INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2002; 17: 279±287.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/gps.588

Validation of the Spanish version of the geriatric depression

scale (GDS) in primary care
M. I. FernaÂndez-San MartõÂn1*, C. Andrade2, J. Molina3, P. E. MunÄoz4, B. Carretero5,
M. RodrõÂguez6 and A. Silva7
1
Area of Preventive Medicine and Public Health, Department of Sanitary and Socio-Medical Sciences,
University of AlcalaÂ, Madrid, Spain
2
Primary Health Care Unit Pintores, Health Area 10, Madrid, Spain
3
Mental Health Service, Community of Madrid, Spain
4
Mental Health Service, Community of Madrid, Spain
5
Navy Social Institute, Madrid, Spain
6
Mental Health Service, Health Area 10, Madrid, Spain
7
Area of Preventive Medicine and Public Health, Department of Sanitary and Socio-Medical Sciences,
University of AlcalaÂ, Madrid, Spain

SUMMARY
Objective To estimate the predictive value of the 30-question Geriatric Depression Scale (GDS) in Spanish and calculate
the most adequate cut-point for its use in Primary Health Care consultations.
Method 218 patients over the age of 64 treated at three health centers of Area 10 in Madrid were selected. In the ®rst
phase, the subjects completed the GDS, the Mini-Mental State Examination (MMSE) and a questionnaire on health and
socio-demographic variables. They were later interviewed using the Geriatric Mental Schedule (GMS), used as the gold
standard by doctors who were unaware of the results of the GDS. Two categories were contemplated according to the results
of the GMS: cases of depression (diagnosis of psychotic or neurotic depression) and non-psychiatric cases (no psychiatric
diagnosis, although isolated symptoms could be present).
Results 192 aged subjects were interviewed using the GDS and the GMS. Of these, 103 were considered `non-cases of
depression' and 60 others made up the `cases of psychotic/neurotic depression' group. For the most effective cut-point
(9/10), sensitivity was 86.7% and speci®city 63.1%. Considering a prevalence of depression of 30%, the predictive value
for positives was 50.2% and for negatives 91.7%. The Cronbach alpha coef®cient was 0.82, and the area below the ROC
curve obtained was 0.85. Those patients with cognitive deterioration had a mean GDS score similar to those that did not
present deterioration (11.16 vs 10.52; p > 0.05).
Conclusions The Geriatric Depression Scale is valid as a screening test in Primary Care consultations due to its high sen-
sitivity and negative predictive value. The most effective Spanish GDS cut-point (9/10) is lower than that obtained in the
original English version (10/11). Copyright # 2002 John Wiley & Sons, Ltd.

key words Ð aged; depression; reproducibility of results; primary health care

*Correspondence to: M. I. FernaÂndez-San MartõÂn, Area de
Medicina Preventiva y Salud PuÂblica, Universidad de AlcalaÂ,
Campus Universitario-Facultad de Medicina, Ctra. Madrid-Barce-
lona, Km. 33,600. E-28871, Alcala de HenaresÐMadrid, Spain.
Tel: 34 1 8854569 34 1 8854532. Fax: 34 1 8854874.
E-mail: maribel.fernandez@uah.es
Contract/grant sponsor: Health Ministry (Fondo de InvestigacioÂn
Sanitaria).
Contract/grant number: 98/0726.
Copyright # 2002 John Wiley & Sons, Ltd.
INTRODUCTION
Depression is the most frequent psychiatric problem in
the aged. Its high prevalence has been revealed by stu-
dies carried out in the general population (Dewey et al.,
1993; Devanand, 1994; FernaÂndez et al., 1995; CerdaÂ
et al., 1997) as well as in patients treated in primary
care (Evans and Katona, 1993; Marwijk et al., 1994;
Gottfries et al., 1997; Barry et al., 1998).
Received 2 July 2001
Accepted 30 October 2001
280 m. i. fernaÂndez-san martõÂn et al.
The detection of depression is dif®cult for primary
care doctors for various reasons, including the insuf-
®cient training of the physician in mental health and
the scarce amount of time available to each patient in
the consultation (Goldberg and Huxley, 1980;
Van Hemert et al., 1993). Also, depression in the
elderly is revealed by symptoms that can be confused
with problems of the aging process itself (slowness,
insomnia), progressive cognitive deterioration (loss
of memory and attention span, disorientation) or phy-
sical diseases for which the aging patient consults his/
her physician (pain, constipation), symptoms which
would more probably be attributed to depression in
an adult (Yesavage and Brink, 1983). This compli-
cates the diagnosis of mental diseases in general in
seniors (Kanowski, 1994).
Screening tests can be useful for the early detection
of depression in Primary Care. However, due to the
aforementioned particularities of this disease in the
aged, the tests used in patients under the age of 65
are not valid for those over this age, thus speci®c tests
have been designed for the aging population. There are
various tests that have been validated in an older popu-
lation, such as the Zung Self-Rating Scale for Depres-
sion or SDS (Zung, 1965) and the Geriatric
Depression Scale or GDS (Brink et al., 1982; Yesavage
and Brink, 1983). The latter has been translated into a
number of languages and used at various levels of
health assistance (primary care, geriatric clinics, hos-
pitals) and in community studies (Montorio and Izal,
1996). The authors speci®cally designed the scale
for the elderly, and as such the scale uses a Yes/No for-
mat to simplify its completion. They also excluded
from the symptoms those which could be confused
with somatic diseases or pseudo-dementia.
Different studies of the adaptation of the GDS scale
to Spanish have been written. Its predictive value has
been assessed in patients treated in a psychiatric
department (Ramos et al., 1991), in a small group
of elderly residents in a home (Lobo et al., 1990),
and its psychometric characteristics have been studied
in community elderly subjects (Salamero and Marcos,
1992). In addition, other studies evaluate the psycho-
metric behavior of the scale in aged rest home resi-
dents, without any modi®cations to its structure
(Izal and Montorio, 1993) and adding two more
answer options (PeÂrez et al., 1990).
Given that none of the previously mentioned ver-
sions have been validated in a primary care setting
and that GDS is frequently used at this level, the pre-
sent study was proposed, with the objective of esti-
mating the predictive value of the 30-question
Geriatric Depression Scale (GDS) in Spanish and
Copyright # 2002 John Wiley & Sons, Ltd.
calculating the most adequate cut-off point for its
use in primary health care consultations.
METHOD
The present study was performed in Area 10, public
health and administrative zone of the Spanish
National Health System. Area 10 is located in the
south of the Community of Madrid and covers some
235,000 inhabitants. The study population are persons
over the age of 64 assigned to three health centers of
Area 10 in Madrid (5,000 aged). Those elderly
patients treated outside the centers, such as those
who are handicapped or in rest homes, were excluded.
We also excluded `displaced' patients, being those
that live less than four consecutive months at a resi-
dence corresponding to one of the health centers.
We systematically selected 218 persons over the
age of 64 who were treated at the health center under
the `on demand' method of consultation (consulta-
tions solicited by the patients themselves, thus
appointments ordered by the doctor were also
excluded) during the months of February, March
and April of 1998.
The following variables were gathered:
Descriptive variables
Date of birth, marital status, sex, academic studies
and social class according to occupation and position
held in said occupation: ordinal variable ranging
between classes l and V (Alvarez-Dardet et al., 1995).
Variables related with state of health
(1) Psychopharmaceuticals prescribed in the last six
months. Information obtained from the patient's clini-
cal records; (2) health as perceived by the patient; (3)
presence of mental disease at any time during the sub-
ject's life, according to information given by the
patient; (4) sensory alterations: vision perceived (with
glasses if used); hearing perceived (with implant if
used) and (5) Cognitive deterioration evaluated by
means of the MMS (Folstein et al., 1975) and adapted
for Spanish by Lobo et al. (1979). The cut-point used
was 23/24 (sensitivity: 85% and speci®city: 82%).
Measurement of depression
The screening test used was the GDS and its results
were compared with those obtained with the GMS,
which was used as a gold standard.
Int J Geriatr Psychiatry 2002; 17: 279±287.
 spanish version of the gds
Geriatric Depression Scale GDS Brink et al. (1982)
and Yesavage and Brink (1983). This scale is
comprised of 30 questions with a dichotomous
YES/NO response which is evaluated as either 1 or
0. A response with a value of 1 indicates the presence
of a depressive symptom. There are 10 inverted
questions in which a negative response is scored as 1.
The validation of the 30-question version obtained a
sensitivity of 80% and a speci®city of 100% (cut-
point 10/11). The original English version was
translated into Spanish in this study by two bilingual
health professionals.
Geriatric Mental Schedule (GMS). Standardized
clinical interview that con®rms the diagnosis of a
psychiatric case. Created by Copeland et al. (1976)
and Gurland et al. (1976) and adapted for Spanish
(Lobo et al., 1988; Saz, 1991).
These tests were complemented with the AGECAT
computerized diagnostic program (Copeland et al.,
1986; Dewey and Copeland, 1986). The interview
consists of 286 questions referring to the month prior
to the interview, exploring the presence of 152 symp-
toms. The diagnostic decisions which the programs
contemplates are the following: no diagnosis, organic
psychosis, functional psychosis, hypomania, psycho-
tic depression, others psychoses, obsessive neurosis,
phobic neurosis, hypochondria, neurotic depression,
state of anxiety. Psychotic and neurotic depression
joined in the same group follow the diagnostic criteria
281
interviewed the patient and completed the GDS and a
questionnaire that included the variables described.
After a few days (2 weeks maximum) the patient
was given another appointment and, in this second
phase, doctors trained in psychiatry performed
the GMS interview. These doctors were trained in
the use of GMS by a psychiatrist; they were also
unaware of the result obtained by the patient in the
GDS.
The values for Sensitivity (S) and Speci®city (Sp)
were calculated for various cut-points. The Positive
Predictive Values (PPVs) and Negative Predictive
Values (NPVs) were obtained by means of the Bayes
Theorem, considering various values of prevalence.
Likewise, the ROC curve was drawn, calculating the
area below the curve, and the internal consistency of
the GDS was evaluated with the Cronbach alpha coef-
®cient. Con®dence intervals (CI) were calculated for
the measurements up to 95%.
A multiple logistic regression analysis was carried
out in order to adjust the classi®cation of the GDS
with the MMS cognitive deterioration test, meaning
that we checked whether the S and Sp values of the
GDS were modi®ed with the results of the MMS test.
The dependent variable is the classi®cation as a case
of depression/non-psychiatric case in accordance with
the GMS interview. Two independent variables were
included: the classi®cation from the GDS (with the
most effective cut-point) and the classi®cation from
the MMS (with the 23/24 cut-point). The statistical
for depression of the DSM-III classi®cation. In addi-
tion to the diagnoses, a Case Probability Index (CPI)
is also generated, which is scored from 1 to 5 (no
symptoms, mild symptoms, threshold case, moderate
case and serious case). The psychiatric case is de®ned
starting from a score of 3, which is considered the
threshold level. In the study carried out by Copeland
et al. (1986) and Dewey and Copeland (1986), the
authors demonstrated that the inter-observer reliabil-
ity between the AGECAT diagnoses and those given
by the psychiatrists that evaluated the same subjects
was 0.80 for depression, 0.88 for organic deteriora-
tion and 0.74 for the diagnosis of lack of psychiatric
pathology.
In this study, the cases were divided into two cate-
gories according to the results of the GMS: cases of
depression (aged patient with diagnosis of psychotic
or neurotic depression, level 3 or higher on the CPI)
and non-psychiatric cases (aged patient without any
psychiatric diagnosis, although isolated symptoms
may be present; level 2 or lower on the CPI).
The interviews took place in the health centers. In
an initial phase, medical residents of Family Medicine
Copyright # 2002 John Wiley & Sons, Ltd.
signi®cance of the  coef®cients was evaluated by
means of the Wald test.
RESULTS
The percentage of patients who refused the GMS psy-
chiatric interview after having answered the GDS was
11.9% (26/218). The socio-demographic and clinical
characteristics of the aged subjects, including those
who refused the GMS as well as those who did not,
are presented in Table 1. No statistically signi®cant
differences were found between the two groups.
The seniors interviewed (192) were mostly women
(63.5%), 39.5% were 75 years of age or older, 65.6%
were married, an important percentage had received
no education (64.2%) and the majority had been
unskilled or skilled manual workers (87.7%).
47.1% of the subjects described their state of health
as being average, more than half reported having suf-
fered insomnia, and around 40% reported having suf-
fered depression or anxiety at some time in their lives.
According to the corresponding clinical records,
27.4% had taken anxiolytics in the previous six
Int J Geriatr Psychiatry 2002; 17: 279±287.
282 m. i. fernaÂndez-san martõÂn et al.

Table 1. Characteristics of the aged patients selected for GMS interview

Did not refuse GMS Refused GMS

No. Percentage* No. Percentage*

Sex
Male 70 36.5 6 23.1
Female 122 63.5 20 26.9
Age (in years)
65 to 69 56 30.3 3 12.5
70 to 74 56 30.3 8 33.3
75 to 79 41 22.2 8 33.3
over 80 32 17.3 5 20.8
Marital status
Single 4 2.1 1 3.8
Married 126 65.6 15 57.7
Separated/divorced 4 2.1 Ð Ð
Widowed 58 30.2 10 38.5
Academic studies
Illiterate 26 13.7 4 15.4
Can read and write, no studies 96 50.5 13 50.0
Primary studies 63 33.2 9 34.6
Secondary studies 5 2.7 Ð Ð
Social class
I and II (Businessmen, managers) 3 1.6 Ð Ð
III (Skilled worker-non-manual) 20 10.7 2 8.0
IV (Skilled worker-manual) 79 42.2 9 36.0
V (Unskilled workers) 85 45.5 14 56.0
Self-perception of state of health:
Very good 9 4.7 Ð Ð
Good 65 34.0 14 53.8
Average 90 47.1 9 34.6
Bad 22 11.5 2 7.7
Very bad 5 2.6 1 3.8
Report having suffered the
following at some time in their
lives**
Insomnia 107 57.2 11 42.3
Depression 73 38.8 8 32.0
Anxiety 64 40.0 10 38.5
Psychopharmaceuticals in the
previous six months**
Anxiolytics 46 27.4 6 27.3
Antidepressants 22 13.1 3 13.6
Sensory alterations**
Visual 55 28.6 5 20.0
Auditory 27 14.1 4 16.0
Cognitive deterioration (MMS) 34 17.8 7 26.9
Mean GDS score (CI 95%) 10.67 (9.94 ±11.42) 10.87 (8.70±13.05)

*Percentages calculated over total variables.

**Percentages of those who answer YES for each variable.

months. According to the MMS, 17.8% of the patients
presented cognitive deterioration.
The mean score obtained on the GDS by the 192
aged patients was 10.67 (CI: 9.94±11.42). The GDS
questions that were least answered (Table 2) were
numbers 5 (`Are you hopeful about the future?'), 20
(`Is it hard for you to get started on new projects?')
and 22 (`Do you feel that your situation is hopeless?').
The question-total correlation coef®cients of the scale
were statistically signi®cant ( p < 0.01), except the
coef®cients representing two questions: numbers 28
(`Do you prefer to avoid social gatherings?') and 29
(`Is it easy for you to make decisions?'). The mean cor-
relation for these items was 0.40 (range ˆ 0.04 ± 0.66).

Copyright # 2002 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2002; 17: 279±287.
 spanish version of the gds 283

Table 2. Patients who did not answer each question of the GDS scale
GDS SCALE No.* Item-whole correlation**

1. En general ¿ se siente satisfecho con su vida? 2 0.45

2. ¿ Ha abandonado muchas de sus actividades e intereses? 1 0.30
3. ¿ Siente que su vida esta vacõÂa? 3 0.55
4. ¿ Se aburre con frecuencia? 1 0.58
5. ¿ Es optimista con respecto al futuro? 13 0.33
6. ¿ Se preocupa con pensamientos que no se puede quitar de la cabeza? 1 0.62
7. ¿ Esta de buen humor la mayor parte del tiempo? 3 0.42
8. ¿ Tiene miedo a que le suceda algo malo? 0 0.35
9. ¿ Se siente feliz la mayor parte del tiempo? 3 0.46
10. ¿ Siente con frecuencia que nada o nadie le puede ayudar? 1 0.41
11. ¿ Esta a menudo inquieto y nervioso? 6 0.53
12. ¿ Pre®ere quedarse en casa en vez de salir y hacer cosas nuevas? 2 0.38
13. ¿ Se preocupa con frecuencia del futuro? 2 0.44
14. ¿ Siente que tiene maÂs problemas de memoria que los demaÂs? 7 0.36
15. ¿ Piensa que es maravilloso estar vivo? 2 0.37
16. ¿ Se siente a menudo decaõÂdo y triste? 2 0.66
17. ¿ Se siente inuÂtil tal y como esta ahora? 0 0.58
18. ¿ Le preocupa mucho el pasado? 1 0.19
19. ¿ Cree que la vida es muy emocionante? 7 0.24
20. ¿ Le resulta difõÂcil empezar con nuevos proyectos? 11 0.26
21. ¿ Se siente lleno de energõÂa? 3 0.35
22. ¿ Cree que su situacioÂn no tiene salida? 11 0.37
23. ¿ Cree que la mayorõÂa de la gente esta en mejor situacioÂn que usted? 2 0.27
24. ¿ Se preocupa a menudo por cosas de poca importancia? 1 0.44
25. ¿ Siente a menudo ganas de llorar? 0 0.55
26. ¿ Le cuesta concentrarse? 4 0.45
27. ¿ Esta usted contento de levantarse por la manÄana? 0 0.41
28. ¿ Pre®ere evitar los encuentros sociales? 3 0.13
29. ¿ Es faÂcil para usted tomar decisiones? 6 0.04
30. ¿ Tiene la mente tan clara como antes? 1 0.23

*n ˆ 192.
**All the correlation coef®cients are statistically signi®cant ( p < 0.01), except the coef®cients corresponding to items 28 and 29.

So as not to exclude any patients from the analysis,
the score obtained by those who did not complete the
scale was adjusted to 30, taking into account the num-
ber of questions answered. This was carried out once
we checked that there were no statistically signi®cant
differences between the group of patients that
answered all the questions and the group that left
some questions incomplete, regarding the following
variables: sex ( p ˆ 0.87), mean age ( p ˆ 0.39), aver-
age GDS score ( p ˆ 0.53) and cognitive deterioration
according to the MMS ( p ˆ 0.52).
Later, the psychiatric diagnoses obtained by means
of the GMS-AGECAT interview in these 192 elderly
subjects were the following: 75 did not receive any
diagnosis, 27 were classi®ed with organic psychosis,
two were assigned to the group of other psychoses, 54
received a diagnosis of psychotic depression and six
of neurotic depression. The remaining 28 persons pre-
sented symptoms for some diagnoses, but without
reaching the threshold to be considered a case. For
the analysis of the validity of the GDS test, we there-
fore compared the 103 non-psychiatric cases (75 plus
28 with some symptoms but without diagnosis) with
the 60 cases of psychotic and neurotic depression
(54 plus 6).
Table 3 shows the GDS values for the aged patients
diagnosed as cases of depression and the group
without psychiatric pathology. The cases of depres-
sion had a mean of 14.85 positive answers, while
the non-depression cases had a mean of 8.27
( p < 0.001). 78% of the cases were in the threshold
category of the case probability index and 62% of
the non-cases had symptoms that did not constitute
a psychiatric case. Women represented 86.7% of the
cases and 51.5% of the non-cases ( p < 0.001).
The area below the ROC curve was 0.85 (CI: 0.79±
0.91; p < 0.001 under the assumption of null hypoth-
esis that the true area is 0.5). The most effective cut-
points, taking into account the S and Sp values, were
points 9/10 and 10/11 (Table 4). For the former, S was

Copyright # 2002 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2002; 17: 279±287.
284 m. i. fernaÂndez-san martõÂn et al.

Table 3. Comparison between cases and non-cases of depression according to the GMS interview
Total GMS depression case GMS non-depression case
n ˆ 163 n ˆ 60 n ˆ 103

Mean score GDS (CI) 10.70 14.85 8.27

(9.87±11.52) (13.63±16.07) (7.50±9.05)
Case probability index (GMS)
No symptoms 23.9% Ð 37.9%
Mild symptoms 39.9% Ð 62.1%
Threshold case 28.8% 78.3% Ð
Moderate case 8.0% 21.7% Ð
Serious case Ð Ð Ð
Sex
Male 35.6% 13.3% 48.5%
Female 64.4% 86.7% 51.5%
Mean age (CI) 73.50 74.39 72.98
(72.51±74.49) (72.53±76.26) (71.84±74.13)

Table 4. Characteristics of the GDS scale for the selected cut- the GDS and are nonetheless cases of depression, and
points true negatives were: 87.5% of women vs 43.1% of
Cut-point 9/10 Cut-point 10/11 women among the true negatives, and a mean age
of 82.10 years vs a mean age of 72.25 years among
Validation the true negatives. The mean score on the GDS was
Sensibility 86.7% (78.1±95.3%) 81.7% (71.9±91.5%)
Speci®city 63.1% (53.8±72.4%) 68.0% (59.0±77.0%)
also clearly higher, the score range in this group of
Positive predictive false negatives being between 7 and 9 points.
value for The false positives, meaning those which obtained
different prevalences: a score higher than 9 on the GDS and were not cases
15% 29.3% (19.9±38.7%) 31.1% (21.0±41.1%) of depression, differed from the true positives as fol-
20% 37.0% (27.0±47.0%) 39.0% (28.4±49.5%)
25% 43.9% (33.7±54.2%) 46.0% (35.2±56.8%) lows: 65.8% were women vs 86.5%, respectively. The
30% 50.2% (39.8±60.5%) 52.2% (41.4±63.1%) mean score obtained on the GDS was quite lower in
35% 55.9% (45.6±66.1%) 57.9% (47.2±68.6%) the group of false positives (12.67) than in the group
40% 61.0% (51.0±71.1%) 63.0% (52.5±73.4%) of true positives (15.89). The GDS score range for the
Negative predictive
value for
false positives was 10 to 17. 76.3% had psychiatric
different prevalences: symptoms on the GMS without reaching threshold
15% 96.4% (92.1±100%) 95.5% (90.9±100%) case level.
20% 95.0% (90.0±100%) 93.7% (88.4±99.0%) The internal consistency of the GDS, measured by
25% 93.4% (87.8±99.1%) 91.8% (85.8±97.8%) means of the Cronbach alpha coef®cient, was 0.82.
30% 91.7% (85.4±98.0%) 89.7% (83.0±96.3%)
35% 89.8% (82.9±96.7%) 87.3% (80.1±94.6%) An adjustment was made to the GDS (cut-point 9/
40% 87.7% (80.1±95.2%) 84.8% (77.0±92.6%) 10) with the MMS cognitive deterioration test, by
means of multiple logistical regression. The depen-
dent variable was the classi®cation as case/non-case
86.7% and Sp was 63.1%. For the latter cut-point, S according to the GMS interview. The result of the
decreases somewhat (81.7%) and Sp increases
slightly (68.0%). If the test were applied in a popula-
tion with a prevalence of depressive disorders of 30%,
PPV would be 50.2% and 52.2%, while NPV would
be 91.7% and 89.7%, for cut-off points 9/10 and
10/11, respectively.
Described below are the characteristics of the false
positives and negatives resulting from a cut-point
value of 9/10 (Table 5). The differences between false
negatives, meaning those which scored less than 10 on
Copyright # 2002 John Wiley & Sons, Ltd.
Wald test to evaluate the null hypothesis if the  coef-
®cient of the MMS variable is zero was not statisti-
cally signi®cant ( p ˆ 0.57). Therefore, there was no
relationship between the classi®cation made using
the MMS and the result of the GMS, nor were the S
and Sp values of the GDS modi®ed according to the
results obtained on the MMS. The mean score of the
GDS for the cases of cognitive deterioration was
11.16 (CI: 9.58±12.74) and 10.52 for the non-cases
(CI: 9.68±11.35).
Int J Geriatr Psychiatry 2002; 17: 279±287.
 spanish version of the gds 285

Table 5. Comparison between subjects correctly and incorrectly classi®ed by GDS (cut-point 9/10)
Negative Positive

TN FN TP FP
n ˆ 65 nˆ8 n ˆ 52 n ˆ 38

Sex
Male 56.9% 12.5% 13.5% 34.2%
Female 43.1% 87.5% 86.5% 65.8%
p ˆ 0.03* p ˆ 0.02
Mean age (CI) 72.25 82.10 73.18 74.26
(70.86±73.64) (75.78±88.43) (71.41±74.94) (72.26±76.27)
p ˆ 0.001** NS
Mean GDS score (CI) 5.70 8.08 15.89 12.67
(5.13±6.28) (7.33±8.83) (14.73±17.06) (12.09±13.26)
p ˆ 0.004** p < 0.001
GDS score
0±1 4.5% Ð
2±3 15.4% Ð
4±5 26.1% Ð
6±7 30.8% 25.0%
8±9 23.1% 75.0%
10±14 42.3% 81.6%
15±19 32.7% 18.4%
20±24 23.1% Ð
25±30 1.9% Ð
Case probability index
No symptoms 46.2% Ð Ð 23.7%
Mild symptoms 53.8% Ð Ð 76.3%
Threshold case Ð 75% 78.8% Ð
Moderate case Ð 25% 21.2% Ð
Serious case Ð Ð Ð Ð

*Signi®cance calculated with the Fisher exact test.

**Signi®cance calculated with the Mann±Whitney test.
TN, True negatives; FN, False negatives; TP, True positives; FP, False positives.

DISCUSSION to hospital criteria, while the group of healthy patients

The 30-question GDS is a valid instrument for its use
in the detection of probable depressive disorders in
the aged who are treated in Primary Care. The 9/10
cut-point is that which offers greater sensitivity
(86.7%) without decreasing in excess the value of
speci®city (63.1%). This cut-point is somewhat lower
than that established by Brink et al. (1982) and
Yesavage and Brink (1983) in the design and valida-
tion of the scale (10/11), for which they obtained an S
similar to ours (84%) but a much greater Sp (95%). In
another study performed in London with primary care
patients (Evans and Katona, 1993), values similar to
ours were obtained (S:85%, Sp:68%) but with the ori-
ginal cut-point. In Spain, Ramos (1991) concluded
that the most adequate cut-point is 17/18 for a S of
100% an Sp of 85%. This other study clearly differs
from ours with regards to the population evaluated:
the cases of depression were elderly patients treated
in a Psychiatric Department and diagnosed according
did not have psychiatric histories. The differences
between cases and non-cases in our study are fewer:
all are patients who had consulted their physician for
some reason, none of the cases had severe depression
according to the GMS, and an important percentage
of the non-cases (62%) had psychiatric symptoms,
but did not reach threshold level. All this may lessen
the discriminating ability of the scale. The high per-
centage of false positives (FP) obtained can also be
explained by these circumstances: many of the aged
patients that had scored positive on the GDS and were
not con®rmed as cases by the GMS were close to the
threshold in both tests.
Taking into account the prevalence of depression in
aged patients in Primary CareÐ37% in London
(Evans and Katona, 1993), 21% in the Netherlands
(Marwijk et al., 1994), 13% in Sweden (Gottfries
et al., 1997), 18% and 9% in American woman and
men, respectively (Barry et al., 1998)Ðthe NPVs
obtained are high, while the PPVs are less than

Copyright # 2002 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2002; 17: 279±287.
286 m. i. fernaÂndez-san martõÂn et al.
50%. However, given that the GDS would be used by
the general practitioner as a screening tool, it is
important that the instrument has high S and NPV
in order to detect the majority of cases, albeit at the
cost of labeling as ill those patients that are not in rea-
lity. Those aged patients with positive results who
therefore have a higher probability for depression
should be evaluated in depth by the general physician
before initiating any treatment. The authors of the
GDS designed the scale so that it would be able to
detect depression independently of the cognitive
deterioration of the aged subject, thus those symp-
toms that could be indicative of both pathologies were
not included. In our study, the mean score of the GDS
was similar in patients with and without cognitive
deterioration; the same happened in the Burke et al.
study (1992); likewise, it has been reported that that
GDS is valid for patients with mild or moderate
dementia (Feher et al., 1992). However, it must
be pointed out that patients classi®ed as having
cognitive deterioration can have high scores on the
MMS due at least in part to a low educational level.
This fact was manifested in a study created by the
authors with these same patients (Andrade et al.,
1999), as well as in the revalidation of the MMS scale
by the author of the ®rst translation into Spanish
(Lobo et al., 1999).
The GDS was devised by its authors to be com-
pleted by patients. However, it can be dif®cult for
aged Spaniards to do so by themselves, as 14% of
the aged subjects in our study were illiterate and
50% had received no education whatsoever. For this
reason, it was the doctor who questioned the patient
and completed the scale with the answers given. We
believe that the comprehension of the questions was
very high. Only those questions related to future pro-
jects in the lives of the aged patients (numbers 5 and
20) or number 22, which may re¯ect a more abstract
idea, were more likely to be left unanswered despite
the interviewers' insistence, most probably due to not
having been understood.
What remains to be contemplated is a second ana-
lysis of this scale to try to improve its validity starting
with a reduction in the number of questions, taking
into account the psychometric properties, as other
authors have already done (D'Ath et al., 1994). This
would lead to greater use of the GDS in Primary Care
consultations because less time would be needed for it
to be completed. Scales with fewer questions are
already being used in a multitude of languages (some
of the translations are available on Internet at
Yesavage, 2001) and as a screening test in Primary
Care (Gottfries et al., 1997).
Copyright # 2002 John Wiley & Sons, Ltd.
Contemplating the results obtained, the current
proposal of the GDS scale with a cut-point of 9/10
should be used when applied in Primary Care consul-
tations, given the difference in results in the various
Spanish versions carried out in different environ-
ments.
ACKNOWLEDGEMENT
This work is part of a Project ®nanced by Health Min-
istry (Fondo de InvestigacioÂn Sanitaria) investigation
grant 98/0726.
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