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Factorial and Diagnostic Validity of the Beck Depression Inventory-II (BDI-II) in Croatian Primary Health Care

Journal of Clinical Psychology in Medical Settings volume 20, pages 311–322 (2013)Cite this article

Abstract

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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References

  • Al-Windi, A. (2005). Depression in general practice. Nordic Journal of Psychiatry, 59, 272–277.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  CAS  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  CAS  Google Scholar 

  • Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio: Psychological Corporation.

    Google Scholar 

  • 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.

    Google Scholar 

  • 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.

    Article  Google Scholar 

  • Bentler, P. M. (1980). Multivariate analysis with latent variables: Causal modelling. Annual Review of Psychology, 31, 419–456.

    Article  Google Scholar 

  • Bollen, K. A., & Long, J. S. (1993). Testing structural equation models. New York: Sage.

    Google Scholar 

  • 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.

    Article  PubMed  CAS  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    PubMed  Google Scholar 

  • 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.

    Article  PubMed  CAS  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Google Scholar 

  • 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.

    Google Scholar 

  • 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.

    Google Scholar 

  • Gilbody, S., Sheldon, T., & House, A. (2008). Screening and case-finding instruments for depression: A meta-analysis. Canadian Medical Association Journal, 178, 997–1003.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  CAS  Google Scholar 

  • Hecimovic, H., Bosnjak, J., & Demarin, V. (2008). Prevalence of mood dysfunction in epilepsy patients in Croatia. Collegium Antropologicum, 32, 65–68.

    PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • Jöreskog, K., & Sörbom, D. (1993). LISREL 8: Structural equation modeling with the SIMPLIS command LANGUAGE. Chicago: Scientific Software International Inc.

    Google Scholar 

  • 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.

    Article  Google Scholar 

  • Katon, W. J. (2003). Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry, 54, 216–226.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • Mitchell, A. J. (2012). Clinical utility of screening for clinical depression and bipolar disorder. Current Opinion in Psychiatry, 25, 24–31.

    PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • Oyserman, D., Coon, H. M., & Kemmelmeier, M. (2002). Rethinking individualism and collectivism: Evaluation of theoretical assumptions and meta-analyses. Psychological Bulletin, 128, 72–73.

    Google Scholar 

  • 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.

    Article  PubMed  CAS  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Richards, D. (2011). Prevalence and clinical course of depression: A review. Clinical Psychology Review, 31, 1117–1125.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    PubMed  Google Scholar 

  • 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.

    Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  CAS  Google Scholar 

  • Steiger, J. H. (1990). Structural model evaluation and modification: An interval estimation approach. Multivariate Behavioral Research, 25, 173–180.

    Article  Google Scholar 

  • 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.

    PubMed  Google Scholar 

  • 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.

    Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • Tucker, L. R., & Lewis, C. (1973). A reliability coefficient for maximum likelihood factor analyses. Psychometrika, 18, 1–10.

    Article  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • Vanheule, S., Desmet, M., Verhaeghe, P., & Bogaerts, S. (2007). Alexithymic depression: Evidence for a depression subtype? Psychotherapy and Psychosomatics, 76, 135–136.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Wancata, J., & Friedrich, F. (2011). Depression: a diagnosis aptly used? Psychiatria Danubina, 23, 406–411.

    PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  CAS  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • World Health Organization (WHO). (1998). Info package: Mastering depression in primary care. Frederiksborg: WHO, Regional Office for Europe, Psychiatric Research Unit.

    Google Scholar 

  • 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.

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Acknowledgments

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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Authors and Affiliations

  1. Department of Psychiatry, University Hospital Center Zagreb, Zagreb, Croatia

    Nenad Jakšić

  2. Psychiatric Hospital “Sveti Ivan”, Zagreb, Croatia

    Ena Ivezić

  3. Department of Psychology, Faculty of Humanities and Social Sciences, University of Zagreb, Croatia, I. Lucica 3, 10 000, Zagreb, Croatia

    Nataša Jokić-Begić

  4. Department of General Psychology, Institute of Psychology, Károli Gáspár University of the Reformed Church, Budapest, Hungary

    Zsuzsanna Surányi

  5. Department of Family Medicine, Andrija Štampar School of Public Health, University of Zagreb, Zagreb, Croatia

    Stanislava Stojanović-Špehar

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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

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Keywords

  • BDI-II
  • Depression
  • Primary health care
  • Factor structure
  • Cut-off score