Background
Standardized diagnostic criteria for depression have raised several questions regarding the classification of adolescents with depression. In fact, dichotomizing the population into cases and non-cases does not take into account that a substantial proportion of depressed adolescents have sub-syndromal depressive symptomatology [
1]. Yet these young people have significant morbidity and are at high risk of developing full-blown major depression [
2].
Recent findings [
4,
24] support the view that measures of depression in adolescence are best implemented in a dimensional model, where depressive disorders are conceptualized as a continuum of severity, from mild to severe. Thus, subjects who meet DSM-IV diagnostic criteria for MDD [
3] represent the extreme of a continuum rather than a distinct group [
4].
The feasibility of clinical trials in adolescent populations depends on the availability of valid measures [
5]. In fact, many studies have utilized depression scales despite limited data regarding their validity with young people. For adolescents aged 13 and older, the most widely used self-reports include the Centre for Epidemiological Studies Depression Scale (CES-D) [
6] and the Beck Depression Inventory (BDI) [
7]. Likewise, the most frequently used clinician reports include the Hamilton Depression Rating Scale (HDRS) [
8,
9], the Montgomery-Asberg Depression Rating Scale (MADRS) [
10], and the Children's Depression Rating Scale CDRS-R [
11]. However, these instruments are not specific to adolescents, lack construct validity, and have limited or unknown reliability and validity in this age group [
12‐
14].
Following the dimensional perspective outlined by Fergusson, the main aim of our study was to design and validate a dimensional scale, the Adolescent Depression Rating Scale (ADRS) to quantify the intensity of depression in adolescents aged from 13 to 20 years. On the basis of recommendations by Myers and Winters [
13,
14] (construct validity as the core of depression rating scale development, the use of two scales – self report and clinician versions – to obtain a robust measure, both having short forms to facilitate reiterated and longitudinal assessments), the decision was made to develop two versions of the ADRS: a self-report and a clinician-report instrument. The clinician-report ADRS is designed to be used in clinical and research settings and the self-report ADRS for epidemiological studies.
This paper reports on the validation of the French version of the ADRS. This validation is based on a multi-centre study in France, Belgium and Switzerland. A validation study is presently in progress for the English, Spanish, Chinese, Arabic, and Hebrew versions of the instrument.
Results
Sample
Four-hundred and two adolescents aged 16.5 (sd 2.0), 125 males (mean age 16.5 (sd 1.8)), 277 girls (mean age 16.6 (sd 1.9)) were assessed. One-hundred and twenty-six patients were depressed (mean age 16.4/sd 1.9; 32 males, 94 girls), 139 patients had a depressive experience but no MDD (mean age 16.6 (sd 1.8); 45 males; 94 girls) and 137 patients were not depressed (mean age 16.7 (sd2.1); 48 males, 89 girls). Seven patients out of 409 patients initially included were dropped because of missing data.
Item analysis
For both clinician and self-report initial versions of the ADRS, the proportion of missing data per item was low (<5%). There was no item responses with floor effect >50%, or ceiling effect >50%. Inter-item correlation was <0.70, meaning there was no redundancy.
Factor structure
For the initial version of the clinician-report ADRS over the whole sample of patients, the screeplot is in favour of a uni-dimensional instrument, since 44% of variance is contained in the first principal component while a second eigenvalue is approximately equal to 1 (1.05). This justifies the use of a single score as a summation of all items. To explore structure more precisely a factor analysis was conducted for a 2-factor solutions. This solution was clinically interpretable, with a factor that could be related to an "internal negative state" including irritability, feelings of being overwhelmed, negative perception of self, ideas of death, sleep disturbances and the empathetic perceptions of the clinician; and a second factor grouping "external manifestations" (including school, leisure activities and relationships). Most items were clearly attributable to a single factor except for the item "clinging relationships". Since this item was sometimes found difficult to rate by some investigators, it was discarded. On the remaining 10-item ADRSc (table
3), a new series of factor analyses was performed across the 3 groups defined according to a level of depression (table
4).
Table 3
English final version of ADRS clinician version (ADRSc)
1 | Irritability | Absence of any irritability, either self-perceived or perceived by the observer | 0 |
| | Irritability perceptible or felt in dealings with the subject, although he/she can control it | 2 |
| | Considerable irritability in dealings with the subject, generating conflict, relational difficulties | 4 |
| | Intense, overpowering irritability making dealings and exchanges virtually impossible | 6 |
2 | Overwhelming experience of depression | No depressive feelings or thoughts (= gloominess, despair, sadness) | 0 |
| | Depressive feelings or thoughts present but controlled and manageable | 2 |
| | Feeling of being overwhelmed by depressive feelings or thoughts | 4 |
| | Intense feeling of being overwhelmed by depressive suffering that is devastating and impossible to contain | 6 |
3 | Negative perceptions of self | Perceptions of self are serene and relevant | 0 |
| | Tendency to depreciation of self and accomplishments | 2 |
| | Depreciation of self and accomplishments | 4 |
| | Self viewed as completely worthless, useless, overpowering despair | 6 |
4 | Ideas of death | No preoccupation regarding death or suicide | 0 |
| | Occasional preoccupations regarding death or suicide | 2 |
| | Recurrent preoccupations regarding death or suicide | 4 |
| | Pervasive and intrusive ideas regarding death or suicide | 6 |
5 | Mental slowing | No sign of mental slowness, thought and speech fluid | 0 |
| | Occasional difficulties in putting ideas together, mental inertia that hinders concentration | 2 |
| | Considerable difficulty concentrating, obvious repercussions on daily life or school | 4 |
| | Massive mental inertia, that can result in concentration being impossible or the interview being difficult | 6 |
6 | Sleep | No sleep disturbance, whether in duration or quality(= sleeplessness, nightmares, not feeling rested, sleeping excessively) | 0 |
| | Occasional sleep disturbance, unusual to the subject | 2 |
| | Marked, persistent sleep disturbance | 4 |
| | Major, persistent sleep disturbance, resistant insomnia | 6 |
7 | Investment in school, work or job seeking | Sustained investment in school or professional activities | 0 |
| | Loss of motivation for school or work, but activities maintained | 2 |
| | Marked loss of motivation, disinterest for school or professional activities | 4 |
| | Total loss of motivation, complete disinterest for school or professional activities | 6 |
8 | Investment in non-school activities | Interest and enjoyment intact, good investment in usual non-school activities | 0 |
| | Decrease of enjoyment or interest in usual non-school activities, but these are nonetheless maintained | 2 |
| | Loss of enjoyment or interest, repeated absence from usual activities, marked narrowing of activities | 4 |
| | Absence of enjoyment or interest in non-school activities, total cessation of usual activities | 6 |
9 | Relationship withdrawal | No relational withdrawal | 0 |
| | Unusual withdrawal from others | 2 |
| | Relational withdrawal, isolation from others | 4 |
| | Total isolation | 6 |
10 | Perceived empathy from the clinician | Interview felt to have occurred in a serene atmosphere | 0 |
| | Perception of sadness pervading the interview | 2 |
| | Feeling there was over-riding emotion and/or irrepressible sadness | 4 |
| | Perception of intense silent distress | 6 |
Table 4
Maximum Likelihood Factor Analysis of the ADRSc in three groups
Irritability | 0.997 | -0.031 | 0.380 | -0.020 | 0.166 | 0.038 |
Overwhelming depression | 0.340 | 0.507 | 0.797 | 0.168 | 0.653 | 0.261 |
Negative perception of self | 0.303 | 0.209 | 0.468 | 0.177 | 0.343 | 0.289 |
Ideas of death | 0.314 | 0.130 | 0.424 | 0.095 | 0.670 | 0.098 |
Mental slowness | 0.156 | 0.594 | 0.208 | 0.371 | 0.283 | 0.292 |
Sleep | 0.222 | 0.212 | 0.273 | 0.068 | 0.412 | 0.247 |
School investment | 0.145 | 0.422 | 0.149 | 0.455 | 0.272 | 0.629 |
Leisure | 0.137 | 0.476 | 0.077 | 0.919 | 0.103 | 0.887 |
Relationships | 0.061 | 0.488 | 0.046 | 0.542 | 0.277 | 0.624 |
Empathetic perception of clinician | 0.518 | 0.487 | 0.741 | 0.258 | 0.658 | 0.385 |
The stability of the two-factor solution was tested across age (under 16 or 16 and over), gender, and level of depression. There was no gender effect on the structure of the two versions of the ADRS. Factor loadings were however statistically significantly different across age and depression groups (all p values < 0.05).
Overall, the results are similar for the initial patient-report ADRS, especially with regard to the structure of the instrument. However, to be useful in epidemiological studies a self-report measure should be of a limited size. Therefore an item reduction procedure was carried out on the initial 44-item self-report. Items were removed on the basis of clinical considerations (clinical importance of the item itself), but also on the basis of readability, relevance, redundancy, item distribution across the different domains of the depressive experience derived from the qualitative phase, and statistical considerations (loading < 0.4, inter-item correlation > 0.6).
This procedure yielded a 10-item instrument, ADRSp (table
2). A factor analysis conducted on this shorter instrument confirmed a two-factor structure comparable to the structure of the clinician version reported above (table
5). We present the Factor analysis of the final ADRSc and ADRSp for the three groups of the sample.
Table 2
French and English final version of ADRS patient version (ADRSp)
1 | I have no energy for work/school | Je n'ai pas d'énergie pour l'école, pour le travail |
2 | I have trouble thinking | J'ai du mal à réfléchir |
3 | I feel overwhelmed by sadness and listlessness | Je sens que la tristesse, le cafard me débordent en ce moment |
4 | Nothing really interests or entertains me | Il n'y a rien qui m'intéresse, plus rien qui m'amuse. |
5 | What I do is useless | Ce que je fais ne sert à rien |
6 | When I feel this way I wish I were dead | Au fond, quand c'est comme ça, j'ai envie de mourir |
7 | Everything annoys me | Je ne supporte pas grand-chose |
8 | I feel downhearted and discouraged | Je me sens découragé |
9 | I sleep badly | Je dors très mal |
10 | School/work doesn't interest me just now, I can't cope. | A l'école, au boulot, j'y arrive pas |
Table 5
Maximum Likelihood Factor Analysis of the ADRSp in three groups
No energy for work | 0.041 | 0.997 | 0.125 | 0.990 | -0.014 | 0.712 |
Trouble thinking | 0.547 | 0.147 | 0.246 | 0.032 | 0.289 | 0.344 |
Overwhelmed by sadness | 0.597 | 0.247 | 0.613 | 0.069 | 0.570 | 0.190 |
Nothing really interests me... | 0.665 | 0.107 | 0.389 | 0.142 | 0.579 | 0.225 |
What I do is useless | 0.413 | 0.128 | 0.368 | 0.193 | 0.532 | -0.001 |
Ideas of death | 0.572 | 0.175 | 0.474 | 0.098 | 0.614 | -0.069 |
Everything annoys me | 0.628 | 0.046 | 0.582 | 0.157 | 0.474 | 0.094 |
Discouraged | 0.552 | 0.207 | 0.559 | 0.344 | 0.507 | 0.057 |
Sleep badly | 0.225 | 0.211 | 0.448 | 0107 | 0.599 | 0.092 |
Not coping at school/work | 0.229 | 0.510 | 0.166 | 0.538 | 0.076 | 0.794 |
Scale internal consistency
The internal consistency of the two final versions of the ADRS was good. The Cronbach alpha coefficient for ADRSp was 0.74 in the non-depressed group; 0.74 for the intermediate group and 0.79 for depression group. For the ADRSc, the Cronbach alpha was 0.78 in the non-depressed group, 0.75 for the intermediate group and 0.75 for the depression group
Concurrent validity
All instruments were significantly correlated. As shown in table
6, Pearson correlation coefficients between ADRSc and the HDRS, BDI and the CGI ranged from 0.62 to 0.8 (all p-values < 0.05). Pearson correlations between the ADRSp and the HDRS, BDI and the CGI ranged from 0.51 to 0.83 (all p-values < 0.05).
Table 6
Pearson's correlations coefficient between ADRS, HDRS, BDI and CGIs
ADRSc
| - | 0.63 | 0.80 | 0.61 | 0.80 |
ADRSp
| | - | 0.56 | 0.82 | 0.52 |
HDRS
| | | - | 0.52 | 0.74 |
BDI
| | | | - | 0.48 |
CGI
| | | | | - |
It is noteworthy that the CGI ratings are more strongly correlated with the ADRS (self or clinician-rated) than with the HDRS or the BDI-13 (statistically significant with a bootstrap procedure).
Discriminant validity: contrasted groups
As shown in Table
7, effect sizes of the HDRS, BDI, ADRSc and ADRSp were compared among the three groups. These effect sizes are intended to assess the sensitivity of the ADRS in differentiating groups with and without depression. The ADRSp shows a larger effect size than the BDI. This difference was statistically significant at the 5% level in differentiation of the non-depressed and depressed groups (including intermediate group). The ADRSc shows a larger effect size than the HDRS, and this difference was statistically significant in differentiating the groups [no depression] and [intermediate depression + depression] and in differentiating the groups [no depression + intermediate depression] and [depression].
Table 7
Discriminant validity and Minimum clinically relevant difference of ADRSc, ADRSp, HDRS and BDI
Levels of depression
| | | | |
No depression | 8.9 (6.1) | 6.0 (4.2) | 2.3 (2.5) | 8.6 (6.8) |
Intermediate group | 17.7 (7.6) | 11.0 (5.4) | 4.1 (2.7) | 12.9 (8.3) |
Depression | 28.2 (8.9) | 17.2 (6.2) | 6.0 (2.7) | 19.4 (8.9) |
Effect size
| | | | |
no dep vs (inter+dep) | 1.41 | 1.21 | 0.94 | 0.79 |
(no dep+inter) vs dep | 1.51 | 1.30 | 1.01 | 0.94 |
Sensitivity/specificity
| Cut-off 15: 0.76/0.80 Cut-off 20: 0.83/0.78 | | Cut off 3: 0.79/0.60 Cut-off 4: 0.80/0.60 | |
Minimum clinically relevant difference
| 5.2 | 3.1 | 0.9 | 2.5 |
Receiver operator curve analysis: sensitivity and specificity
The optimal cut-off point was determined by plotting sensitivity versus specificity for each possible cut-off and examining the point that maximized the summation of sensitivity and specificity. Here, two binary "gold standards" can be proposed to compute sensitivity and specificity: depression according the clinical judgment, or depression according to both clinical judgment and DSM-IV. Both analyses were performed. For the ADRSp, the cut-off corresponding to the clinical judgment of depression was 3 and the cut-off corresponding to the DSM-IV was 4. For the ADRSc, these cut-offs were 15 and 20, respectively. Sensitivity and specificity are reported in table
7.
Minimum clinically relevant difference
Finally, minimum clinically relevant variations in score on a scale are of major interest when interpreting results of clinical trials or epidemiological studies. This minimum variation can be estimated from the slope coefficient of the linear regression of ADRS on CGI (Norman et al. 2001) (Table
7). As a rule-of-thumb, a variation of 5 points on the ADRSc may be considered as the minimum clinically important difference, while a variation of 1 point is clinically important for the ADRSp.
Discussions and conclusions
The purpose of this study was to develop and validate a depression scale especially designed for adolescents. Our study showed that both the clinician and self-report versions of the ADRS had acceptable psychometric properties with good convergent, discriminant, and factorial validity, and good internal consistency.
The final 10-item versions of the clinician-report and self-report ADRS yielded two factors: "internal state" (items: irritability, overwhelmed by depression, negative perceptions of self, ideas of death, sleep and "external manifestations" (mental slowness, implication in school, leisure activities, relationships) (table
2). The factorial structure of the ADRS reinforces the construct validity of the scale since it is consistent with the preliminary qualitative phases of the development the ADRS scales. Depression in adolescents did indeed appear as
a complex emotional state, involving irritability, a feeling of being overwhelmed by the depressive experience, negative perceptions of self, thoughts about death; this is accompanied by
non-emotional manifestations: mental slowness, sleep disturbances, and
manifestations through social interactions at school, work, in leisure, and in relationships with others.
From the psychometric point of view, the non-emotional manifestations are divided into two types: one is linked to the complex emotional state and forms the dimension "Internal state", the other is linked to manifestations through social interactions and forms the dimension "External manifestations". Internal state and external manifestations are dimensions that are already well known in depression, and they are described here in a way that is specific to adolescence. Although deficiencies in social relationships are not included in the definition of depression, any exploration of depression should place strong emphasis on the impact of social skill deficits and dysfunctional interpersonal behaviours [
23].
It can be noted that in the ADRS the item "leisure" in the clinician version and the item "nothing really interests me or entertains me" in the self-report version explore manifestations of anhedonia, and the item "negative self-perception" explores one facet of a symptom often pointed to in depression: feelings of worthlessness. Recently, Wilcox and Anthony [
24]) reported that persistent anhedonia during childhood or adolescence-was 17 times more prevalent in a sample of male adults with major depressive disorder than in a sample of controls, and this figure increased to 31–32 times in females. Feelings of worthlessness in childhood and adolescence were also associated with major depressive disorder in adulthood. Pine [
25] and Murphy [
26], also pointed to the prognostic significance of persistent anhedonia when it appears before early adulthood.
From a public health standpoint, identifying specific early clinical features might make it possible to provide anticipatory guidance or other early interventions that could prevent or reduce the impact of depressive disorders. In addition, the small number of items in the ADRS self-report involves little respondent burden, thereby allowing it to be combined with other short instruments that screen for different mental health conditions, enabling its use in epidemiological studies.
The results of this study need to be considered in light of the following limitations. First, only five adolescents were interviewed in the qualitative phase, this may be considered as a small number, even if a saturation of the
verbatim collected appeared at this stage. Second, the sample under study was made up of psychiatric and medical outpatients or inpatients at multiple sites, even if this heterogeneity may be interesting in terms of generalisability, it may be criticised on scientific grounds. The strategy used to classify patients in the sample needs also to be discussed. A dimensional scale must be able to assess different levels of depression ranging from none to severe, for instance in clinical trials before and after treatment. Thus in our sample, three groups of depressive experience were formed: the non-depressed group, the intermediate group comprising patients who were depressed but not MDD (without consideration of the categories of depression), and the MDD group. We took the MDD form as the most severe form of depressive experience [
4,
24].
Other limitations must be noted. Inter-rater agreement was not measured in this first validation study. Also, since there is substantial overlap between anxiety and depressive symptomatology, subsequent studies should evaluate whether the ADRS differentiates between young people suffering from anxiety alone and those with depression [
27]. These two points will be studied in a second validation step.
Finally, no standardized instruments were used to assess subjects' psychopathology. However, all interviewers were senior psychiatrists with vast experience in assessing and treating children with psychiatric disorders. In addition, to diagnose MDD they used the DSM-IV criteria. Perhaps a replication study could implement standardized strategies to classify the patients according to depression categories and to explore co-morbidities.
The ADRSp and ADRSc have been designed and validated in French (in France, Belgium and Switzerland). Translations have been made into English (Canadian, American, British), Spanish, Italian, Arabic and Hebrew. Back-translations have been performed for all these versions, and problems remain with the Arabic and Hebrew versions of the ADRSc and the English version of the ADRSp.
Acknowledgements
The study has been founded by the Assistance Publique-Hôpitaux de Paris (grant number CRC03020, AP-HP 2003).
ARL has been paid by this grand for the coordination of the project.
The other authors did not receive any financing for their participation to this work.
The authors would like to acknowledge the member of the ADRS European validation group for the acquisition of data in France (Dr. F Atger, Dr. I. Atger, Dr. P. Benoit, Dr. O Bricou, Dr. S. Campredon, Dr. T. Chaltiel, Dr. J. Chambry, Dr. D. Cohen, Dr. B. Dutray, Dr. P. Gerardin, Dr. O. Ginoux, Dr. O. Guilbaud, Dr. F. Lamidié, Pr. M.R. Moro, Dr. S. Pavoine, Dr. J. Payet, Dr. D. Périsse, Dr. M. Terral, Dr. A. Tuset and Dr. E. Weiss), in Belgium (Pr. V. Delvenne, Dr. A. François, D.r H. Nicolis and Pr. N. Zdanowicz) and in Switzerland (Dr. F. Narring and Dr. A. Meynard)
Competing interests
The author(s) declare that they have no competing interests.
Authors' contributions
ARL: initiation of the research, study concept and design, performing statistical analyses, interpretation of data, drafting the manuscript. This study was conducted as a thesis project for ARL under the supervision of BF.
BB and IG: participation in the interpretation of the results, and revision of the draft paper
BF: supervision of the statistical analysis and revision of the draft paper
All authors read and approved the final manuscript.