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Original Article
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.
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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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.
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.
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.
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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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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