EVIDENCE FOR THE VALIDITY OF THE AMERICAN MEDICAL ASSOCIATION'S CAREGIVER SELF-ASSESSMENT QUESTIONNAIRE AS A SCREENING MEASURE FOR DEPRESSION

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To the Editor: Establishing when a stressed family caregiver might need assistance is an important public health concern.1 The recently published American Medical Association Caregiver Self-Assessment Questionnaire (CSAQ)2 is a readily available tool that can help determine when to pursue additional assessment. The CSAQ has been reported to have a reliability coefficient alpha of 0.78 based on data collected during the scale's development; scoring guidelines are included with the measure,2 but we are not aware of field testing or other use of the CASQ. Therefore, we sought to further test this measure in a sample of 106 family caregivers by comparing the CSAQ with validated measures for depression, burden, stress, and grief. The primary hypothesis, based on scrutiny of the CSAQ's individual items, was that the scale would demonstrate acceptable sensitivity and specificity as a screen for depression.

The short form of the Center for Epidemiological Studies Depression Scale (CES-D) is a reliable and valid 10-item screening tool that is well established and has been widely used to assess depression severity.3 The CES-D and the CSAQ were co-administered along with three other measures chosen to represent psychological syndromes, other than depression, that caregivers may experience: the Perceived Stress Scale, 4-item version (PSS4); the Rapid Screen for Caregiver Burden (RSCB); and the Inventory of Traumatic Grief, pre-loss version (ITGPL).

The sample population included 106 family caregivers recruited from an inpatient geriatric psychiatry unit (n=54), an outpatient memory disorders program (n=39), and community outpatient programs related to caregiving and mental health (n=12). Sixty-six percent of the responding caregivers were women (n=70), and the majority were white (97.2%, n=103). For most caregivers, the care recipient was a parent (50.0%, n=53) or a spouse (38.7%, n=41); the remainder reported an “other” relationship (10.4%, n=11). Most care recipients had a prior diagnosis of dementia or mild cognitive impairment (91.5%, n=93), whereas others experienced a mood or anxiety disorder (6.6%, n=7) or Parkinson's disease (1.9%, n=2).

The mean score for the caregiving participants completing the CES-D was 10.7±6.6 and the mean CSAQ score was 6.5±3.9. The CES-D and the CSAQ were highly correlated in the expected direction (Pearson r=.807, P<.001) and showed similar patterns of correlation with other measures (Table 1). In the current sample, the CSAQ showed high internal consistency (Cronbach α=0.82). A sensitivity and specificity analysis was performed to determine the ability of the CSAQ to predict depressive symptoms. The reported CES-D cutoff score of 10 or greater was used to indicate a case of significant depression.3 According to the scoring instructions accompanying the CSAQ,2 if any one of four criteria is met, follow-up is recommended. Scored in this manner, the measure's sensitivity to predict significant depressive symptoms is 0.98, with a specificity of 0.52. Similar analyses were conducted using a simpler single-criterion scoring method of summing the total number of yes responses for the yes/no questions. With this method, a CSAQ score of 6 or greater resulted in a sensitivity of 0.91 and a specificity of 0.77, and a cut-point set at a CSAQ score of 5 or greater resulted in a sensitivity of 0.98 and a specificity of 0.63.

Table 1. Correlations Between the Caregiver Self-Assessment Questionnaire, the Center for Epidemiologic Studies Depression Scale, and Other Measures of Stress, Burden, and Grief
MeasuresCSAQCES-DPSS4RSCBInventory for Traumatic Grief,
Pre-Loss Version
  • This table shows the Pearson correlation coefficients between measures, the mean and standard deviation for each measure and the actual range of reported scores for individual measures in this sample. The data are based on a sample of 106 respondents with a valid listwise N=104. Regarding the Caregiver Self-Assessment Questionnaire (CSAQ), the mean, minimum and maximum scores refer only to the measure's 16 “Yes/No” questions.

  • *

    All correlations are significant at p<.001.

  • CES-D=Center for Epidemiologic Studies Depression Scale; PSS4= Perceived Stress Scale, 4-Item Version; RSCB= Rapid Screen for Caregiver Burden.

CSAQ 0.807*0.682*0.707*0.594*
CES-D  0.753*0.673*0.687*
PSS4   0.689*0.656*
RSCB    0.752*
Mean Score ± Standard Deviation6.5 ± 3.910.7 ± 6.66.3 ± 3.511.8 ± 6.819.7 ± 12.7
Range of Reported Scores0–150–290–140–280–58

In summary, the American Medical Association's CSAQ is an easy-to-use and valid self-report screening measure that appears to be sensitive for the detection of depressive symptoms. Detecting depressive symptoms and preventing the onset of a major depressive episode is essential for chronically stressed caregivers, particularly in the context of caring for someone with dementia.4 The majority of participants in the current study cared for patients with dementia, a condition typically diagnosed and treated in the primary care setting.5 Given the evidence that psychosocial treatment improves caregiver health,6 it is essential to establish clinical practice patterns that employ measures such as the CSAQ, followed by further assessment when indicated. The data presented here support the hypothesis that the CSAQ functions as a screening measure for depressive symptoms; with this in mind, clinicians and investigators may choose to use this scale as a depression screen. Alternatively, clinicians may use one of the many other available and established depression screening measures while the CSAQ undergoes further field testing. As the CSAQ receives continued use, additional analyses and replication of these results in larger and more-diverse samples is suggested.

ACKNOWLEDGMENTS

Research and administrative assistance were provided by Ellen Darling, BA, Heather Harrell, BA, and Nomanda Nongauza, BA. Ms. Harrell received no compensation for her role in the study. Ms. Darling and Ms. Nongauza received compensation related to employment at Butler Hospital.

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.

Dr. Epstein-Lubow is an employee of Butler Hospital, Providence, Rhode Island, and previously worked as an unpaid consultant to a research project supported by Forest. Stephen Salloway has provided consulting services to Eisai, Pfizer, Forest, Medivation, Myriad, Elan, Sanofi-Aventis, and Merck. He has received honoraria from Pfizer, Eisai, Novartis, Forest, and Elan. He has also received research support from Eisai, Pfizer, Forest, Janssen, Myriad, Elan, Neurochem, Wyeth, Cephalon, the National Institutes of Health, and the Norman and Rosalie Fain Family Foundation.

Author Contributions: Dr. Epstein-Lubow developed the study concept and design, acquired data, analyzed and interpreted the data, and drafted and revised the manuscript. Dr. Salloway assisted in acquisition of data. Mr. Hinckley assisted with acquisition and analysis of data. Drs. Miller and Gaudiano assisted with analysis and interpretation of data. Drs. Miller, Gaudiano, and Salloway and Mr. Hinckley completed critical revision of the manuscript.

Sponsor's Role: There was no external funding for this study. This work was supported by Butler Hospital. The sponsor had no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation, review or approval of the letter.

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