Cardiovascular diseases (CVD) are the most common non-communicable diseases globally and were responsible for an estimated 17.8 million deaths in 2017. More than three quarters of CVD deaths were in low-income and middle-income countries [
1,
2]. CVD is the leading cause of death among Jordanian adults, accounting for about 37% of all deaths in Jordan [
3]. Depressive symptomatology is common among patients with CVD, and affects approximately 20 to 40% of all patients [
4]. The coexistence of CVD and depression appears to be bidirectional [
5,
6].
Depression was found to be associated with an increase in the occurrence of cardiovascular events, worsening health-related quality of life, and increased mortality rate due to various pathophysiological mechanisms [
4,
7]. Depression is observed in more than 50% of patients diagnosed with CVD, but is usually alleviated with appropriate management and support. If depressive symptoms are left unaddressed in CVD patients, they can develop into a major depressive disorder [
7]. The health-related quality of life of patients with coronary artery diseases (CAD) is significantly affected by coexisting depressive symptomatology [
8,
9]. The incidence and prevalence of depression in patients with CVD in Jordan is unknown as there is no screening or tracking for depression currently. Therefore, early identification of depression is essential to provide appropriate intervention for these patients, so that they can be successfully rehabilitated to their routine life. Researchers have examined the effect of intervention on depression in patients with CAD [
10]. For instance, social support plays a major role in managing both cardiovascular diseases and depression at the same time. Greater perceived social support can lead to an improvement in depressive symptoms, which in turn can improve the patient’s overall quality of life [
10]. The perception of social support has been linked to the prognosis of CAD and the associated mortality [
11]. Low functional social support can be a risk factor for developing CAD and can impact CAD-related mortality [
11]. In addition, the absence of social support can lead to a poor prognosis and adverse outcomes in patients diagnosed with CVD [
12]. Furthermore, low social support in those with cardiovascular events are major predictors of depression in patients with CVD [
13]. Thus, it is crucial to assess depression in patients with CVD.
Researchers use various self-report questionnaires to assess depression in patients with CVD. The most frequently used questionnaires include: the Patient Health Questionnaire (PHQ) [
14], Beck’s Depression Inventory (BDI) [
15], the Hospital Anxiety Depression Scale (HADS) [
16], the Center for Epidemiologic Studies Depression Scale-10 (CES-D) [
17], and the Cardiac Depression Scale (CDS) [
18]. Among these instruments, only the CDS is designed specifically for screening depression in patients with CVD. The CDS is specifically beneficial in cardiac settings compared to the BDI.
Description of the instrument
The CDS was developed and validated by Hare and Davis (1996), and comprises 26 items clustered in seven subscales. The subscales are sleep, uncertainty, mood, hopelessness, inactivity, anhedonia, and cognition. The items are rated on a 7-point Likert scale, with the seven items reverse-coded. Higher total scores are indicative of more severe levels of depression [
18]. The CDS demonstrated high consistency reliability (α = 0.90) and excellent criterion validity compared to the BDI [
18].
The CDS was validated in studies that recruited patients with CVD. For example, Kiropoulos and colleagues [
19] tested the CDS, the BDI and the State Trait Anxiety Inventory (STAI) on a group of 152 patients with coronary heart disease (CHD). Their results supported the dimensionality of the original scale, as well as the concurrent validity of the CDS compared to the BDI; the STAI was also supported. In another British study on patients with CHD, the concurrent validity of CDS was established compared to the HADS and the BDI, in which Cronbach’s αlpha for CDS was found to be 0.93 in a sample of 395 patients [
20].
A systematic review of the studies that evaluated the psychometric properties of the CDS concluded that the CDS was a psychometrically reliable measure of depression in patients with CHD [
21]. Chavez and colleagues found that the CDS was a highly reliable and valid instrument with very good sensitivity in diagnosing depression in patients with CVD. To date, no other measure has been designed specifically to assess depression in patients with CHD [
21]. The CDS was translated into Persian [
22] and Chinese [
23]. Both studies showed satisfactory internal consistency reliabilities. Wang and colleagues’ study [
23] had a Cronbach’s α of 0.91 in a sample of 200 participants, and Gholizadeh and colleagues’ study [
22] had a Cronbach’s αlpha of 0.88 in a sample of 261 participants. These psychometric properties of the CDS reported for the Chinese and the Iranian cultures support the feasibility of using the CDS as a screening tool for depression in patients with CVD in the Jordanian population as well.
The CDS was also translated and validated in the Arabic language [
24]. Papasavvas and colleagues assessed the psychometric properties of the Arabic version of the CDS in a sample of 260 participants from one clinical setting and confirmed the feasibility of using the CDS with Arabic speaking patients. Although, the participants in Papasavvas and colleagues’ study were from 18 different Arab countries, the majority (54%) were from two countries: Egypt and Qatar. The feasibility of the CDS in the cultural context of the Jordanian population has not been assessed yet.
The research team translated the CDS into Arabic (Jordanian) to screen Jordanian patients with CAD. This approach was used because the previous Arabic version of the CDS was not culturally applicable and adequate for the Jordanian population. Although several countries use Arabic as their national language, there are several differences in the words and the meanings of words (i.e., different accents). Therefore, this translation (Arabic-Jordanian) was used in two studies to screen Jordanian patients with CAD for depression. The purpose of this secondary data analysis was to evaluate the psychometric properties of the Arabic version of the CDS in a sample of Jordanian patients diagnosed with CAD.