The difficulty in diagnosing depression and related disorders calls for the development of comprehensive testing frameworks. The need for effective and efficient testing tools is corroborated by the increase in the rates of depression, making it a public health concern. According to Lépine and Briley (2011), epidemiological data showed that general population has a prevalence rate of between 10% and 15%. The mortality and morbidity associated with depression are of immense concern. Empirical evidence shows that depressed individuals are 20 times more likely to commit suicide than the general population. Depression is also a risk factor for some non-communicable disorders including cardiovascular diseases. The effects of depression on the quality of life affect all spheres and are a burden to the healthcare and economic sectors (Lépine & Briley, 2011). Therefore, early diagnosis is recommended for the prevention of progression to a chronic state. Initially, mental health professionals viewed depression from a psychodynamic perspective. The development of Beck Depression Inventory (BDI) was instrumental in the paradigm shift towards the perception of depression as being rooted in the patient’s thoughts. The BDI was developed in 1961 and refers to “a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression” (Beck, Ward, Mendelson, et al. , 1961). The BDI framework operates on the construct of depressive symptoms, which makes it understanding important in diagnosing depressive disorders.
Administration of BDI
The current in use version of BDI model was published in 1996 and reliable for evaluation of depressive symptoms. The test has been adapted into different computerized forms, card form, the 13-item short form, and the BDI-II. Administration takes between 5 to 15 minutes depending on whether it is self or supervised. Fifth-sixth grade reading is recommended for adequately understanding the test questions. Paper and electronic forms are the most commonly administered. Test developers and administrators express concerns about the equivalence of scores between internet-based administrations and paper and pencil administration. Statistical analyses of measures of neuroticism, extroversion, agreeableness, and conscientiousness support the similarity in the scores of the two modes of administration (Chuah, Drasgow, & Roberts, 2006). Therefore, emphasis must be on the procedure of administration to ensure adequate understanding of the questions.
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The most aspects of the BDI are the ease of understanding and rating, and the simple scoring procedure. The implication is that the test can be self-scored or administered by a professional via paper or electronic medium. Nevertheless, it is imperative for the patient or professional administrator to familiarize themselves with the BDI by noting is length, purpose, target populations, and meaning of the scores. Careful reading of the questions is recommended during administration. Administration entails rating the items based on the patient condition during the past two weeks and the day of the test. In instances where multiple statements equally describe the patient condition, the response with the higher number on the scale is chosen. The objective is to answer the questions accurately. The test must be administered in a stress-free environment. For instance, the examinee may be asked to close all other application on their devices during internet administration. Ascertaining the preparedness of the examinee is necessary to ensure they can engage appropriately and adequately during the test session.
Why BDI is Administered
The BDI questionnaire was developed from clinical observations of symptoms and attitudes manifested by both depressed psychiatric and non-depressed psychiatric patients, implying that it is administered to determine the severity of depression in the above two population groups (Gordon, 2016). The initial version of the test relied on the centrality of the theory of negative cognition to depression. The BDI-II, which has been translated into seven languages, and has no basis on any depression theory. Its shorter version, the BDI Fast Screen for Medical Patients (BDI-FS), is used in primary care settings; and has seven-reported items that correspond to depressive symptoms that occur two weeks before the day of the test (Gordon, 2016).
The questionnaire assesses the presence or absence of affective, cognitive, somatic, and vegetative symptoms of depression by taking into account the Diagnostic and Statistical Manual (DSM-IV) criteria on major depression. Depressive symptoms commonly evaluated in the 21-scale questionnaire include mood, pessimism, guilt, self-dislike, sense of failure, punishment, suicidal ideation, self-dissatisfaction, crying, body image change, irritability, self-accusation, insomnia, social withdrawal, work difficulty, irritability, indecisiveness, loss of libido, fatigability, change in body image, somatic preoccupation, loss of appetite, and weight loss. Health care providers and researchers administer the BDI in different settings as an assessment tool. The objective is to quantify the assessment of the severity of depression. The ability of the test to reflect the intensity of depression implies it can be used to monitor the development of the condition over time, a crucial parameter in judging the effectiveness of treatment methods.
Target Populations
The BDI is used to evaluate the severity of depression symptoms in both depressed and non-depressed psychiatric patients in the general population. The test is recommended for measurement of the intensity of depression symptoms in patients aged 13 years and above (Gordon, 2016). The age limit of the test can be attributed to the fact that understanding its questions requires at least fifth-sixth grade reading skills. The implication is that children below the age of 13 cannot comprehend BDI test questions. Nevertheless, BDI played a significant role in the development of the children depression inventory (CDI) model published in 1979 (Kovacs, 1992).
Restriction of BDI to patients aged 13 and above can be attributed to the use of adult groups in its development. According to Smarr and Keefer (2011), development and validation of BDI were done using both psychiatric and normal populations. The developers conducted studies on outpatient samples diagnosed with severe psychiatric conditions, substance abuse problem, depressive disorders, and college students. Validation of the BDI-II involved samples of college students, adult, and adolescent psychiatric outpatients. On the other hand, the BDI-FS was validated using an array of patients in the primary care settings including inpatients referred for psychiatric consultation, outpatients examined through family practice, internal medicine, and pediatrics (Smarr & Keefer, 2011). In all instances, the sample population involved adults who could give informed consent to participate. The differential manifestations of depression in adults and children make the test unsuitable for use with the latter.
Validity and Reliability of the Test
Evidence on validity and reliability of the BDI test is inconsistent in the pertinent literature. Wang and Gorenstein (2013) comprehensive review of the BDI test revealed that 25% of the articles examine failed to report reliability coefficients of the test. The implication is the assumption that test score reliability of BDI has failed to prevail in its clinical application. Nevertheless, Wang and Gorenstein (2013) argued that the relevance of BDI as a psychometric instrument owes to its reliability and the capacity to distinguish between depressed and non-depressed patients, owing to its improved content and structural validity. The validity of the model owes to some revisions done to reword and add items to it, thus ensuring it adequately reflects the DSM-IV depression criteria. The model is constructed on the observed positive correlation between it and hopelessness in normative samples; and has demonstrated consistency with cognitive-affective, performance, and somatic diagnostic factors across groups (Smarr & Keefer, 2011). The BDI model has demonstrated consistency in its Cronbach's α with those reported in psychiatric samples.
Scoring of the Test
It is crucial to understand that the BDI does not set arbitrary cutoff point for each type of depression. However, the model has ranges that indicate the severity of depression the patient is experiencing. A score of 0-13 implies no depression; 14-19 represents mild depression; 20-28 moderate depression, and 29-63 severe depression. According to Smarr and Keefer (2011), the items on the test are easily hand scored by summing up the score in each (0 for rarely or none of the time to 3 for most or all of the time). Elimination of bias in the test is done by wording items 4, 8, 12, and 16 in the positive direction and reverse coding them. Severe symptoms of depression, reflected by a higher score are weighted based on the frequency of occurrence in the week preceding the test. The score of 16 or more is considered a typical cutoff for clinical depression, and such cases are referred for further diagnostic evaluation.
Advantages and Disadvantages of the Test
The validity and reliability of BDI have seen it recommended for use in primary health care in baseline assessment of the severity of depression. Taking and periodically retaking the test is not only crucial in evaluating the severity of depression, but also tracking the progress and effectiveness of treatment methods. The criterion-based validity adopted for use in the test has demonstrated exceptional sensitivity and specificity in detection of the disorder compared to gold standard. Also, the method is developed using depressive symptoms from both psychiatric and non-psychiatric patients, making it reflection of the severity of the condition. The test has been translated into different languages because it is easy to understand, meaning it can be applied in different social settings. Adaptation into internet forms implies it can also be administered remotely. However, the BDI test has the potential to generate many false positives based on its cutoff score for depression (≥16). The BDI also fails to address issues about the possibility of examinees to alter the presentation of scores due to underlying motives. Also, its specificity to patients of a specific age group implies the benefits are limited to adult populations.
References
Beck, A.T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961) An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571.
Chuah, S. C., Drasgow, F., & Roberts, B. W. (2006). Personality assessment: Does the medium matter? No. Journal of Research in Personality , 40 (4), 359-376.
Gordon Jackson-Koku; Beck Depression Inventory, Occupational Medicine , 66(2), 174–175.
Kovacs, M. (1992). Children's Depression Inventory. North Tonawanda, NY: Multi-Health Systems, Inc.
Lépine, J. P., & Briley, M. (2011). The increasing burden of depression. Neuropsychiatric disease and treatment , 7 (Suppl 1), 3-7.
Smarr, K. L., & Keefer, A. L. (2011). Measures of depression and depressive symptoms: Beck Depression Inventory‐II (BDI‐II), Center for Epidemiologic Studies Depression Scale (CES‐D), Geriatric Depression Scale (GDS), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire‐9 (PHQ‐9). Arthritis care & research , 63 (S11).
Wang, Y. P., & Gorenstein, C. (2013). Psychometric properties of the Beck Depression Inventory-II: a comprehensive review. Revista Brasileira de Psiquiatria , 35 (4), 416-431.
