European R. C. Campo Journalof s & B. Psychological Gonalves:Assessment The Portuguese 2011; 2011 Vol.

. Version Hogrefe 27(4):258264 Publishing of BDI-II

Original Article

The Portuguese Version of the Beck Depression Inventory-II (BDI-II)

Preliminary Psychometric Data with Two Nonclinical Samples
Rui C. Campos1 and Bruno Gonalves2
1

Department of Psychology, University of vora, Portugal 2 Faculty of Psychology, University of Lisbon, Portugal

Abstract. Beck Depression Inventory-II (BDI-II) is one of the most popular and widely investigated instruments for assessing the severity of depressive symptomatology. The authors developed a Portuguese version of the inventory. This paper presents two studies: one with a college student sample (n = 547) and another with a community sample (n = 200). Reliability, factor structure, and validity data were obtained. The Portuguese version presents a good internal consistency, a factor structure very similar to the one obtained by Beck, Steer, and Brown (1996) with the original version, and presents an adequate convergent validity with the Center for Epidemiologic Studies of Depression Scale. Confirmatory factor analysis provides support for the fit of a two-factor model. Keywords: Beck Depression Inventory-II, Portuguese version, psychometric data, preliminary studies, depression, measurement

The high prevalence of depressive symptoms, both in the general population and in several types of clinical settings, including the psychiatric one, makes the assessment of depressive symptomatology an extremely important aspect of psychological assessment. Self-report instruments, such as questionnaires or inventories, present several advantages including the simplicity of the administration procedure (as compared to structured clinical interviews, for example), the simplicity and objectivity of the scoring procedures, and the existence of normative data to help the interpretation of the results. There are several inventories for the assessment of the severity of depressive symptomatology and the Beck Depression Inventory is one of the most often used and investigated (Dozois & Covin, 2004; Piotrowski, Sherry, & Keller, 1985; Ritterband & Spielberger, 1996). Hiroe et al. (2005) state that the BDI-II, because of its psychometric properties, is likely to remain the most popular instrument to assess the severity of depressive symptomatology, like its predecessor, the BDI-A. The BDI-II score is a good index of the severity of present depressive symptoms often used in clinical practice and in research (Brantley, Dutton, & Wood, 2004). It is a suitable instrument for measuring depressive symptoms in college student samples (e.g., Carmody, 2005; Sanz, Navarro, & Vzquez, 2003), as well as in the general population (e.g., Abdel-Khalek, 2001; Sanz, Perdign, & Vzquez, 2003), and adolescent samples (CaEuropean Journal of Psychological Assessment 2011; Vol. 27(4):258264 DOI: 10.1027/1015-5759/a000072

nals, Blad, Carbajo, & Domnech-Labera, 2001). Despite this, it is worth mentioning that the BDI-II is not a diagnostic instrument, but rather assesses the presence and the severity of depressive symptoms. The first version of BDI dates back to 1961 (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The 21 items were developed only to assess the severity of depressive symptoms and not to reflect a particular theory of depression. They were developed on the basis of the clinical observation of depressed patients and of their own descriptions of their symptoms (Beck & Steer, 1987). These clinical observations and descriptions were systematically structured in 21 symptoms or symptomatic groups. In 1979 a revised version, the BDI-A, was published (Beck & Steer, 1987). The authors compared the psychometric characteristics of both versions and concluded that they were similar in the assessment of depression in psychiatric patients. The modifications were not significant. The wording of some items was slightly changed and the number of responses per item was reduced to four alternatives per symptom. In the original version the items had four, five, or even six response alternatives. The Beck Depression Inventory-II (Beck, Steer, & Brown, 1996) was published in 1996, and was developed to assess symptoms corresponding to diagnostic criteria for depressive disorders listed in the DSM-IV. This version also contains 21 items and can be administered to individuals of at least 13 years of age. Four items were dropped
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(Weight loss, Body image change, Somatic preoccupation, and Work difficulty) and replaced by four new items (Agitation, Worthlessness, Concentration difficulty, and Loss of energy), in order to assess symptoms typical of severe depressions. Modifications were also made so that the items also reflected reversed neurovegetative symptoms. The items referring to sleep pattern changes and appetite changes were modified to assess for increases as well as decreases in appetite and sleep. Wording of the remaining items was also slightly altered. As in the former versions, the total score is the sum of the scores in the 21 items. The studies on the factor structure of the BDI-II in nonclinical samples have often found a structure of two factors, called Cognitive-affective and Somatic (Beck et al., 1996; Dozois, Dobson, & Ahnberg, 1998; Steer & Clark, 1997; Whisman et al., 2000). In the Spanish adaptation the same two-factor structure was obtained, both with a college students sample (Sanz, Navarro et al., 2003), and with a sample from the general population (Sanz, Perdign et al., 2003). Interestingly, despite the differences between BDIII and its prior version, the BDI-A, the same two-factor structure was obtained with the latest (e.g., Endler & Rutherford, 1999), namely with the Brazilian version (Gorenstein et al., 1999; Wang, Andrade, & Gorenstein, 2005). However, other studies on the BDI-II, using confirmatory factor analysis (CFA) to test different models, concluded that a three-factor model provided the best fit to the data (Al-Musawi, 2001; Carmody, 2005; Osman et al., 1997). In the study of Al-Musawi, the three factors were called Cognitive-affective, Overt emotional upset, and Somatic complaints, and in the study of Osman et al. they were called Negative attitude, Performance difficulty, and Somatic elements. These same factors were reported by Carmody. Al-Musawi (2001) used an Asiatic sample and Carmody (2005) used a very heterogeneous sample, composed of individuals from different ethnic backgrounds. However, Osman et al. (1997) did use a sample composed of a majority of White/European Americans. It is important to say that in clinical samples two factors are also frequently obtained, but they differ from those obtained with nonclinical samples, a Cognitive factor, and an Affective-somatic, both in psychiatric clinical samples (Bedi, Koopman, & Thompson, 2001; Beck et al., 1986; Steer, Ball et al., 1999; Steer, Rissmiller, & Beck, 2000), and in other clinical samples (Arnau, Meagher, Norris, & Bramson, 2001; Viljoen, Iverson, Griffiths, & Woodward, 2003). Several efforts were made to adapt the BDI-II for different languages and cultures (e.g., Al-Musawi, 2001; Alansari, 2005; Carmody, 2005; Dozois et al., 1998; Ghassemzadeh, Mojtabai, Karamghadiri, & Ebrahimkhani, 2005; Joe, Woolley, Brown, Ghahramanlou-Holloway, & Beck, 2008; Kojima et al., 2002; Rodrguez-Gmez, Dvila-Martnez, & Collazo-Rodrguez, 2006; Sanz, Perdign et al., 2003; VanVoorhis & Blumentritt, 2007; Whisman et al., 2000). Although a previous adaptation of the original version of the BDI (Beck et al., 1961) exists for the Portuguese population (Vaz Serra & Abreu, 1973) the revised version
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of this instrument has not yet been adapted or its psychometric properties evaluated.

Aim of the Study

The aim of the present study was to develop a Portuguese version of the BDI-II and to conduct an initial evaluation of its psychometric properties. Two studies were conducted: One with a college student sample and another with a community sample to obtain cross-validation data for convergent validity and CFA. The procedure of BDI-II translation into Portuguese was conducted in several stages: the accomplishment of a preliminary translation, the evaluation of this translation by specialists in the field and in the language of the inventory, the backtranslation, and its subsequent evaluation. The translation and administration of the BDI-II in this study were authorized by Harcourt Assessment and the copyright fees were paid. In the preliminary translation, item and instruction formats were maintained. We tried to translate the items in the most literal way, and when this was not possible, we tried to maintain the meaning of the original item. We had in mind the guide-lines of Van de Vijver and Hambleton (1996). After the preliminary translation was concluded, it was evaluated by three clinical psychologists. Then, an English translator backtranslated the translated form into English without having access to the original form. Finally, another translator compared the backtranslation with the original form. They were remarkably similar. All the same, we made some very small modifications to the wording of some items.

Study I Study Using a Student Sample

Method
Participants
A convenience sample of 547 college students from several Portuguese universities participated in this study. Participation was voluntary and participants gave informed consent. Of these, 220 participants (40.2%) were male and 327 (59.8%) were female. Age ranged from 18 to 55 years (M = 20.65, SD = 3.54). Race was, in the vast majority of cases (about 95%), Caucasian. The data from nine participants were eliminated because their protocols were considered invalid (at least three items with missing values). The remaining missing values were replaced by the mean value for each item.

Measures
As part of a larger research project concerning depression and depressive personality, participants responded to sevEuropean Journal of Psychological Assessment 2011; Vol. 27(4):258264

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eral questionnaires, including the Portuguese version of the Depressive Personality Disorder Inventory, in packs that did not exceed four instruments. Packs included the Portuguese version of the BDI-II.

Procedure
Students responded in groups varying from 15 to 50 individuals at the beginning or (in the majority of cases) at the end of their classes. After a brief explanation about the purpose of the administration, each participant received a pack, containing a cover page with instructions and explaining the confidential and anonymous nature of the participation. Following this cover page, participants found a sociodemographic questionnaire and the instruments.

As the score distributions were highly and positively skewed, the Mann Whitney U test was used to compare the results obtained by male and female students, z = 3.85 (p < .001). Female students had a higher mean M = 9.72 (SD = 7.82) than male students, M = 7.64 (SD = 7.74). We also compared male and female students regarding the 21 BDIII items. After Bonferroni correction, was set at .0024 and there were significant differences between the groups, with female students scoring highly in 5 of the 21 items: 1 Sadness, 10 Crying, 15 Loss of energy, 18 Changes in appetite, and 21 Loss of interest in sex.

Reliability
Cronbachs coefficient for the 21 BDI-II items was .90. No item-total correlation was lower than .30. Table 1. Results on the BDI-II (means and standard deviations) for the student sample and for the subsamples of male and female students
Total sample M BDI-II 8.88 (n = 538) SD 7.85 Male M 7.64 (n = 215) SD 7.74 Female M 9.72 (n = 323) SD 7.82

Results
Means and standard deviations of the BDI-II for the student sample and for the subsamples of male and female students are presented in Table 1. Table 2 presents the descriptive statistics of the 21 BDI-II items (means, standard deviations, and percentage of symptomatic responses). Symptomatic responses are those scored with 1, 2, or 3 points.

Table 2. Results on the 21 BDI-II items (means, standard deviations, and percentage of symptomatic responses) for the student sample
Total sample Item 1 Sadness**a 2 Pessimism 3 Past failure 4 Loss of pleasure 5 Guilty feelings 6 Punishment feelings 7 Self dislike 8 Self criticalness 9 Suicidal thoughts or wishes* 10 Crying** 11 Agitation 12 Loss if interest 13 Indecisiveness** 14 Worthlessness** 15 Loss of energy**a 16 Changes in sleeping pattern 17 Irritability 18 Changes in appetite**a 19 Concentration difficulty* 20 Tiredness or fatigue**
a a

Male % 23 31 31 32 42 19 18 45 13 31 42 22 43 18 38 67 30 49 43 46 M .17 .33 .39 .36 .41 .31 .27 .59 .10 .26 .47 .30 .46 .17 .36 .83 .32 .44 .52 .48 SD .46 .60 .65 .67 .56 .70 .69 .73 .33 .71 .69 .61 .71 .50 .65 .75 .61 .63 .74 .70 % 15 27 31 28 38 22 16 46 9 15 38 23 37 12 28 65 26 37 38 39

Female M .33 .39 .37 .41 .48 .23 .33 .55 .18 .64 .52 .27 .66 .31 .52 .92 .38 .71 .65 .64 SD .57 .60 .60 .61 .55 .58 .75 .69 .45 .90 .64 .57 .84 .66 .63 .79 .58 .76 .79 .72 % 29 34 31 35 45 18 19 45 16 41 45 21 48 21 46 69 33 57 47 52

M .27 .37 .38 .40 .45 .26 .30 .57 .15 .49 .50 .28 .58 .26 .46 .88 .36 .60 .59 .57

SD .53 .60 .62 .63 .55 .63 .72 .70 .41 .85 .66 .59 .80 .60 .65 .78 .59 .72 .77 .72

.19 .53 15 .12 .42 9 .25 .58 18 21 Loss of interest in sex** Note. *Differences between male and female students for p < .05. **Differences between male and female students for p < .01. aAfter Bonferroni correction only these items presented significant differences. Mann Whitney U-test was used.
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Exploratory Factor Analysis

To study the factor structure of the inventory we followed the same procedures used by Beck et al. (1996). We conducted a common factor analysis, followed by a promax rotation. Since the item endorsement rates indicated that the students responses were very positively skewed, a square-root transformation was applied to the data before this analysis. We did want to stay close to the Beck et al. procedure of transforming the items. The number of factors to be extracted was determined by parallel analysis (Horn, 1965), considering the magnitude of the eigenvalues derived from a principal component analysis, also following the Beck et al. procedure. The first four principal components eigenvalues were 6.773, 1.393, 1.064, 1.021 and the first four eigenvalues for the random dataset were 1.368, 1.304, 1.256, 1.214, so two factors should be extracted. The factors eigenvalues were 5.71 and 4.70. The correlation between these two oblique factors was .69. The promax-rotated iterated principal factor loadings for the college students sample are presented in Table 3. Only five Table 3. Promax-rotated iterated principal factor loadings for the sample of college students
Item 1 Sadness 2 Pessimism 3 Past failure 4 Loss of pleasure 5 Guilty feelings 6 Punishment feelings 7 Self-dislike 8 Self-criticalness 9 Suicidal thoughts or wishes 10 Crying 11 Agitation 12 Loss if interest 13 Indecisiveness 14 Worthlessness 15 Loss of energy 16 Changes in sleeping pattern 17 Irritability 18 Changes in appetite 19 Concentration difficulty 20 Tiredness or fatigue 21 Loss of interest in sex Eigenvalues Correlation between factors Factor I 1.00 Factor II .69 1.00 Note. *Item 15 is not assigned to Factor II because of high loadings for both factors. Bold highlighted are the salient (> .35) item loadings.
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items had factor loadings lower than .35 in both factors. Two of them, Item 10 and Item 21, presented a factor loading (.34) that is very close to .35, and the remaining three items presented factor loadings that are higher than .30. We labeled the two factors Cognitive-affective and Somatic, taking into account the items factor loadings. Our factor structure is similar to the one obtained by Beck et al. (1996). Coefficients of congruence (Gorsuch, 1983) between our factors and the Beck et al. factors were 0.90 and 0.80, respectively, for Factor I and Factor II.

Study II Study using a community sample

Method
Participants and Procedure
A convenience community sample of 200 adults living in the district of vora, Portugal, participated in this study. Of these, 100 participants (50%) were male and 100 (50%) were female, their ages ranging from 18 to 69 years (M = 36.1, SD = 11.54). The majority of the participants were Caucasian and their education levels ranged from 6 to 19 years (M = 12.1, SD = 3.47). Only a minority was unemployed. All participants volunteered to participate and gave informed consent. All protocols were collected in individual sessions by trained undergraduate research assistants.

Factor I .65 .59 .47 .45 .36 .31 .82 .42 .53 .34 .10 .65 .32 .77 .31 .07 .28 .05 .22 .02 .34 5.71

Factor II .04 .07 .05 .19 .13 .12 .18 .10 .01 .28 .58 .00 .29 .11 .40* .54 .32 .56 .43 .72 .09 4.7

Measures
Participants responded to the BDI-II and to the Portuguese version (Gonalves & Fagulha, 2004) of the Center for the Epidemiologic Studies of Depression Scale (CES-D; Radloff, 1977). The CES-D is a well-known 20-item inventory that measures the affective and somatic symptoms of depression. Scores range from 0 to 60, with higher scores indicating more severe depression. Although the scale is typically used as a continuous measure, a score of 16 or higher is regarded as the clinical cut-off for at least a mild case of depression (Radloff, 1977). The CES-D is well suited for administration to adults from the general population. Respondents are asked to indicate the frequency with which they have experienced each symptom over the past week on a 4-point rating scale (0 to 3). The CES-D has acceptable levels of internal consistency and convergent validity. Extensive evidence from a variety of samples attests to the psychometric properties of the CES-D (see Eaton, Muntaner, Smith, Tien, & Ybarra, 2004). The Portuguese version (Gonalves & Fagulha, 2004) presents good psychometric characteristics. The Cronbachs in different samples ranged between .87 and .92. In the present sample, the coefficient for the CES-D was .88.
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Results
Reliability
Cronbachs coefficient was .91 for the 21 BDI-II items.

Convergent Validity
The Portuguese version of the BDI-II correlates significantly with the Portuguese version of the CES-D (r = .71, p < .001). Factor I of the BDI-II correlates .65 and Factor II correlates .60 with the CES-D.

Confirmatory Factor Analysis

In order to cross-evaluate the fit of the two-factor model obtained with the student sample to the data, we computed a maximum likelihood CFA (with the AMOS 17.0 software package). As with the student sample, a square-root transformation was applied to the data before CFA was computed. We estimated factor loadings and did not fix the loadings of the CFA model using the loadings of the exploratory factor analysis (EFA) model computed with the student sample. Six goodness-of-fit indexes were used (, /df, root mean square residual (RMR), goodness-of-fit index (GFI), comparative fit index (CFI), and incremental fit index (IFI). Models were compared using the Akaike information criterion (AIC). The two-factor model obtained from the EFA resulted in a proper fit for the data ( = 155.42, df = 89, p < .001, /df = 1.746, RMR = .016, GFI = .903, CFI = .929, IFI = .931, and AIC = 217.423). Results for a three-factor model were less satisfactory ( = 320.33, df = 193, p < .001, /df = 1.660, RMR = .021, GFI = .860, CFI = .911, IFI = .913, and AIC = 396.329). All the items loading on Factor I in the two-factor solution also loaded on Factor I in the three-factor solution. Items 11, 16, 17, 18, and 20 loaded on Factor II in the three-factor solution, and Items 13, 15, and 19 loaded on Factor III. The higher AIC of the three-factor model indicates it is a less parsimonious model. Considering all the goodness-of-fit indexes, except the /df index, the two-factor model showed a better fit to the data. Moreover, the fit of the three-factor model was significantly worse than that for the two-factor model, (df = 104) = 164.91, p < .0001, and AIC = 178.9061.

Discussion
We obtained psychometric data for the Portuguese version of the BDI-II regarding reliability, factor structure, and va1

lidity, using two samples, a college students sample and a community sample. Female students had a higher mean than male students. This difference is congruent with other research on the BDI-II (e.g., Beck et al., 1996; Dozois et al., 1998). After Bonferroni correction, there were also significant differences by gender in 5 of the 21 items, with female students scoring higher. We obtained quite acceptable results in terms of internal consistency. In both samples, was in an acceptable range. In other studies with nonclinical populations (Al-Musawi, 2001; Beck et al., 1996; Dozois et al., 1998; Osman et al., 1997; Steer & Clark, 1997; Whisman, Perez & Ramel 2000), very similar values were obtained, namely in the Spanish adaptation, both with a college student sample (Sanz, Navarro et al., 2003), and with a general population sample (Sanz et al., 2003). In clinical samples, other authors have obtained values similar to the ones obtained in this study (Arnau et al., 2001; Beck, Steer, Ball, & Ranieri, 1996; Beck et al., 1996; Steer, Ball, Ranieri, & Beck, 1999; Steer, Clark, Beck, & Ranieri, 1999; Steer, Kumar, Ranieri, & Beck, 1998; Steer, Rissmiller, & Beck, 2000; Sprinkle et al., 2002). As regards factor structure, we obtained two factors with the student sample, which we labeled Cognitive-affective and Somatic, taking into account the items factor loadings. This factor structure is very similar to the structures obtained with other nonclinical samples (Dozois et al., 1998; Steer & Clark, 1997; Whisman et al., 2000), and is also very similar to the structure obtained by Beck et al. (1996). Coefficients of congruence (Gorsuch, 1983) between our factors and the Beck et al. factors highlight important evidence of measurement equivalence in both forms of the BDI-II. Regarding the items that can be attributed to each factor and using .35 as a cut-off point, as did Beck et al. (1996), the similarity between our results (presented in Table 3) and those presented in the manual (Beck et al., 1996) is remarkable. In the Beck et al. data, Items 2 (Pessimism) and 21 (Loss of interest in sex) had factor loadings lower than .35 on Factor I and also on Factor II; in our results, Items 6 (Punishment feelings), 10 (Crying), 13 (Indecisiveness), 17 (Irritability), and 21 (Loss of interest in sex) had factor loadings lower than the cut-off point on Factor I and Factor II. However, with the exception of Item 17 (Irritability), which had very similar factor loadings on both factors, and Item 11 (Agitation), all items had a higher factor loading on the same factor in both studies. Item 11 is the only one that can be attributed to different factors in the two studies. In our study it belongs to Factor II, Somatic, but in the Beck et al. study, it belongs to Factor I, Cognitive-affective. An item to evaluate agitation seems to be more consistent with a somatic factor than with a cognitive-affective factor. The two-factor model seems to present a better fit to the data than a three-factor model both in a random subset of the students sample and in a community cross-validation

Burnham and Anderson (1998) suggest that if AIC values for one model (e.g., path estimates are free to be estimated) are 10 or more units lower than AIC values for a second model (e.g., constrained to the same values across groups), there is strong evidence that the first model is better than the second model.
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sample. These results accord well with some of the previous research on the BDI-II (Dozois & Covin, 2004; Dozois et al., 1998; Steer & Clark, 1997; Sanz, Navarro, et al., 2003; Sanz, Perdign, et al., 2003; Whisman et al., 2000) but not with other studies on the BDI-II, which concluded that a three-factor model provided the best fit to the data (Al-Musawi, 2001; Carmody, 2005; Osman et al., 1997). Results also support the convergent validity of the Portuguese version of the BDI-II with the CES-D. The CES-D is also a self-report measure that assesses the state symptom correlates of depression, but (differently from the BDI-II) asks the individual to report the frequency of depressive symptoms in the previous week, not the severity of symptoms in the previous 2 weeks. Perhaps because of that, the magnitude of the Pearson correlation between the two measures was no higher than .71. Both factors of the BDI-II present acceptable correlations with the CES-D.

Limitations of the Study

Generally speaking, these preliminary psychometric data seem quite encouraging. Nevertheless, this study has a major limitation, since a clinical sample was not used. It will be necessary to obtain additional reliability and validity data using a large clinical sample of patients with different diagnoses to study the factor structure in this kind of population, to establish cut-off points, to study item-option characteristic curves, and to study the ability of the instrument to differentiate patients with different diagnoses.

Acknowledgments
The translation and administration of BDI-II were authorized by Harcourt Assessment and the copyright fees were paid. This study was supported by Servier Portugal, Especialidades Farmacuticas, lda, whom we wish to thank. We also wish to thank Prof. Constana Biscaia, Department of Psychology, University of vora; Prof. Rosa Novo, Faculty of Psychology, University of Lisbon; Dr. Miguel Pimenta, private Clinical Psychologist; Dr. Jane Duarte, English translator; and Dr. Paulo Mendes, English translator for their collaboration in the BDI-II translation process. We also wish to thank to Prof. Avi Besser, Ph.D., Department of Behavioral Sciences and Center for Research in Personality, Life Transitions, and Stressful Life Events, Sapir Academic College, D. N. Hof Ashkelon, Israel, for his important contribution in the CFA section.

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Published online: June 20, 2011

Rui C. Campos Department of Psychology University of vora Apartado 94 7702-554 vora Portugal Tel. +351 26 676-8050 Fax +351 26 676-8073 E-mail rcampos@uevora.pt
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