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Running Head: THOMPSON BDI-II TEST REVIEW

Test Review: Beck Depression Inventory Second Edition (BDI-II) Shauna Thompson ID 10017221 University of Calgary APSY 660 Fall Session 2009

Thompson BDI-II Test Review

Test Description The Beck Depression Inventory Second Edition (BDI-II; Beck, Steer, & Brown, 1996) is a 21-item self-report scale used to screen for the presence and severity of depression symptoms in both clinical and non-clinical populations of adults and adolescents 13 years of age and older. The BDI-II replaces the BDI-IA (Beck, Rush, Shaw, & Emery, 1979) which was an amended version of the original BDI (Beck, Ward, Mendelson, Mock, and Erbaugh, 1961). The BDI-II was developed to assess for symptoms of depressive disorders corresponding to the diagnostic criteria in the Fourth Edition of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders (DSMIV, 1994). Over the 40 years that it has been in use, the BDI has become one of the most widely used instruments for assessing the severity of depression symptoms in clinical populations, and detecting depression symptoms in normal populations (Beck et al., 1996). The BDI-II contains a number of significant revisions from the earlier versions that brought the inventory in line with the updated diagnostic criteria of the DSM-IV for depression. Four of the original items that dealt with weight loss, changes in body image, somatic preoccupation and work difficulty were dropped and replaced with items addressing worthlessness, agitation, concentration difficulty, and loss of energy. The test authors indicate that this was done in order to index symptoms typical of severe depression or depression warranting hospitalization (Beck et al., 1996, p.1). The timeframe respondents are asked to consider was extended from one week two weeks to be consistent with the DSM-IV criteria for major depression. Items dealing with sleep loss and appetite loss were revised to include both increases and decreases in sleeping and

Thompson BDI-II Test Review

appetite, and with the exception of 3 items (those dealing with feelings of punishment, thoughts of suicide, and interest in sex), and many of the statements used in rating the other symptoms were reworded. The BDI-II is composed of 21 items on a double-sided page, each corresponding to a symptom of depression in the DSM-IV. Each item has a bolded header to help focus the respondent on the items overall purpose, followed by four statements arranged in increasing severity on a Likert-type scale ranging from 0 to 3. Two items (those dealing with sleeping pattern and appetite) have seven statements that address an increase or decrease in the behaviours, and they are also scored from 0 to 3. Training for the administration of the BDI-II is available via the manual through video. While the BDI-II is user-friendly and may be easily administered and scored by paraprofessionals, scores should only be interpreted by trained mental health professionals with the appropriate training and clinical experience. As with all measures, the clinician interpreting the BDI-II should be familiar with the American Psychological Associations Standards for Educational and Psychological Testing (1999). Additionally, since depression is often associated with other psychiatric concerns, including risk for suicide, it is important that the clinician reviewing the data have the necessary therapeutic training or access to appropriate referral sources to help address a clients depression. Though originally published in English, the BDI-II has been translated into Arabic, Bulgarian, Chinese, Farsi, Finnish, French, German, Japanese, Korean, Norwegian, Portuguese, Spanish, Swedish, and Turkish. Currently norms are available only for the Spanish translation, though it is suggested that the psychometric properties

Thompson BDI-II Test Review

overall appear to be satisfactory for the Spanish, Arabic, Chinese, Turkish and Japanese translations particularly (Ippen & Wong, 2005). The BDI-II can be purchased through Pearson Education. The cost of the BDI-II Complete Kit, which includes the manual and 25 record forms, is $109. Additional record forms are available in packages of 25 for $49, and are available in English or Spanish. The 38-page manual describes the administration instructions, scoring procedure, and clinical interpretation of BDI-II scores. It also provides information on the history and development of the measure, standardization and norm development, and studies proving the reliability and validity of the BDI-II. To administer the BDI-II the examiner needs only the record form and a pen or pencil. Administration, Scoring, and Interpretation The BDI-II is a user-friendly instrument that presents with few administration challenges. The Average administration time is between 5 and 10 minutes, and it can be done individually or in a group setting. The testing environment should be well-lit and quiet so that the client can complete the test without distraction. Once the examiner has determined that the client can read and comprehend the test content, the BDI-II can be self-administered and clients can complete it independently. Directions for selfadministration are printed clearly on the record form, and may be clarified by the examiner. For clients who have reading difficulties or problems with concentration, test instructions and items can be presented orally. Oral administration instructions are printed in the test manual. Once the client has completed the test it is important the examiner carefully review the items to ensure that no items were skipped or left blank to allow the client the opportunity to complete any omitted items.

Thompson BDI-II Test Review

The BDI-II is scored by summing the ratings for the 21 items. In the event that the client endorses multiple statements for item, the alternative with the highest point-value is counted. The maximum score possible is 63. Regardless of the total score, if a client endorses a higher-rated option for items dealing with changes in sleeping pattern or changes in appetite, test developers note that these responses should be noted for diagnostic purposes. Though the BDI-II is very simple to score by hand, it is also possible to enter the responses into Pearsons scoring program Q Local to generate scores and an interpretive report (for a fee). As with all computer-generated reports it is important the clinician be very discriminating about accepting and using any information contained in the report, and is best served by using the report as a guide to interpretation and further investigation. When interpreting the BDI-II, test developers encourage special attention be paid to the responses a respondent gives for the items addressing pessimism and suicidal thoughts and wishes, as well as those dealing with changes in appetite or sleeping patterns as indicators of potential suicide risk. The BDI-II reflects the more obvious cognitive and affective symptoms of depression, and it also reflects the somatic and vegetative symptoms of depression, so it is important for the clinician to examine each clients overall pattern of responses. Each person will likely display their own distinctive combination of depressive symptoms, so each set of responses should be examined and addressed individually. Using receiver operating characteristic curves in a clinical sample, Beck et al. (1996) developed new (higher) cut scores, along with definitions of severity that suggest a score of 0-13 indicates minimal depression, 14-19 indicates mild depression, 20-28

Thompson BDI-II Test Review

indicates moderate depression, and 29-63 indicates severe depression. These cut scores were derived for the clinical purposes of screening for major depression. There is considerable discussion in the manual and the literature (Dozois, Dobson, & Ahnberg, 1998) about appropriate cut scores to use for different populations. According to the test authors, cut scores are not universal across all populations, and should be based on the clinical considerations for which the instrument is being administered (Beck et al., 1996, p.11). The sensitivity of the measure is considered to be more important than specificity, so clinicians are encouraged to adopt somewhat of a lower threshold to decrease the likelihood of false negatives when using the BDI-II to screen for depression. In determining which cut scores to use, the clinician must consider the purpose of administration and the characteristics of the population. If the BDI-II is being used in order to identify to maximum number of clients with depression then the threshold should be lowered to decrease the possibility of false negatives. Though lower cut scores will result in a higher number of false positives, it still provides relevant information when screening for depression. Finally, in evaluating BDI-II scores it is important for clinicians to remember that all self-report inventories are subject to response bias, whereby a client may endorse more or less symptoms than they actually have. It is critical to keep in mind that though the BDI-II is a very effective screening tool it cannot provide enough information in isolation to inform a depression diagnosis. Establishment of depression and the determination of the severity of depression must be done through a thorough and multimodal process of assessment. Standardization

Thompson BDI-II Test Review

In order to investigate the psychometric properties of the BDI-II, test developers used a sample of 500 outpatients from a number of psychiatric outpatient clinics in New Jersey, Pennsylvania, and Kentucky (that served as the clinical group) and a sample of 120 Canadian university students (that served as a comparative normal group). Participants in the outpatient sample completed the measure as part of a standard intake battery of psychological tests used at the clinics. The mean age of the outpatient sample was 37.20 years (SD = 15.91). 317 were women (63%) and 183 were men (37%). The ethnic makeup of the sample was as follows: 454 (91%) Caucasian, 21 (4%) African American, 21 (4%) Asian American, and 7 (1%) Hispanic. All of the patients were diagnosed by qualified clinicians (psychologists or psychiatrists) according to the criteria of the DSM-III-R or the DSM-IV. Of the 500 outpatients, 53% were diagnosed with mood disorders, 18% with anxiety disorders, 16% with adjustment disorders and 14% with other types of disorders. Relating to depression: Of the total sample, 12% were diagnosed with single-episode major depressive disorders, 21% with recurrent-episode, major depressive disorders, 7% with bipolar disorders, 10% with dysthymic disorders, and 3% with depressive disorders not otherwise specified (NOS). In the student sample, the measure was completed in a typical classroom setting during an introductory psychology course at the University of New Brunswick. The mean age of the sample was 19.58 years (SD = 1.84). Of the sample, 67 were women (56%) and 53 were men (44%), and participants were predominantly Caucasian. Technical Adequacy The manual provides evidence of content, construct and factorial validity, as well as internal consistency and test-retest stability. Correlations with ethnicity, age and sex were evaluated, and the quality of diagnostic discrimination was also considered.

Thompson BDI-II Test Review

Beck et al, (1996) provide a series of item-option characteristic curves for each of the 21 items on the BDI-II for the sample of 500 outpatients as generated by a computer program that provides a graphic representation of how well the four statements relating to each symptom item were differentiated from one another, as well as how well the overall set of options for each item monotonically measures latent trait of self-reported depression (p.17). These graphs show that all items reflect the expected ordinal rankings (scores of 0-3) with respect to discriminating between respondents with less depression and those with more depression (for example, patients with more severe levels of depression endorsed items of higher rank in the symptom categories). However, it is important to note that options in 4 items (those that addressed feelings of punishment, thoughts and wishes of suicide, agitation and loss of interest in sex) did not display the rank order anticipated in test development. In illustration, it was expected that outpatients with more severe depression would be more likely to endorse the higher options (score = 2 or 3) related to suicidal thoughts and wishes. After examining the item-option characteristic curves it was found that these patients were actually more likely to endorse the first, lower scoring option (score = 0). Beck et al. interpret this to mean that those with severe depression are unlikely to acknowledge serious suicidal intent. Test-retest stability coefficients were reported using a sample of 26 students who were administered the BDI-II in their first and second therapy sessions, approximately one week apart. The test-retest correlation was significant (.93, p<.001). The mean score from the first session (20.27, SD=10.46) and second session (19.42, SD=10.38) were comparable. Construct validity was analyzed by comparing BDI-IA and BDI-II scored in a sample of 191 outpatients during their initial evaluations. The order of presentation was counterbalanced, and at least one other measure was given between administrations of the two versions of the

Thompson BDI-II Test Review

BDI. Correlation between the two versions of the BDI was .93 (p<.001). The mean BDI-IA score was 18.92 (SD=11.32) and the mean of the BDI-II score was 21.88 (SD=12.69). When analyzed for correlations of the BDI-II scores with ethnicity and age in the sample of 500 outpatients, neither correlation was significant (.04 and -.03 respectively). However, a significant difference in mean score was identified with respect to sex: the mean BDI-II score for female outpatients was 23.61 (SD=12.31) and the mean score for the male outpatients was 20.44 (SD=13.28). In the student sample, age was inversely correlated with the BDI-II scores (r=-18, p<.05). Once again the scores for female students were significantly greater than male students (14.55, SD=10.75 and 10.04, SD=8.23 respectively). To evaluate the BDI-IIs diagnostic discrimination, scores between and within the outpatient and student groups were compared. As it would be expected, the mean score of the outpatient group (M=22.45, SD = 12.75) was greater than that of the student group (M = 12.56, SD = 9.93). In fact, the severity of depression reported by the outpatient group was approximately double that found in the student group. Differentiation was also shown within the outpatient group. BDI-II scores for outpatients with mood disorders were higher than those with anxiety, adjustment or other types of disorders. Additionally, patients with more severe depressive disorders also got higher scores on the BDI-II than those with less serious depressive disorders. To provide evidence of the convergent and divergent validity of the BDI-II, Beck et al. (1996) compared BDI-II scores with scores on several other psychological tests, including the Beck Hopelessness Scale (BHS), the Scale for Suicide Ideation (SSI), the Hamilton Psychiatric Rating Scale for Depression (HRSD), and the Hamilton Rating Scale for Anxiety (HRSA) (as listed in Beck et al., 1996). The BDI-II was found to be positively related to measures of anxiety,

Thompson BDI-II Test Review

suicidal ideation, and hopelessness. The strongest relationship was found to exist between scores on the BDI-II and the HRSD (r = .71) (rather than the HRSA, where r = .47), lending support for discriminant validity between anxiety and depression. Conclusion The BDI-II is a screening tool used to identify the presence and severity of depression symptoms consistent with the criteria of the DSM-IV for major depression. User-friendly and easy to administer, the BDI-II can be administered orally to those with reading difficulties or concentration problems and can be completed in a very short amount of time. Translated into several languages, the BDI-IIs psychometric properties have been established in numerous populations, including different cultural groups, psychiatric inpatients, individuals with traumatic brain injury, and the deaf population. The BDI-II is designed to assess state-related depression, and can therefore be used as a repeatable screening tool prior to therapeutic sessions or to evaluate change over the course of therapeutic interventions. A number of things should be kept in mind for clinicians who include this measure in their psychological battery. As with all self-report measures, the high facevalidity of the BDI-II lends itself to possible over reporting or underreporting of depressive symptomology, so client reports on the severity of their symptoms may be inflated or underrepresented. Using the cut scores provided in the manual may increase the likelihood of false negatives or lead to under-diagnoses of depression in some client groups, and care must be taken to evaluate client responses according to the desired goal of the assessment. The finding that females consistently produce higher total scores on the BDI-II also requires attention when interpreting individual results. Individuals with

Thompson BDI-II Test Review

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lower levels of education or who complete the test in a language other than their dominant language may have difficulty understanding item content, requiring the examiner to be vigilant to ensure a good level of comprehension prior to (or throughout) administration. In spite of the strengths of the BDI-II there are still several areas with room for improvement. Norms are available for the Spanish language translation, but more research needs to be done on other translations to ensure adequate validity and reliability. Research must be continued with different ethnic populations to provide evidence for or against the use of the BDI-II across different ethnic groups, as the normative sample group was 91% Caucasian. Though the test authors indicate that the BDI-II can be used on adolescents ages 13 and older, the normative sample used was all adults. Finally, additional research must be continued with adolescent populations, and with individuals of varying socioeconomic status, as the majority of studies to date have included adults and lower numbers of individuals of lower socioeconomic status. In conclusion, the BDI-II is a very simple, quick, effective, reliable and valid screening tool for assessing the presence and severity of depression symptoms in adults and adolescents 13 years of age and older. With a 40-year history of clinical use and evaluation the BDI-II has a strong base of support for use across time and populations, a body of evidence that continues to grow.

Thompson BDI-II Test Review

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References

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed. text revision). Washington, D.C.: Author. Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: The Psychological Corporation. Dozois, D.J.A., Dobson, K.S., & Ahnberg, M.J.L. (1998). A psychometric evaluation of the Beck Depression Inventory-II. Psychological Assessment, 10, 83-89. Ippen, C. G., Wong, C (2005). Review of Beck Depression Inventory Second Edition. Ippen, C.G., Igelman, R., Taylor, N., and Kulkarni, M. (Eds). : National Child Traumatic Stress Network Measure Review Database. Retrieved June 20, 2009 from http://nctsn.org/nctsn_assets/pdfs/measure/BDI-II.pdf Kumar, G., Steer, R.A., Teitelman, K.B., & Villacis, L. (2002). Effectiveness of Beck Depression Inventory-II subscales in screening for major depressive disorders in adolescent psychiatric inpatients. Assessment, 9, 164-170. Osman, A., Kopper, B.A., Guttierez, P.M., Barrios, F., & Bagge, C.L. (2004). Reliability and validity of the Beck Depression Inventory-II with adolescent psychiatric inpatients. Psychological Assessment, 16, 120-132. Osman, A., Downs, W.R., Barrios, F.X., Kopper, B.A., Gutierrez, P.M., and Chiros, C.E. (1997). Factor structure and psychometric characteristics of the Beck Depression Inventory-II. Journal of Psychopatholoty and Behavioral Assessment, 19, 359-376. Steer, R.A., Kumar, G., Ranieri, W.F., & Beck, A.T. (1998). Use of the Beck Depression Inventory-II with adolescent psychiatric outpatients. Journal of Psychopathology and Behavioral Assessment, 20, 127-137.

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