629842

research-article2016
APY0010.1177/1039856216629842Australasian PsychiatryLiu et al.

Australasian
Measurement in Psychiatry Psychiatry
Australasian Psychiatry

An evidence-based scale for 2016, Vol 24(5) 466­–469

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DOI: 10.1177/1039856216629842
symptoms in Australian adults apy.sagepub.com

Xin Liu  Research Fellow, School of Health Sciences, Wuhan Sport University, China; School of Medicine, The University of
Queensland, Woolloongabba, QLD, Australia
Luis Furuya-Kanamori  PhD Candidate, Research School of Population Health, The Australian National University, Canberra,
ACT, Australia
Dan Siskind  Associate Professor, Queensland Center for Mental Health Research, Brisbane, QLD, and; Metro South Addiction
and Mental Health Service, Brisbane, QLD, Australia
David Crompton  Professor, School of Medicine, The University of Queensland, Australia; Metro South Addiction and Mental
Health Services, Brisbane, QLD, and; Centre for Neuroscience, Recovery and Mental Health, Brisbane, QLD, Australia
Gail M Williams  Professor, School of Public Health, The University of Queensland, Woolloongabba, QLD, Australia
Karam Kostner  Associate Professor, School of Medicine, The University of Queensland, Woolloongabba, QLD, and; Mater
Health Services, Brisbane, QLD, Australia
Luis Vitetta  Professor, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
Suhail A Doi  Associate Professor, Research School of Population Health, The Australian National University, Canberra, ACT, Australia

Abstract
Objective: To develop and test a self-reported scale designed to measure the antecedents of depression.
Methods: Participants of the Sustainable Mastery of Innovative Lifelong Exercise (SMILE) Tai Chi program were
invited to complete the scale for antecedents of depressive symptoms. The scale included questions regarding
events/factors the participants have experienced over the past three months and preceded their depressive symp-
toms. The reliability of the questions was assessed using the Cronbach’s alpha. Principal components analysis was
used to examine if there were domains of interest across the scale questions.
Results: A total of 126 participants completed the scale. The scale had a good internal consistency (Cronbach’s α =
0.82). Principal components analysis identified three components (life events, psychosocial problems, and physical/
health problems) in the scale and the components detected the root categories of depression in more than 56% of
the cases.
Conclusions: This simple self-administered scale has proven to provide a reliable measure for the antecedent factors
of depression in the SMILE Tai Chi cohort; further validation of the scale in different settings is encouraged.

Keywords:  depression, depressive symptoms, antecedents, scale, self-assessment, self-administered

D
epression is a common mental disorder, with an
estimated 350 million people of all ages affected
worldwide.1 Depression is also an independent
risk factor for heart disease,2 with growing evidence of
a bi-directional relationship between depression and a
range of physical illnesses such as heart disease, stroke,
diabetes, cancer, arthritis, osteoporosis, and obesity.3,4
Findings from the World Health Survey conducted by
the World Health Organization indicate that depres-
sion is a leading cause of disability.5 Furthermore,
depression is associated with the greatest decrement in
health of any chronic disease, and co-morbid d­ epression
i­ncrementally worsens other health problems more
than many other disease combinations.5,6 In addition,
the Longitudinal Investigation of Depression Outcomes
study has reported that depression is associated with a
17%–46% increase in healthcare costs.7
Corresponding author:
Xin Liu, Translational Research Institute, School of
Medicine, The University of Queensland, 199 Ipswich Road,
Woolloongabba, QLD 4012, Australia.
Email: xin.liu@uqconnect.edu.au

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Liu et al.

The identification of patients with depression through a were instructed to use a 4-point scale (ranging from 0 to
scale is the first step towards the start of the therapy, fol- 3, with 3 indicating higher frequency) to rate the extent
lowed by the identification of the antecedent(s) that to which the events and/or factors experienced over the
triggered the depressive episode. The life events and per- past three months have interfered with/caused their
sonal risks causing depression were reported previously;8 depressive symptoms.
however, to our best knowledge there is no reliable scale
The internal consistency (reliability) of the 11 questions
available that identifies the antecedents of depression.
of the SMILE scale for antecedents of depressive symp-
For that reason, researchers from the Sustainable Mastery
toms was determined by the Cronbach’s alpha coeffi-
of Innovative Lifelong Exercise (SMILE) Tai Chi program
cient. Principal components analysis was used to assess
developed a self-reported scale designed to measure the
if there were domains of interest across the scale ques-
antecedents of depression.
tions.13 A varimax rotation with Kaiser normalization
was used to maximize the sum of the variances of the
square loadings.14
Methods
The SMILE Tai Chi Program received ethical approval
from the Human Research Ethics Committees of both Results
Princess Alexandra Hospital and The University of
A total of 126 participants completed the SMILE scale for
Queensland. The SMILE Tai Chi program9 recruited par-
antecedent depressive symptoms. Among the 126 par-
ticipants using a wide range of methods, such as adver-
ticipants, 76% were female and the overall age ranged
tisements and referral from primary care physicians/
from 28.89 to 76.78 years (mean 53.88 years, standard
general practitioners (GPs), from October 2009 to March
deviation (SD) 9.74 years). Seventy percent of the par-
2010.
ticipants were on antidepressant medication and the
The eligibility criteria included: (1) age between 18 and patients’ CES-D10 score range was 0 to 30 (mean 13.98,
80 years; (2) depression (diagnosed by GPs); (3) being on SD 6.76). Twenty-six participants had a CES-D10 score of
antidepressants for depression or having a short form of 10–14 (moderate depressive symptoms); whereas, 70
the Center for Epidemiological Studies Depression Scale participants had a CES-D10 score >14 (severe depressive
(CES-D10) rating score of 10 or higher;10 and (4) having symptoms).
central obesity (waist circumference more than 95 cm
The SMILE scale for antecedent depressive symptoms
(men) and 80 cm (women)) and/or body mass index of
scores ranged from 0 to 33 (mean 12.7, SD 6.6). The scale
more than 30 kg/m2).11 The CES-D10 scale was selected
had a good internal consistency (Cronbach’s α = 0.82)
for depression screening among the participants because
for the 11 questions (see Table 1). Principal components
this scale has proven to be well accepted by the general
analysis with the varimax rotation identified a three-
population, it has been validated in the general popula-
component solution that accounted for 56.1% of the
tion (not just in psychiatric inpatients), and has a high
explained variance. The three components were life
internal consistency.12 The cut-off point of CES-D10 ≥ 10
events, psychosocial problems, and physical/health
was selected as it has a sensitivity and specificity of 96%
problems. The mean values of the 11 questions across
and 100%, respectively.10 Only patients with central
these three groups in descending importance were 6.17
obesity were enrolled because the one of the SMILE Tai
(SD 3.84) for the psychosocial problems group, 5.20 (SD
Chi program objectives was to examine the effect of Tai
2.92) for the life events group, and 1.37 (SD 1.31) for the
Chi on obesity. Exclusion criteria included contraindica-
physical/health problems group, respectively.
tions to physical activity, mental illness other than
depression (such as bipolar disorder or schizophrenia),
any severe or acute general medical problem, type 1 dia-
betes, current pregnancy, being within three months’
Discussion
post-partum, or anticipating pregnancy during the Several screening scales for affective disorders have been
course of the study. developed throughout the years;10,12,15–17 however, for
the first time a self-administered reliable scale that meas-
Researchers from the SMILE Tai Chi program designed a
ures the antecedent factors of depression has been devel-
scale for antecedent depressive symptoms which con-
oped and successfully tested. The results indicate that
sisted of 11 questions (see Appendix 1). The SMILE Tai
the SMILE scale for antecedent depressive symptoms
Chi program researchers consisted of a psychiatrist, a
identifies three main antecedents of depressive symp-
complementary and alternative medicine expert, a car-
toms: life events; psychosocial problems; and physical/
diologist, a mind-body movement therapy expert, and a
health problems. These three domains identify the root
biostatistician. The SMILE scale was developed based on
categories of depression in a primary care setting in more
‘the life events and personal factors that put a person as
than 56% of the cases.
risk’ from beyondblue, Australia.8 Participants of the
SMILE Tai Chi program were asked to complete the There were several limitations in our study. First, the
SMILE scale for antecedent depressive symptoms SMILE scale for antecedents of depressive symptoms
between August and December 2010; the participants was  administered once; thus, the test-retest reliability

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 Australasian Psychiatry 24(5)

Table 1.  Internal consistency of the components and principal component analysis of the SMILE scale for
predictors of depression

Communality Cronbach’s Rotated component Component

α if item is matrix name
deleted
  Component  
  1 2 3  
a Family circumstances/conflict 0.48 0.80 0.72 0.27 –0.22 (a) Life events
b Interpersonal conflict (outside family) 0.50 0.80 0.66 0.07 0.37  
c Recent losses and disappointments 0.57 0.79 0.75 0.26 0.00  
d Poor working conditions 0.38 0.81 0.55 0.06 0.20  
e Past bad experiences 0.67 0.78 0.52 0.55 0.22 (b) Psycho-social
problems
f High anxiety 0.61 0.79 0.34 0.62 0.24  
g Unemployment 0.40 0.81 0.03 0.76 –0.09  
h Family (inherited) disposition 0.51 0.80 0.17 0.74 0.05  
i Personality (e.g. a lifelong worrier; a 0.52 0.80 0.15 0.65 0.33  
perfectionist; sensitive to personal criticism;
unassertive; self-critical and negative; shy;
socially anxious and having low self-esteem
j Drugs and/or alcohol 0.26 0.82 0.00 0.13 0.78 (c) Physical/health
problems
k Medical illness and/or treatments 0.40 0.81 0.43 0.09 0.50  
Explained variance (%) 22.26 21.83 12.02  

Numbers in bold print indicate the factor set.

(intra-class correlation coefficient) was not assessed. Funding

Second, the SMILE scale for antecedents of depressive
symptoms has not yet been validated in a different
cohort of patients. Finally, the patients were recruited
based on depression identified by GPs (not a psychia-
trist) and being on antidepressants for depression and/or
depression scores above a pre-determined threshold;
therefore, the participants were likely to be experiencing
a range of depressive disorders. While this may poten-
tially limit the generalizability of our findings to a spe-
cific diagnostic category of depression, such as major
depressive disorder, our findings are relevant to the pop-
ulation of depressed patients seen in primary care.
The SMILE scale for antecedents of depressive symptoms
is a simple and reliable self-administered scale to detect
the antecedent factors of depression. For future studies,
we recommend that the scale should be reported in
This work was supported by beyondblue and the National Heart Foundation (G 088 4034). The
study sponsor had no further role in the study design and collection, analysis, and interpreta-
tion of data, or in the writing of the article and the decision to submit it for publication.
LFK is funded by an Endeavour Postgraduate Scholarship (#3781_2014), an Australia National
University Higher Degree Scholarship, and a Fondo para la Innovación, Ciencia y Tecnología
Scholarship (#095-FINCyT-BDE-2014).
Disclosure
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of the paper.
Funding
The authors received no financial support for the research, authorship, and/or publication of
this article.
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Appendix 1.

SMILE scale for antecedents of depressive symptoms.

During the PAST THREE MONTHS, how much did the following events/factors interfere with/cause your
depressive symptoms?
(please circle one number on each line)

  Never Rarely Sometimes Often

a Family circumstances/conflict 0 1 2 3
b Interpersonal conflict (outside family) 0 1 2 3
c Recent losses and disappointments 0 1 2 3
d Poor working conditions 0 1 2 3
e Past bad experiences 0 1 2 3
f High anxiety 0 1 2 3
g Unemployment 0 1 2 3
h Family (inherited) disposition 0 1 2 3
i Personality (e.g. a lifelong worrier; a perfectionist; sensitive to personal 0 1 2 3
criticism; unassertive; self-critical and negative; shy; socially anxious and
having low self-esteem
j Drugs and/or alcohol 0 1 2 3
k Medical illness and/or treatments 0 1 2 3

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