Aging & Mental Health
Vol. 13, No. 6, November 2009, 899–904
Validation and factor structure of the Thai version of the EURO-D scale for depression among
older psychiatric patients
Tawanchai Jirapramukpitaka*, Niphon Darawuttimaprakornb, Sureeporn Punpuingband Melanie Abasc
aDepartment of Psychiatry, Faculty of Medicine, Thammasat University, Klong Luang, Pathumthani, Thailand;bInstitute for
Population and Social Research, Mahidol Univeristy, Salaya, Nakhonpathom, Thailand;cInstitute of Psychiatry, King’s
College London, Denmark Hill, London, UK
(Received 17 December 2008; final version received 11 May 2009)
Objectives: To assess the concurrent and the construct validity of the Euro-D in older Thai persons.
Method: Eight local psychiatrists used the major depressive episode section of the Mini International
Neuropsychiatric Interview to interview 150 consecutive psychiatric clinic attendees. A trained interviewer
administered the Euro-D. We used receiver operating characteristic (ROC) analysis to assess the overall
discriminability of the Euro-D scale and principal components factor analysis to assess its construct validity.
Results: The area under the ROC curve for the Euro-D with respect to major depressive episode was 0.78 [95%
confidence interval (CI) 0.70–0.90] indicating moderately good discriminability. At a cut-point of 5/6 the
sensitivity for major depressive episodes is 84.3%, specificity 58.6%, and kappa 0.37 (95% CI 0.22–0.52)
indicating fair concordance. However, at the 3/4 cut-point recommended from European studies there is high
sensitivity (94%) but poor specificity (34%). The principal components analysis suggested four factors. The first
two factors conformed to affective suffering (depression, suicidality and tearfulness) and motivation (interest,
concentration and enjoyment). Sleep and appetite constituted a separate factor, whereas pessimism loaded on its
Conclusion: Among Thai psychiatric clinic attendees Euro-D is moderately valid for major depression. A much
higher cut-point may be required than that which is usually advocated. The Thai version also shares two common
factors as reported from most of previous studies.
Keywords: aged; depressive disorders; Thailand; validation studies
Depression in older persons is reported to be asso-
ciated with substantially reduced quality of life and
increased mortality (Penninx et al., 1999; Penninx,
Leveille, Ferrucci, van Eijk, & Guralnik, 1999) and
increased use of all health and social service resources
(Watts et al., 2002). In spite of its public health
significance, levels of recognition and treatment of
depression by physician are reported to be rather low
(Crawford, Prince, Menezes, & Mann, 1998; Dearman,
Waheed, Nathoo, & Baldwin, 2006; Koenig, 2007).
There has been little research from Thailand on
depression in older people. Given the importance of
detection of depression in older people, there is a need
to validate a Thai version of a depression screening
Euro-D was an instrument developed by 14
European countries for screening depression in the
elderly (Prince et al., 1999). It has also been used in low
income and middle income countries in other regions
(Castro-Costa et al., 2007; Prince et al., 2004). Its
concurrent and criterion validity across 14 different
settings in Europe was satisfactory (Prince et al., 1999).
Most of the previous Euro-D studies suggest two
common factors; affective suffering (including depres-
sion, tearfulness and wishing to death) and motivation
(including loss of interest, poor concentration and lack
of enjoyment). Evidence for its cross-cultural validity
in developing countries including China, India, Latin
America and Africa suggest a similar factor structure
across these settings (Prince et al., 2004). There is as yet
no evidence for the validity of Euro-D in Thailand.
In the current study we attempted to test Euro-D’s
internal reliability, its concurrent validity against the
diagnosis of major depressive episodes provided by the
mini international neuropsychiatric interview (MINI)
(Sheehan et al., 1998) and its construct using principal
component analysis (PCA) on a sample of psychiatric
clinic elderly attendees.
We sampled consecutive patients attending a busy
outpatient practice in a psychiatric hospital in the
suburb of Eastern Bangkok. Patients aged 60 or above
were approached in the waiting room when they
attended the clinic to see their doctor. There were
eight psychiatrists participating in the study. A
research worker, who was a postgraduate student in
patients and asked for informed consent. Study was
*Corresponding author. Email: firstname.lastname@example.org
ISSN 1360–7863 print/ISSN 1364–6915 online
? 2009 Taylor & Francis
conducted according to the guidelines issued by the
institutional review board of the hospital involved.
After reading a study information sheet, those who
agreed to take part were interviewed either before or
after seeing their doctor in a private room on the
premises. Those with evidence of severe cognitive
impairment, dangerous behaviours, very frail, or with
limitations of comprehension were excluded. We
continued recruitment until our target of 150 com-
pleted interviews was met. The majority of the patients
were presenting with common conditions such as
anxiety, depression, dementia, and substance-related
Interviews with Euro-D were carried out before or
after the participants saw their doctors. Each of the
eight psychiatrists administered MINI-Thai version,
the major depressive episode section (Kittiratpaiboon
& Wongkampin, 2004), while the trained research
worker administered Euro-D. We blinded the MINI
interviewers to the Euro-D responses obtained by the
research worker and vice versa.
The Euro-D is a structured common depressive
symptoms scale derived from the geriatric mental
Challop, 1984) and other measures including the
Centre for Epidemiological Studies Depression Scale
(CES-D) (Radloff, 1977), Zung Self-Rating Depression
Scale (ZSDS) (Zung, 1965), and the Comprehensive
Psychological Rating Scale
Schalling, 1979). It was designed to be administered
by trained lay interviewers and only consists of 12
items dealing with: depression, pessimism, wishing
death, guilt,sleep, interest,
fatigue, concentration, enjoyment and tearfulness. A
cut-point of 3/4 was identified using receiver operating
characteristic (ROC) analysis in studies carried out in
14 European countries and produced a range of
sensitivity (63%–83%) and specificity (49%–95%).
Principal components analysis generated two factors
(affective suffering and motivation) that were common
to nearly every participating European country (Prince
et al., 1999) and for Indian, Latin-American and
Caribbean centres (Prince et al., 2004). Internal con-
sistency was universally satisfactory, ranging from
0.83–0.93 (Prince et al., 2004).
In Thailand, the Euro-D items appeared to cover
symptoms recognised locally as common in psycho-
logical disorders in older adults. The original version
was carefully translated and back-translated into
English. First, a team of bilingual mental health
professionals and social scientists developed the first
translation, paying particular attention to conceptual
and semantic equivalence. Two English speaking old
age psychiatrist with training and extensive experience
with the GMS assisted to answer any questions about
the original version. The first translation was piloted
on an urban community sample of 12 elderlies to test
its clarity and comprehensibility. Some questions (e.g.,
sleep, irritability, appetite, weight loss) simply required
translation. Others were adapted to ensure local
equivalence or to aid comprehension (i.e. depression,
concentration and pessimism). ‘Can you concentrate
on entertainment or reading’ was replaced with ‘Can
you concentrate on daily activities that you like, such
as listening to the monks’ teachings, the radio or
depressed?’ was replaced with ‘have you been feeling
sad, gloomy or in despair’. It was most difficult to
translate the question on pessimism. The original
question asks ‘tell me your hopes for the future’ and
rates pessimism if the person cannot describe at least
one hope. In the Thai context we anticipated that older
people, most of whom were Buddhist, would not
mention any hopes because they were expected at their
age to view life with contentment and to take each day
as it comes. Asking about ‘future hopes’ might
therefore elicit feelings of unfamiliarity and discom-
fort. This could lead to misinterpreting true pessimism.
We changed the wording to ‘do you have any hope that
in the near future good things might happen to you?’.
We hoped that the modified closed question would
enable to valid response.
The MINI was used as gold standard criterion
measure. MINI is a short structured diagnostic inter-
view, developed for DSM-IV and ICD-10 psychiatric
disorders. The section on major depressive episode was
used. The Thai version of MINI was validated against
diagnoses made by local psychiatrists in a clinical
setting (Kittiratpaiboon & Wongkampin, 2004) and
used as a gold standard criterion against a newly
(Arunpongpisal et al., 2006). It was also used as a
main diagnostic instrument in a recent national mental
health survey (Department of Mental Health, 2003).
The output data from the MINI and Euro-D were read
into STATA and the following parameters were
(1) The prevalence of major depressive disorder
according to each method of assessment.
(2) The absolute numbers of participants in each
cell of the cross tabulation by test and criterion
status, that is true positive, false negative, false
positive and true negative.
(3) The kappa with 95% confidence intervals (CI)
as the primary measure of agreement.
(4) Coefficient of agreement (the proportion of
participants classified as positive by either
900T. Jirapramukpitak et al.
assessment that are classified as positive by
(5) To assess concurrent validity, the scores of the
Euro-D were compared with the diagnosis of
major depressive disorder provided by the
MINI. A positive case was defined as an
individual who was diagnosed as having a
major depressive episode. The area under the
rROC, with the correspondent 95% CI, was
estimated for major depressive disorder criter-
ion. The optimal cut-off point was identified
and sensitivity, specificity, positive, and nega-
tive predictive values were calculated.
(6) The inter-item correlations and Cronbach’s
alpha coefficients were calculated as measures
of the internal consistency of the Euro-D.
(7) A PCA of the Euro-D was performed, in an
Demographic and clinical characteristics
Over a 2-month period we approached 167 patients of
whom 150 completed the interview (response rate
89.8%). The demographic characteristics of the sample
are shown in Table 1. The principal diagnoses were
mood disorders (29.3%), anxiety disorders (23.3%),
organic mental disorders (16%), headache (4%), sub-
stance abuse and dependence (2.7%) and other
Table 2 shows the prevalence of each Euro-D symptom
across the whole sample and the prevalence of each
Euro-D symptom comparing patients who were
diagnosed and not diagnosed with depression.
As shown in Table 2, the mean number of items
rated as present during the past month per subject was
4.9 (95% CI 4.4–5.3). The frequencies of items ranged
from 16.7% (concentration) to 58.7% (irritability).
Only one item (pessimism) did not significantly
discriminate patientsdepressedfrom thosewho
were not. Over 75% of depressed patients reported
that they had been depressed, had sleep trouble, had
been irritable, and felt fatigue.
The concordance between Euro-D and MINI for
major depressive episode was fair. The level of agree-
ment for the sample (kappa) was 0.37 (95% CI 0.22–
0.52). Euro-D tended to overdiagnosis with respect to
MINI with a prevalence of 39.3% compared with 34%
for major depressive disorder according to MINI. The
area under ROC curve for the overall discriminability
of the Euro-D scale against the criterion of MINI
major depressive disorder was 0.78 (95% CI 0.70–0.85)
(Figure 1). Inspection of psychometric indices at
different cut-points suggests a cut-point of 5/6 with
sensitivity of 84.3% and specificity of 58.6%. The
positive and negative predictive values were 55.9 and
80.2, respectively (Table 3). A higher cut-point of 6/7
will yield lower sensitivity (64.7%) and higher specifi-
city (73.7%) (Table 3).
The Cronbach’s alpha for the total scale was suffi-
ciently high at 0.72, although the internal consistency
could be improved upon by the omission of EURO4
(pessimism), which marginally increased the standar-
dised alpha to 0.74.
For factor analysis, the adequacy of the data for factor
analysis was assessed by inspecting the correlation
matrix, which showed that 10 coefficients in 66 were
40.3. Moreover, the Kaiser–Mayer–Oklin value was
0.77 and the Barlett’s test of sphericity achieved a high
level of statistical significance (p50.001), supporting
the factorability of the correlation matrix.
Principal component analysis revealed the presence
of at least three components with eigenvalues exceed-
ing 1, following inspection of the scree plot (Table 4).
Factor one conformed to affective suffering (depres-
sion, suicidality and tearfulness) with smaller contri-
bution (0.4–0.5) from guilt, irritability and fatigue, and
factor two indicated motivation (interest, concentra-
tion and enjoyment) but negligible loadings from other
items. The affective suffering factor account for 26%
of the variance in the items, and the motivation factors
for 12%. The third factor, with eigenvalue marginally
over 1, was largely loaded on by sleep and appetite.
older people’s health and quality of life which needs
a screening instrument to identify individuals at
risk. Euro-D is a useful instrument which serves
is animportantcondition affecting
Table 1. Sociodemographic characteristics (n¼150).
(SD¼7.0, range 59–88)N%
4 years (primary school)
Aging & Mental Health901
this purpose. To our knowledge, this is the first study
to test the reliability and validity of Thai version of
Euro-D. Attempts were made to ensure that content
and semantic equivalence were achieved by strict
minor modifications to make the items more compre-
hensible and relevant to the Thai context. It was found
to be feasible and easily administrable by trained
interviewers in this clinical setting.
Our results show that the frequency of individual
items rated as present during the previous month in
this study was somewhat higher than those reported in
a previous Euro-D studies in European countries
(Prince et al., 1999). The prevalence of the pessimism
item was particularly high and it did not discriminate
well between the depressed and the nondepressed
groups. Although we altered the original version of
the item it was still the case that few older people
volunteered any hopes for the future. The Buddhist
doctrines of contentment and acceptance of the current
life situation are likely to explain this view. The hope of
better living in the future, for instance in terms of
gaining material good, contradicts the traditional path
toward merit in the afterlife (Pfanner & Ingersoll,
1962). Guilt was also highly prevalent. This may be due
to people misunderstanding the guilt item or the
tendency to volunteer feeling a burden on children
and this being rated as a symptom. It is widely
perceived among Thai older people that they should
rely on their children when they get old and dependent
(Knodel, Chayovan, & Siriboon, 1992), but many
expressed guilt about this. Fatigue was also high,
possibly because there were extra untreated physical
illnesses or because many older Thai people are still
working hard to make ends meet even after their
retirement. Further studies using item response theory
analysis to explore for differential item functioning
(DIF) may be helpful to investigate whether there is
item bias in the Thai version and to explain the high
levels of these symptoms. The area under the ROC
curve for the overall discriminability of the Euro-D
scale against the criterion of any MINI depressive
disorders was 0.78 (0.70–0.85). This rather impressive
degree of overall prediction, coupled with the high
sensitivity (94%) and poor specificity (34%) of the
Euro-D cut-point of 3/4 suggested that this cut-point is
too low for the Thai clinical sample. A cut-off score of
5/6 had lower sensitivity (84.3%) but higher specificity
(58.6%) to screen major depressive episode compared
with the usual cut-off reported previously. This higher
cut-off might reflect more depressive symptoms among
psychiatric patients. The majority of cases of depres-
sive disorders in clinical settings obviously tend to be
more severe compared with cases in general popula-
tion. In community settings, cases may tend to have
lower screening score. Further validation studies in the
community setting will be needed. Taking account of
the Thai context and improving the clarity of the
wordings may help to improve the overall sensitivity
The Cronbach alpha coefficient shows a high
internal consistency for the whole Euro-D question-
naire, although the item on pessimism would appear to
improve the overall internal consistency if deleted. As
discussed earlier, the concept of pessimism may be
different among Thai elderly. Finding a better way to
Table 2. Euro-D item prevalences and scale scores (N¼150).
Depressive patients diagnosed by MINI
pYes (n¼51) %No (n¼99) %
Area under ROC curve = 0.7753
Figure 1. Area under ROC curve.
902 T. Jirapramukpitak et al.
address the issue of pessimism may help to improve the
overall psychometric properties.
One of the questions raised in a validation study is
about what is the real construct behind the instrument
to be validated. The Euro-D was mainly derived from
GMS/AGECAT and designed to be used by trained
lay interviewers, whereas MINI was based on ICD-10
and DSM-IV criteria and used by mental health
professionals as a diagnostic tool for major depressive
episode. These discrepancies may provide an explana-
tion for the fair kappa for the agreement between
Euro-D and MINI cases.
It is striking that the internal structure of the
Euro-D as suggested by principal components analysis
is consistent with most of the previous studies (Castro-
Costa et al., 2007; Prince et al., 2004). Our version of
the Euro-D also shares two common constructs, the
first one being affective suffering, including depression,
tearfulness and wishing to die, and second one being
motivation including loss of interest, poor concentra-
tion and lack of enjoyment. They were mapped well
onto the two common main factors reported pre-
viously, although there were slight differences in the
individual items included in each factor (Castro-Costa
et al., 2007; Prince et al., 1999; Prince et al., 2004). The
two extra factors were identified in our study, one
including sleep and appetite and the other one
including pessimism. The three items had eigenvalues
of about 1. This may not be so surprising as three- or
four-factor structure was also reported in some of the
European settings. For example, sleep and appetite
were found to be loading on another factor in Sweden,
Netherlands and Iceland and pessimism loading on a
separate factor in Germany (Prince et al., 1999).
Although the four-factor structure is somewhat differ-
ent, it remains difficult to establish that it does vary
from the European studies. Confirmatory factor
analysis may be a useful technique to test whether
the four-factor model has better overall goodness-of-fit
than the two-factor solution.
There were some limitations in this study. First, the
study was conducted in a psychiatric hospital on a
sample of patients with a variety of mental conditions.
The study sample was obviously different from those
based in communities or general practice. Second, the
sample size available for this validation study was
relatively small. More studies with a larger sample size
in a variety of clinical settings are warranted. In
addition, item bias cannot be excluded as an explana-
tion for the relatively high prevalences of many
Euro-D items in our study. Further studies in cross-
cultural settings using item response theory analysis
should provide more clues.
In conclusion, this is the first study to test the
reliability and validity of Thai version of Euro-D. This
validation study reports the use of Euro-D in a clinical
setting. The instrument has demonstrated rather
different properties to those shown in previous studies.
The different cut-point found in the current study
suggests the need for caution in interpretation of
Euro-D scores in Thailand. Further studies are still
needed to validate Euro-D in the Thai community.
This research was supported by the Wellcome Trust, UK
(WT 078567). We are grateful to the patients who
Kalayarajanakarind Institute for their assistance in facilitat-
ing the study. We are particularly indebted to Dr Kampanart
Tansitabudkul and Dr Wanatda Tomkapanit. We thank
Prof. Martin Prince for his help with the Euro-D.
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