Beck Depression Inventory

The Beck Depression Inventory (BDI, BDI-II), created by Dr. Aaron T. Beck, is a twenty-one question multiple choice self-report inventory that is one of the most widely used instruments for measuring the severity of depression. The most current version of the questionnaire is designed for individuals aged 13 and over and is composed of items relating to depression symptoms 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 1971 as the BDI-1A, and the BDI-II, published in 1996. The BDI is widely used as an assessment tool by healthcare professionals and researchers in a variety of settings.

Development and history of the BDI
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.

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 that a person is not depressed, 10-18 indicates mild-moderate depression, 19-29 indicates moderate-severe depression and 30-63 signifies 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, under the heading Mood there are two responses 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, published by Beck in 1971. 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 consistency 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.

BDI-II
The BDI-II was a 1996 revision of the BDI, developed in response to the American Psychiatric Association's 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 twenty-one 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).

Two-factor approach to depression
Depression can be thought of as having two components: the psychological or "cognitive" 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 cognitive 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 closely related rather than totally distinct.

Impact of the BDI
The development of the BDI was an important event in psychiatry and psychology because it represented the shift of healthcare professionals' view of depression from a Freudian, psychodynamic perspective, to one guided by the patient's own thoughts or "cognitions". It also established a principle followed in the development of further self-report questionnaires, that items can initially be gathered by verbatim reports from patients themselves, with validation studies suggesting theoretical constructs (e.g. using factor analysis), rather than trying to develop an instrument from a purely theoretical basis which may prove to be invalid.

The instrument remains widely used in research. A search on Pubmed returns 3,209 peer-reviewed articles that have used the inventory in the measurement of depression, and it has been translated into multiple European languages as well as Arabic, Japanese, Persian, and Xhosa.

Limitations of the BDI
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 it. Like all questionnaires, the way the test is administered can have an effect on the final score. For instance, if a patient is asked to fill the form out in front of other people in a clinical environment, social expectations might elicit a different response compared to administration via a postal survey.

Another serious limitation is that in participants with concomitant physical illness, it has been suggested that the BDI's reliance on physical symptoms such as fatigue might artificially inflate scores due to symptoms of the illness, rather than of depression. In response to this criticism, Beck and his colleagues have developed a measure called the "Beck Depression Inventory for Primary Care" (BDI-PC). This is 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. Researchers and clinicians who work with medically ill populations might also consider using the Center for Epidemiologic Studies - Depression Scale (CES-D) or the Hospital Anxiety and Depression Scale (HADS) as alternative measures.

The BDI provides a measure of severity of symptoms, rather than a diagnosis. Some may consider it inappropriate to make a diagnosis of depression solely on the basis of a self report inventory.