The aim of this study was to examine the factorial and diagnostic validity of the Beck Depression Inventory-Second Edition (BDI-II) in Croatian primary health care. Data were collected using a medical outpatient sample (N = 314). Reliability measured by internal consistency proved to be high. While the Velicer MAP Test showed that extraction of only one factor is satisfactory, confirmatory factor analysis indicated the best fit for a 3-factor structure model consisting of cognitive, affective and somatic dimensions. Receiver operating characteristics (ROC) analysis demonstrated the BDI-II to have a satisfactory diagnostic validity in differentiating between healthy and depressed individuals in this setting. The area under the curve (AUC), sensitivity and specificity were high with an optimal cut-off score of 15/16. The implications of these findings are discussed regarding the use of the BDI-II as a screening instrument in primary health care settings.
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Al-Windi, A. (2005). Depression in general practice. Nordic Journal of Psychiatry, 59, 272–277.
Applied Health Sciences (Mental Health), University of Aberdeen. (2011). Assessing the validity of the PHQ-9, HADS, BDI-II and QIDS-SR 16 in measuring severity of depression in a UK sample of primary care patients with a diagnosis of depression. Edinburgh: NHS Quality Improvement Scotland (NHS QIS).
Arnarson, T. O., Olason, D. T., Smári, J., & Sigurethsson, J. F. (2008). The Beck Depression Inventory Second Edition (BDI-II): Psychometric properties in Icelandic student and patient populations. Nordic Journal of Psychiatry, 62, 360–365.
Arnau, R. C., Meagher, M. W., Norris, M. P., & Bramson, R. (2001). Psychometric evaluation of the Beck Depression Inventory-II with primary care medical patients. Health Psychology, 20, 112–119.
Bauer, M., Bschor, T., Pfennig, A., Whybrow, P. C., Angst, J., & Versiani, M. (2007). World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders in primary care. The World Journal of Biological Psychiatry, 8, 67–104.
Bech, P., Rasmussen, N. A., Raabaek Olsen, L., Noerholm, V., & Abildgaard, W. (2001). The sensitivity and specificity of the Major Depression Inventory, using the Present State Examination as the index of diagnostic validity. Journal of Affective Disorders, 66, 159–164.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio: Psychological Corporation.
Beck, A. T., Steer, R. A., Brown, G. K., & Van der Does, A. J. W. (2002). BDI-II-NL Handleiding [BDI-II-Dutch Manual]. Lisse: Psychological Corporation.
Bedi, R. P., Koopman, R. F., & Thompson, J. M. (2001). The dimensionality of the Beck Depression Inventory-II and its relevance for tailoring the psychological treatment of women with depression. Psychotherapy: Theory, Research, Practice, Training, 38, 306–318.
Bentler, P. M. (1980). Multivariate analysis with latent variables: Causal modelling. Annual Review of Psychology, 31, 419–456.
Bollen, K. A., & Long, J. S. (1993). Testing structural equation models. New York: Sage.
Buckley, T. C., Parker, J. D., & Heggie, J. (2001). A psychometric evaluation of the BDI-II in treatment-seeking substance abusers. Journal of Substance Abuse Treatment, 20, 197–204.
Bunevicius, A., Staniute, M., Brozaitiene, J., & Bunevicius, R. (2012). Diagnostic accuracy of self-rating scales for screening of depression in coronary artery disease patients. Journal of Psychosomatic Research, 72, 5–22.
Campos, R. C., & Goncalves, B. (2011). The Portuguese version of the Beck Depression Inventory-II (BDI-II)—preliminary psychometric data with two nonclinical samples. European Journal of Psychological Assessment, 27, 258–264.
Carmody, D. P. (2005). Psychometric characteristics of the Beck Depression Inventory-II with college students of diverse ethnicity. International Journal of Psychiatry in Clinical Practice, 9, 22–28.
Cepoiu, M., McCusker, J., Cole, M. G., Sewitch, M., Belzile, E., & Ciampi, A. (2008). Recognition of depression by non-psychiatric physicians—a systematic literature review and meta-analysis. Journal of General Internal Medicine, 23, 25–36.
Curzik, D., & Jokic Begic, N. (2012). The utility of BDI-II in assessment of pre- and postpartum depression symptoms and their relation to labor pain. Psychiatria Danubina, 24, 167–174.
de Graaf, L. E., Gerhards, S. A., Arntz, A., Riper, H., Metsemakers, J. F., Evers, S. M., et al. (2009). Clinical effectiveness of online computerised cognitive-behavioural therapy without support for depression in primary care: Randomised trial. British Journal of Psychiatry, 195, 73–80.
Dozois, D. J. A., Dobson, K. S., & Ahnberg, J. L. (1998). A psychometric evaluation of the Beck Depression Inventory-II. Psychological Assessment, 10, 83–89.
Dutton, G. R., Grothe, K. B., Jones, G. N., Whitehead, D., Kendra, K., & Brantley, P. J. (2004). Use of the Beck Depression Inventory-II with African American primary care patients. General Hospital Psychiatry, 26, 437–442.
Filipcic, I., Popovic-Grle, S., Marcinko, D., Basic, S., Hotujac, L., Pavicic, F., et al. (2007). Screening for depression disorders in patients with chronic somatic illness. Collegium Antropologicum 31, 139–143.
Gaynes, B. N., Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Balasubramani, G. K., McGrath, P. J., et al. (2008). Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: Results from STAR*D. Journal of General Internal Medicine, 23, 551–560.
Gaynes, B.N., Rush, A.J., Trivedi, M., Wisniewski, S.R., Balasubramani, G.K., Spencer, D.C., et al. (2005). A direct comparison of presenting characteristics of depressed outpatients from primary vs. specialty care settings: preliminary findings from the STAR*D clinical trial. General Hospital Psychiatry, 27, 87–96.
Gilbody, S., Sheldon, T., & House, A. (2008). Screening and case-finding instruments for depression: A meta-analysis. Canadian Medical Association Journal, 178, 997–1003.
Gilbody, S. M., Whitty, P. M., Grimshaw, J. M., & Thomas, R. E. (2003). Improving the detection and management of depression in primary care. Quality and Safety in Health Care, 12, 149–155.
Hecimovic, H., Bosnjak, J., & Demarin, V. (2008). Prevalence of mood dysfunction in epilepsy patients in Croatia. Collegium Antropologicum, 32, 65–68.
Huffman, J. C., Doughty, C. T., Januzzi, J. L., Pirl, W. F., Smith, F. A., & Fricchione, G. L. (2010). Screening for major depression in post-myocardial infarction patients: Operating characteristics of the Beck Depression Inventory-II. International Journal of Psychiatry in Medicine, 40, 187–197.
Jackson, J. L., Passamonti, M., & Kroenke, K. (2007). Outcome and impact of mental disorders in primary care at 5 years. Psychosomatic Medicine, 69, 270–276.
Jöreskog, K., & Sörbom, D. (1993). LISREL 8: Structural equation modeling with the SIMPLIS command LANGUAGE. Chicago: Scientific Software International Inc.
Kapci, E. G., Uslu, R., Turkcapar, H., & Karaoglan, A. (2008). Beck Depression Inventory II: Evaluation of the psychometric properties and cut-off points in a Turkish adult population. Depression and Anxiety, 25, 104–110.
Katon, W. J. (2003). Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry, 54, 216–226.
King, M., Nazareth, I., Levy, G., Walker, C., Morris, R., Weich, S., et al. (2008). Prevalence of common mental disorders in general practice attendees across Europe. The British Journal of Psychiatry, 192, 362–367.
Kojima, M., Furukawa, T. A., Takahashi, H., Kawai, M., Nagaya, T., & Tokudome, S. (2002). Cross-cultural validation of the Beck Depression Inventory-II in Japan. Psychiatry Research, 110, 291–299.
Kolaric, B., Tesic, V., Ivankovic, D., & Begovac, J. (2006). Prevalence of moderate and severe depression among Croatian patients infected with human immunodeficiency virus. Collegium Antropologicum, 30, 85–88.
Kumar, G., Steer, R. A., Teitelman, K. B., & Villacis, L. (2002). Effectiveness of Beck Depression Inventory–II subscales in screening for major depressive disorders in adolescent psychiatric inpatients. Assessment, 9, 164–170.
Lehtinen, V., Michalak, E., Wilkinson, C., Dowrick, C., Ayuso-Mateos, J. L., Dalgard, O. S., et al. (2003). Urban-rural differences in the occurrence of female depressive disorder in Europe—evidence from the ODIN study. Social Psychiatry and Psychiatric Epidemiology, 38, 283–289.
Licht-Strunk, E., Beekman, A. T., de Haan, M., & van Marwijk, H. W. (2009). The prognosis of undetected depression in older general practice patients. A one year follow-up study. Journal of Affective Disorders, 114, 310–315.
Mackinger, H. F., & Svaldi, J. J. (2004). Autobiographical memory predicts cognitive but not somatic change in sleep apnea patients vulnerable for affective disorder. Journal of Affective Disorders, 81, 17–22.
Mitchell, A. J. (2012). Clinical utility of screening for clinical depression and bipolar disorder. Current Opinion in Psychiatry, 25, 24–31.
NHS Employers and the General Practitioners’ Committee. (2009). Quality and outcome frameworks: Guidance for GMS contract 2009/10.
Nuevo, R., Dunn, G., Dowrick, C., Vazquez-Barquero, J. L., Casey, P., Dalgard, O. S., et al. (2009). Cross-cultural equivalence of the Beck Depression Inventory: A five-country analysis from the ODIN study. Journal of Affective Disorders, 114, 156–162.
O’Connor, B. P. (2000). SPSS and SAS programs for determining the number of components using parallel analysis and Velicer’s MAP test. Behavior Research Methods, Instrumentation, and Computers, 32, 396–402.
O’Connor, E. A., Whitlock, E. P., Beil, T. L., & Gaynes, B. N. (2009). Screening for depression in adult patients in primary care settings: A systematic evidence review. Annals of Internal Medicine, 151, 793–803.
Olsen, L. R., Jensen, D. V., Noerholm, V., Martiny, K., & Bech, P. (2003). The internal and external validity of the Major Depression Inventory in measuring severity of depressive states. Psychological Medicine, 33, 351–356.
Osman, A., Kopper, B. A., Barrios, F., Gutierrez, P. M., & Bagge, C. L. (2004). Reliability and validity of the Beck Depression Inventory-II with adolescent psychiatric inpatients. Psychological Assessment, 16, 120–132.
Oyserman, D., Coon, H. M., & Kemmelmeier, M. (2002). Rethinking individualism and collectivism: Evaluation of theoretical assumptions and meta-analyses. Psychological Bulletin, 128, 72–73.
Pibernik-Okanovic, M., Peros, K., Szabo, S., Begic, D., & Metelko, Z. (2005). Depression in Croatian Type 2 diabetic patients: prevalence and risk factors. A Croatian survey from the European Depression in Diabetes (EDID) Research Consortium. Diabetic Medicine, 22, 942–945.
Pignone, M. P., Gaynes, B. N., Rushton, J. L., Burchell, C. M., Orleans, C. T., Mulrow, C. D., et al. (2002). Screening for depression in adults: A summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 136, 765–776.
Pintea, S., & Moldovan, R. (2009). The receiver-operating characteristic (ROC) analysis: Fundamentals and applications in clinical psychology. Journal of Cognitive and Behavioral Psychotherapies, 9, 49–66.
Priebe, S., Bogic, M., Ajdukovic, D., Franciskovic, T., Galeazzi, G. M., Kucukalic, A., et al. (2010). Mental disorders following war in the Balkans. Archives of General Psychiatry, 67, 518–528.
Reeves, G. M., Rohan, K. J., Langenberg, P., Snitker, S., & Postolache, T. T. (2012). Calibration of response and remission cut-points on the Beck Depression Inventory-Second Edition for monitoring seasonal affective disorder treatment outcomes. Journal of Affective Disorders, 138, 123–127.
Richards, D. (2011). Prevalence and clinical course of depression: A review. Clinical Psychology Review, 31, 1117–1125.
Segal, D. L., Coolidge, F. L., Cahill, B. S., & O’Riley, A. A. (2008). Psychometric properties of the Beck Depression Inventory—II (BDI-II) among community-dwelling older adults. Behavior Modification, 32, 3–20.
Sharp, L. K., & Lipsky, M. S. (2002). Screening for depression across the lifespan: A review of measures for use in primary care settings. American Family Physician, 66, 1001–1009.
Sikorski, C., Luppa, M., König, H. H., van den Bussche, H., & Riedel-Heller, S. G. (2012). Does GP training in depression care affect patient outcome? A systematic review and meta-analysis. BMC Health Services Research. doi:10.1186/1472-6963-12-10.
Spitzer, R. L., Williams, J. B., Gibbon, M., & First, M. B. (1994). Structured clinical interview for DSM-IV axis I disorders—patient edition. New York: New York State Psychiatric Institute.
Steer, R. A., Kumar, G., Ranieri, W. F., & Beck, A. T. (1998). Use of the Beck Depression Inventory-II with adolescent psychiatric outpatients. Journal of Psychopathology and Behavioral Assessment, 20, 127–137.
Steer, R. A., Rissmiller, D. J., & Beck, A. T. (2000). Use of the Beck Depression Inventory-II with depressed geriatric inpatients. Behavior Research and Therapy, 38, 311–318.
Steiger, J. H. (1990). Structural model evaluation and modification: An interval estimation approach. Multivariate Behavioral Research, 25, 173–180.
Stojanovic-Spehar, S., Blazekovic-Milakovic, S., Amerl-Sakic, V., Kolic, N., & Supe, S. (2009). Depression prevalence and estimation of psychosocial parameters within adult population in City of Zagreb. Psychiatria Danubina, 21, 497–507.
Streiner, D. L., & Cairney, J. (2007). What’s under the ROC? An introduction to Receiver Operating Characteristics Curves. The Canadian Journal of Psychiatry, 52, 121–128.
Tarricone, I., Stivanello, E., Poggi, F., Castorini, V., Marseglia, M. V., Fantini, M. P., et al. (2012). Ethnic variation in the prevalence of depression and anxiety in primary care: A systematic review and meta-analysis. Psychiatry Research, 195, 91–106.
Tucker, L. R., & Lewis, C. (1973). A reliability coefficient for maximum likelihood factor analyses. Psychometrika, 18, 1–10.
Uslu, R. I., Kapci, E. G., Oncu, B., Ugurlu, M., & Turkcapar, H. (2008). Psychometric properties and cut-off scores of the Beck Depression Inventory-II in Turkish Adolescents. Journal of Clinical Psychology in Medical Settings, 15, 225–233.
Vanheule, S., Desmet, M., Groenvynck, H., Rosseel, Y., & Fontaine, J. (2008). The factor structure of the Beck Depression Inventory II: An evaluation. Assessment, 15, 177–187.
Vanheule, S., Desmet, M., Verhaeghe, P., & Bogaerts, S. (2007). Alexithymic depression: Evidence for a depression subtype? Psychotherapy and Psychosomatics, 76, 135–136.
VanVoorhis, C. R. W., & Blumentritt, T. L. (2007). Psychometric properties of the Beck Depression Inventory-II in a clinically identified sample of Mexican American adolescents. Journal of Child and Family Studies, 16, 789–798.
Viljoen, J. L., Iverson, G. L., Griffiths, S., & Woodward, T. S. (2003). Factor structure of the Beck Depression Inventory-II in a medical outpatient sample. Journal of Clinical Psychology in Medical Settings, 10, 289–291.
Wancata, J., & Friedrich, F. (2011). Depression: a diagnosis aptly used? Psychiatria Danubina, 23, 406–411.
Weissman, M. M., Neria, Y., Gameroff, M. J., Pilowsky, D. J., Wickramaratne, P., Lantigua, R., et al. (2010). Positive screens for psychiatric disorders in primary care: a long-term follow-up of patients who were not in treatment. Psychiatric Services, 61, 151–159.
Whisman, M. A., Perez, J. E., & Ramel, W. (2000). Factor structure of the Beck Depression Inventory-Second Edition (BDI-II) in a student sample. Journal of Clinical Psychology, 56, 545–551.
Wiebe, J. S., & Penley, J. A. (2005). A psychometric comparison of the Beck Depression Inventory-II in English and Spanish. Psychological Assessment, 17, 481–485.
World Health Organization (WHO). (1998). Info package: Mastering depression in primary care. Frederiksborg: WHO, Regional Office for Europe, Psychiatric Research Unit.
World Health Organization (WHO). (2001). What is depression? In Depression. Retrieved from http://www.who.int/mental_health/management/depression/definition/en/.
World Health Organization (WHO). (2006). Mastering depression in primary care (version 22). Retrieved from http://www.gp-training.net/protocol/psychiatry/who/whodep.htm#A.
Beck Depression Inventory®-Second Edition. Copyright © 1996 by Aaron T. Beck with permission of publisher, Harcourt Assessment, Inc. Croatian translation copyright © 2006 by Aaron T. Beck with permission of publisher, Harcourt Assessment, Inc. Reproduced with permission. All rights reserved. “Beck Depression Inventory” and “BDI” are trademarks of Harcourt Assessment, Inc. registered in the United States of America and/or other jurisdictions.
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Jakšić, N., Ivezić, E., Jokić-Begić, N. et al. Factorial and Diagnostic Validity of the Beck Depression Inventory-II (BDI-II) in Croatian Primary Health Care. J Clin Psychol Med Settings 20, 311–322 (2013). https://doi.org/10.1007/s10880-013-9363-2
- Primary health care
- Factor structure
- Cut-off score