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Vol. 68. Núm. 9.
Páginas 1274-1287 (septiembre 2013)
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Vol. 68. Núm. 9.
Páginas 1274-1287 (septiembre 2013)
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Assessment of depression in medical patients: A systematic review of the utility of the Beck Depression Inventory-II
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Yuan-Pang WangI,
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gnap_inbox@hotmail.com

Tel.: 55 11 2661-6976
, Clarice GorensteinI,II
I Institute & Department of Psychiatry (LIM-23), University of São Paulo Medical School, São Paulo/SP, Brazil
II Institute of Biomedical Sciences, Department of Pharmacology, University of São Paulo, São Paulo/SP, Brazil
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To perform a systematic review of the utility of the Beck Depression Inventory for detecting depression in medical settings, this article focuses on the revised version of the scale (Beck Depression Inventory-II), which was reformulated according to the DSM-IV criteria for major depression. We examined relevant investigations with the Beck Depression Inventory-II for measuring depression in medical settings to provide guidelines for practicing clinicians. Considering the inclusion and exclusion criteria seventy articles were retained. Validation studies of the Beck Depression Inventory-II, in both primary care and hospital settings, were found for clinics of cardiology, neurology, obstetrics, brain injury, nephrology, chronic pain, chronic fatigue, oncology, and infectious disease. The Beck Depression Inventory-II showed high reliability and good correlation with measures of depression and anxiety. Its threshold for detecting depression varied according to the type of patients, suggesting the need for adjusted cut-off points. The somatic and cognitive-affective dimension described the latent structure of the instrument. The Beck Depression Inventory-II can be easily adapted in most clinical conditions for detecting major depression and recommending an appropriate intervention. Although this scale represents a sound path for detecting depression in patients with medical conditions, the clinician should seek evidence for how to interpret the score before using the Beck Depression Inventory-II to make clinical decisions.

KEYWORDS:
Beck Depression Inventory
Depression
Medical Illness
Psychometric Scale
Screening
Validation Study
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INTRODUCTION

Patients with chronic medical illness have a high prevalence of major depressive illness (1). Depressive symptoms may co-occur with serious medical illnesses, such as heart disease, stroke, cancer, neurological disease, HIV infection, and diabetes (1–3). The functional impairment associated with medical illnesses often causes depression. Patients who present depression along with medical illness tend to have more severe symptoms, more difficulty adjusting to their health condition, and more medical costs than patients who do not have co-existing depression (2). While prompt treatment of depression can improve the outcome of the co-occurring physical illness, proper and early recognition of treatable depression can result in a faster recovery and can shorten the patient's hospital stay.

Formal assessment of depression by a liaison psychiatrist or clinician-administered instruments, such as the Hamilton Depression Rating Scale (4) and the Montgomery-Åsberg Depression Rating Scale (5), are onerous to implement in routine clinical settings. In contrast, self-report measures for depression can be cost-effective for use in busy specialty medical clinics. Throughout the second half of the 20th century, along with the discovery of effective antidepressant drugs and the development of cognitive-behavioral therapy, several patient-rated assessment scales for detecting depression were proposed. Popular instruments include the Beck Depression Inventory (BDI) (6), the Self-Rating Depression Scale (7), the Center for Epidemiologic Studies Depression Scale (8), the Patient Health Questionnaire-9 (9), the Inventory of Depressive Symptomatology (10), and the Depression in the Medically Ill (11). Alternative scales have been developed to measure depression in specific populations, such as postpartum women (12) and patients with schizophrenia (13). Other scales have been devoted to quantify depression in specific age groups, such as adolescents (14) and the elderly (15). The utility of these scales in the medically ill is challenging because the frequent presence of somatic symptoms in physical diseases can mislead their score interpretation. If the clinician is unable to decide which existing instrument to use and how to interpret the results, the advancement of self-rating scales can represent a step backward.

Among the investigations on using self-assessment measures to evaluate depression, the BDI outnumbers the other measures in the amount of published research: there are more than 7,000 studies so far using this scale. Aaron T. Beck and colleagues developed the 21-item BDI in 1961 to aid clinicians in the assessment of psychotherapy for depression (6). The easy applicability and psychometric soundness of this scale have popularized its use in a variety of samples (16–19) and in healthcare settings worldwide (20–22). This inventory has received two major revisions: in 1978 as BDI-IA (23) and in 1996 as BDI-II (24). This later reformulation covers psychological and somatic manifestations of a two-week major depressive episode, as operationalized in the DSM-IV (25). Four items of the BDI-IA (weight loss, distorted body image, somatic preoccupation, and inability to work) were replaced with agitation, worthlessness, difficulty concentrating, and energy loss to assess the intensity of depression. The items of appetite and sleep changes were amended to evaluate the increase and decrease in depression-related vegetative behaviors (24,26–28). Different from the original version, which intended to measure negative cognitions of depression, the BDI-II does not reflect any particular theory of depression. The English version of BDI-II has been translated and validated in 17 languages so far, and it is used among countries in Europe, the Middle East, Asia, and Latin America (29–32).

Investigations on depression and its instrumentation must be considered in view of the pressure for evidence-based decisions in clinical practice and the information explosion of the literature. Recently, the BDI-II has been ever-increasingly used in the medically ill to evaluate depressive states that occur at high prevalence in healthcare settings. The authors systematically reviewed the validity of the BDI-II to quantify the severity of depression among medical patients and discuss the interpretation of its metric conventions. The performance of the BDI-II (and its short version) among patients with medical illnesses who often present somatic complaints is contrasted with its performance among non-medical patients, among whom psychological symptoms are the most prominent features.

METHODS

Both investigators, with previous experience on psychometric instruments, conducted this systematic review by searching the Web of Sciences (ISI), Medline, and PsycINFO databases. The following MeSH terms were used to scan studies through the search builder of each database: “valid∗” OR “reliab∗” OR “sensitiv∗” OR “specific∗” OR “concurrent” OR “divergent” OR “convergent” OR “factor analysis”. Following the search, we filtered articles containing the term “Beck Depression Inventory” published during the time period “1/1/1996 to 10/10/2012”. There was no language or age range restriction. The initial search resulted in 822 retrieved articles, with 409 from ISI, 328 from Medline, and 85 from PsycINFO. The reference sections of the review articles of the depression instruments (33–35) and book chapters (36–38) were examined to identify potential studies. Additional efforts to locate relevant studies by hand and to contact experts in the field identified seven psychometric articles on medical samples, totaling 829 articles.

After checking for duplication and overlap, 528 articles remained in the list. Filtering non-medical articles, we eliminated 170 articles in which “student,” “psychiatric,” or “community” was mentioned in the title or abstract. The retained 358 articles were screened for eligibility by reading the abstract. Two articles were not accessible, even upon request to the author, resulting in 356 full-text articles that were assessed for eligibility.

The exclusion criteria were as follows: (1) non-psychometric studies, such as clinical trials, editorials, letters, reviews, meta-analyses, practice guideline, randomized controlled trials, and case reports; (2) non-medical samples (student, psychiatric, or non-clinical); (3) small sample size (N<30); (4) BDI-I; and (5) reanalysis or duplicated analysis of an original dataset. The sample was considered “non-clinical” when study participants consisted of workers, caregivers, and community dwellers. Regardless of the nosological controversy of chronic fatigue syndrome and chronic pain as medical illnesses, these conditions were included due to their high occurrence in healthcare settings. Samples with less than 30 participants were only retained when the study addressed a very important problem, such as between-version comparison or content analysis. A summary analysis of the complete sample was preferable when multiple analyses were available (such as separate reports by gender, ethnicity, or depressed versus non-depressed groups).

The reasons for excluding 286 articles were as following: 174 studies did not contain the original data using the BDI-II (167 non-psychometric studies and seven reviews); 95 studies utilized non-medical samples (34 student samples, 31 psychiatric samples, and 30 non-clinical samples); 13 studies provided a reanalysis or secondary data analysis; three studies used BDI-I; and one study had a small sample size. The final list resulted in 70 articles that are dedicated to investigating the psychometric performance of the BDI-II in medical patients. The flowchart in Figure 1 displays each step of the search process.

Figure 1.

Flowchart of the search to scan for studies investigating psychometric properties of the Beck Depression Inventory-II among medical patients.

(0.06MB).

Studies on medical diseases were grouped according to the sample recruitment source as outpatients or primary care (k = 52) and hospital (k = 12) (Table 1). Studies investigating the short version BDI-FS (k = 10) are displayed separately. Four studies reported data on both BDI-II and BDI-FS. Several investigations did not provide a clear description of the healthcare setting or recruited participants from different levels of health service. Likewise, the heterogeneous selection of patients might reflect different groups of participants or stages of disease course. Sixteen studies reported a sample size with less than 100 respondents, but all of the studies had more than the minimum of 30 subjects.

Table 1.

Description of psychometric studies of the Beck Depression Inventory-II in medical samples by language version, sample size (N), sample description, gender distribution (%W), mean score (SD), and reliability (Cronbach's alpha).

Authors, year  Language  Sample description  %W  Mean Score (SD)  Alpha 
Normative sample             
Beck et al., 1996 (24English  120  College students  44  12.6 (9.9)  0.93 
    500  Psychiatric outpatients  62  22.5 (12.8)  0.92 
Outpatients/Primary Care (k = 52)             
Arnarson et al., 2008 (41Icelandic  248  Adult outpatients  82  21.3 (12.2)  0.93 
Arnau et al., 2001 (42English  333  Adult - primary care  69  8.7 (9.4)  0.94 
Brown et al., 2012 (43English  111  Chronic fatigue outpatients  83  17.7 (9.1)  0.89 
Beck & Gable, 2001 (44English  150  Postpartum outpatients  100  NR  0.91 
Bunevicius et al., 2012 (45Lithuanian  522  Coronary outpatients  28  11.0 (8.2)  0.85 
Carney et al., 2009 (46English  140  Insomnia outpatients  74  14.1 (10.2)  0.91 
Carvalho Bos et al., 2009 (47Portuguese  331  Pregnancy outpatients  100  NR  0.88 
    354  Postpartum outpatients  100  NR  0.89 
Chaudron et al., 2010 (48English  198  Postpartum outpatients  100  NR  NR 
Chilcot et al., 2008 (49English  40  Renal hemodialysis outpatients  40  11.1-12.9 (9.3-9.4)  NR 
Chilcot et al., 2011 (50English  460  Renal disease outpatients  35  11.9 (8.3)  NR 
Chung et al., 2010 (51Chinese  62  Heart disease outpatients  31  18.2 (7.9)  NR 
Corbière et al., 2011 (29French  206  Chronic pain outpatients  53  17.2 (11.5)  0.84 
Dbouk et al., 2008 (52English  129  Hepatitis C outpatients  50  17.1 (11.6)  NR 
de Souza et al., 2010 (53English  50  Huntington's disease  48  8.8 (8.9) ND 26.8 (6.9) D  NR 
del Pino Pérez et al., 2012 (54Spanish  205  Coronary outpatients  26  9.2 (7.6)  NR 
Dutton et al., 2004; Grothe et al., 2005 (55,56English  220  Adult - primary care  52  12.6 (10.4)  0.90 
Findler et al., 2001 (57English  98  Traumatic brain injury (mild)  55  12.2 (9.6)  NR 
    228  Traumatic brain injury (moderate to severe)  33  9.7 (8.1)  NR 
Frasure-Smith & Lespérance, 2008 (58English/French  804  Coronary outpatients  19  NR  0.90 
Griffith et al., 2005 (59English  132  Epilepsy outpatients  72  15.9 (11.1)  NR 
Hamid et al., 2004 (60Arabic  493  Women - primary care  100  13.0 (8.1)  NR 
Harris & D'Eon, 2008 (61English  481  Chronic pain outpatients  58  26.9 (11.7)  0.92 
Hayden et al., 2012 (62English  83  Obese bariatric outpatients  71  13.4 (9.1)  0.89 
Jones et al., 2005 (63English  174  Epilepsy outpatients  66  NR  0.94 
Kanner et al., 2010 (64English  193  Epilepsy outpatients  68  10.6 (6.3)  NR 
King et al., 2012 (65English  489  Traumatic brain injury  10  19.7 (11.8)  NR 
Kiropoulos et al., 2012 (66English  152  Coronary heart disease outpatients  34  9.4 (8.9) ND 17.8 (8.7) D  NR 
Kirsch-Darrow et al., 2011 (67English  161  Parkinson outpatients  31  9.5 (7.2)  0.89 
Ko et al., 2012 (68Korean  121  Epilepsy outpatients  35  9.7 (6.3) ND 29.9 (11.7) D  NR 
Lipps et al., 2010 (69English  191  HIV infection outpatients  61  14.1 (11.0) W 10.2 (9.1) M0,89 
Lopez et al., 2012 (70English  345  Chronic pain outpatients  23.0 (12.2)  0.93 
Masuda et al., 2012 (71Japanese  327  Myasthenia gravis outpatients  67  11.3 (7.9)  NR 
Neitzer et al., 2012 (72English  150  Renal hemodialysis outpatients  48  12.3 (10.8)  NR 
Ooms et al., 2011 (73Dutch  136  Tinnitus outpatients  35  11.3 (9.5)  NR 
Osada et al., 2011 (74Japanese  56  Fibromyalgia outpatients  86  NR  NR 
Patterson et al., 2011 (75English  671  Hepatitis C outpatients  16.2 (12.2)  0.84-0.91 
Penley et al., 2003 (30English/Spanish  122  Chronic renal outpatients  41  15.0 (12.5)  0.92 
Pereira et al. 2011 (76Portuguese  503  Pregnant outpatients  100  NR  NR 
Poole et al., 2009 (77English  1227  Chronic pain outpatients  62  24.7 (11.6)  0.92 
Rampling et al., 2012 (78English  266  Epilepsy outpatients  59  NR  0.94 
Roebuck-Spencer, 2006 (79English  60  Systemic lupus erythematosus outpatients  80  NR  NR 
Su et al., 2007 (80Chinese  185  Pregnant outpatients  100  7.0 (5.0) ND 17.0 (10.2) D  NR 
Suzuki et al., 2011 (81Japanese  287  Myasthenia gravis outpatients  67  11.1 (8.1)  NR 
Tandon et al., 2012 (82English  95  Perinatal women  100  NR  0.9 
Teng et al., 2005 (83Chinese  203  Postpartum outpatients  100  7.8 (6.3) ND 25.8 (10.4) D  NR 
Turner et al., 2012 (84English  72  Stroke outpatients  47  13.4 (12.9)  0.94 
Turner-Stokes et al., 2005 (85English  114  Brain injury outpatients  43  Median 10 (IQR 5-19)  NR 
Viljoen et al., 2003 (86English  127  Adult - primary care  63  NR  NR 
Wan Mahmud et al., 2004 (87Malay  61  Postpartum I outpatients  100  4.4 (5.5)  0.89 
    354  Postpartum II outpatients  100  6.2 (6.4)   
Warmenhoven et al., 2012 (88Dutch  46  Cancer outpatients  43  14.7 (9.9)  NR 
Williams et al., 2012 (89English  229  Parkinson disease outpatients  33  6.5 (5.2) ND 14.7 (7.4) D  0.90 
Young et al., 2007 (90English  194  Cardiac outpatients  35  8.6-13.4 (7.7-12.3)  NR 
Zahodne et al., 2009 (91English  71  Parkinson disease outpatients  32  11.7 (7.9)  NR 
Hospitalized (k = 12)             
Di Benedetto et al., 2006 (92English  81  Acute cardiac syndrome  19  NR  > 0.90 
Gorenstein et al., 2011 (93Portuguese  334  Adult - hospitalized  48  12.2 (11.6)  0.91 
      170 physically disabled 164 intellectually disabled    14.5 (11.2) 9.7 (11.4)   
Homaifar et al., 2009 (94English  52  Traumatic brain injury 10  25 (14.6)  NR 
Huffman et al., 2010 (95English  131  Myocardial infarction  20  9.8 (9.4)  NR 
Jamroz-Wisniewska et al., 2007 (96Polish  104  Multiple sclerosis  74  14.4 (9.2)  NR 
Low & Hubley, 2007 (97English  119  Coronary disease  25  8.0 (7.1)  0.89 
Pietsch et al., 2012 (40German  314  Adolescents patients) (252 hospital inpatients)  60  7.5 (6.5) ND 25.8 (10.1) D  0.91 
Rowland et al., 2005 (98English  51  Traumatic brain injury  28  5.6 ND 20.1 D  NR 
Siegert et al., 2009 (99English  353  Neurological diseases  40  13.6 (10.1)  0.89 
Thomas et al., 2008 (100English  50  Stroke  38  12.7 (8.9)  NR 
Thombs et al., 2008 (101English/French  477  Acute myocardial infarction  17  9.2 (7.9)  NR 
Tully et al., 2011 (102English  226  Cardiac heart disease  17  8.6 (6.2) a 9.1 (6.4) b  0.850.87 
BDI Fast Screen version (k = 10)             
Beck et al., 1997 (26English  50  Medical inpatients  60  5.8 (4.5)  0.86 
Brown et al., 2012 (43)English  111  Chronic fatigue outpatients  83  4.3 (3.2)  NR 
Neitzer et al., 2012 (72)English  146  Renal hemodialysis outpatients  48  2.7 (3.4)  NR 
Pietsch et al., 2012 (40)German  314  Adolescents) (252 hospital inpatients)  60  1.9 (2.4) ND 8.1 (3.5) D  0.82 
Poole et al., 2009 (103)English  1227  Chronic pain outpatients  62  7.1 (4.30)  0.84 
Scheinthal et al., 2001 (104English  75  Geriatric outpatients  56  2.3 (3.1)  0.83 
Servaes et al., 2000 (105Dutch  85 16  Disease-free cancer outpatients Chronic fatigue outpatients  43.5 50  0.4-2.3 (0.9-1.8) 2.6 (1.8)  NR 
Servaes et al., 2002 (106Dutch  57 57  Disease-free breast cancer outpatients Chronic fatigue outpatients  100 100  2.3-4.2 (2.2-3.9) 3.3 (2.6)  NR 
Steer et al., 1999 (107English  120  Medical outpatients  50  2.2 (3.0)  0.85 
Winter et al., 1999 (39English  100  Adolescent outpatients  50  1.9 (3.1)  0.88 

N: sample size;%W: percentage of women; SD: standard deviation; Alpha: Cronbach's alpha coefficient of internal consistency;

NR: not reported.

IQR: interquartile range.

M

: men, W: women; ND: non-depressed; D: depressed; a: pre-surgery; b: post-surgery.

Mixed sample of in- and outpatients.

Separate analysis of the short version of the BDI-II in the same study.

Among the 70 retained studies, the BDI-II was administered to adults in primary care (k = 4) and clinics of cardiology (k = 12), neurology (k = 12), obstetrics (k = 8), brain injury (k = 6), nephrology (k = 5), chronic pain (k = 4), chronic fatigue (k = 4), oncology (k = 3), and infectious disease (k = 3). Only two studies assessed adolescent medical patients (39,40).

Almost all of the identified studies were published after 2000, and the great majority (approximately 64%) of studies was published in the past five years, suggesting a recent trend for using the BDI-II in medical settings. Nearly 70% of the articles applied the English version of BDI-II, but 13 non-English versions of the scale were found.

Overview

The BDI-II performed well in adult patients with a wide array of medical diseases (Table 1). For the purpose of comparison, data from Beck's studies on non-medical and medical samples (24,26) are listed as normative references. Usually, non-patient samples reported the item scores in the lower part of the range of possible scores (from 0 to 3), with a skewed distribution of item scores. Based on scores of 500 psychiatric outpatients, Beck et al. (24) suggested the following ranges of BDI-II cut-off scores for depression: 0–13 (minimal), 14–19 (mild), 20–28 (moderate), and 29–63 (severe). As an example, the mean score of the BDI-II in samples with mood disorder was M = 26.6, and the mean scores for major depressive episode, recurrent depression, and dysthymia were 28.1, 29.4, and 24.0, respectively.

Confirming the expectation that medical patients would report more somatic symptoms, most of the investigations reported a slightly higher mean total score for medical patients than non-patients (Table 1), but scores were still around or below the threshold of 13/14 that is recommended by Beck to detect mild depression. Exceptions of this observation were studies on chronic pain (29,61,70,77), with mean total scores ranging from 17.2 to 26.9. The type of respondents might influence item endorsement and the scale total score.

In comparison with the previous version, the item characteristics of the BDI-II have been changed in terms of endorsement rate, homogeneity, and content coverage (34). The homogeneity of the scale was described for 17 of 21 items in the original study (24), showing acceptable item-total correlations of rit ≥0.5 (108). Different item endorsements and coverage are reported for different versions of the instrument: substantial item-total correlation was described for 15 items in the Brazilian-Portuguese version (93) and 10 items in the Arabic version (32). Direct comparison of the scores between different language versions should be avoided.

In contrast with patient samples, somatic items, such as “change in sleeping pattern” and “change in appetite,” presented low scores for non-clinical samples. However, “tiredness or fatigue,” might present special clinical significance in patients with chronic fatigue syndrome (43) or cardiac coronary disease (45,51). Regardless of the severity of depression, the item “loss of sexual interest” displayed the worst item-total correlation, although it was significantly related to the whole construct under consideration (23,24). Thombs et al. (101) suggested that the assessment of symptom severity with BDI–II would be substantially biased in medically ill patients compared with non-medically ill patients due to the misattribution of somatic symptoms from medical conditions to depression. The authors found that post-acute myocardial infarction patients did not have higher somatic symptom scores than psychiatry outpatients who were matched on cognitive/affective scores. Compared with undergraduate students, somatic symptom scores in cardiac patients were only approximately one point higher, indicating that somatic symptom variance is not necessarily related to depression in medically ill and non-medically ill respondents.

The item “suicidal thoughts” was the least reported item among non-medical settings; however, a substantial correlation still demonstrates its contribution to depression (23,24). Investigations on the ability of separate items, e.g., “pessimism” and “loss of energy,” to predict disease outcome or treatment response can help clinicians in the management of depression. The contribution of self-rated somatic vs. cognitive symptoms in medical samples should be clarified by item analysis to identify whether items are appropriately assigned to a scale.

BDI-Fast Screen

Experts view somatic symptoms among medical patient as the harbinger of depression and anxiety in the healthcare setting (3,109–111). Preferably, the assessment of depression in patients with medical illness should avoid confounding physical symptoms. The correct identification of comorbid depressive disorders in medical patients is crucial in understanding its origin and in controlling the physical symptom burden.

Two measures were designed with the objective of eliminating somatic items. The first proposed measure is the Hospital Anxiety Depression Scale (HADS) (112), which has a seven-item depression subscale. Despite the lack of comprehensive data on its psychometric properties (113) and challenges to its factorial validity (114), the HADS remained widely used as a research measure of depression in the medically ill.

The seven-item BDI for Primary Care (BDI-PC) (26) was developed in 1997 after removing somatic items, such as fatigue and sleep problems, from the BDI. This version was projected for evaluating depression in patients whose behavioral and somatic symptoms are attributable to biological, medical, alcohol, and/or substance abuse problems that may confound the diagnosis of depression. The BDI-PC was later renamed the BDI ® Fast Screen for Medical Patients (BDI-FS), and it consists of items 1 to 4 and 7 to 9 of the BDI-II (27).

The BDI-FS requires less than five minutes for completion, and scoring is similar to the BDI-II. For interpretation, the manual suggests that scores 0–3 indicate minimal depression; 4–6 indicate mild depression; 7–9 indicate moderate depression; and 10–21 indicate severe depression (27). Validation studies (k = 10) have demonstrated the ability of this non-somatic scale to discriminate depressed vs. non-depressed medical patients (39,26,104,107), chronic pain patients (103), and conditions where fatigue is a prominent feature (43,105,106). Less popular than its full version, more investigations are needed to establish the utility of this short version in medical settings before recommending its extensive use.

Reliability

Thirty-seven of 70 retrieved psychometric articles (52.9%) did not report reliability coefficients for the data. In comparison to the internal consistency of previous versions of the BDI (average Cronbach's alpha coefficient of approximately 0.85) (23), the reliability of the BDI-II among medical samples was satisfactory, with an alpha of approximately 0.9, ranging between 0.84 and 0.94 (Table 1). In addition, Beck (26) reported a coefficient of 0.86 for the BDI-FS, and further studies reported the coefficient ranging from 0.82-0.88 (39,40).

No information on the retest reliability is available for medical samples. However, the stability of the BDI-II, as expressed by retest coefficients of Pearson's r of 0.92 and 0.93, was reported by Beck and colleagues (24) for psychiatric and student samples, respectively. Further evidence of acceptable stability through re-application of the BDI-II was demonstrated for student samples (range: 0.73-0.96) (115,116).

The retest effect – that is, lower scores on the second application, even without intervention – may affect the reliability of BDI-II in healthcare settings. This effect could be unrelated to a true change in severity and could be purely the result of the measurement process. Although this fact would not preclude using this scale in follow-up or interventional studies among medical patients, nothing should be stated concerning the scale performance in this respect. Therefore, clinicians should be careful when making important treatment decisions based on non-empirical information assumed from non-clinical samples.

Item Response Theory

Most validation studies of BDI-II were analyzed in accordance with classic test theory, assuming a true score for each respondent's summed score and disregarding the measurement error. In other words, two individuals with the same total score may differ greatly in terms of relative severity and frequency of symptoms. This discrepancy might be particularly taxing in medical settings, where physical symptoms are common complaints and overlap with “true” depression-related somatic symptoms.

In the last decades, the item response theory (IRT) is an increasingly used method in psychometrics, in addition to the dominant classic test theory of true score paradigm. Briefly, the IRT distinguishes between moderate and severe cases of depression using item-level analysis to account for measurement error (117). The response of a respondent for a given ability should be modeled to each item in the test. For example, when a given depression scale is composed only of items that measure mild depression, this instrument would have great difficulty identifying severe depression because both levels of severity should be characterized by high scores on all items. In addition, if items assessing psychological and physical symptoms were only loosely related, a single score would not distinguish between two potentially different groups of depressed patients - with primarily psychological or with primarily vegetative symptoms. This scenario is particularly pressing in medical settings that are investigating clinical changes in depressive syndrome.

Seigert and colleagues (99) reported an illuminating study after examining each BDI-II item for differential item functioning in a neurological sample (n = 315). The authors identified misfits to model expectations for three items that seemed to measure different dimensions: changes in sleeping pattern, changes in appetite, and loss of interest in sex. These vegetative items were removed and re-scored in an iterative fashion to the scale. In the real world, the likelihood of receiving a rating of 1 on the insomnia item was essentially the same, regardless of the overall severity of depression, but the likelihood of receiving a rating of 3 on sad mood could be low, even when overall depression was severe.

Waller and colleagues (118) investigated the latent structure of the BDI-II through differential item functioning and item level factor analysis in samples of women with breast cancer and women with clinical depression. Items of negative cognitions about the self, e.g., worthlessness, self-dislike, and punishment feelings, were less likely to be reported by breast cancer patients than depressed patients. Negative cognitions about the self appear to be related to different factors in breast cancer. The analyses also found many differences at both the item and factor scale levels, suggesting caution when interpreting the BDI-II in breast cancer patients.

These studies advocate that the rating scheme is not ideal for many BDI-II items, thus affecting the scale's capacity to detect change in medical conditions. Systematic IRT analysis of the BDI-II items can strengthen the scale coverage in assessing heterogeneous depressive conditions among medical patients.

Convergent and Divergent Validity

Table 2 displays the studies that compared the BDI-II with scales measuring depression, anxiety, and miscellaneous constructs as criteria that were determined at essentially the same time to check for concurrent validity. The convergent validity between the BDI-II and the BDI-I was 0.93 (28). The shorter version, BDI-FS, also presented an acceptable correlation of 0.85 (72). In general, the overlap of the construct measured by BDI-II with other widely used scales to assess depression, e.g., the Center for Epidemiologic Studies of Depression, the Hamilton Depression Rating Scale, Edinburg Postnatal Depression Scale, and the Hospital Anxiety and Depression Scale-Depression, was adequate and ranged from 0.62 to 0.81 (Table 2).

Table 2.

Concurrent validity of the Beck Depression Inventory-II with measures of depression, anxiety, and other miscellaneous constructs in medical samples.)

Concurrent instrument    Study 
Depression measure   
BDI-I  Beck Depression Inventory – I  0.93  28 
BDI-FS  Beck Depression Inventory – Fast Screen  0.85  72 
HADS-D  Hospital Anxiety and Depression Scale-Depression  0.62 - 0.71  26), 41 
CES-D  Centre for Epidemiologic Studies of Depression  0.72 - 0.87  29, 41, 52, 63, 69 
HRSD  Hamilton Rating Scale for Depression - revised  0.71 - 0.75  24, 87 
EPDS  Edinburgh Postnatal Depression Scale  0.72 - 0.82  44, 83, 87 
GDS  Geriatric Depression Scale  0.81  104
PHQ  PRIME-MD Patient Health Questionnaire  0.84  52 
CDS  Cardiac Depression Scale  0.65; 0.69  66, 92 
POMS-D  Profile of Mood States Depression Scale  0.77  59 
PDSS  Postpartum Depression Screening Scale  0.68; 0.81  44, 76 
DISC  Depression Intensity Scale Circles  0.66  85 
NGRS  Numbered Graphic Rating Scale  0.65  85 
Anxiety measure
BAI  Beck Anxiety Inventory  0.60  24, 41 
HARS  Hamilton Anxiety Rating Scale - revised  0.47  24 
STAI  State-Trait Anxiety Inventory  0.64; 0.83  66, 92 
PSWQ  Penn State Worry Questionnaire  0.61  41 
HADS-A  Hospital Anxiety and Depression Scale-Anxiety  0.65  41 
Miscellaneous       
SSI  Scale for Suicide Ideation  0.37  24 
BHS  Beck Hopelessness Scale  0.68  24 
MPQ-PRI  McGill Pain Questionnaire (Pain Rating Index)  0.32  61 
SF-36 MH  Short Form 36-Item Health Survey – Mental Health  0.45 - 0.70  43), 57 
SF-36 PH  Short Form 36-Item Health Survey – Physical Health  0.12 - 0.29  43), 57 
SPS  Social Provisions Scale  0.39 - 0.42  69 
CIS-F  Checklist Individual Strength - Fatigue  0.58  105 
NDDI-E  Neurologic Disorders Depressive Inventory in Epilepsy  0.81 - 0.85  64, 68 
NSI  Neurobehavioral Symptom Inventory  0.77  65 
MG-QOL  Myasthenia Gravis Quality of Life Scale  0.52  71 
JFIQ  Fibromyalgia Impact Questionnaire  0.58  74 
ANAM  Automated Neuropsychological Assessment Metrics-Mood  0.67  79 
SCQR  Stroke Cognitions Questionnaire Revised  0.54 - 0.80  100 
STOP-D  Screening Tool for Psychological Distress  0.83  90 
LARS  Lille Apathy Rating Scale  0.45  91 
AS  Apathy Scale  0.58  91 
UPDRS-III  Unified Parkinson's Disease Rating Scale  0.38  91 

r: Pearson's product moment correlation. Negative correlation is omitted in the numerical value.

The concurrent validity refers to the BDI-FS version.

A complete list of retrieved studies can be obtained from the authors upon request.

Additionally, the convergent validity between the BDI-II and scales that assess anxiety was significant and differed across comparison instruments: Beck Anxiety Inventory (0.60) (24,41), Hamilton's Anxiety Rating Scale (0.47) (24), State-Trait Anxiety Inventory (0.83) (92), Penn State Worry Questionnaire (0.61) (41), and Hospital Anxiety and Depression Scale-Anxiety (0.65) (41). These results were expected due to the extent that anxiety symptoms were highly comorbid with depressive symptoms or that they could be attributed to the characteristics of the compared instruments. As a broad indicator of mental health, a high score on the BDI scale could also be explained by other disorders, physical illnesses, or social problems (69). Most likely, the construct covered by the BDI-II is beyond the “pure” depressive-type of psychopathology. As such, the convergent validity of the scale with hopelessness (24) and fatigue (105) was also substantial. In the medical setting, the clinician should not assume depression as a primary issue when BDI-II is used without a thorough clinical assessment.

Concerning divergent validity, studies have indicated poor correlation (r<0.4) with instruments assessing chronic pain (61), physical health (43), and substance use disorders (119). Suicidal ideation, which is one of core features of depression and an item on the BDI-II, was only poorly correlated with the instrument (24).

Criterion-oriented Validity

Psychometric experts view the interpretation of the raw scores on tests, such as the BDI-II, as problematic, unless they are converted into standardized scores (e.g., T score or stanine method) (108,120). No known standardized norms have been reported for the BDI-II to date. As an alternative to the norm-referenced method, the criterion-referenced method is the most widespread practice for interpreting BDI-II scores. Usually, the total score is compared with a cut-off score established according to a gold-standard criterion (e.g., clinical assessment or structured interview).

When clinicians intend to screen probable cases of major depression in medical settings, the sensitivity should be viewed as the most important indicator to minimize the chance of false-negative cases (Table 3). Sometimes, the BDI-II can overestimate the prevalence of depression in particular conditions, e.g., medically ill patients would record more items that address physical complaints. According to the samples, medical studies have reported good performance with high sensitivity (from 72% to 100%). Occasionally, the researcher might want to improve the specificity to select a pure sample of depressed patients. For research purposes, Beck et al. (24) recommended raising the cut-off score to 17 to obtain homogeneous samples of depressed individuals.

Table 3.

Criterion validity and cut-off point of the Beck Depression Inventory-II for detecting major depressive episode in medical samples.

Authors  Sample  Cut-off  Sensitivity  Specificity  PPV  NPV  AUC  % MDD  Criterion 
Outpatients                   
Arnarson et al. (41Adult outpatients  20  82  75  NR  NR  87  42.1  MINI 
Arnau et al. (42Adult - primary care  18  94  92  54  99  96  23.2  PHQ 
Beck & Gable 2001 (44Postpartum outpatients  20  56  100  100  93  95  12  SCID-I 
Bunevicius et al. (45Coronary outpatients  14  89  74  29  98  90  11  MINI 
Carney et al. (46Insomnia outpatients  17  81  79  NR  NR  83.8  NR  SCID-I 
Chaudron et al. (48Postpartum outpatients  20  45.3  91.1  NR  NR  90  37  SCID-I 
Chilcot et al. (49Renal hemodialysis  16  89  87  89  87  96  22.5  MINI 
de Souza et al. (53Huntington's disease  11  100  66  48  100  85  50  SCAN 
Dutton et al. (55Adult - primary care  14  87.7  83.9  69.5  94.2  91  29.5  PRIME-MD 
Frasure-Smith & Lespérance (58Coronary outpatients  14  91.2  77.5  NR  NR  92  13.7  SCID-I 
Jones et al. (63Epilepsy outpatients  11  96  80  48  99  94  17.2  MINI 
    15  84  87  55  97  92    SCID-I 
    11  95.7  78.3  42  99  94    MINI + SCID 
Hayden et al. (62Obese bariatric outpatients  13  100  63.9  29.7  100  84.7  13.3  SCID-I 
Pereira et al. (76Pregnant outpatients  16  83.3  93.1  14.3  99.7  95  1.3  DIGS 
Rampling et al. (78Epilepsy outpatients  14  93.6  74  44  98  90  17.7  MDI (ICD-10) 
    15  93.8  78.9  49.5  98  93  18  MDI (DSM-IV) 
Su et al. (80Pregnant outpatients  12  72.7-75.0  82.7-82.9  NR  NR  81.9-86.6  12.4  MINI 
Tandon et al. (82Perinatal women  12  84.4  81.0  NR  NR  91  33.7  SCID-I 
Teng et al. (83Postpartum outpatients  14  92  83  42  99  NR  11.8  MINI 
    12  96  79           
Turner et al. (84Stroke outpatients  11  92  71  NR  NR  89  18  SCID-I 
Turner-Stokes et al. (85Brain injury outpatients  14  74  80  69  84  NR  39.8  DSM-IV 
Wan Mahmud et al. (87Postpartum outpatients  100  98  87.5  100  99.5  48  CIS 
Warmenhoven et al. (88Cancer outpatients  16  90  69  NR  NR  82  22  PRIME-MD 
Williams et al. (89Parkinson outpatients  95  60  62  94  85  34.1  SCID-I 
Hospital sample                   
Homaifar et al. (94Traumatic brain injury  19  87  79  NR  NR  NR  44.2  SCID-I 
Huffman et al. (95Myocardial infarction  16  88.2  92.1  62.5  98.1  96  13  SCID-I 
Low & Hubley (97Coronary disease  10  100  75  21  100  92  11.8  SCID-I 
Pietsch et al. (40Adolescents  19  86  93  47  99  93  6.7  Kinder-DIPS 
BDI-FS                   
Beck et al. (26Medical inpatients  82  82  NR  NR  92  66  PRIME-MD 
Neitzer et al. (72Renal hemodialysis  97.2  91.8  81.4  98.9  98  28.7  BDI-II ≥ 16 
Pietsch et al. (40Adolescents  81  90  37  99  92  6.7  Kinder-DIPS 
Poole et al. (103Chronic pain outpatients  81  92  NR  NR  94  59.4  BDI-II ≥ 19 
    75  93  NR  NR  94  47.8  BDI-II ≥ 22 
Scheinthal et al. (104Geriatric outpatients  100  84  NR  NR  93  11  Clinical assessment 
Steer et al. (107Medical outpatients  97  99  NR  NR  99  24.2  PRIME-MD 
Winters et al. (39Adolescent outpatients  91  91  NR  NR  98  11  PRIME-MD 

PPV: positive predictive value; NPV: negative predictive value; AUC: area under the curve;%MDD: proportion of major depression disorder; NR: not reported.

PHQ: PRIME-MD Patient Health Questionnaire; MINI: Mini International Neuropsychiatric Interview; PRIME-MD: Primary Care Evaluation of Mental Disorders; CIS: Clinical Interview Schedule; SCID-I: Structured Clinical Interview for DSM-IV Axis I Diagnosis; MDI: Major Depression Inventory; Kinder-DIPS: Diagnostisches Interview bei psychischen Störungen im Kindes und Jugendalter; DIGS: Diagnostic Interview for Genetic Studies; SCAN: Schedules for Clinical Assessment in Neuropsychiatry.

According to Table 3, the best cut-off to indicate cases of depressive syndrome in medical samples was established on the ground of the unique characteristics of the sample. The possible threshold ranged widely, from 7 to 22 (89,103). For example, Poole et al. (103) found that raising the BDI-II cut-off score to 22 could reduce the number of false-positives produced by the uneven item response of chronic pain patients. Consequently, the researcher can change the flexibility of the cut-off score by comparing different thresholds for a new sample or study purpose.

A significant diagnostic accuracy of 82% and higher, as expressed by the area under the receiver operating characteristics (ROC) curve, was calculated according to the tradeoff between sensitivity and specificity. However, the ability of a scale to differentiate between depressive vs. non-depressive groups depends not only on the sensitivity and specificity of its cut-off scores but also on the frequency of the disorder in the samples that are being studied. In addition, sources of threshold variation may depend on the type of the sample (outpatient or hospitalized), medical disease, and external gold-standard criterion for depression. Most investigators were unanimous in recommending the BDI-II as a screening tool in the first phase of two-stage studies to prevent excessive cases of false positives if the scale is used as a single tool (121). Caution is warranted when using the cut-off guidelines presented for criterion-referenced interpretation and when the BDI-II is misused as a diagnostic instrument.

The BDI-FS was projected to reduce the number of false-positives for depression in patients with medical problems. Similar to its full version, the BDI-FS has shown excellent performance to detect probable cases of depression with a cut-off of 4, as expressed by a large area under the ROC curve (Table 3). To reduce the number of false-positives in chronic pain patients, Poole et al. (103) suggested raising the cut-off value to 5. To detect depression in German adolescent medical patients, Pietsch et al. (40) recommended a threshold of 6. In comparison to the 21-item version, this non-somatic version of BDI has been less extensively investigated, which prevents a more conclusive recommendation for systematic use in medical conditions.

Using rating scales to identify patients for detailed assessment has been advocated to improve the search for depression through screening programs, but the detection rates, treatments, and outcomes are controversial. There is no agreement on the score interpretation of rating scales as screening tools, e.g., the Hamilton Rating Scale for Depression is viewed as a non-trustworthy judgment of the severity of a patient's depression (122,123). In addition, the four-option formulation of the BDI items is viewed as being more complicated than the yes-no alternative of a screening questionnaire, such as the Geriatric Depression Scale (15). Although existing literature supports the use of the BDI-II as a screening measure of depression, in-depth analysis of moderator factors that influence the performance of this scale should be conducted.

Content and Construct Validity

The acceptance of the content as a qualitative representation of the measured trait is critical for the content validity of a given scale (124). The BDI-I reflected six of the nine criteria for DSM-based depression (21,125), while the BDI-II encompassed all DSM-based depressive symptoms. As a consequence, the tests' ability to detect a broader concept of depression has been changed (28,126). The content covered by the BDI-II seems adequate but narrower than its former version (34).

Construct validation interprets a test measure through a specific attribute or quality that is not “operationally defined,” demonstrated as a latent structure or construct (127). Exploratory and confirmatory factor analyses determine which psychological events make up a test construct by reducing the item number to explain the structure of data covariance. This family of multivariate techniques demonstrates the dimensionality of a given scale and the pattern of item clustering on one, or more than one, factor (128). A robust measurement instrument for depression should establish the dimensions being measured and the types, categories, and behaviors that constitute an adequate representation of depression.

Table 4 lists 20 investigations that reported the factor structure of the BDI-II, which was used in 43% of the retained studies. These articles were grouped according to the healthcare setting and the factor extraction framework. Researchers have adopted both exploratory and confirmatory strategies with different purposes, e.g., to identify problems with items that have non-significant factor loadings or data cross-validation. The use of the state-of-art confirmatory approach is a trend in studies investigating the latent structure of BDI-II.

Table 4.

Construct validity of the latent structure of the Beck Depression Inventory-II in medical samples.

Study  Sample  Method  Factor 1  Factor 2  Factor 3  Factor 4 
Normative study             
Beck et al. (24College students  EFA  Cognitive-affective  Somatic-vegetative     
  Psychiatric outpatients  EFA  Cognitive-affective  Somatic-vegetative     
Outpatient/Primary Care             
Arnau et al. (42Adult - primary care  PCA  Somatic-affective  Cognitive  (Depression)   
Brown et al. (43Chronic fatigue outpatients  EFA  Cognitive  Somatic-affective     
Carvalho Bos et al. (47Pregnancy outpatients  PCA  Cognitive-affective  Anxiety  Fatigue   
  Postpartum outpatients  PCA  Cognitive-affective  Somatic-anxiety  Guilt   
Chilcot et al. (50Renal disease outpatients  EFA  Cognitive  Somatic     
    CFA  Cognitive  Somatic  General depression (G)   
Corbière et al. (29Chronic pain outpatients  CFA  Cognitive  Affective  Somatic   
del Pino Pérez et al. (54Coronary outpatients  EFA  Somatic-affective  Cognitive     
    CFA  Somatic-affective  Cognitive  (Depression)   
Grothe et al. (56Adult - primary care  CFA  Cognitive  Somatic  (Depression)   
Harris & D'Eon (61Chronic pain outpatients  CFA  Negative attitude  Performance difficulty  Somatic  (Depression) 
Kirsch-Darrow et al. (67Parkinson outpatients  CFA  Dysphoric mood  Loss of interest/pleasure  Somatic   
Lipps et al. (69HIV infection outpatients  C-PCA  Cognitive  Affective  Somatic   
Lopez et al. (70Chronic pain outpatients  EFA  Negative rumination  Somatic Complaint  Mood   
Patterson et al. (75Hepatitis C outpatients  EFA  Cognitive-affective  Somatic     
    CFA  Cognitive-affective  Somatic     
Penley et al. (30Chronic renal outpatients  CFA  Cognitive  Somatic-affective     
Poole et al. (77)Chronic pain outpatients  EFA  Negative thoughts  Behavior and activities     
    CFA  Negative thoughts  Behavior and activities     
Viljoen et al. (86Adult - primary care  EFA  Somatic-affective  Cognitive  (Depression)   
Wan Mahmud et al. (87Postpartum outpatients  PCA  Affective  Somatic  Cognitive   
Hospital sample             
Gorestein et al. (93Adult - hospitalized  EFA  Cognitive-affective  Somatic     
Rowland et al. (98Traumatic brain injury  PCA  Negative self-evaluation  Symptoms of depression  Vegetative symptoms   
Siegert et al. (99Neurological disease  PCA  Cognitive-affective  Somatic     
    CFA  Cognitive-affective  Somatic     
Thombs et al. (101Acute myocardial infarction  CFA  Cognitive  Somatic  General depression (G)   
Tully et al. (102Cardiac heart disease  CFA  Cognitive  Affective  Somatic   

EFA: exploratory factor analysis; PCA: principal component analysis;

C-PCA: confirmatory principal component analysis; CFA: confirmatory factor analysis.

(G) General factor of depression for the bifactor model.

(Depression) Higher order depression dimension for the hierarchical model.

Only 18 items were used in the factorial model.

Using an exploratory strategy, Beck and colleagues reported a two-factor oblique structure for student and psychiatric samples (24), the cognitive-affective and somatic-vegetative dimensions. Although this bidimensional structure could be replicated among medical patients (30,42,43,50,54,56,75,77,86), several investigators reported different solutions (29,47,61,67,69,70,87). Somatic symptoms of depression have clustered as a dominant dimension, e.g., in primary care (42,86) and in coronary patients (54), or as an independent third dimension (29,61,67,69).

These alternative solutions could not be replicated by confirmatory strategy, but the somatic factor was observed as an ever-present factor among medical patients (Table 4). Summarizing the factor structure of the existing BDI investigations through meta-analysis (35), much of the data variability can be explained by the common dimension of “severity of depression” and by the other part, “somatic symptoms.” Due to the misattribution of somatic symptoms from medical conditions to depression, the assessment of depressive symptom severity with the BDI-II can be substantially biased in medically ill patients compared with non-medically ill patients. Among factor analytical investigations, the somatic dimension has emerged as being highly correlated with the cognitive dimension (>0.50, range 0.49-0.87).

The heterogeneous characteristics of depressive conditions could partially explain these proposed factor structures in medical patients. The alternative structural analysis of the BDI-II was strengthened by two model breakthroughs: the hierarchical model and the bifactor model. The hierarchical structure of higher-order depression to explain the variance of the lower-order cognitive and somatic dimensions was tested in several medical samples (42,54,56,61). Although scant, the bifactor model identified a scale solution with a general depression, in addition to the traditional bidimensional structure (50,101). The data variance of the BDI-II supported a higher order, or a parallel construct, of “general depression” and suggested caution when interpreting subscale scores.

DISCUSSION

The present systematic review is intended to aid practicing professionals and clinical researchers in several specialties in assessing depression in their patients and in interpreting the score through the BDI-II. Ideally, deciding which depression scale is optimal for use in medical settings should meet some desirable features from the patient's and the clinician's perspectives. Patients should find the measure user-friendly and the instructions easy to follow. The questions should be understandable and applicable to the patient's problem. The scale should be brief to allow routine administration at intake and follow-up visits. From the clinician's perspective, the instrument should provide clinically convenient information to increase the efficiency of medical evaluation. Clinicians should find the instrument user-friendly and easy to administer and score with minimal training. To be trustworthy, the information provided by any measure for depression should rely on sound psychometric characteristics and demonstrate good reliability, validity, and sensitivity to change.

The BDI-II is a brief scale that is acceptable to patients and clinicians, covers all DSM-IV diagnostic criteria for major depressive disorder, and stands as a reliable indicator of symptom severity and suicidal thoughts. Its validity and case-finding capability as a screening instrument is well established. Conversely, its use as an indicator of sensitivity to change, medical patient's remission status, psychosocial functioning, and quality of life deserve further investigation. The BDI-II is copyrighted and must be purchased from the publisher, which obstructs its wider use. Because direct comparisons demonstrating that the BDI-II is more reliable or valid than other depression scales are lacking, it is unwise to justify the cost of its systematic adoption.

Systematic reviews are susceptible to publication bias, that is the likelihood of over-representation of positive studies in contrast with non-significant results that frequently remain unpublished. In psychometric analyses due to its descriptive nature this kind of bias is minimized. Despite its reasonable psychometric characteristics, the BDI-II has some limitations. The spectrum bias refers to the differential performance of a test between different settings, thus affecting the generalizability of the results. For example, the somatic factor is a primary dimension among medical patients (42,54,86) instead of depressive cognition in non-clinical individuals. In addition, the work-up or verification bias occurs when respondents with positive (or negative) diagnostic procedure results are preferentially referred to receive verification by the gold-standard procedure, allowing considerable distortion in the accuracy of a given test. For example, medical patients with multiple somatic complaints might be routinely referred to psychiatric assessment and, thus, would be more likely labeled as depressed. To the extent that these types of bias may occur, the cut-off scores need to be checked psychometrically to convey the sample characteristics. Techniques assessing the item-level (e.g., item-total correlation and IRT analysis) and the scale-level (e.g., signal detection analysis and factor analysis) can improve the feasibility and strengthen the validity of using this scale to detect depressive symptoms in medical settings.

In the healthcare context, the perceived burden of scale completion by the clinician is the major obstacle to using standardized scales, such as the Hamilton Depression Rating Scale, which is unlikely to meet with success. As a self-report questionnaire to measure depression, the BDI-II holds the advantages of releasing the overburdened clinician from the paperwork of scale administration and of improving the efficiency of the clinical encounter by providing mental status assessment that correlates well with clinician-rated tools.

The stated purpose of the BDI-II is not to diagnose major depressive episode; thus, the investigators must grasp its appropriateness for detecting depressive symptoms and monitoring treatment efficacy and its comparability with observer-rated scales, such as the Hamilton Depression Rating Scale of Depression or the Montgomery-Åsberg Depression Rating Scale. Short scales that are less reliant on physical symptoms, such as the BDI-FS, should receive more investigation to demonstrate their usefulness in screening for depression in medically ill patients.

Finally, the BDI-II suffers from the intrinsic limitations of self-report questionnaires. Some individuals cannot complete the scale due to illiteracy, physical debility, or compromised cognitive functioning. The widespread use of the BDI-II among the elderly is not suggested. Reporting bias that minimizes or over-reports symptom severity is a possible hazard that reduces its validity in several patients.

As a tradeoff between the psychometric robustness and enumerated disadvantages of the BDI-II, this self-report scale can be viewed as a cost-effective option because it is inexpensive in terms of professional time needed for administration and because it correlates well with clinician's ratings. Therefore, the BDI-II stands as a valid DSM-based tool with broad applicability in routine screening for depression in specialized medical clinics.

AUTHOR CONTRIBUTIONS

Both authors performed the review, collected data, interpreted the results, and have written and approved the final version of the manuscript.

ACKNOWLEDGMENTS

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) sponsored this article, and Dr. Yuan-Pang Wang is the recipient of the Grant (Process# 2008/11415-9). Conselho Nacional de Pesquisa (CNPq) sponsors Prof. Clarice Gorenstein.

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No potential conflict of interest was reported.

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