CHAPTER 65: CORNELL SCALE FOR DEPRESSION IN DEMENTIA (CSDD)

Description

The Cornell Scale for Depression in Dementia (CSDD) is a 19-item, clinician-administered scale specifically developed to assess signs and symptoms of major depression in persons with neurocognitive disorders (NCD) of the Alzheimer’s and related types of cognitive impairment (Alexopoulos, 2002). The CSDD uses a comprehensive interview approach that derives information from both the patient and an informant, thus information is elicited through two semi-structured interviews (Alexopoulos, 2002). The interviews focus on depressive symptoms during the previous week where many of the items can be filled in through direct observation of the patient (Alexopoulos, 2002). The signs and symptoms of depression are measured by the CSDD scale and categorized into five general content areas: (1) mood-related signs (anxiety, sadness, lack of reactivity to pleasant events, irritability); (2) behavioral disturbances (agitation, multiple physical complaints, loss of interest); (3) physical signs (loss of appetite, weight loss, lack of energy); (4) cyclic functioning (diurnal variation of mood, difficulty falling asleep, multiple awakenings during sleep, early morning awakenings); and (5) ideational disturbances (suicide, poor self-esteem, pessimism, mood-congruent delusions) (Harwood, Ownby, Barker, & Duara, 1998). The CSDD has 38 items total (19 each for patient and informant) and all items are rated for severity on a scale of 0 to 2 where (0) suggests the symptom is absent, (1) mild or intermittent, and (2) severe. Scores above 10 indicate a probable major depression and scores above 18 indicate a definite major depression, while scores below 6 are typically associated with absence of significant depressive symptoms (Alexopoulos, 2002). The CSDD can be completed in less than 15 minutes.

Psychometrics

Using 2 studies of 103 and 32 subjects the correlation between 2 raters for the total score was r = 0.81 and 0.97, respectively (Lage-Barca, Engedal, & Selbaek, 2010). The same study found that for nursing home patients a cutoff score of 6/7 produced a sensitivity of 0.79 and a specificity of 0.68; a score of 7/8 the sensitivity was 0.76 and specificity was 0.75; and at 8/9 the sensitivity was 0.69 and the specificity was 0.81 (Lage-Barca et al., 2010) A subsequent study of 63 subjects with early onset neurocognitive disorder (NCD) found that at an optimal cutoff score of 5/6 results yielded a sensitivity of 0.83 and a specificity of 0.57 (Leontjevas, van Hooren, & Mulders, 2009). Their research also suggested that the following 3 of the 19 items were able to discriminate depressed patients from non-depressed patients: (1) sadness, (2) loss of interest, and (3) lack of energy (Leontjevas et al., 2009). The same study also established congruent validity between the Montgomery-Asberg Depression Rating Scale and the CSDD, which was significant at 0.79 (Leontjevas et al., 2009). Snowdon, Rosengren, Daniel, and Suyasa (2011) found that of 223 residents of a nursing home in Australia, 23% scored > 12 which indicated probable depression, 21% were possibly depressed, and 29% were not depressed; however, clinicians also found themselves unable to make CSDD ratings in 14% of cases because of severe dementia and rating proved impossible in another 10%, thus meaningful scores were not available for a substantial proportion of the residents suggesting that its usefulness may be limited to only specific populations, such as those with mild to moderate symptomology. Finally, a factor analysis by Kurlowicz, Evans, Strumpf, and Maislin (2002) concluded that the CSDD has a psychobiological orientation, with a broad spectrum of depressive symptoms in the affective, cognitive, somatic, and behavioral realms and that somatic items comprised 37% (7/19) of items on the test.

Advantages

There is a significant amount of research in support of the CSDD for use in clinical practice and no special training or certifications are needed. The assessment is unique from other interview/self-report scales in that scores are based on information collected from both the subject and informant giving the clinician unique insight into depressed subjects.

Disadvantages

The assessment is specific to those with NCD relative to Alzheimer’s and related types and accurate assessment may be difficult for certain sub-populations as noted in the study by Kurlowicz et al. (2002), thus scores may be weighted more heavily toward informant responses in those patient groups.

Administration

The 38 items of the CSDD are delivered according to a standardized format that is done through the use of two structured interviews, with the client and with an informant, where each interview has clearly outlined instructions as well as scoring interpretations contained in the examiner’s manual. Items are scored as either 0 = absent, 1 = mild to intermittent, 2 = severe, or A = unable to evaluate. The total score range for both forms is 0 to 38, with higher values representing greater severity of depressive symptoms.

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