Beck Depression Inventory
Encyclopedia
The Beck Depression Inventory (BDI, BDI-II), created by Dr. Aaron T. Beck
, is a 21-question multiple-choice
self-report inventory
, one of the most widely used instruments for measuring the severity of depression
. Its development marked a shift among health care professionals, who had until then viewed depression from a psychodynamic perspective, instead of it being rooted in the patient's own thoughts.
In its current version the questionnaire is designed for individuals aged 13 and over, and is composed of items relating to symptoms of depression 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.
There are three versions of the BDI—the original BDI, first published in 1961 and later revised in 1978 as the BDI-1A, and the BDI-II, published in 1996. The BDI is widely used as an assessment tool by health care professionals and researchers in a variety of settings.
Throughout his work, Beck drew attention to the importance of "negative cognitions": sustained, inaccurate, and often intrusive negative thoughts about the self. In his view, it was the case that these cognitions caused depression, rather than being generated by depression.
Beck developed a triad of negative cognitions about the world, the future, and the self, which play a major role in depression.
An example of the triad in action taken from Brown (1995) is the case of a student obtaining poor exam results:
The development of the BDI reflects that in its structure, with items such as "I have lost all of my interest in other people" to reflect the world, "I feel discouraged about the future" to reflect the future, and "I blame myself for everything bad that happens" to reflect the self. The view of depression as sustained by intrusive negative cognitions has had particular application in cognitive behavioral therapy (CBT), which aims to challenge and neutralize them through techniques such as cognitive restructuring
.
When the test is scored, a value of 0 to 3 is assigned for each answer and then the total score is compared to a key to determine the depression's severity. The standard cut-offs are as follows:
Higher total scores indicate more severe depressive symptoms.
Some items on the BDI have more than one statement marked with the same score. For instance, there are two responses under the Mood heading that score a 2: (2a) I am blue or sad all the time and I can't snap out of it and (2b) I am so sad or unhappy that it is very painful.
for the BDI-IA was good, with a Cronbach's alpha
coefficient of around 0.85, meaning that the items on the inventory are highly correlated with each other.
However, this version retained some flaws; the BDI-IA only addressed six out of the nine DSM-III criteria for depression. This and other criticisms were addressed in the BDI-II.
publication of the Diagnostic and Statistical Manual of Mental Disorders
, Fourth Edition, which changed many of the diagnostic criteria
for Major Depressive Disorder.
Items involving changes in body image
, hypochondria, and difficulty working were replaced. Also, sleep loss and appetite loss
items were revised to assess both increases and decreases in sleep and appetite. All but three of the items were reworded; only the items dealing with feelings of being punished, thoughts about suicide, and interest in sex remained the same. Finally, participants were asked to rate how they have been feeling for the past two weeks, as opposed to the past week as in the original BDI.
Like the BDI, the BDI-II also contains 21 questions, each answer being scored on a scale value of 0 to 3. The cutoffs used differ from the original: 0–13: minimal depression; 14–19: mild depression; 20–28: moderate depression; and 29–63: severe depression. Higher total scores indicate more severe depressive symptoms.
One measure of an instrument's usefulness is to see how closely it agrees with another similar instrument that has been validated against clinical interview by a trained clinician. In this respect, the BDI-II is positively correlated with the Hamilton Depression Rating Scale
with a Pearson r of 0.71, showing good agreement. The test was also shown to have a high one-week test–retest reliability (Pearson r =0.93), suggesting that it was not overly sensitive to daily variations in mood. The test also has high internal consistency (α=.91).
The affective subscale contains eight items: pessimism
, past failures, guilty feelings, punishment feelings, self-dislike, self-criticalness, suicidal thoughts or wishes, and worthlessness. The somatic subscale consists of the other thirteen items: sadness, loss of pleasure, crying, agitation, loss of interest, indecisiveness, loss of energy, change in sleep patterns, irritability, change in appetite, concentration difficulties, tiredness and/or fatigue, and loss of interest in sex. The two subscales were moderately correlated at 0.57, suggesting that the physical and psychological aspects of depression are related rather than totally distinct.
and psychology
; it represented a shift in health care professionals' view of depression from a Freudian, psychodynamic perspective, to one guided by the patient's own thoughts or "cognitions". It also established the principle that instead of attempting to develop a psychometric tool based on a possibly invalid theory, self-report questionnaires when analysed using techniques such as factor analysis
can suggest theoretical constructs.
The BDI was originally developed to provide a quantitative assessment of the intensity of depression. Because it is designed to reflect the depth of depression, it can monitor changes over time and provide an objective measure for judging improvement and the effectiveness or otherwise of treatment methods. The instrument remains widely used in research; in 1998, it had been used in over 2000 empirical studies. It has been translated into multiple European languages
as well as Arabic, Chinese
, Japanese
, Persian
, and Xhosa.
In participants with concomitant physical illness the BDI's reliance on physical symptoms such as fatigue may artificially inflate scores due to symptoms of the illness, rather than of depression. In an effort to deal with this concern Beck and his colleagues developed the "Beck Depression Inventory for Primary Care" (BDI-PC), a short screening scale consisting of seven items from the BDI-II considered to be independent of physical function. Unlike the standard BDI, the BDI-PC produces only a binary outcome of "not depressed" or "depressed" for patients above a cutoff score of 4.
Although designed as a screening device rather than a diagnostic tool, the BDI is sometimes used by health care providers to reach a quick diagnosis.
The BDI is copyright
ed, a fee must be paid for each copy used, and photocopy
ing it is a violation of copyright. There is no evidence that the BDI-II is more valid or reliable than other depression scales, and public domain
scales such as the Patient Health Questionnaire
– Nine Item (PHQ-9) has been studied as a useful tool.
Aaron T. Beck
Aaron Temkin Beck is an American psychiatrist and a professor emeritus in the department of psychiatry at the University of Pennsylvania. He is widely regarded as the father of cognitive therapy, and his pioneering theories are widely used in the treatment of clinical depression...
, is a 21-question multiple-choice
Multiple choice
Multiple choice is a form of assessment in which respondents are asked to select the best possible answer out of the choices from a list. The multiple choice format is most frequently used in educational testing, in market research, and in elections-- when a person chooses between multiple...
self-report inventory
Self-report inventory
A self-report inventory is a type of psychological test in which a person fills out a survey or questionnaire with or without the help of an investigator...
, one of the most widely used instruments for measuring the severity of depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
. Its development marked a shift among health care professionals, who had until then viewed depression from a psychodynamic perspective, instead of it being rooted in the patient's own thoughts.
In its current version the questionnaire is designed for individuals aged 13 and over, and is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss
Weight loss
Weight loss, in the context of medicine, health or physical fitness, is a reduction of the total body mass, due to a mean loss of fluid, body fat or adipose tissue and/or lean mass, namely bone mineral deposits, muscle, tendon and other connective tissue...
, and lack of interest in sex.
There are three versions of the BDI—the original BDI, first published in 1961 and later revised in 1978 as the BDI-1A, and the BDI-II, published in 1996. The BDI is widely used as an assessment tool by health care professionals and researchers in a variety of settings.
Development and history
Historically, depression was described in psychodynamic terms as "inverted hostility against the self". By contrast, the BDI was developed in a novel way for its time; by collating patients' verbatim descriptions of their symptoms and using these to structure a scale which could reflect the intensity or severity of a given symptom.Throughout his work, Beck drew attention to the importance of "negative cognitions": sustained, inaccurate, and often intrusive negative thoughts about the self. In his view, it was the case that these cognitions caused depression, rather than being generated by depression.
Beck developed a triad of negative cognitions about the world, the future, and the self, which play a major role in depression.
An example of the triad in action taken from Brown (1995) is the case of a student obtaining poor exam results:
- The student has negative thoughts about the world, so he may come to believe he does not enjoy the class.
- The student has negative thoughts about his future, because he thinks he may not pass the class.
- The student has negative thoughts about his self, as he may feel he does not deserve to be in college.
The development of the BDI reflects that in its structure, with items such as "I have lost all of my interest in other people" to reflect the world, "I feel discouraged about the future" to reflect the future, and "I blame myself for everything bad that happens" to reflect the self. The view of depression as sustained by intrusive negative cognitions has had particular application in cognitive behavioral therapy (CBT), which aims to challenge and neutralize them through techniques such as cognitive restructuring
Cognitive restructuring
Cognitive restructuring, sometimes used synonymously with Debating, is the process of learning to identify irrational or maladaptive thoughts and challenge their veracity using strategies such as logical disputation....
.
BDI
The original BDI, first published in 1961, consisted of twenty-one questions about how the subject has been feeling in the last week. Each question has a set of at least four possible answer choices, ranging in intensity. For example:- (0) I do not feel sad.
- (1) I feel sad.
- (2) I am sad all the time and I can't snap out of it.
- (3) I am so sad or unhappy that I can't stand it.
When the test is scored, a value of 0 to 3 is assigned for each answer and then the total score is compared to a key to determine the depression's severity. The standard cut-offs are as follows:
- 0–9: indicates minimal depression
- 10–18: indicates mild depression
- 19–29: indicates moderate depression
- 30–63: indicates severe depression.
Higher total scores indicate more severe depressive symptoms.
Some items on the BDI have more than one statement marked with the same score. For instance, there are two responses under the Mood heading that score a 2: (2a) I am blue or sad all the time and I can't snap out of it and (2b) I am so sad or unhappy that it is very painful.
BDI-IA
The BDI-IA was a revision of the original instrument, developed by Beck during the 1970s and copyrighted in 1978. To improve ease of use, the "a and b statements" described above were removed, and respondents were instructed to endorse how they had been feeling during the preceding two weeks. The internal consistencyInternal consistency
In statistics and research, internal consistency is typically a measure based on the correlations between different items on the same test . It measures whether several items that propose to measure the same general construct produce similar scores...
for the BDI-IA was good, with a Cronbach's alpha
Cronbach's alpha
Cronbach's \alpha is a coefficient of reliability. It is commonly used as a measure of the internal consistency or reliability of a psychometric test score for a sample of examinees. It was first named alpha by Lee Cronbach in 1951, as he had intended to continue with further coefficients...
coefficient of around 0.85, meaning that the items on the inventory are highly correlated with each other.
However, this version retained some flaws; the BDI-IA only addressed six out of the nine DSM-III criteria for depression. This and other criticisms were addressed in the BDI-II.
BDI-II
The BDI-II was a 1996 revision of the BDI, developed in response to the American Psychiatric Association'sAmerican Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
publication of the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
, Fourth Edition, which changed many of the diagnostic criteria
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
for Major Depressive Disorder.
Items involving changes in body image
Body image
Body image refers to a person's perception of the aesthetics and sexual attractiveness of their own body. The phrase body image was first coined by the Austrian neurologist and psychoanalyst Paul Schilder in his masterpiece The Image and Appearance of the Human Body...
, hypochondria, and difficulty working were replaced. Also, sleep loss and appetite loss
Anorexia (symptom)
Anorexia is the decreased sensation of appetite...
items were revised to assess both increases and decreases in sleep and appetite. All but three of the items were reworded; only the items dealing with feelings of being punished, thoughts about suicide, and interest in sex remained the same. Finally, participants were asked to rate how they have been feeling for the past two weeks, as opposed to the past week as in the original BDI.
Like the BDI, the BDI-II also contains 21 questions, each answer being scored on a scale value of 0 to 3. The cutoffs used differ from the original: 0–13: minimal depression; 14–19: mild depression; 20–28: moderate depression; and 29–63: severe depression. Higher total scores indicate more severe depressive symptoms.
One measure of an instrument's usefulness is to see how closely it agrees with another similar instrument that has been validated against clinical interview by a trained clinician. In this respect, the BDI-II is positively correlated with the Hamilton Depression Rating Scale
Hamilton Depression Rating Scale
The Hamilton Rating Scale for Depression , also known as the Hamilton Depression Rating Scale or abbreviated to HAM-D, is a multiple choice questionnaire that clinicians may use to rate the severity of a patient's major depression. Max Hamilton originally published the scale in 1960 and reviewed...
with a Pearson r of 0.71, showing good agreement. The test was also shown to have a high one-week test–retest reliability (Pearson r =0.93), suggesting that it was not overly sensitive to daily variations in mood. The test also has high internal consistency (α=.91).
Two-factor approach to depression
Depression can be thought of as having two components: the affective component (e.g. mood) and the physical or "somatic" component (e.g. loss of appetite). The BDI-II reflects this and can be separated into two subscales. The purpose of the subscales is to help determine the primary cause of a patient's depression.The affective subscale contains eight items: pessimism
Pessimism
Pessimism, from the Latin word pessimus , is a state of mind in which one perceives life negatively. Value judgments may vary dramatically between individuals, even when judgments of fact are undisputed. The most common example of this phenomenon is the "Is the glass half empty or half full?"...
, past failures, guilty feelings, punishment feelings, self-dislike, self-criticalness, suicidal thoughts or wishes, and worthlessness. The somatic subscale consists of the other thirteen items: sadness, loss of pleasure, crying, agitation, loss of interest, indecisiveness, loss of energy, change in sleep patterns, irritability, change in appetite, concentration difficulties, tiredness and/or fatigue, and loss of interest in sex. The two subscales were moderately correlated at 0.57, suggesting that the physical and psychological aspects of depression are related rather than totally distinct.
Impact
The development of the BDI was an important event in psychiatryPsychiatry
Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...
and psychology
Psychology
Psychology is the study of the mind and behavior. Its immediate goal is to understand individuals and groups by both establishing general principles and researching specific cases. For many, the ultimate goal of psychology is to benefit society...
; it represented a shift in health care professionals' view of depression from a Freudian, psychodynamic perspective, to one guided by the patient's own thoughts or "cognitions". It also established the principle that instead of attempting to develop a psychometric tool based on a possibly invalid theory, self-report questionnaires when analysed using techniques such as factor analysis
Factor analysis
Factor analysis is a statistical method used to describe variability among observed, correlated variables in terms of a potentially lower number of unobserved, uncorrelated variables called factors. In other words, it is possible, for example, that variations in three or four observed variables...
can suggest theoretical constructs.
The BDI was originally developed to provide a quantitative assessment of the intensity of depression. Because it is designed to reflect the depth of depression, it can monitor changes over time and provide an objective measure for judging improvement and the effectiveness or otherwise of treatment methods. The instrument remains widely used in research; in 1998, it had been used in over 2000 empirical studies. It has been translated into multiple European languages
Languages of Europe
Most of the languages of Europe belong to Indo-European language family. These are divided into a number of branches, including Romance, Germanic, Balto-Slavic, Greek, and others. The Uralic languages also have a significant presence in Europe, including the national languages Hungarian, Finnish,...
as well as Arabic, Chinese
Chinese language
The Chinese language is a language or language family consisting of varieties which are mutually intelligible to varying degrees. Originally the indigenous languages spoken by the Han Chinese in China, it forms one of the branches of Sino-Tibetan family of languages...
, Japanese
Japanese language
is a language spoken by over 130 million people in Japan and in Japanese emigrant communities. It is a member of the Japonic language family, which has a number of proposed relationships with other languages, none of which has gained wide acceptance among historical linguists .Japanese is an...
, Persian
Persian language
Persian is an Iranian language within the Indo-Iranian branch of the Indo-European languages. It is primarily spoken in Iran, Afghanistan, Tajikistan and countries which historically came under Persian influence...
, and Xhosa.
Limitations
The BDI suffers from the same problems as other self-report inventories, in that scores can be easily exaggerated or minimized by the person completing them. Like all questionnaires, the way the instrument is administered can have an effect on the final score. If a patient is asked to fill out the form in front of other people in a clinical environment, for instance, social expectations have been shown to elicit a different response compared to administration via a postal survey.In participants with concomitant physical illness the BDI's reliance on physical symptoms such as fatigue may artificially inflate scores due to symptoms of the illness, rather than of depression. In an effort to deal with this concern Beck and his colleagues developed the "Beck Depression Inventory for Primary Care" (BDI-PC), a short screening scale consisting of seven items from the BDI-II considered to be independent of physical function. Unlike the standard BDI, the BDI-PC produces only a binary outcome of "not depressed" or "depressed" for patients above a cutoff score of 4.
Although designed as a screening device rather than a diagnostic tool, the BDI is sometimes used by health care providers to reach a quick diagnosis.
The BDI is copyright
Copyright
Copyright is a legal concept, enacted by most governments, giving the creator of an original work exclusive rights to it, usually for a limited time...
ed, a fee must be paid for each copy used, and photocopy
Photocopier
A photocopier is a machine that makes paper copies of documents and other visual images quickly and cheaply. Most current photocopiers use a technology called xerography, a dry process using heat...
ing it is a violation of copyright. There is no evidence that the BDI-II is more valid or reliable than other depression scales, and public domain
Public domain
Works are in the public domain if the intellectual property rights have expired, if the intellectual property rights are forfeited, or if they are not covered by intellectual property rights at all...
scales such as the Patient Health Questionnaire
Patient Health Questionnaire
The Patient Health Questionnaire is a multiple-choice self-report inventory, used as a screening and diagnostic tool for mental health disorders of depression, anxiety, alcohol, eating, and somatoform. It was designed for use in the primary care setting and lacks coverage for disorders seen in...
– Nine Item (PHQ-9) has been studied as a useful tool.
See also
- Beck Anxiety InventoryBeck Anxiety InventoryThe Beck Anxiety Inventory , created by Dr. Aaron T. Beck and other colleagues, is a 21-question multiple-choice self-report inventory that is used for measuring the severity of an individual's anxiety.-BAI:...
- Beck Hopelessness ScaleBeck Hopelessness ScaleThe Beck Hopelessness Scale is a 20-item self-report inventory developed by Dr. Aaron T. Beck that was designed to measure three major aspects of hopelessness: feelings about the future, loss of motivation, and expectations...
- Diagnostic classification and rating scales used in psychiatryDiagnostic classification and rating scales used in psychiatryThe following diagnostic systems and rating scales are used in psychiatry and clinical psychology.-Diagnostic Criteria:*Diagnostic and Statistical Manual of Mental Disorders *ICD-10 Chapter V: Mental and behavioural disorders...
- Major Depression InventoryMajor Depression InventoryThe Major Depression Inventory is a self-report mood questionnaire developed by the World Health Organisation. The instrument was constructed by a team led by Professor Per Bech, a psychiatrist based at Frederiksborg General Hospital in Denmark...
Further reading
- Beck A.T. (1988). "Beck Hopelessness Scale." The Psychological CorporationHarcourt AssessmentHarcourt Assessment was a company that published and distributed educational and psychological assessment tools and therapy resources and provided educational assessment and data management services for national, state, district and local assessments...
.