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Beck Depression Inventory-II | HaPI Newsletter Spring 1996

Beck Depression Inventory-II

Aaron T. Beck and Robert A. Steer

PDF available here

After 35 years, the symptom content of the Beck Depression Inventory (BDI-I; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961, Archives of General Psychiatry, 4, 561-571) has been upgraded to correspond to the diagnostic criteria for Depressive Disorders now listed in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV; American Psychiatric Association, 1994, Washington, DC). Although an amended (revised) Beck Depression Inventory (BDI-IA; Beck, Rush, Shaw, & Emery, 1979, Cognitive therapy of depression. New York: Guilford) has been available since the 1970s, the amended version only reflected changes in the layout and wording of the original 21 symptoms. However, in the upgraded Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, in press),* the BDI-IA Weight Loss, Body Image Change, and Somatic Preoccupation items have been replaced with Work Difficulty, Agitation, Concentration Difficulty, Worth­ lessness, and Loss of Energy items. These changes should have an important impact upon the evaluation of self-reported depression because the BDI-IA is one of the most widely used measures for assessing the severity of depression in psychiatric patients and screening for possible depression in normal populations (Piotrowski & Keller, 1992, Journal of Training in the Practice of Professional Psychology, 6, 74-82).

The first suggestion about upgrading the symptom content of BDI-IA was made by Moran and Lambert (1983, The assessment of psychotherapy outcome. New York: Wiley), who reported that its 21 items adequately met only six of the nine diagnostic criteria given for Affective Disorders by the American Psychiatric Association (1980) in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) (DSM-Ill). For example, decreases in appetite and sleep were addressed, but increases in appetite and sleep were not. Explicit items addressing psychomotor activity and agitation, which the DSM-ill criteria include in the diagnosis of Major Depressive Disorders, were also missing. Vredenburg, Krames, and Flett (1985, Reports, 57, 767-778) later raised similar questions about how adequately the BDI­ I addressed DSM-ill criteria.

Evidence supporting the need for upgrading the BDI-IA’s symptom content was also provided by Beck and Steer (1984, Journal of Clinical Psychology, 40, 1365-1367), who found that the Weight Loss, Somatic Preoccupation, and Body Image Change items were less useful in assessing the severity of depression in outpatients than they had been in long-term hospitalized patients. The Weight Loss item is probably less effective in evaluating depression in outpatients because the amount of weight loss is dependent on the length of the depression, and depressed patients are now being treated at an earlier stage of their illness than they had been in 1961 when Beck constructed the BDI-I.

For detailed comparative purposes, several broad differences between the BDI-II and BDI-IA should be stressed. First, 18 items addressing similar symptoms in the BDI-IA were retained in the BDI-Il, butonly threeof these BDI-IAitems were not reworded, Punishment Feelings, Suicidal Thoughts or Wishes, and Loss of Interest in Sex. Second, the old BDI-IA labels for the symptom groups were also changed in some instances in the BDI-II to reflect new clinical nuances that were attached to some items. For example, the BDI-IA labelof Social Withdrawal was changed to Loss of Interest because both people and activities are now stressed in the BDI-Il, whereas only interpersonal activities were emphasized in the BDI-IA. Third, the directions for the BDI-Il were changed from those given for the BDI-IA. Respondents are now asked to describe themselves for the ”Past TwoWeeks, Including Today,” instead of for one week as they are in the BDI-IA, to be consistent with DSM-IV criteria for major depressive disorders. However, like the BDI-IA, the BDI-Il is scored by summing the highest ratings for eac·h of the 21 items. Each item is rated on a four-point scale ranging from 0 to 3, and the total scores can range from 0 to 63 – the higher the total score, the greater the severity of symptoms.

In evaluating the psychometric characteristics of the BDI-Il, Beck, Steer, and Brown (in press) studied 500 psychiatric outpatients who were drawn from four different psychiatric outpatient clinics, and 120 college students. With respect to data bearing on the reliability and validity of the BDI-Il, they found, as expected, that the mean BDI-II score (M = 22 . 45), SD = 12.75) of the outpatients was higher than the student group’s mean BDI-II score (M = 12.56, SD = 9.92), t (618) = 7 .94, p < .001. For 191 of the outpatients who were administered the BDI-IA and BDI-II on the same day, the correlation between both instruments was .93, Q < .001. These outpatients’ mean BDI-IA and BDI-II scores were 18.92 (SD = 11.32) and 21.88 (SD = 12.69), respectively, and the mean BDI-II score was 2.96 points higher than that of the BDI-IA, paired t (190) = 8.56,…Q < .001. Furthermore, the mean number of BDI-II items endorsed by the 191 outpatients was 13.54 (SD = 5.45), whereas the mean number of BDI-IA items endorsed by the same outpatients was 12.14 (SD = 5.33). The mean difference of 1.40 items indicated that the outpatients were endorsing more items on the BDI-II than they were on the BDI-IA, paired t (190) = 9.63 , Q < .001. Therefore, Beck, Steer, and Brown (in press) suggested that higher cut-off score limits be used with the BDl-II than those proposed by Beck and Steer (1993, Manual for the Beck Depression Inventory, Psychological Corporartion) for the BDI-IA. Thus BDI-II total scores ranging from 0 to 13 are considered to be “Minimal,” those from 14 to 19 “Mild,” from 20 to 28 “Moderate,” and total scores from 29 to 63 are considered to be “Severe.”

With respect to the reliability of the BDI-II, the coefficients alpha of the 500 outpatients and 120 college students were high at .92 and .93, respectively. All of the corrected item-total correlations for the 21 BDI-II items in both the outpatient and college student samples were significant beyond the .05 level, one-tailed test. The stability of the BDI-II for 26 outpatients who were administered the BDI-II at the times of their first and second cognitive therapy sessions, which were approximately one week apart, was also high {r = .93, Q < .001).

The BDI-II displayed convergent and discriminant validity with respect to clinically rated depression and anxiety; it was more positively correlated with the revised Hamilton Psychiatric Rating Scale for Depression (Riskind, Beck, Brown, & Steer, 1987, Journal of Nervous and Mental Disease, 175, 474-479) (r = .71) than with the revised Hamilton Rating Scale for Anxiety (Riskind et al., 1987) (r = .47), Hotelling T (84) = 2.96,
p < .01) for 87 outpatients.

Furthermore, the BDI-II was positively correlated (p < .001) to both the Beck Hopelessness Scale (BHS; Beck & Steer, 1993, Manualfor the Beck Hopelessness Scale, Psychological Corporation) (r = .68) and the Scale for Suicide Ideation (SSI; Beck, Kovacs, Weissman, 1979, Journal of Consulting and Clinical Psychology, 47, 343-352) (r = .37) in 158 outpatients; the BHS and the SSI have repeatedly been described as positively related to depression.

Finally, iterated-principal factor analyses with oblique rotations were also performed by Beck et al. (in press), separately, on the intercorrelations among the 21 BDI-II responses of the 500 outpatients and 120 college students. Two highly correlated cognitive-affective and somatic dimensions were found in both samples, and the symptom compositions of similarly-named factors in both samples were comparable.

In summary, the initial findings about the psychometric properties of theBDI-II indicate that it is a reliable and valid instrument for measuring the severity of self-reported depression in late adolescents and adults. Although the BDI-IA and the BDI-II share 18 similar symptoms, the BDI­ II’s overall symptom content is more comparable to that used by the DSM-N for diagnosing depressive disorders than is that of the BDI-IA. Therefore, when evaluating the severity of depression according to DSM-IV criteria, the BDI-II should be more discriminating than the BDI-IA.

*Copies of the BDI-II and the Preliminary Manual for the Beck Depression Inventory II (Beck, Steer, & Brown, in press) are available from The Psychological Corporation, 555 Academic Court, San Antonio, TX 78204-2498.

Aaron T. Beck, MD, is University Professor of Psychiatry Emeritus, University of Pennsylvania School of Medicine, where he has served on the faculty since 1954. Dr. Beck is the author or co-author of more than 300 articles and ten books. He is best known for his work on cognitive therapy for depressive illness and for development of the widely-used Beck Depression Inventory. Dr. Beck has received the American Psychiatric Association Foundation’s Prize for Research in Psychiatry and the Albert Einstein Award from the Albert Einstein College of Medicine, among other awards.

Robert A. Steer, EdD, is Professor of Psychiatry and Adjunct Professor of Obstetrics and Gynecology, School of Osteopathic Medicine, University of Medicine and Dentistry of the State University of New Jersey, and Adjunct Professor of Psychology and Psychiatry, Depanment of Psychiatry, University of Pennsylvania. In addition to teaching psychometrics to medical students and residents, Dr. Steer also develops computer programs for the administration and interpretation of psychological tests.

3-2-spring-1996

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