Beck Depression Inventory (BDI, BDI-II)

Evidence Reviewed as of before: 19-08-2008
Author(s): Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Beck Depression Inventory (BDI) is one of the most widely used screening instruments for measuring the severity of depression in both adults and adolescents over the age of 13 (McDowell & Newell, 1996). The inventory is composed of items relating to depressive symptoms such as:

  • hopelessness and irritability
  • cognitions (such as guilt or feelings of being punished)
  • physical symptoms (such as fatigue, weight loss, and lack of interest in sex).

The BDI can be used, but is not limited to, persons with stroke.

In-Depth Review

Purpose of the measure

The Beck Depression Inventory (BDI) is one of the most widely used screening instruments for measuring the severity of depression in both adults and adolescents over the age of 13 (McDowell & Newell, 1996). The inventory is composed of items relating to depressive symptoms such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex. The BDI can be used, but is not limited to, persons with stroke.

Available versions

There are two versions of the BDI

The original BDI, first published in 1961 and later revised in 1971 (BDI-IA) and the BDI-II, a revised version of the BDI that was published in 1996, created to correspond with the updated DSM-IV criteria for depression.

Features of the measure

Items:
– The original BDI
Contains 21 items and identifies symptoms and attitudes associated with depression. The respondent must recall the relevance of each statement for today: mood, pessimism, sense of failure, lack of satisfaction, guilt, sense of punishment, self-hate, self-accusations, self-punitive wishes, crying spells, irritability, social withdrawal, indecisiveness, body image, work inhibition, sleep disturbance, fatigability, loss of appetite, weight loss, somatic preoccupation, and loss of libido.

– The BDI-IA
Same as the original BDI, but the respondent must recall the relevance of each statement based on the previous week including today.

– The BDI-II
Contains 21 items and identifies symptoms and attitudes associated with depression. The BDI-II dropped four items (Weight Loss, Body Image Change, Somatic Preoccupation, and Work Difficulty) from the original BDI and replaced them with four new items (Agitation, Worthlessness, Concentration Difficulty, and Loss of Energy). The respondent must recall, based on the previous two weeks, the relevance of each statement relating to: sadness, pessimism, sense of failure, loss of pleasure, guilt, expectation of punishment, dislike of self, self-accusation, suicidal ideation, episodes of crying, irritability, social withdrawal, indecisiveness, worthlessness, loss of energy, insomnia, irritability, loss of appetite, preoccupation, fatigue, and loss of interest in sex (Beck & Steer, 1988).

Scoring:
– BDI scoring: 
Each item is evaluated on a severity scale ranging from 0-3, with a total score ranging from 0-63

  • 0-10 on the BDI is considered absent or minimal depression;
  • 10-18 mild to moderate depression;
  • 19-29 is moderate depression;
  • 30-63 is severe depression.

– BDI-II scoring:
0-13 is considered none or minimal range depression;

  • 14-19 mild depression;
  • 20-28 moderate depression;
  • 29-63 severe depression.

Subscales:
None typically reported.

Equipment:
Only a pencil and the test are needed.

Training:
Traditionally, the BDI was designed to be administered by a trained interviewer. Today however, the BDI is commonly self-administered as it is short and simple to use. Patients must be able to understand spoken or written language and have a fifth- to sixth-grade reading level to adequately understand the questions (Groth-Marnat, 1990).

Time:
The BDI takes from 5-10 minutes to complete when self-administered, and 15 minutes to complete when interviewer-administered (Beck & Steer, 1988; McDowell & Newell, 1996). The questions are posed around a two-week period including today, as opposed to around the past week as in the original BDI. Thus, in the early post-stroke period, the BDI may be an inappropriate tool as the responses given in the early period are unlikely to provide a valid estimate of depression.

Alternative forms of the BDI

The BDI-SF is a short form of the BDI and is composed of 13-items (Beck & Beck, 1972). The BDI-SF appears to have a level of internal consistency (coefficient alphas) comparable to that of the long form (Beck, Steer, & Garbin, 1988). Pearson product-moment correlation coefficients between the BDI and the BDI-SF have ranged from 0.89 to 0.97 indicating that the short form is an acceptable substitute for the long (Beck, Rial, & Rickets, 1974).

The BDI-FastScreen for medical patients (formerly known as BDI-Primary Care)is a 7-item self-report inventory designed specifically for use as a screening tool in medical patients. The BDI-FastScreen takes less than five minutes to complete and questions are posed around the past two weeks including today. It is thought to be a clinically effective screen for identifying medical inpatients who should be evaluated for depression, however, it has not been found to be as sensitive a measure as the full BDI-II (Beck, Guth, & Steer, 1997; Sharp & Lipsky, 2002).

Client suitability

  • Can be used with:

    Patients with stroke
    Aben, Verhey, Lousberg, Lodder and Honig (2002) found that the BDI was as acceptable a screening tool as the Hospital Anxiety and Depression Scale (HADS), the Symptom CheckList-90 Depression Scale (SCL-90), and the Hamilton Depression Rating Scale (HDRS) for detection of post-stroke depression. However, while the BDI is one of the more commonly used measures of post-stroke depression, there is insufficient literature to conclude that it is a reliable and valid diagnostic tool in the stroke population (Turner-Stokes & Hassan, 2002). One concern regarding diagnosis of depression in individuals with stroke is that the somatic symptoms commonly associated with depression may also arise from the stroke itself, or from hospitalization (e.g. fatigue). Because of its relatively low reliance on somatic symptoms, the BDI is considered one of the more useful tools in assessing post-stroke depression (Turner-Stokes & Hassan, 2002). Further, Aben et al. (2002) found a high rate of misdiagnosis of depression in stroke patients (almost 40% with the BDI), which makes the BDI less suitable for diagnosis in clinical settings. In patients with stroke, self-administration of the BDI may pose a difficulty because of stroke-specific communication difficulties and/or because of age-associated declines such as decreased vision, and therefore may require a trained interviewer. Patients must be able to understand spoken or written language and have a fifth- to sixth-grade reading level to adequately understand the questions (Groth-Marnat, 1990).

    Should not be used in:

    • Patients who are severely cognitively impaired. For these patients, the Structured Assessment for Depression in Brain Damaged Individuals is a potential alternative (Turner-Stokes & Hassan, 2002).
    • Patients with aphasia. For patients with aphasia, the Stroke Aphasic Depression Questionnaire (SADQ) and the Aphasic Depression Rating Scale (ADRS) were developed to detect depression.
    • Patients with seriously impaired communication but a reliable yes/no response, the Structured Assessment for Depression in Brain Damaged Individuals is a potential alternative (Turner-Stokes & Hassan, 2002).

    In what languages is the measure available?

    • Arabic – validated (Abdel-Khalek et al., 1998)
    • Cambodian – translated without validation (Savin et al., 1996)
    • Chinese – validated (Zheng et al., 1988)<
    • Dutch – validated (Bosscher et al., 1986)
    • Finnish – validated (Raitasalo, 1995)
    • French – validated (Collet et al., 1986)
    • German – validated (Hautzinger, 1991)
    • Italian – translated without validation (Ranchetti, 1987)
    • Japanese – validated (Kojima et al., 2002)
    • Korean – translated without validation (Sung et al., 1992)
    • Persian – validated (Ghassemzadeh et al., 2005)
    • Polish – validated (Parnowski et al., 1977)
    • Portuguese – validated (Gorenstein et al., 1996; 1999)
    • Spanish – validated (Sanz et al., 2005)
    • Serbo – Croatian (roman script) validated (Grubac, 1989)
    • Swedish – validated (Byrne et al., 1995)
    • Turkish – validated (Hisli, 1988)
    • Xhosa – translated without validation (Drennan et al., 1991)

    Summary

    What does the tool measure? Depression.
    What types of clients can the tool be used for? Both adults and adolescents over the age of 13. Can be used, but is not limited to, persons with stroke.
    Is this a screening or assessment tool? Screening.
    Time to administer Self-administration: 5-10 minutes; interview-administration: 15 minutes.
    The questions are posed around a two-week period including today, as opposed to around the past week as in the original BDI. Thus, in the early post-stroke period, the BDI may be an inappropriate tool as the responses given in the early period are unlikely to provide a valid estimate of depression.
    Versions Original BDI; BDI-II; BDI-FastScreen for medical patients; BDI-Short Form.
    Other Languages Validated in: Arabic; Chinese; Dutch; Finnish; French; German; Japanese; Persian; Polish; Portuguese; Spanish; Serbo – Croatian (roman script); Swedish; Turkish
    Translated without validation in: Cambodian; Italian; Korean; Xhosa.
    Measurement Properties
    Reliability
    • Out of 1 study and 1 meta-analysis examining internal consistency, both reported excellent internal consistency.
    • The 1 study examining test-retest reported adequate test-retest.
    Validity

    Content validity:
    The BDI-II was designed to take into account the depressive criteria of the DSM-IV.

    Criterion:
    Adequate to excellent correlation coefficients with the depression scale of the Minnesota Multiphasic Personality Inventory, Zung Self-Rating Depression Scale, Multiple Affect Adjective Checklist, Depression Scale HOPKINS Symptom Check List, Hamburg Depression Scale, Inventory to Diagnose Depression.
    Poor to excellent in psychiatric patients with F-Rating; DSM-III; Hamilton Depression Rating Scale; adequate to excellent in non-psychiatric patients.

    Construct:
    Excellent correlation with BDI-IA; Revised Hamilton Psychiatric Rating Scale for Depression; Geriatric Depression Scale. Adequate correlation with the Beck Hopelessness Scale; Scale for Suicide Ideation; Beck Anxiety Inventory; Revised Hamilton Anxiety Rating Scale.

    Does the tool detect change in patients? Out of 2 studies examined, both found that the BDI is able to detect significant change in patients with stroke and in psychiatric patients with affective and anxiety disorders.
    Acceptability Although the BDI takes only 5-10 minutes, problems with completion have been noted within a stroke population. The scale has not been tested for administration using proxy respondents.
    Feasibility The BDI is short and simple to administer and requires no training. There is limited information available regarding its effectiveness when used for evaluation purposes in a longitudinal study.
    How to obtain the tool?

    The BDI can be purchased at: http://harcourtassessment.com

    Psychometric Properties

    Overview

    There is an abundance of research on the psychometric properties of the BDI. However, little research has been conducted specifically in a post-stroke population. For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the BDI. We then selected to review articles from high impact journals, and from a variety of authors. We preferentially reviewed studies examining the psychometric properties of the BDI-II rather than the BDI-IA, when available, as the BDI-II corresponds closely to DSM-IV depression criteria and is found to be a more reliable measure of depression (Beck & Steer, 1988).

    Reliability

    Internal consistency:
    In a meta-analysis by Beck and Steer (1988), the internal consistency of the BDI had a Cronbachs alpha of 0.86 for psychiatric patients and 0.81 for non-psychiatric subjects. The BDI-II is superior to the BDI-IA in terms of its internal consistency (Beck & Steer, 1988).

    Aben et al. (2002) compared the internal consistency of the BDI to the Hospital Anxiety and Depression Scale, and the Symptom CheckList-90 Depression Scale in 202 patients 1-month post-stroke. The BDI was associated with a Cronbachs alpha of 0.83, alpha for the Hospital Anxiety and Depression Scale = 0.85, and for the Symptom CheckList-90, 0.88. Although, the BDI had a lower internal consistency than the other two self-rated scales, it was considered to have excellent internal consistency (Cronbachs alpha exceeded 0.80) in this patient population.

    Test-Retest:
    The BDI-II test-retest, administered 1-week apart in a sample of 895 college students, had an intraclass correlation coefficient (ICC) for agreement of 0.73 (Wiebe & Penley, 2005) showing adequate test-retest reliability for the BDI-II.

    Validity

    Concurrent validity:
    In a review article on the validity of the BDI (Richter, Werner, Heerlein, Kraus, & Sauer, 1998), studies on the concurrent validity of the BDI with other self-rating depression scales (including the depression scale of the Minnesota Multiphasic Personality Inventory (MMPI), the Zung Self-Rating Depression Scale, the Multiple Affect Adjective Checklist, the Depression Scale HOPKINS Symptom Check List, the Hamburg depression scale and the Inventory to Diagnose Depression) indicated moderate to high correlation coefficients with all scales, with mean coefficients ranging from 0.58 to 0.79.

    Coefficients of concurrent validity when using the observer rated scales (F-Rating, a clinical rating scale, in most cases, it is a four graded rating – for no severe depression; DSM-III; and Hamilton Depression Rating Scale), varied to a larger degree than validity coefficients associated with self-rating (0.19 to 0.90 in psychiatric patients; 0.55 to 0.75 in non-psychiatric patients). The validity coefficients varied depending on the composition of the sample (severity of depression, number of psychotic patients).

    Aben et al. (2002) interviewed 202 patients 1 month after their first stroke. First, they were interviewed with both the depression section of the Structured Clinical Interview for DSM-IV (SCID) and the Hamilton Depression Rating Scale. Patients were diagnosed as having major depression if they had at least one core symptom (i.e. depressed mood or loss of interest) and at least four other symptoms of depression that had lasted at least 2 weeks. Then patients filled out the BDI at home after the interview. In these patients, using a cut-off score of 10 to represent clinically significant depression, the BDI was found to have a sensitivity of 80.0 and a specificity of 61.4 suggesting that the BDI is an acceptable screening instrument for post-stroke depression (Aben et al., 2002).

    Content validity:
    The BDI-II was designed to take into account the depressive criteria of the DSM-IV.

    Construct validity:
    The BDI is able to differentiate between a number of hypothesized relationships between biological, behavioral, and attitudinal variables indicative of depression (Beck et al, 1988). For example, Brooksbank and Coppen (1967) studied the biological correlates of depression, and reported that patients with higher BDI scores had higher concentrations of plasma 11-hydroxycorticosteroids (a biological correlate of depression) than patients with lower BDI scores. With respect to behavioral relationships, Albert and Beck (1975) reported that the BDI was positively related to teacher ratings of student maladjustment in the seventh grade (r= 0.62) and in the eighth grade (r= 0.60). Further evidence comes from the positive relationships found with depression as measured by the BDI and a variety of medical symptoms (e.g. headaches, upset stomachs) (Armstrong, Goldenberg, & Stuart, 1980; Cavanaugh, Clark, & Gibbons, 1983), depressive thoughts (Dobson & Breiter, 1983; Gotlib, 1984), suicidal behaviors (Emery, Steer, & Beck, 1981; Lester & Beck, 1975; Silver, Bohnert, Beck & Marcus, 1971), loneliness (Gould, 1982; Reynolds & Gould, 1981), and stress (Hammen & Mayol, 1982; Monroe, Imhoff, Wise, & Harris, 1983).

    Analyses of convergent and divergent validity of the BDI-II have given the following correlations:

    • r = 0.93 with the BDI-IA (191 patients) (Beck, Steer, Ball, & Ranjeri, 1996)
    • r = 0.59 with the Beck Hopelessness Scale (160 patients) (Beck, Brown, Epstein, & Steer, 1988)
    • r = 0.37 with the Scale for Suicide Ideation (158 patients)
    • r = 0.48 with the Beck Anxiety Inventory (160 patients) (Beck et al., 1988)
    • r = 0.71 with the Revised Hamilton Psychiatric Rating Scale for Depression (87 patients) (Riskind, Beck, Brown, & Steer, 1987)
    • r = 0.47 with the Revised Hamilton Anxiety Rating Scale (87 patients) (Riskind et al., 1987)

    These results are congruent with the fact that anxiety, suicidal ideas, and hopelessness are correlated with depression, without being identical concepts.

    Snyder, Stanley, Novy, Averill, and Beck (2000) demonstrated convergence between the BDI and the Geriatric Depression Scale (r = 0.78). Divergence was shown between measures of anxiety (r = 0.33), worry (r = 0.39) and quality of life (r = -0.46).

    In a factor analysis of the BDI responses of patients and non-patients, Beck and Steer (1988) found that 3 factors were consistently identified across diagnostic groups. These were: cognitive-affective, performance, and somatic. In a factor analysis of the BDI-II, two factors were identified: somatic-affective and cognitive (Beck & Steer, 1996).

    Responsiveness

    House et al. (1991) followed 128 patients over a period of one year after their first stroke. The BDI was found to be concordant with DSM criteria over this time, and was sensitive to change. For stroke patients the somatic symptoms declined over one year, while there was no significant change in cognitive affective symptoms.

    Both the BDI and the Montgomery Asberg Depression Rating Scale (MADRS-S) were able to detect significant change in 86 psychiatric patients with mainly affective and anxiety disorders during treatment with antidepressants (Svanborg & Asberg, 2001).

    Only two studies were identified on the psychometric properties of the BDI specific to a post-stroke population (Aben et al., 2002; Turner-Stokes & Hassan, 2002).

    A 3-year randomized controlled trial (RCT) to examine the psychometric properties of the Hamilton Depression Rating Scale, Hospital Anxiety and Depression Scale, and BDI in patients with stroke is currently being conducted by Ching-Lin Hsieh, at the School of Occupational Therapy, College of Medicine and National Taiwan University. This study will compare the validity, responsiveness, and acceptability of these scales in 200 patients post-stroke. The inter-rater reliability of the three depression scales will be examined in the first year in 60 chronic stroke patients and in the second year, the test-retest reliability and measurement error of the three depression scales will be examined. This study is expected to be complete in July 2008.

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    See The Measure

    The BDI can be purchased at: http://harcourtassessment.com

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