Development of the Depression in Chronic Illnesses Scale

Patient Health Questionnaire depression scale (PHQ) is an eighty-two items measure, divided into five clinical components (Kroenke, Spitzer & Williams, 2001). PHQ is used to assess mood, anxiety, somatoform inclination, alcoholism and disorders related to eating habits. PHQ is found to be beneficial in primary care settings because of the early screening and detection the disorder. Responses ranging from “not at all to nearly every day” and score from 0 to 3 points. Respondents asked to mark his/her feelings they gone through by the past two weeks. PHQ has three shorter versions; one with nine items derived from the original version called Patient Health Questionnaire Depression Scale-9 (PHQ-9), eight items and two item versions are called PHQ-8 (Kroenke, Strine, Spitzer, Williams, Berry & Mokdad, 2008)and PHQ-2 respectively.

Zung Depression Inventory (Zung, 1965) is a 20 items self-rating depression inventory for diagnosis depression in psychiatric settings. Where, 20 items divided into 10 negative statements and 10 positive statements, included affective, somatic and psychological symptoms of depression. The response format ranged from 1 (a little of the time) to 4 (most of the time) points scale and the diagnostic scores divide into category of four. Scores ranging between 20-80 points, where, less than50 regarded normal, less than 60 as having mild depression, less than 70 as having major depression, while 70 and above regarded as severe major depression.

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Besides the adolescents and adult depression measures, there was a need to have measures for assessing depression in geriatric people. There is not much work done on this issue. Depression is not a process of aging, though somewhat people affected by it in their late life. The reason could be retirement from jobs, impairment in daily routine, cognitive functioning, and decreased quality of life (Blazer, 2009). Among other measure of depression available, Geriatric Depression Scale (GDS) is uses commonly in hospitals and by other health care professionals (Yesavage, Brink, Rose, Lum, Huang, Adey & Leirer, 1983). GDS is developed by Yesavage (1982) in a dichotomous yes/no format, has two measures one is long form consisting 30-item questionnaire, while other is short form consisting 15-item questionnaire. GDS assessed the intensity of depression, participant felt in the preceding week (Greenberg, 2007).

Children depression scales are significant components of assessing depression and their mental health. Children’s self-report measures of depression are relatively newer addition although fastest emerging in clinical psychology because of the importance of the issue. Weinberg Depression Scale for Children and Adolescents (WDSCA) is a 56 items, dichotomous response format measure developed for assessing depression in children and adolescent aged 5-21 years.

Another commonly used questionnaire is Center for Epidemiological Studies Depression Scale Modified for Children (CES-DC) is a derivation of adult CES-D. CES-DC is a 20 items measure with the same statements although the wordings related to children’s level of comprehension (Faulstich, Carey Ruggiero, Enyart & Gresham, 1986).

One more measure for addressing depressive symptoms in terms of behavior and feelings in childrens is Children’s Depression Scale (CDS)-3rd Ed. CDS is a 50 item scale developed for the childrens 7 to 18 years of age. CDS has two depression and pleasure scales with separate forms for boys and girls (Poznannski, Cook & Carroll, 1979).

Multi-score Depression Inventory for Children (MDI-C) is developed for childrens age ranging between 8-12years. MDI-C is 79-items original scale and 47-items short version with true/false response format. MDI-C addressed children’s mood, affect, behavior, self-esteem, social interaction, defiance, and learned helplessness. Moreover there is another children inventory developed named Child Depression Inventory (CDI). CDI is an extension of BDI, with 27 items and 10 items scale for children and adolescents. The age is ranged between 7-17 years. CDI covers broad spectrum of child’s behavior, emotional problems in home and school living for preceding 2 weeks.

Likewise, Mood and Feelings Questionnaire (MFQ) developed by Angold & Costello (1987) assess the child’s recent feelings and affect. MFQ is a 33-items long form and 13-items short form, and score ranging between 0 (not true) to 2 (true) points.



Use of self administered diagnostic tool for depression has been increased these days as a quick and reliable step in measuring depression for accurate treatment regimen in patients with chronic illnesses.

An analytical approach employed in the development of the Depression in Chronic Illnesses Scale (DCIS) i.e. the item selection and the method of assessing the individual’s level of Depression was based on a theory. In the case of present scale the theory was that of Beck’s (1967). The theory holds that cognitive distortions, dysfunctional beliefs and negative thoughts about an experience are responsible for having depression (Compass & Gotlib, 2002). Mental and behavioral problems interlinked and begin because of the negatively twisted thinking processes. Furthermore, depression has four major components that are affective, cognitive, behavioral and biological.

The present study carried out in two phases, where the first phase involved in development of the DCIS scale whilst second phase in validation of the newly developed scale.

Phase I

Development of the Depression in Chronic Illnesses Scale

The development of scale involved following steps:

Step 1: In-depth interview with chronically ill patients from various hospitals, view-points of health professionals and people from different community settings.


Three different samples were taken for this step in which 30 participants (20 females and 10 males) of health professionals, 30 people (15 females and 15 males) from different community settings and 30 chronically ill patients (13 females and 17 males) from various hospitals of Karachi were recruited as respondents.


Health care professionals:

30 (20 females and 10 males) health care professionals (e.g. doctors, psychologists & nurses) were approached. Their age ranged between 25-40 years. Initially a brief verbal presentation was given them about purpose of the study. Then they were requested to provide their view points for depression that could be their observation or experience in their lives (Annexure A, English) and (Annexure B, Urdu). Following instruction was given along with two sheets of paper.

“Depression isa mental state described by one’s feeling of sadness, loneliness, hopelessness, low self-esteem, and self-reproach”.

They were allowed to express their views easily in any language i-e English or Urdu.

People from community settings:

30 participants (15 females and 15 males) from different community settings i.e house wives, office workers, teachers and students from colleges and universities of Karachi were approached. Their age ranged from 18-45 years. Initially the reason of the study was extensively explained to them. Then they were requested to provide their view points about depression that could be their observation or experience in their lives (Annexure A, English) and (Annexure B, Urdu). Following instruction was given along with two sheets of paper.

“Depression isa mental state described by one’s feeling of sadness, loneliness, hopelessness, low self-esteem, and self-reproach”.

They were allowed to express their views easily in any language i-e English or Urdu.

Chronically ill patients:

30 chronically ill patients (13females and 17 males) were approached from different hospitals of Karachi. Their age ranged between 28-48 years. They were extensively and clearly explained the purpose of study and the reason for interview to put them in ease. They were further explained about confidentiality. A semi-structured in-depth interview was done on each chronically ill patient individually that explored their perspective, cognitions, feelings and behaviors about their illness in general and specific situations of life. They were asked open-ended questions (Annexure C), such as “how are you feeling today?” Their responses were recorded for further analysis.


The information explored during semi-structured in-depth interview with patients was summarized and analyzed. The point of views provided by health professionals and people from different community settings used for content analysis. The data from patients, heath care professionals and people from different community settings was qualitatively analyzed and common and relevant content was retained and uncommon content discarded.

Step 2: item writing and selection

Initially pool of the items were generated through quantitative analysis by using the definitions provided by the chronically ill patients, health professionals and people from different community settings (step 1)

Few items from established measures of depression such as Beck depression inventory (1967) were selected and those selected items were culturally relevant items as well. Primarily the selected items were translated in Urdu then included in the item pool (step 2).

Before given the item pool to the experts for rating, the content of the items was closely scrutinized by the researcher and supervisor to find out major weaknesses. Omissions and inclusions according to their relevance in each component were made and repetitive items and ambiguous items were deleted.

Then, to determine the construct validity of the final scale the panels of judges/psychologists were asked to scrutinize items of the scale keeping in focus the Beck model of Depression. Psychologists were given printed material on the theoretical model of Depression as proposed by Beck (1967), that explained briefly and precisely the three aspects of depression, along with few sample items from already developed scale of Beck depression Inventory.

After giving the material on Beck’s (1967) theory they were requested to rate each item on a 1 to 5 rating scale according to its relevance in each of the three components (Annexure D). They were asked to give an item a score of 1 if it is not at all related to the component/concept in question and give a rating of 4 or 5 if the item seems to be highly related to the component/concept in question. The items that had an average rating of 4 and above were selected and the items that had rating below 4 were discarded. Psychologists were replied back with their expert perspective in an objective manner to rate the formulated items for each component of the scale. Finally selected items were reduced to 28 total items (Annexure E).

Step 3: Pilot Study


A pilot study carried out by using the judge’s and psychologist’s rated scale and with the purpose of to evaluate the adequacy of scale and to make needed alterations accordingly. The sample of 60 (31 males & 29 females) chronically ill patients and they were conveniently selected from various hospitals of Karachi. The age ranges of participants were between 18 to 50 years.


A 28 itemed scale was administered (Annexure F) on the participants with a demographic form in which they asked to write their name, age, education and illness. Those participants selected for pilot study who can comprehend Urdu easily. Further they were required to identify vague, repetitive, and difficult to understand items.


Finally selected scale after pilot study reduced to 18 items (Annexure G). Item those were difficult to understand, and vague for majority of the participants were excluded.

Step 4: factor analysis and item total correlation


To find out factor analysis and item total correlation, final Depression in Chronic Illnesses Scale (18 items) was administered on 270 (154 males, & 116 females) chronically ill patients from various hospitals of Karachi. Their age ranged between 18- 50 years and they were conveniently selected.


Later than taking the written permission from hospital’s authorities, participants were explained about the details and purpose of the study along with a short demographic form, consent form (Annexure I) and final Depression in Chronic Illnesses Scale. Only those participants were included who volunteer to participate thus they could self-report the questionnaire. They were then requested to choose the one option of all eighteen items on DCIS, about which they think most related to their feelings during past six months. The choice of options was from strongly agree, agree and disagree to strongly disagree.

Phase II: Validation of Chronic Illnesses Scale

The second phase involved in determining the newly developed scale’s psychometric properties. Item total correlation, alpha internal consistency, split half reliability and convergent validity was calculated

Reliability Analysis

Sample and procedure:

For test re-tests reliability a sample consisted of 60 chronically ill patients (26 females, 34 males), age ranging from 18-50 years, recruited from various hospital of Karachi and for internal consistency analysis sample consisted of 270 chronically ill patients (103 males, & 90 females) with the age range of 18-50 years from different hospitals of Karachi. The Depression in Chronic Illnesses Scale was administered twice on participants at an interval of one week. Test re-tests reliability found out by computing Pearson r by using SPSS IBM version 22. Those participants comprehend easily the language of the scale were selected. For calculating internal consistency (item-total correlation & inter-items correlation) Cronbach’s alpha was computed and for split half reliability all items were divided randomly into two equal sets, then split-half reliability estimated by the proportion between these two total scores.

Validity Analysis

To assess the convergent validity the two scales were administered along with DCIS on 100 chronically ill patients selected from various hospitals of Karachi, age ranging between 18 to 50 years. Only those participants were selected who were bilingual or easily comprehend English language. The two scales used for assessing convergent validity were,

Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977)

Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960)


Participants were asked to complete the Depression in Chronic Illnesses Scale with Center for Epidemiologic Studies Depression Scale. The Hamilton Rating Scale for Depression was used by the administrator.


The Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) is a 20-item self-report rating scale that assesses mood, somatic complaints, interactions with others, and motor functioning. It’s a 4-point rating scale, scores ranges from 0-3 (rarely or none of the time=0, some or little of the time=1, occasionally or a moderate amount of time=2 and most or all of the time=3). The final score spans from 0 to 60, with a higher score indicating high intensity of depression. People with a final score of 16 or lower are identified as non-depressed; however, the higher are typically identified as a depressive ‘case’ (Annexure I).

Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960) is a 17-item, multiple choice clinician/health professional’s observation rating scale, design to assess the severity of depression in terms of mood, somatic complains, work and activity, sleep and insight. It’s a type of semi structured interview. Score ranging from 0-52, where score more than 23 indicative of very high intensity of depression, 19-22 high intensity, 14-18 moderate intensity, 8-13 mild and lower than 8 indicative of no depression (Annexure J).

Cut off Scores

In order to find out classificatory indices of DCIS, quartile 1, quartile 3 and intra-quartile had been calculated of eighteen items of the scale i.e. mild, moderate and severe level of depression in patients with chronic illnesses.


After computing the eighteen items of DCIS, the classificatory indices of the scores are, 0-16.25 indicates minimal depression, 17-25 indicates mild depression, 25-33 indicates moderate depression and more than 33 points indicates severe level of depression.

Operational Definitions:


Depression generally a state of mood characterize by a pessimistic sense of inadequacy dejection and a despondent lack of activity. Depression causes changes in view, emotion, behavior, and physical well-being. It is a widespread, intricate and complicated disorder, (Horwath, 2004).


Reliability of a test is referring to the consistency of a test.A test is reliable when it produces consistent and steady results over time (Phelan, & Wren, 2005). There are different types of reliability in which, test re-test reliability is a correlation between the scores of same group test at two different times on same test. This type of reliability uses to evaluate consistency of a test over time. Inter-rater reliability achieved by given a test to more than one judges for rating. The ratings then compare to establish the consistency of a test. Internal consistency reliability is correlation between items of the same test. Split half reliability is correlation between two halves of one test to assess the internal consistency of a test. Parallel-forms reliability is measured by comparing the correlation of scores of two different tests used for assessing same construct. These two tests administered at same time on same sample


Validity is one of the basic attributes of a test. Validity is a degree to which a test is measure what claims to measure (Cronbach, 1971). A test would be considered valid when it efficiently measures the specific characteristic that it means to be measure. There are four common types of estimation validity. Predictive validity is referring to the accuracy that how well a test guesses the future performance. The usual method is use to measure the approach to predict the future behavior solely on the basis of obtained scores. Criterion related validity used to predict future or current performance on a test. Content validity is referring to the extent to which how much a test represents every single item of the same construct. Construct validity refer to the extent to which a test measure a theoretical construct or attribute. Convergent and discriminant validity are two type of construct validity in which construct validity refers to which a test positively correlate with other measure of same construct while discriminant validity refer to a test does not correlate with other measure of different construct (Campbell & Fisk, 1959a).

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