Screening for Depression in the General Population with the Center for Epidemiologic Studies Depression (CES-D): A Systematic Review with Meta-Analysis

PLoS One. 2016 May 16;11(5):e0155431. doi: 10.1371/journal.pone.0155431. eCollection 2016.


Objective: We aimed to collect and meta-analyse the existing evidence regarding the performance of the Center for Epidemiologic Studies Depression (CES-D) for detecting depression in general population and primary care settings.

Method: Systematic literature search in PubMed and PsychINFO. Eligible studies were: a) validation studies of screening questionnaires with information on the accuracy of the CES-D; b) samples from general populations or primary care settings; c) standardized diagnostic interviews following standard classification systems used as gold standard; and d) English or Spanish language of publication. Pooled sensitivity, specificity, likelihood ratios and diagnostic odds ratio were estimated for several cut-off points using bivariate mixed effects models for each threshold. The summary receiver operating characteristic curve was estimated with Rutter and Gatsonis mixed effects models; area under the curve was calculated. Quality of the studies was assessed with the QUADAS tool. Causes of heterogeneity were evaluated with the Rutter and Gatsonis mixed effects model including each covariate at a time.

Results: 28 studies (10,617 participants) met eligibility criteria. The median prevalence of Major Depression was 8.8% (IQ range from 3.8% to 12.6%). The overall area under the curve was 0.87. At the cut-off 16, sensitivity was 0.87 (95% CI: 0.82-0.92), specificity 0.70 (95% CI: 0.65-0.75), and DOR 16.2 (95% CI: 10.49-25.10). Better trade-offs between sensitivity and specificity were observed (Sensitivity = 0.83, Specificity = 0.78, diagnostic odds ratio = 16.64) for cut-off 20. None of the variables assessed as possible sources of heterogeneity was found to be statistically significant.

Conclusion: The CES-D has acceptable screening accuracy in the general population or primary care settings, but it should not be used as an isolated diagnostic measure of depression. Depending on the test objectives, the cut-off 20 may be more adequate than the value of 16, which is typically recommended.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Depression / epidemiology*
  • Humans
  • Mass Screening
  • Population Surveillance*
  • Psychiatric Status Rating Scales
  • Psychometrics
  • ROC Curve
  • Reproducibility of Results
  • Sensitivity and Specificity

Grant support

This study is supported by a grant from Instituto de Salud Carlos III FEDER, (PI08/90724) and from the DIUE of the Generalitat de Catalunya, Spain (2014 SGR 748; 2009 SGR 1095). Gemma Vilagut was supported by “Fondo de Investigación Sanitaria, Instituto de Salud Carlos III (ISCIII)” (ECA07/059); Carlos G. Forero was supported by “Ministerio de Ciencia e Innovación”, FSE (JCI-2009-05486); Gabriela Barbaglia was supported by “Ministerio de Ciencia e Innovación” Rio Hortega grant (CM 10-00099), Spain. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.