive value for MDD (0.53), but much lower sensitivity (0.45). To our knowledge, although there are established CES-D cutoff scores for chronic illnesses other than HIV disease, a CES-D cutoff score for women living with HIV (WLWH) has never been formally ascertained. Determining an appropriate cutoff score for WLWH will aid both HIV care providers and researchers whose focus is on individuals who meet DSM criteria for depression. This study provides preliminary data on the assessment of the CES-D to screen for MDD using data from a randomized controlled trial of African American lowincome WLWH in rural Alabama. Participants included in this analysis were African American WLWH (‡19 years of age) enrolled in the Tele-C.A. R.E. study, a randomized controlled trial comparing cognitive behavioral therapy designed to increase medication adherence and reduce depression in WLWH to a supportive psychotherapy control intervention. Participants were recruited at HIV clinics across rural Alabama. Informed consent was obtained from all participants included in the study. This study used data from the baseline assessment of the Tele-C.A. R.E. study. MDD was indicated by diagnosis using the Mini-International Neuropsychiatric Interview. We compared CES-D scores and participant characteristics between the MDD (n = 29) and non-MDD (n = 18) groups using measures of effect size: Cohen’s d (standardized mean difference) for continuous variables, and d-equivalent for categorical variables. We estimated the CES-D score cutoff that minimized the distance between the receiver operating characteristic (ROC) curve and the point of perfect prediction of MDD diagnosis (specificity = 0, sensitivity = 1) in the sample. Nonparametric Bootstrap (2000 resamples, stratified by MDD group) was used to estimate uncertainty about the cutoff value and accuracy measures, in the form of 95% confidence intervals (CIs) for area under the ROC curve (AUC), number of false positives and false negatives, sensitivity, specificity, PPV, and negative predictive value (NPV). The Bootstrap approach was used to avoid making any distributional assumptions for these quantities; however, the resulting CIs are still based on the sample and, therefore, should be interpreted with respect to the specific population from where the sample was drawn: African American WLWH. Analyses were conducted using R system software v.3. 3.2. On average, participants were 47 years of age, received an HIV diagnosis 9 years previously, and reported taking ART for about 7.5 years. About 11% of participants were immunosuppressed (CD4 count <200 cells/lL) and 13% had a