Diagnostic Accuracy of Post-traumatic Stress Disorder Checklist - Civilian Version and Modified Versions of Center for Epidemiologic Studies Depression Scale among 1988 Spitak Earthquake Survivors

Abstract

Background: Post-traumatic stress disorder (PTSD) is one of the most commonly studied and central psychopathologies in the aftermath of disasters. Depression in its turn is another significant contributor to the global burden of disease and is estimated to affect 350 million people worldwide. Considering short- and long-term adverse affects of depression and anxiety disorders, routine screenings of their symptoms become more and more important. The growing awareness of the issue favors the focus of scientific studies on the generation of “psychometrically sound” instruments and accurate detection of those conditions in epidemiological research, in particular assessing performance of corresponding screening tests among various samples. Significance: Notwithstanding the number of instruments that have been employed in the investigations to measure PTSD and depressive disorders among survivors of 1988 Spitak earthquake, no criterion validity studies of PTSD Checklist Civilian (PCL-C) or Center for Epidemiologic Studies Depression Scale (CES-D) modified scale yielding clinically validated measures have been conducted in Armenia. Aim: Investigate diagnostic accuracy of the Armenian versions of PCL-C and CES-D modified (16 item scale vs. 20 item scale with negatively restated Positive Affect items) among 1988 Spitak earthquake survivors. Methods: The study was a cross-sectional quantitative analysis. People aged 39 and older who were in Gyumri during the1988 earthquake comprised the study population. Sample size was calculated to be 126, and study participants were recruited based on a two-stage cluster sampling strategy. Study used two screening tests: PCL-C and CES-D modified version with negatively restated Positive Affect items. Structured Clinical Interview for DSM Disorders (SCID) was chosen as the reference standard for the screening instruments. Results: The majority of the sample was female (75.6%), married (66.9%), with university (33.9%) or professional/technical (30.7%) education. The mean age of the participants was 55.7 years; 26.2% of the participants met the criteria for current PTSD diagnosis and 28.4%- for current major depressive episode based on SCID. PCL-C performed well in the study population (Cronbach’s α=0.861), resulting in an AUC of 0.903 and an optimal cutoff score of 50. Both versions of CES-D demonstrated acceptable internal consistency for the total scores (Cronbach’s α=0.879 for CES-D (16) and 0.911 for CES-D (20). Items 4 (restated item “not as good as other”), 15 (“unfriendly people”) and 19 (“people disliked”) demonstrated relatively low corrected item-total correlations. Principal component analysis showed that negatively restated Positive Affect items, did not construct the factor of (lack of) Positive Affect. The AUCs for CES-D (16) and CES-D (20) were 0.895 and 0.902, while the optimal cutoffs 19 and 21, respectively. CES-D (16) and CES-D (20) did not differ significantly in their overall diagnostic performance. CES-D (16) performed better among males than among females. Conclusions: The Armenian version of PCL-C is an accurate screening tool for identifying PTSD symptomatology among Armenians with a trauma history with the most optimal and efficient cutoff score of 50 among 1988 Spitak earthquake survivors. Armenian versions of CES-D (16) and CES-D (20) with negatively restated positive affect items are valid tools to measure major depression symptomatology in Armenian population with optimal cutoff scores of 19 and 21, respectively. Given the failure of the negatively restated items to construct a separate factor of (lack of) Positive Affect, CES-D (16) is a more practical alternative for measuring depressive symptomatology in the Armenian population.