Journal of Affective Disorders 274 (2020) 450–456

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Validation of the Arabic version of the center for epidemiologic studies T

depression-revised: A comparison of the CESD-R and CESDR-12
⁎
Jehad Rababaha, , Mohammed M. Al-Hammouria, Barbara L. Drewb, Wafa'a Ta'ana,
Ayat Alawawdehc, Zainab Dawoodd, Wa'ed Jawhare
a
Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
b
College of Nursing, Kent State University, Kent, OH, USA
c
Health Center, Jordan University of Science and Technology, Irbid, Jordan
d
Shmaisani Hospital, Amman, Jordan
e
Al-Kindi Hospital, Amman, Jordan

A R T I C LE I N FO A B S T R A C T

Keywords: Background: The Center for Epidemiologic Studies Depression-Revised (CESD-R) is a widely used tool to screen
Center for epidemiologic studies depression- for depression in the general population. An Arabic version of the CESD-R has not yet been translated and
revised validated. Thus, this article reports the findings of two studies that were conducted to examine the psychometric
CESD-R properties of the Arabic version of the CESD-R.
Depression
Methods: Both studies were conducted using cross-sectional designs among college students from two large
College students
universities in Jordan. A total of 988 students were recruited from University A and 251 from University B. Data
Factor analysis
were collected using self-report measures of depression, perceived stress, and quality of life. Exploratory factor
analysis was performed followed by a series of confirmatory factor analyses to compare different versions of the
Arabic CESD-R. Measurement invariance was performed across both samples and gender of participants.
Results: The analyses revealed that the goodness-of-fit indices for the 20-item version of the Arabic CESD-R are
not supported. Alternatively, a shorter version (CESDR-12) was created and the results supported its reliability,
validity, and measurement invariance. This version, compared to a 10-item version, is supported theoretically as
the items are more reflective of the DSM-V criteria for diagnosing depression.
Limitations: The specificity and sensitivity of the CESDR-12 were not evaluated in this article.
Conclusion: The Arabic CESDR-12 is a reliable, valid tool to screen for depression. Considering the prevalence
and potential consequences of depression among college students, this tool could be used to identify those at risk
and provide timely counseling and interventions.

1. Introduction
The Center for Epidemiologic Studies Depression (CES-D) scale,
which was developed in 1977 (Radloff, 1977), is a widely used measure
to screen for depression in the general population. Despite its estab-
lished psychometric properties and the consequent utilization in re-
search and clinical settings, the CES-D does not reflect recent updates of
depression and depressive symptomatology as defined by the Diag-
nostic and Statistical Manual of Mental Disorders IV and V (DSM-IV/V)
(American Psychiatric Association, 2013). Hence, the CES-D was criti-
cized for not providing a comprehensive coverage of depression
(González and Jenkins, 2014). Such variation and lack of consistency of
the CES-D with the diagnostic criteria led to the development of the
CESD-R (Eaton et al., 2004). The revised version was created to mea-
sure the core symptoms of depression identified in the DSM-V. In ad-
dition, the CESD-R is congruent with the duration requisite (i.e. at least
two weeks) for diagnosing depression.
The CESD-R was developed by conducting extensive research stu-
dies in different settings and among various populations.
Eaton et al. (2004) summarized the main studies including piloting a
40-item scale among household residents and inpatients, conducting
telephone surveys, and surveying low-income vulnerable populations.
The ultimate goal of these studies was to develop a reliable, valid
measure of depression. The outcome was the establishment of a revised
20-item version, CESD-R, that provides a more comprehensive coverage
of the DSM-V criteria for diagnosing depression. It is worth noting that

⁎
Corresponding author. Faculty of Nursing, Jordan University of Science and Technology, P.O. Box 3030 Irbid 22110, Jordan.
E-mail address: jarababah@just.edu.jo (J. Rababah).

https://doi.org/10.1016/j.jad.2020.05.124
Received 22 February 2020; Received in revised form 19 April 2020; Accepted 17 May 2020
Available online 26 May 2020
0165-0327/ © 2020 Elsevier B.V. All rights reserved.
J. Rababah, et al.
the DSM-V diagnostic criteria for depression include the following nine
symptom groups: 1) depressed mood, 2) loss of interest, 3) weight/
appetite changes, 4) insomnia or hypersomnia, 5) psychomotor
changes, 6) fatigue, 7) feeling of worthlessness, 8) diminished ability to
think/concentrate, and 9) suicidal ideation (American Psychiatric
Association, 2013).
The psychometric properties of the English version of the CESD-R
were examined in a study conducted by Van Dam and
Earleywine (2011). The reported Cronbach's α was 0.92 indicating an
excellent internal consistency of the scale. Both exploratory and con-
firmatory factor analyses were performed by Van Dam and Earleywine,
and the results supported the construct validity of the CESD-R. A two-
factor solution, negative mood and functional impairment, provided the
best fit explanation of the CESD-R both theoretically and psychome-
trically. Van Dam and Earleywine concluded that the CESD-R is a re-
liable, valid measure of depression and recommended using it in the
general population. Shorter versions of the CESD/CESD-R have been
created and tested including the CES-D-10 (Björgvinsson et al., 2013)
and CESDR-10 (Haroz et al., 2014).
Besides its established psychometric properties, the use of the CESD-
R has other advantages. The CESD-R is available for free in the form of a
paper and pencil and web-based measure, and it is intended to be used
for preliminary assessment of depression in community settings. The 20
items and the responses of the CESD-R are simply written, conse-
quently, the administration of the measure does not take more than few
minutes. Revising positively worded items enhanced the simplicity of
the CESD-R, compared to the original CES-D, and made the former more
congruent with the DSM-V criteria for screening for depression.
Moreover, explanation of the CESD-R scores is easy to understand by
healthcare providers and lay people.
1.1. Depression in college students
College students’ health is a multidimensional phenomenon that
necessitates considering various domains including thorough assess-
ment of psychological health. One of the major issues encountered by
many college students is depressive symptoms and depression. The
prevalence of depressive symptoms is higher among college students
than the general population (Ibrahim et al., 2013). According to
Beiter et al. (2015), the top three sources of depression among college
students are academic performance, pressure to succeed, and post-
graduation plans. In turn, depression could negatively affect college
students’ health-related quality of life (HRQOL) (Pekmezovic et al.,
2011), in-class involvement (Carton and Goodboy, 2015), and academic
achievement (Boyraz et al., 2017). Additionally, depression is asso-
ciated with an increased risk of alcohol use (Dennhardt and
Murphy, 2011; Horgan et al., 2016), unhealthy eating (Ward and
Hay, 2015), and suicidal ideation (Cukrowicz et al., 2011; Wang et al.,
2019). With the globally growing number of higher education students,
it is logical to assume that depression is a major health concern for
college students worldwide. The total number of higher education
students worldwide is about 200 million, representing a significant
proportion of the world's population, and the number is expected to
multiply in the future (The World Bank, 2017).
The literature regarding the prevalence of depressive symptoms and
depression among college students in Arab countries shows variations.
Zawawi and Hamaideh (2009), using the CES-D, reported that almost
half of Jordanian university students suffer from major depression. It
was reported in another study, conducted using the Beck Depression
Inventory, that 75% of Jordanian university students have depressive
symptoms (Hamdan-Mansour et al., 2009). Variations in the literature
regarding depressive symptoms prevalence could be attributed to many
factors. In particular, methodology and the use of updated, valid re-
search tools often play a significant role in findings. A review of the
literature in the CINHAL, Medline, PsychInfo, and Education databases
using the keywords Center for Epidemiologic Studies Depression-
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Journal of Affective Disorders 274 (2020) 450–456
Revised, CESD-R, and Arabic revealed no articles. Previous studies in
Arab countries were conducted using an Arabic translation of the CES-D
(e.g. Ayyash-Abdo et al., 2016). Hence, the congruence of the results
with the DSM-V criteria to diagnose depression is not supported. An
Arabic version of the CESD-R has not been translated and validated yet
(Dr. W. Eaton, personal communication). Therefore, this article reports
the results of two studies that were conducted to examine the psycho-
metric properties of the Arabic version of the CESD-R including its re-
liability, validity, and measurement invariance. The psychometric
properties of the original CESD-R are compared to those of two short
versions (CESDR-10 and CESDR-12).
2. Methods
2.1. Design and sample
A cross-sectional research design was used to conduct both studies
among college students at two large governmental universities in
Jordan. After obtaining the Institutional Review Board (IRB) approvals
from Jordan University of Science and Technology, a total of 1239
students participated in both studies: 988 from University A (Sample 1)
and 251 from University B (Sample 2). The participants were recruited
using quota sampling with an intention to recruit 25% of each sample
from the 1st, 2nd, 3rd, and ≥4th year of study. Before starting the
studies, approvals were obtained from the IRB at Jordan University of
Science and Technology. A signed informed consent was obtained from
each participant personally and a copy was given to each participant.
2.2. Measures
A package containing a demographic questionnaire, as well as the
Arabic versions of the CESD-R (20-item version), CESDR-12, the
Perceived Stress Scale-10 (PSS-10), and the Quality of Life Index (QLI)
was used to collect the data. The CESD-R was administered to the
participants in Sample 1, whereas the CESD-R-12 was used for Sample
2. The PSS-10 and QLI were completed by all participants in both
samples. Perceived stress was assessed because many studies showed
that depression and stress are positively correlated among college stu-
dents (Gerber et al., 2013; Kaya et al., 2019; Sawatzky et al., 2012). On
the other hand, QOL is negatively correlated with depression
(Pekmezovic et al., 2011).
CESD-R. The CESD-R is a 20-item tool used to measure depression
in the general population as well as those at risk for depression disorder
(Eaton et al., 2004). A Likert, 5-point scale is used and the responses to
the 20 items are as follows: (a) 0 = “Not at all or less than one day”, (b)
1 = “One to two days”, (c) 2 = “Three to four days”, (d) 3 = “Five to
seven days”, and (e) 4 = “Nearly every day for two weeks”
(Eaton et al., 2004). The first four items ask for the frequency of
symptoms during the last week. The total score of the CESD-R is cal-
culated as the sum of the 20 items, with higher scores indicating more
severe depressive symptoms. The cutoff score of the CESD-R to identify
depression is 16. Explanation of the CESD-R scoring is available on the
CESD-R webpage (CESD-R (n.d.) January 2020).
After obtaining the permission to translate and use the CESD-R, the
tool was forward-translated into Arabic by a certified, bilingual (English
and Arabic) translator. It was then independently back-translated to
English by another certified, bilingual translator. The translated and
back-translated versions were then reviewed by a third translator who
also compared the resulting back-translated version with the CESD-R
developed by Eaton et al. (2004). Ambiguity arose among the three
translators regarding two items of the CESD-R; item number 7: “I could
not get going”, and 13: “I felt fidgety”. Therefore, a meeting was ar-
ranged among two authors (J.R. and M.A.) and the three translators.
The purpose of the meeting was to reconcile the final translated version
of the CESD-R. The translated version was cognitively tested in a small
sample (N = 10), which was then included in the final analysis, to
J. Rababah, et al.
check accuracy and understanding of the Arabic version of the CESD-R.
The purpose of cognitive testing is to make sure that the items are
understandable by the intended users (Toma et al., 2017). Even though
there are different dialects of the Arabic language, the CESD-R was
translated to Formal Arabic to maximize its use in other Arab countries.
CESDR-12. Items of this short version were extracted from the
original 20-item CESD-R. In the item selection process, two key prin-
ciples were considered: a) selecting the items with the highest factor
loadings, and b) making sure that the items are reflective of the diag-
nostic criteria set by the DSM-V. In addition, attention was given to the
cultural appropriateness of this short version. The items of the CESDR-
10 were selected based on the factor loadings, i.e. the 10 items with the
highest factor loadings. On the other hand, the items of the CESDR-12
were selected based on both factor loadings and the symptom groups of
depression as outlined in the DSM-V criteria. The rationale for using
CESDR-12 not CESDR-10 is explained in the results section.
PSS-10. The PSS-10 is a 10-item intended to assess stress as per-
ceived by the study participants (Cohen and Williamson, 1988). It is a
widely used tool that is easy to understand and administer. The parti-
cipants were asked to report their own appraisal regarding how much
specific situations have been stressful during the last month. The PSS-10
employs a 5-point rating scale ranging from 0 (never) to 4 (very often).
Positive items were reversed before running analyses and then the total
score was obtained by summing up the scores of individual items. The
higher the total score on the PSS, the greater the perceived stress is.
Regarding its psychometric properties, the PSS has been used and va-
lidated among various populations and settings. The PSS-10 was pre-
viously translated into Arabic and validated (Chaaya et al., 2010).
QLI. The generic version (Arabic) of the QLI (Ferrans and
Powers, 1985) was used to measure participants’ Quality of Life (QOL).
The QLI involves two sections with a total of 66 items: the first is used
to assess satisfaction with 33 items, and the second assesses the im-
portance of those 33 items to the individual. A six-option scale is used
in the QLI, with a score of one means very dissatisfied and very un-
important and a score of six indicates very satisfied and very important.
Detailed guidelines regarding scoring of the QLI are available on the
web (Ferrans and Powers, January 2020) provided detailed guidelines
regarding scoring of the QLI. The total QLI score ranges from zero to 30
following a syntax provided by the instrument developers, with a
higher score indicating better QOL. The QLI was previously translated
and its psychometrics were evaluated (Halabi, 2006).
2.3. Data analysis
Descriptive statistics, internal consistency, and exploratory factor
analysis (EFA) were performed using SPSS (Version 23). A series of
Confirmatory Factor Analyses (CFA) were performed using AMOS
(Version 23). The purpose of conducting multiple CFA analyses was to
thoroughly evaluate the factor structure of different versions of the
CESD-R. For all CFA analyses, multiple goodness-of-fit indices were
used to assess the acceptability of the models (Hair et al., 2014;
Kline, 2015). The following cutoff values were used: Root Mean Square
of Error Approximation (RMSEA) ≤.07, Comparative Fit Index (CFI)
≥.95, and Chi Square/Degrees of Freedom (Chisq/df) < 5. These fit
indices represent absolute, incremental, and parsimonious fit, respec-
tively.
The authors used a random split half method for Sample 1, and the
analyses were conducted in four successive phases.
Phase 1 (first random split half of Sample 1). During this phase,
both EFA and CFA were performed. The EFA, principal component
analysis (PCA) with varimax rotation, was conducted to investigate the
overall structure of the CESD-R and the factor loadings. The EFA was
conducted using a random split half of Sample 1 (n = 494). Then, the
first CFA was performed on the same random split half (n = 494). The
translated CESD-R (20-item version) was used in this initial analysis.
The analysis involved comparison of different forms of the CESD-R
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Journal of Affective Disorders 274 (2020) 450–456
including a one-, two-, and four-factor solutions. The overall psycho-
metric properties of the CESD-R, including factor loadings and fit in-
dices, were evaluated.
Phase 2 (second random split half of Sample 1). After comparing
the different versions of the CESD-R, the authors selected 12 items of
the original scales with the highest factor loadings. Then, another CFA
was conducted on the second random split half of Sample 1 (n = 494)
using the short version, CESD-R-12. A single factor, depression, was
examined in this CFA.
Phase 3 (Sample 2). Based on the results of Phase 2, the authors
intended to further evaluate the factor structure of the CESD-R-12. The
third CFA was performed using the CESD-R-12 on Sample 2 (n = 251).
Furthermore, the correlations between the CESD-R-12 and the PSS-10
and QLI were assessed using Pearson's correlations (r). Thus, con-
vergent and divergent validities were examined through performing the
correlation between the CESD-R-12 and PSS-10 and QLI scores.
Phase 4 (measurement invariance). Evaluation of the measure-
ment invariance (i.e. multiple-group CFA invariance), across the two
samples and gender of participants, was performed. Measurement in-
variance was performed using the stepwise procedure starting with the
least restricted solution (Brown, 2006). Three measurement invariance
procedures were performed as suggested by Brown (2006) as follows: a)
equal form (configural invariance), b) equality of factor loadings (me-
tric invariance), and c) equality of indicator intercepts (scalar in-
variance).
3. Results
3.1. Participants’ characteristics
Table 1 summarizes and compares the participants’ characteristics
for both studies. The CESD-R total scores ranged from 0–60 in partici-
pants from Sample 1. In Sample 1, 26.3% of the participants reported
scores less than the cutoff score of 16 indicative of no depression. For
participants from Sample 2, the scores ranged from 0 to 36. Determi-
nation of the cutoff score for the CESDR-12 indicative of possible de-
pression has not yet been determined.
3.2. Phase 1
The PCA results showed that CESD-R 20 has four factors with ei-
genvalues exceeding the cutoff point of one. The four-factor solution
suggested by this PCA presented 60.53% explanation of variance.
However, 12 items of the original CESD-R had cross loadings on more
than one factor.
Regarding the CFA, one-, two-, and four-factor models were eval-
uated. The one-factor model was assessed to investigate whether the 20
items of the CESD-R represent one latent factor (i.e. depression). The
two-factor solution was evaluated to compare the results with the lit-
erature regarding the psychometric properties of the CESD-R. The four-
factor was performed based on the PCA results reported earlier. The
goodness-of-fit indices for these three CFA models did not support ac-
ceptability of the models (Table 2). In addition, the factor correlations,
for the two- and four-factor models, ranged from 0.70 to 0.96. Such
high correlation does not support the divergent validity of the 20-item
CESD-R.
3.3. Phase 2
A one-factor model of a shortened version of the CESD-R (CESDR-
12) was evaluated during this phase. Factor loadings and DSM-V di-
agnostic criteria for depression, as discussed in the introduction, were
considered to select the items of the shortened version of the CESD-R.
During the selection of items process, item # 2 of the original CESD-R "I
could not shake off the blues" was removed despite its acceptable factor
loading. The reason for deleting this item from the Arabic version is the
J. Rababah, et al. Journal of Affective Disorders 274 (2020) 450–456

Table 1
Participants’ characteristics.
Sample 1(n = 988) Sample 2 (n = 251)
Total 1stSplit Half 2ndSplit Half

Average age (SD) 21.11 (2.22) 19.55 (0.90) 22.67 (2.05) 21.2 (2.04)
Gender:
Male 465 (47.1%) 216 (43.7%) 248 (50.2%) 138 (55%)
Female 523 (52.9%) 278 (56.3%) 246 (49.8%) 113 (45%)
Year of Study:
1st 192 (19.4%) 134 (27.1%) 58 (11.7%) 55 (21.9%)
2nd 287 (29.0%) 216 (43.7%) 71 (14.4%) 64 (25.5%)
3rd 208 (21.1%) 94 (19.0%) 114 (23.1%) 61 (24.3%)
≥4th 301 (30.5%) 50 (10.2%) 251 (50.8%) 71 (28.3%)
Smoker
No 725 (73.4%) 380 (76.9%) 345 (69.8%) 180 (71.7%)
Yes 263 (26.6%) 114 (23.1%) 149 (30.2%) 71 (28.3%)
Average CESDR (SD) 26.84 (14.58) 26.27 (14.48) 27.41 (14.68) 15.28 (9.52)
Average PSS-10 (SD) 20.66 (5.95) 20.4 (5.84) 20.91 (6.06) 19.85 (6.24)
Average QLI (SD) 19.36 (4.55) 19.92 (4.36) 18.79 (4.67) 19.72 (3.60)

SD: standard deviation,.

Table 2 Table 3
CFA of the different versions of the CESD-R. Measurement Invariance.
Model X2, df RMSEA CFI Chisq/df Invariance Across Study Across Gender
Sample 1 Sample 2
Original CESD-R (Phase 1) (2ndsplit)
One-Factor 981.07, 170 (p <0.001) .10 .82 5.77
Two-Factor 966.28, 169 (p < .001) .10 .83 5.72 Equal form:
Four-Factor 675.41, 164 (p < .001) .08 .89 4.12 RMSEA .049 .057 .062
CESDR-10 (Phase 2) CFI .95 .94 .92
One-factor 126.68, 35 (p < .001) .073 .96 3.62 Chisq/df 2.79 2.58 1.96
CESDR-12 (Phase 2) Equality of factor X2 = 4.70, X2 = 13.63, X2 = 7.96,
One-Factor 183.69, 54 (p < .001) .07 .95 3.40 loadings df = 12, p = .97 df = 12, p = .33 df = 12, p = .79
CESDR-12 (Phase 3) Equality of X2 = 13.13, X2 = 37.61, X2 = 26.32,
One-Factor 117.98, 54 (p < .001) .069 .95 2.19 indicator df = 24, p = .96 df = 24, p = .04 df = 24, p = .34
intercepts

lack of a comparable meaning of this expression in Arabic. Two versions

of the CESD-R were evaluated: CESDR-10 and CESDR-12. The fit indices values presented in Table 3 indicate that all three types of measurement
of the CESDR-12 were better than those for the CESDR-10 (Table 2). In invariance of the CESDR-12 are supported across samples and gender of
addition, items of the CESDR-12 covers the nine symptom groups of participants.
depression as specified by the DSM-V, whereas the items of the CESDR-
10 covered only six symptom groups of depression. The goodness-of-fit 3.6. Internal consistency and correlations
indices for the CESDR-12 were: RMSEA = 0.057, CFI = 0.970, and
Chisq/df = 2.58. The internal consistency of the CESDR-12 is supported; both the
Cronbach's α and composite reliability values were 0.91 (Table 4 and
3.4. Phase 3 Fig. 1). The Cronbach's α of the PSS-10 and QLI were also acceptable
(Table 4). Regarding the CESDR-12 correlations with the other mea-
The CESDR-12 was administered and evaluated for Sample 2 during sures, the results showed that it is correlated positively with the PSS-10
this phase. The single latent factor, depression, model showed accep- and negatively with the QLI. Table 4 presents the correlations in ad-
table goodness-of-fit indices (Table 2). Considering the theoretical and dition to the Cronbach's α values for the CESDR-12, PSS-10, and QLI.
statistical support of the CESDR-12, this one-factor version was used to The correlations presented further support the construct validity of the
perform measurement invariance. CESDR-12. Fig. 1 depicts the final CESDR-12 model with the fit indices,
composite reliability, and the factor loadings.
3.5. Phase 4
4. Discussion
Measurement invariance was performed across samples (Sample 2
and second random split half of Sample 1) and gender of the partici- The studies reported here was conducted to examine the psycho-
pants. The results regarding equal form invariance showed that the fit metric properties of the Arabic version of the CESD-R, one of the most
indices for all multiple group analyses (across samples and gender) are
still within the criteria set a priori. An exception was the minimal de- Table 4
crease in the CFI, though. While the CFI values dropped below the Correlations and Cronbach's α.
prespecified cutoff point (i.e. ≥.95), some scholars argued that a CFI Measure Cronbach's α Correlations (r)
value above 0.90 is usually associated with a fit model (Hair et al., CESDR-12 PSS-10 QLI
2014). For the equality of factor loadings invariance, multiple groups
1. CESDR-12 .91 –
analyses showed that the X2 is not statistically significant (all p values
2. PSS-10 .74 .42** –
were > 0.05); supporting equal factor loadings invariance. Similarly, 3. QLI .97 −0.52** −0.31** –
equality of indicator intercepts was not statistically significant except
for the second random split half of Sample 1 (p = .04) (Table 3). The ** p < .001.

453
J. Rababah, et al.
Fig. 1. Final model of the CESDR-12. CR: composite reliability.
commonly used tools to screen for depression in the general population.
Different versions of the CESD-R were compared in this article in-
cluding a 20-, 10-, and 12-item ones. In addition, different models were
evaluated; one-, two-, and four-factor structures. The findings revealed
that CESDR-12 is supported both theoretically and statistically. The
items are reflective of the DSM-V criteria for diagnosing depression. The
goodness-of-fit indices of the CESDR-12 are excellent and supportive of
the factor structure of a single latent factor (depression) model. Values
of the Cronbach's α and composite reliability support the reliability of
this short version. Moreover, the authors intended to make the CESDR-
12 more culturally appropriate through deleting an item of the original
measure for lack of comparable translation of the English expression “I
could not shake off the blues”.
Findings of the present studies are, to an extent, consistent with the
findings of the early validation studies (Eaton et al., 2004). The vali-
dation study by Van Dam and Earleywine (2011) revealed that the in-
ternal consistency of the CESD-R was high with a Cronbach's α of 0.93.
This is comparable to the finding of the current studies. Regarding the
validity of the 20-item CESD-R, a two-factor solution was suggested by
Van Dam and Earleywine. The results reported here showed that a two-
factor structure of the Arabic version of the CESD-R does not fit well.
Alternatively, the factor structure and validity of the Arabic CESDR-12
is comparable to the English CESDR-10 (Haroz et al., 2014). However, a
careful comparison of the items of the CESDR-10 (reported by Haroz
et al.) with the CESDR-12 (reported in this article) reveals some var-
iations at the item level. Six items were retained in both versions,
namely: 1) “I felt sad”, 2) “I lost interest in my usual activities”, 3) “I
felt like I was moving too slowly”, 4) “I wish I were dead”, 5) “I was
tired all the time”, and 6) “I could not focus on the important things”.
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Journal of Affective Disorders 274 (2020) 450–456
Such variation could be attributed to the notion that the expression of
depression varies across different cultures (American Psychiatric
Association, 2013). In addition, different age groups experience and
report depression symptomatology differently. Specifically, younger
individuals are at higher risk for sleep disturbances
(American Psychiatric Association, 2013). The criteria set by the DSM-V
clearly describe other behavioral characteristics of depression like ap-
petite and psychomotor changes. Future investigation of the depressive
symptomatology, among the Arab populations, is needed to better un-
derstand this phenomenon.
The psychometric properties of other translated versions of the
CESD-R were compared to the findings reported here. The Polish ver-
sion of the CESD-R (Koziara, 2016) was reported as a reliable (Cron-
bach's α = 0.95) and valid tool to measure depression with three fac-
tors. The Korean version, on the other hand, demonstrated a higher
Cronbach's α value of 0.98, and the PCA revealed a two-factor solution
explaining 76.3% of variance (Lee et al., 2016). Regarding the Spanish
translation, the internal consistency was high (Cronbach's α = 0.92)
(Walsh, 2014). However, Walsh suggested using a 15-item Spanish
version, with two factors, of the CESD-R. As discussed earlier, cross-
cultural differences are believed to produce variations in the factor
structure and item loadings.
As theoretically supposed, depression scores were significantly,
positively correlated with the perceived stress scores. In addition, the
depression scores demonstrated a significant, negative correlation with
participants’ overall QOL. While higher levels of depression indicate
higher stress levels, college students with low level of depression re-
ported a better QOL. These results are consistent with the findings of
previous studies (e.g. Haroz et al., 2014; Van Dam and
J. Rababah, et al.
Earleywine, 2011) and they support convergent and divergent validity
of the Arabic version of the CESD-R.
4.1. Implications
College students need continuous guidance and counseling
throughout their course of study. Guidance is not confined to academic
advising, but extends to encompass psychological counseling. Thus,
psychological counseling clinics/programs have become an essential
component of the student services provided by universities and colleges
and the subsequent student success. Findings of the current study
strongly support the reliability, validity, and measurement invariance
of the Arabic version of the CESDR-12 among college students.
Employing the MAP-IT (Mobilize, Assess, Plan, Implement, and Track)
Framework, suggested by the Healthy Campus 2020, requires integra-
tion of well-established tools to measure health indicators like depres-
sion (Healthy Campus, 2018). The CESDR-12 could be used by psy-
chological counselors to screen for depression among college students.
Using the CESDR-12, early identification of depression in college stu-
dents could be achieved. Accordingly, appropriate plans and interven-
tions would be developed and implemented to help college students
overcome depression. Referrals for mental health services would then
be made, if necessary.
4.2. Limitations
The results of the studies reported here are not without limitations.
Formal (standard) Arabic was used to create the translated version of
the CESD-R. Formal Arabic was used in the translation process to en-
hance utilization of the CESD-R by researchers and clinicians in other
Arab countries. While formal Arabic is the official language of the Arab
World countries, a variety of dialects exists in different countries and
populations. Therefore, some of the terms that were used in the Arabic
version of the CESD-R might not be entirely comprehended by all
Arabic-speaking groups. In addition, the reading level of the translated
version was not determined. This could limit the applicability of the
Arabic version of the CESD-R to populations with an education level of
less than higher education. Another limitation was regarding the spe-
cificity and sensitivity of the CESDR-12; both were not determined.
That is because of the lack of data regarding participants’ history of
being diagnosed with depression. Relatedly, shortening the CESD-R to
12 items, which has advantages, may also limit the sensitivity. Future
research among a sample of people diagnosed with depression should
help identifying the specificity and sensitivity of the Arabic version of
the CESDR-12. In addition, it could be helpful to evaluate the con-
vergent validity of the CESDR-12 with other validated measures of
screening for depression.
4.3. Conclusion
A significant proportion of college students suffer various degrees
and symptoms of depression. With the increasing number of college
students, it is important to utilize reliable, valid measures of depression.
The psychometric properties of the Arabic version of the CESDR-12
were examined and the findings support its reliability, construct va-
lidity, and measurement invariance. Future investigation is warranted
to expand the applicability of the Arabic version of the CESDR-12 in
other Arab countries and among different populations.
Authors contributions
JR,MA and BD concieved the study idea and design. Funding ac-
quisition and methodology were performed by JR, MA, and BD. MA and
WT carried out the research administration and supervision. WT, AW,
ZD, and WJ roles included data curation and analysis under the su-
pervision of JR and MA. JR and MA drafted the manuscript and all
455
Journal of Affective Disorders 274 (2020) 450–456
authors provided insightful revisions. All authors approved the final
version of the paper.
Institutional board review approvals
Before starting the studies, approvals were obtained from the IRB at
Jordan University of Science and Technology. The IRB reference
numbers are 603–2017 (for University A) and 546–2019 (for University
B).
Declaration of Competing Interest
All other authors declare that they have no conflicts of interest.
Role of the Funding source
Both research studies were fully supported by the Deanship of
Research at Jordan University of Science and Technology (Grant
numbers 20180082 and 20190480). The authors are grateful to the
Deanship and University for the fund and for facilitating the process of
conducting these studies. The fund covered the costs of printing all
paper-based questionnaires, providing incentives to the participants,
and purchasing the statistical analysis software.
Acknowledgements
The authors are gratefully thankful to the translators for their di-
ligent efforts. The authors would also like to thank the college students
for taking the time to participate in these studies. Many thanks to the
Deanship of Research at Jordan University of Science and Technology
for facilitating the process of conducting both research studies.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.jad.2020.05.124.
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