Beck Depression Inventory

Related terms:

Hamilton Rating Scale for Depression, Major Depressive Episode, Parkinson's Dis-
ease, Mood Disorder, Depression

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Depression in Late Life

Barry A. Edelstein, ... Stephanie A. Scheck, in Encyclopedia of Applied Psychology,
2004

5.1.1 Beck Depression Inventory

The Beck Depression Inventory (BDI) is a 21-item, multiple-choice inventory. Re-
spondents are asked to rate each item based on four response choices according
to the severity of the symptoms, ranging from the absence of a symptom to an
intense level, during the past week. A 13-item version of the BDI is also available.
Both the original and short forms have reasonable internal consistency for normal
and depressed older adults and adequate test–retest reliability in older adult patient
and nonpatient populations.

A second version of the BDI (BDI-II) was published in 1996 so that items would
be consistent with the revised criteria for depressive disorders in the DSM-IV. The
number of items on the BDI-II is the same as that for the original version. Edelstein
et al. suggest that the BDI-II be used with caution with older adults given the lack
of empirical support for its use with this population.

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Assessment
James N. Butcher, ... G. Cynthia Fekken, in Comprehensive Clinical Psychology, 1998
4.14.3.2 The Beck Depression Inventory
The BDI was first introduced in 1961, and it has been revised several times since
(Beck et al., 1988). The BDI has been widely used as an assessment instrument in
gauging the intensity of depression in patients who meet clinical diagnostic criteria
for depressive syndromes. However, the BDI has also found a place in research with
normal populations, where the focus of use has been on detecting depression or
depressive ideation.

The BDI was developed in a manner similar to the MMPI: clinical observations of
symptoms and attitudes among depressed patients were contrasted to those among
nondepressed patients in order to obtain differentiation of the depressed group
from the rest of the psychiatric patients. The 21 symptoms and attitudes contained
in the BDI reflect the intensity of the depression; items receive a rating of zero to
three to reflect their intensity and are summed linearly to create a score which ranges
from 0 to 63. The 21 items included reflect a variety of symptoms and attitudes
commonly found among clinically depressed individuals (e.g., Mood, Self-dislike,
Social Withdrawal, Sleep Disturbance). The BDI administration is straightforward,
and it can be given as an interview by the clinician or as a self-report instrument
(requiring a fifth or sixth grade reading level).

The BDI is interpreted through the use of cut-off scores. Cut-off scores may be
derived based on the use of the instrument (i.e., if a clinician wishes to identify
very severe depression, then the cut-off score would be set high). According to
Beck et al. (1988), the Center for Cognitive Therapy has set the following guidelines
for BDI cut-off scores to be used with affective disorder patients: scores from 0
through 9 indicate no or minimal depression; scores from 10 through 18 indicate
mild to moderate depression; scores from 19 through 29 indicate moderate to severe
depression; and scores from 30 through 63 indicate severe depression.

Two important issues must be considered by clinicians regarding the results of the
BDI. Unlike the MMPI/MMPI-2 and other major self-report instruments, the BDI
has no safeguards against faking, lying, or variable response sets. Thus, clinicians
are warned against this drawback of the BDI in assessing depressive thoughts and
symptoms. In settings where faking or defensiveness are probable threats to the
validity of the test, clinicians may need to reconsider their use of the BDI. The other
issue pertains to the state–trait debate in assessment. The BDI is extremely sensitive
to differences in the instructions given to an examinee such that certain instructions
yield a state-like index of depressive thinking, whereas, other instructions yield a
more trait-like index of depressive thinking. Again, clinicians are encouraged to use
caution when administering the BDI and to tailor the administration instructions to
the type of index (state or trait) that is desired.
In their review of the psychometric properties of the BDI, Beck et al. (1988) reported
high internal consistency reliability of the instrument among both psychiatric and
nonpsychiatric populations. The authors also reported that the BDI closely parallels
the changes in both patient self-report and clinicians' ratings of depression (i.e., the
BDI score accurately reflects changes in depressive thinking). Finally, they also pre-
sented evidence for the content, concurrent, discriminant, construct, and factorial
validity of the BDI.

The acceptable reliability and validity of the BDI have helped make it a widely used
objective index of depressive thinking among clinicians. Perhaps the most obvious
use of the BDI is as an index of change in the level or intensity of depression. With
an increasing focus on managed healthcare and accountability by psychotherapeutic
service providers, the BDI offers a reliable and valid index of depressive symptoms
and attitudes which can be used effectively to document changes brought about in
therapy.

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Suicide and Suicidality

ISAAC SAKINOFSKY, in Psychiatric Clinical Skills, 2006

RATING SCALES
There are a number of self-report or interviewer-administered scales in existence
attempting to delineate suicidal ideation and strength of the suicidal drive. They have
been well reviewed for the U.S. National Institute of Mental Health by Brown6 and
fall under the following categories: (1) suicidal ideation and behavior, (2) lethality of
suicide attempts (brief screening measures), (3) hopelessness, (4) reasons for living,
(5) care provider attitudes and knowledge concerning suicide, and (6) measures in
development. Many of these scales have satisfactory internal consistency, inter-rater
reliability, test-retest reliability, and concurrent validity, but they are all extremely
poor at predicting which specific person that you will see will take his own life. One
of the best of these is the Scale for Suicide Ideation, a 21-item rating scale that
is administered by the interviewer. Patients who score in the higher category are
seven times more likely to commit suicide than those in the lower category. Such
an estimate of relative risk covers over high proportions of false positives and false
negatives. Calculations of predictive validity tell the story more exactly and show that
it lies between 1% and 3% for the best of the scales.

This has meant that clinicians have been discouraged from using these instruments
by authoritative sources, for example, the American Psychiatric Association.7 Per-
sonally, I would modify this injunction to suggest that appropriate scales may be
used as an ancillary to an overall assessment after you have directly interviewed
the patient and broken through the patient's reserves. They should not be used
instead of spending time with the patient directly because then their results will be
meaningless to you. In my clinic, I use some of the scales because they are systematic
inventories that will corroborate the interview findings. I am as much interested
in how the patient answers the individual items as in the overall scores. I evaluate
the answers against the careful opinion that has been forming in my mind during
the interview. The patient is asked to fill out the scales one by one, always in the
same sequence and in my presence, while I review any preexisting hospital charts
and watch the patient out of the corner of my eye. As each scale is completed, it
is handed to me and gone through immediately. I can then interrupt the patient
to amplify or question his answer to any item on the scale. For obvious reasons
of time limitation, I have included only the following self-report inventories in my
assessments of suicidal persons, and for almost all of them I am indebted to A.T.
Beck, another one of the fathers of research into suicide. There are other scales I
would also have liked to have included or substituted for one or the other of them,
but to make the exercise practicable and also to gather data that can ultimately be
analyzed, I have stuck with the following:

Beck Depression Inventory: I use the earlier 21-item version, which gives a score
ranging from 0 to 63. Each item has four possible degrees of severity, and the patient
is asked to choose the one that is closest to how he feels. Thus, the suicide item
includes the following:

1. “I don't have any thoughts of killing myself.”

2. “I have thoughts of killing myself, but I would not carry them out.”

3. “I would like to kill myself.”

4. “I would kill myself if I had the chance.”

I take an overall score of 16 or greater as indicating clinical depression. However,

above this level I find the numbers do not seem to really discriminate between lesser
and greater degrees of clinical depression. This is due to subjectivity on the part of
the patient. As always, the patient is using the scale as a tool for communicating
with the doctor. I know that some patients demonstrate very high scores above
40 to let me know that they are subjectively hurting and are calling loudly for my
help and attention, whereas others with as great or greater depressed mood tend
to play down their misery. I have known one young man with a score of 12 on the
Beck Depression Inventory who committed suicide within a relatively short time
span. However, in spite of his low depression score, we were able to recognize his
high suicide risk because of his perturbation, hostility, adamance, and high-risk
behaviors. His depression did not take the form of what is usually understood
as clinical depression but may have better conformed to Shneidman's concept of
psychache. Since its publication, I have included the Shneidman scale in my battery,
which measures psychache (generic psychological pain) on a Likert scale and uses
postcard-like pictures as checks on a person's tendency to exaggerate or underplay
the answers. The battery I currently use in my clinic includes the following:

• Psychological Pain Assessment Scale.

▪ Beck Anxiety Inventory: This is a 21-item scale, and it measures symptoms

associated with tension and anxiety (Shneidman's perturbation).
▪ Beck Hopelessness Scale: This is a 20-item scale of true/false choices. Scores
above 10 have been shown to greatly increase the risk of suicide in follow-up
studies of psychiatric patients.
▪ Beck Scale for Suicidal Ideation: This is another 21-item scale that details the
presence and characteristics of suicidal ideation and planning. Although one
can compute an overall score on this scale, I prefer to scrutinize the answers
and use them as discussion points with the patient (e.g., exploring any suicide
planning that may be present).
▪ Modified High-Risk Construct Scale: This inventory (Figure 11-2) is interviewer
based and not a self-report. It arose out of the less structured clinical assess-
ment process I have described above and encompasses those dimensions of
appraisal. An earlier version was tested in a busy psychiatric ER against several
of the self-report inventories used in my clinic as well as the Modified Sad
Persons Score and was found to be the best predictor of admission to hospital
by blinded physicians, followed by the Beck Scale for Suicidal Ideation.8 No
psychometric properties of this scale have been established as yet, nor are
there as yet data on predictive validity. Therefore, the scale should only be used
by you (if you wish) as a means of organizing your clinical observations and
contributing to your thinking about the patient as a suicide risk.

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Rating Scales in Bipolar Disorder

Martha Sajatovic, ... Robert C. Young, in Clinical Trial Design Challenges in Mood
Disorders, 2015

Beck Depression Inventory

The Beck Depression Inventory (BDI) is a 21-item, self-rated scale that evaluates
key symptoms of depression including mood, pessimism, sense of failure, self-dis-
satisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying,
irritability, social withdrawal, indecisiveness, body image change, work difficulty,
insomnia, fatigability, loss of appetite, weight loss, somatic preoccupation, and loss
of libido (Beck & Steer, 1993; Beck, Steer & Garbing, 1988). Individual scale items are
scored on a 4-point continuum (0=least, 3=most), with a total summed score range
of 0–63. Higher scores indicate greater depressive severity. Two subscales include a
cognitive-affective subscale and a somatic-performance subscale.

Selected psychometric properties: mean internal-consistency estimates of the total

scores are 0.86 for psychiatric patients. The BDI mean correlation of total score
with clinical ratings of depression is greater than 0.60. In bipolar depression trials,
the BDI would generally be a secondary outcome measure typically paired with a
commonly used rater-administered scale such as the HAM-D (Saricicek et al., 2011).

Time to complete scale: 5–10 minutes.

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Psychological Assessment of Chronic

Pain Patients
Dennis Thornton PhD, Charles E. Argoff MD, in Pain Management Secrets (Third
Edition), 2009

38 What indices are commonly used for assessing depression?

The Beck Depression Inventory (BDI), Center for Epidemiological Studies Depres-
sion Scale (CES-D), and Hamilton Depression Scale are among the most commonly
employed screening devices. The BDI is a questionnaire consisting of 21 sets of
statements; each set is ranked in terms of severity and scored from 0 to 3. The
statements express feelings common in depression (e.g., guilt, low self-worth, and
suicidal ideation). Each set includes 10 positive and 10 negative statements, and
patients sometimes find it confusing.

The CES-D is a self-administered questionnaire consisting of 20 items to which the

patient indicates the frequency of experience during the past week. Cognitive, affec-
tive, and somatic items are incorporated into this index. The Hamilton Depression
Scale consists of 17 items that are rated by the observer, rather than the patient.

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Clinical Geropsychology
Amy Fiske, ... Margaret Gatz, in Comprehensive Clinical Psychology, 1998

7.09.5.1.1 Depression scales developed with mixed-age sam-

ples
The Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh,
1961) includes 21 items, each including four alternative statements ranging in
order of severity from zero to three. Conventional cutoffs are 0–9 for normal range,
10–18 for mild to moderate depression, 19–29 for moderate to severe depression,
and 30–63 for severe depression (Beck, Steer, & Garbin, 1988). For the 13-item
short form (Beck & Beck, 1972), 0–4 corresponds to none or minimal depression,
5–7 to mild depression, 8–15 to moderate depression, and 16 or higher to severe
depression.

The BDI has demonstrated test-retest and split-half reliability as well as concurrent
validity with older adults (see Gallagher, 1986). With a cutoff of 10, the BDI has shown
good efficiency with older depressed psychiatric outpatients (100% sensitivity,
96% specificity, 100% PPP, 100% NPP; Olin, Schneider, Eaton, Zemansky, & Pollock,
1992). In a sample seeking outpatient mental health services, Kogan, Kabacoff,
Hersen, and Van Hasselt (1994) found that a cutoff of 22 maximized efficiency,
yielding 64% sensitivity and 73% specificity.

The BDI has good efficiency in older medical outpatients (Rapp, Parisi, Walsh,
& Wallace, 1988) and medical inpatients (Norris et al., 1987). Cognitively impaired
individuals have been found to have difficulty comprehending the format (Lyons,
Strain, Hammer, Ackerman & Fulop, 1989) and the BDI may be less sensitive
to detecting major depression in older men when compared with older women
(Allen-Burge, Storandt, Kinscherf, & Rubin, 1994).

The other conspicuous feature of the BDI lies in its inclusion of somatic symptoms.
Zemore and Eames (1979) demonstrated that age differences on the BDI could be
explained entirely by the somatic symptoms, with no age differences on the more
cognitive symptoms.

The Zung Self-rating Depression Scale (SDS; Zung, 1965) contains 20 items, 10
worded positively, and 10 negatively. Items are on a one to four scale; raw scores
are converted into a percentage by dividing the sum of all questions by 0.80.
Conventional cutoffs are 25–43 for no depression, 50–59 for mild to moderate
depression, 60–69 for moderate to severe depression, and 70 or over for severe
depression (Zung, 1967). Older adults have shown higher normal baseline scores
than the validation sample (Zung, 1967) which may be attributed to the large number
of items about somatic symptoms (Berry, Storandt, & Coyne, 1984). Reliability has
been found to be moderate or low, particularly among the oldest old, and sex
and age differences in factor structure have been suggested (Kivela & Pahkala,
1986; Kivela & Pahkala, 1987; McGarvey, Gallagher, Thompson, & Zelinski, 1982).
In medically ill inpatients, the SDS has been found to have a 58% sensitivity and
87% specificity using a cutoff score of 60 (Kitchell et al., 1982) in comparison with
an 82% sensitivity-87% specificity in medical outpatients (Okimoto et al., 1982). A
10-item interviewer-assisted form has been developed and validated for older adults
(Tucker, Ogle, Davison, & Eilenberg, 1986). A cutoff score above 70 is recommended
for the 10-item form.

The Center for Epidemiological Studies— Depression Scale (CES-D; Radloff, 1977)
is a 20-item measure designed for large-scale epidemiological surveys. It can be
self-administered, by paper-and-pencil or using computer speech recognition (-
Muñoz, Gonzales, & Starkweather, 1995), or used in an interview, face-to-face or by
telephone (George, Blazer, Hughes & Fowler, 1989). Four items are worded positively
and are reverse scored; these items have a particularly high rate of omission or
response bias (Callahan & Wolinsky, 1994; Gatz & Hurwicz, 1990). Scores range
from zero to 60. A score of 16 or more is used as the conventional cutoff for
clinical depression, although a cutoff score of 20 may have increased efficiency
with older adults (see Radloff & Teri, 1986; Murrell, Himmelfarb, & Wright, 1983).
Several shorter forms have been developed specifically for use with older adults
by collapsing response categories and giving only 10 or 11 of the items (Andresen,
Malmgren, Carter, & Patrick, 1994; Kohout, Berkman, Evans, & Cornoni-Huntley,
1993). The CES-D has probable measurement invariance across age (Hertzog, Van
Alstine, Usala, Hultsch, & Dixon, 1990), culture (Heikkinen et al., 1995), and physical
health or disability (Davidson et al., 1994). Although the same broad factors emerge,
there are differences across gender and ethnic or racial subgroups with respect
to factor loadings and placement of specific items on factors. Garcia and Marks
(1989) and Callahan and Wolinsky (1994) emphasize that these differences imply
socio-cultural differences in the expression of depression.

Two self-report forms of the observer-rated Hamilton Rating Scale for Depression
(HRSD) have been developed: the Carroll Rating Scale for Depression (CRS; Carroll,
Feinberg, Smouse, Rawson, & Greden 1981; Feinberg, Carroll, Smouse, & Rawson,
1981; Smouse, Feinberg, Carroll, Park, & Rawson, 1981) and the Hamilton Depres-
sion Inventory (HDI; Reynolds & Kobak, 1991). In the CRS, 52 “yes/no” items replace
the HRSD severity ratings. A score of 10 is the recommended clinical cutoff. Koenig,
Meador, Cohen, and Blazer (1988, 1992) examined a 12-item short version of the
CRS in medical inpatients (BCDRS; Duke Depression Evaluation Schedule for the
Elderly, 1988). A cutoff of six yielded the best efficiency.
The Inventory to Diagnose Depression (IDD; Zimmerman & Coryell, 1987; Zim-
merman, Coryell, Corenthal, & Wilson, 1986) is a 22-item instrument designed to
diagnose major depressive disorder according to DSM-III criteria and to provide
information about symptom severity and duration. Although the IDD has been used
with older adults, psychometric properties are unknown.

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Psychological Aspects of Pain

Dale A. Halfaker PhD, ... Ted L. Wunderlich BA, in Pain Procedures in Clinical Practice
(Third Edition), 2011

Beck Depression Inventory

Common screening tests of depression include the Beck Depression Inventory
(BDI), Zung Self-Rating Depression Scale (SDS), and Hamilton Depression Rating
Scale (HAMD). The Beck Depression Inventory has been used since 1961 and is the
most common depression screening instrument. The second edition was published
in 1996 (BDI-II) and represents a revision that is more consistent with current
diagnostic criteria for depression. The BDI-II consists of 21 items, for example,
sadness, pessimism, worthlessness. All items, except two, have four statements of
increasing intensity within the domain. For example under sadness the items start
with “I do not feel sad.” and end with “I am so sad or unhappy I can’t stand it.” The first
item has a score of 0 while the fourth item has a score of 3. The two items evaluating
changes in sleeping patterns and changes in appetite have seven total statements,
one with a value of 0 indicating no change and two items each for values 1, 2, and
3 indicating mild, moderate, and severe problems (both decreased and increased
sleep and decreased and increased appetite). The range of possible scores is 0 to
63. BDI-II scores are classified as minimal (0-13), mild (14-19), moderate (20-28),
and severe (29-63).11,12 The strength of the BDI-II is the ease of use, wide age range
(13 years and older), low reading level (average Flesch-Kincaid Grade Level 3.6), and
substantial body of research. The weaknesses of the BDI-II are typical in screening
measures: no validity scales and high face validity allows persons to easily manipulate
the total score.

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The Use of Standardized Rating Scales
in Clinical Practice
R. MICHAEL BAGBY, ... FIONA S.M. SCHULTE, in Psychiatric Clinical Skills, 2006

EXAMPLES OF POTENTIAL USES

Some Existing Scales

Both the Ham-D and the BDI have been presented as examples of existing stan-
dardized rating scales. Other examples of such scales include the General Assess-
ment of Functioning scale (GAF),8 the Childhood Behavior Checklist (CBCL),9 the
Personality Diagnostic Questionnaire – 4 (PDQ4),10 the Symptom Checklist-90-Re-
vised (SCL-90-R),11 the Yale-Brown Obsessive Compulsive Scale (Y-BOCS),12 and the
Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-1).13 Compendiums
that offer an exhaustive listing of tests and measures can be found in the Recom-
mended Readings at the end of this chapter. These sources will help the clinician
identify and locate standardized tests for a wide range of different uses.

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Neurobiology of Psychiatric Disorders

Antonella Ciaramella, David Spiegel, in Handbook of Clinical Neurology, 2012

Brain
A prevalence of depression (using the Beck Depression Inventory) of 35% was
identified after neurosurgery for brain tumors. Depression was much more highly
correlated with lower quality of life 3 months postsurgery in female patients (Mainio
et al., 2006). In a large-sample study of patients with high-grade glioma, symptoms
of depression were common immediately after surgery and increased throughout
the 6-month postoperative period. In the early postoperative period, physicians
reported depression in 15% of patients, whereas 93% of patients reported symptoms
consistent with depression. The incidence of patient self-reported depression re-
mained similar at 3- and 6-month follow-up, whereas physician-reported depression
increased from 15% in the early postoperative period to 22% at both 3- and 6-month
follow-up (Litofsky et al., 2004). In another study of brain tumor patients, current
major depressive disorder (MDD, using DSM-IV criteria) was reported to be 28%.
Key predictors of MDD included tumor location in the frontal region and family
 psychiatric history (Wellisch et al., 2002). Depression also can be a symptom of a
silent brain tumor. In a retrospective study of a sample with meningioma (benign
tumor), the prevalence of depression (diagnosis according to DSM-III-R criteria,
made by two psychiatrists) was 18%, and almost 45% of these presented with atypical
features of depression (Gupta and Kumar, 2004).

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Suicidal Behavior
Kathryn Castle PhD, Richard Kreipe MD, in Pediatric Clinical Advisor (Second Edi-
tion), 2007

Workup

• Instruments that may facilitate assessment include the Beck Depression In-
ventory (BDI II) and ideation questionnaire, Beck Hopelessness Scale (BHS),
Beck Scale Suicidal Ideation (BSS), Suicidal Ideation Questionnaire, or Reasons
for Living Scale (RLS), but no assessment tool takes the place of a structured
interview.
• Some providers may prefer a more broad based assessment across a range
of behavioral and emotional functioning, such as in Bright Futures or the
Guidelines for Adolescent Preventive Services (GAPS), to put the individual in
context, rather than focusing exclusively on suicidal behavior.

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