J. C. Coyne and V. E. Whiffen (1995) reviewed research on personality vulnerability to depression, focusing on S. J. Blatt's (1974, 1990) concepts of dependency and self-criticism and A. T. Beck's (1983) concepts of sociotropy and autonomy. The authors discuss 6 issues raised in that review: (a) the typological or dimensional nature of vulnerability, (b) the theoretical implications of "mixed" vulnerability, (c) the relations of vulnerability to Neuroticism. (d) the potential confounding of vulnerability with concurrent depression, (e) the potential confounding of vulnerability with social context, and (f) the differentiation of dependency from relatedness. The authors conclude that Blatt's and Beck's concepts are continuous, nearly orthogonal dimensions that can be identified and measured independently from Neuroticism, depression, and social context.

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Psychometric analyses evaluated how primary care patients with and without major depressive disorder endorsed individual response options on the Center for Epidemiologic Studies-Depression Scale (CES-D; L. S. Radloff, 1977). The analyses were then used to identify a subset of items that when appropriately weighted improved the efficiency with which depressed individuals were identified. Efficiency of the revised measure was evaluated relative to standard cutpoints used with the full scale. Results showed that some improvement in most indices of efficiency could be achieved with half as many items and a simplified scoring scheme, but great improvement in one measure was usually achieved only at the expense of other measures of efficiency. The efficiency of the CES-D can be improved with appropriate analytic techniques, but its limitations as a self-report screening measure persist.The use of the Center for Epidemiologic Studies-Depression Scale (CES-D;Radloff, 1977) and other such self-report measures of distress as the sole means of case finding (i.e., identifying individuals as "depressed" for the purposes of research) remains a common if dubious application of these instruments. Self-report measures of depression such as the CES-D, Beck Depression Inventory (BDI;Beck, Ward, Mendelsohn, Mock, & Erlbaugh, 1961), Zung Self-Rating Scale (Zung, 1965), and General Health Questionnaire (GHQ; Goldberg & Hillier, 1979) share a weakness in that a large proportion of high-scoring respondents do not actually meet criteria for a depressive disorder (for a review, see Coyne, 1994). However, there are other, more defensible applications of instruments such as the CES-D, for example, as when scores above a standard cutpoint are used to establish the need for further assessment. One application is in screening for likely depression among medical patients. Depressed persons in the community are more likely to visit a primary care physician than a mental health professional, but most depressed patients go undetected by their physicians (

Scale discriminability is the ability of a measure to discriminate among individuals ordered along some continuum, such as depressive severity. We used a nonparametric item-response model to examine scale discriminability in the Beck Depression Inventory (BDI) and Center for Epidemiclogic Studies Depression Scale (CES-D) in both college and depressed outpatient samples. In the college sample, the CES-D was more discriminating than the BDI, but a standard CES-D cutoff score of 16 overestimated the likely prevalence of depression (45%). The CES-D may be more effective than the BDI in detecting differences in depressive severity in college students but may be less specific. In the depressed outpatient sample, the CES-D was again more discriminating than the BDI. The superior scale discriminability of the CES-D offers one explanation for its poorer specificity in college samples. Endorsing many items that discriminate at low levels of depressive severity can result in scores that exceed a cutoff criterion.The Beck Depression Inventory (BDI; Beck, Shaw, Rush, & Emery, 1979) and the Center for Epidemiologic Studies Depression Scale (CES-D;Radloff, 1977) are among the most frequently used and well-validated self-report measures of depression (for reviews, see Beck, Steer, & Garbin, 1988;Orme, Reis, & Herz, 1986). Although both measures treat depression as a continuous variable, the BDI and the CES-D were initially designed to assess depression in different populations. The BDI was initially intended as a measure of depressive severity for individuals already diagnosed as clinically depressed (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), whereas the CES-D was originally constructed as a measure of depressive severity for adults in the community (Radloff, 1977). Despite this difference, the BDI and CES-D have been used extensively in both clinical and nonclinical populations, and both have been used to estimate the prevalence of cases of depression in various populations.Traditional approaches to psychometric analyses of inventories, such as the BDI and CES-D, use omnibus statistics, such as item-total correlations or reliability coefficients, that average

PURPOSE In 2004, we undertook a consultation with Canadian primary health care experts to defi ne the attributes that should be evaluated in predominant and proposed models of primary health care in the Canadian context. METHOD Twenty persons considered to be experts in primary health care or recommended by at least 2 peers responded to an electronic Delphi process. The expert group was balanced between clinicians (principally family physicians and nurses), academics, and decision makers from all regions in Canada. In 4 iterative rounds, participants were asked to propose and modify operational defi nitions. Each round incorporated the feedback from the previous round until consensus was achieved on most attributes, with a fi nal consensus process in a face-to-face meeting with some of the experts. RESULTSOperational defi nitions were developed and are proposed for 25 attributes; only 5 rate as specifi c to primary care. Consensus on some was achieved early (relational continuity, coordination-continuity, family-centeredness, advocacy, cultural sensitivity, clinical information management, and quality improvement process). The defi nitions of other attributes were refi ned over time to increase their precision and reduce overlap between concepts (accessibility, quality of care, interpersonal communication, community orientation, comprehensiveness, multidisciplinary team, responsiveness, integration).CONCLUSION This description of primary care attributes in measurable terms provides an evaluation lexicon to assess initiatives to renew primary health care and serves as a guide for instrument selection. Med;5:336-344. DOI: 10.1370/afm.682. Ann Fam INTRODUCTIONH ealth systems based on a strong primary health care system are more effective and effi cient than those centered on specialty and tertiary care.1 In Canada, various national and provincial commissions on health care [2][3][4][5][6][7][8] concluded that strengthening and expanding primary health care will meet Canadians' needs for prompt access to comprehensive evidence-based services. Major initiatives have also been undertaken in New Zealand and the United Kingdom to strengthen primary health care. 9,10 As health systems worldwide engage in evaluation efforts to assess the impacts of primary health care renewal initiatives, there is a critical need to provide evaluation frameworks and tools to facilitate these efforts.An important starting point for evaluation is an operational defi nition of the dimension being evaluated. An operational defi nition is a description of a concept in measurable terms. It is used to remove ambiguity, to serve as a guide for the selection of measurement tools, and to reduce the likelihood of disparate results between different data collections. 337 AT T R IBU T ES O F PR IM A RY HE A LT H C A R Edevelop a common lexicon of operational defi nitions of attributes to be evaluated in predominant and emerging models of primary health care in Canada, but many of these defi nitions will be relevant to primary health care mode...