Construct validity of the Beck Depression Inventory in a depressive population

Journal of Affective Disorders 46 (1997) 115–125

Research report

Construct validity of the Beck Depression Inventory in a depressivepopulation

a , b , c , d a , b a a*C.K.W. Schotte , M. Maes , R. Cluydts , D. De Doncker , P. CosynsaDepartment of Psychiatry, University Hospital of Antwerp (U.Z.A.), Wilrijkstraat 10, B-2650 Edegem, Belgium

bFaculty of Psychology, Free University Brussels, Brussels, BelgiumcClinical Research Center-Mental Health (CRC-MH), Antwerp, Belgium

dDepartment Psychiatry, Vanderbilt University, Nashville, TN, USA

Received 7 November 1996; accepted 15 May 1997

Abstract

This study investigates the construct validity of the Beck Depression Inventory (BDI) in a large population of DSM-IIIunipolar depressive inpatients. The BDI correlates weakly with the Hamilton scale and differentiates between minor, majorand melancholic /psychotic unipolar depressive subgroups. Factor analysis of the BDI resulted in psychological /cognitive(BDIPSY) and somatic /vegetative (BDISOM) subscales. The BDISOM subscale displayed a narrower relationship with thedepression construct, as evidenced by a better differential validity and by significant effects for the DST non-suppressionresponse. The present findings generally lend support to the construct validity of the BDI in depressive populations. 1997 Elsevier Science B.V.

Keywords: Depressive disorders; Beck Depression Inventory; Construct validity; Psychodiagnosis

1. Introduction psychometric properties, based on 25 years of exten-sive research. However, most research on the BDI

The Beck Depression Inventory (BDI; Beck et al., investigated its validity in psychiatric, medical or1979) is one of the most popular self-report scales, student populations: research in well-defined depres-designed for the measurement of the intensity of sive populations and especially in samples of depres-depression in patients with psychiatric diagnoses sive inpatients is rare and lacking.(Beck et al., 1961). This instrument is one of the 10 For instance, in their review on the discriminantmost utilized instruments in the clinical practice of validity of the BDI, Beck et al. (1988) review anAmerican psychologists (Watkins et al., 1995). extensive amount of research supporting the differen-

The BDI seems to be a well-investigated depres- tiation by the BDI between psychiatric andsion instrument: Beck et al. (1988) reviewed its nonpsychiatric samples. However, only three studies

were reviewed that investigated the differentiation*Corresponding author. Fax: 1 32 3 8290520 between different types of diagnosed depressive

0165-0327/97/$17.00 1997 Elsevier Science B.V. All rights reserved.PII S0165-0327( 97 )00094-3

116 C.K.W. Schotte et al. / Journal of Affective Disorders 46 (1997) 115 –125

disorders. Not included in this review was the study pression severity and should, therefore, display posi-by Steer et al. (1987b), in which DSM-III major tive associations with depression classificationsdepressive outpatients were compared with (DSM-III subtypes of depression), with other depres-dysthymic outpatients: the major depressive group sion instruments (HDRS interview), and with bio-obtained significantly higher BDI scores. logical depression markers such as the DST. On the

Factor analytic studies investigate whether the other hand, one should find negative or weak as-BDI items can be grouped into factors or com- sociations with measurements of theoretically orponents, representing the constructs that underlie the semantically different concepts, such as the Axis IIinstrument. The BDI research in non-psychiatric diagnosis or sociodemographic variables.samples, such as student populations, tends to The DST received extensive study in the earlyproduce large general factors which merely discrimi- 1980s as a possible diagnostic test for depression.nate the distressed from the non-distressed (Wec- Although neither the specificity nor the sensitivitykowitz et al., 1967). Although factor analytic re- showed adequate test performance for routine clini-search on depression scales is most relevant in cal practice, the DST outcome is associated withdiagnosed depressive populations, only one study depression severity (e.g., Maes et al., 1986; Meador-(i.e., Steer et al., 1987a) investigated the factor Woodruff et al., 1988) and with the more severestructure of the BDI exclusively based on diagnosed forms of depression such as melancholic and/ordepressed patients (Startup et al., 1992). Using a delusional depressions (Holsboer, 1992). The rela-sample of 300 outpatients diagnosed with DSM-III tionship of self-report depression scales with themajor depressive disorder, Steer et al. (1987a) found response on the DST test remains unclear: somethree components, which were identified as reflect- authors report significant interactions (e.g., Sangal eting, respectively, affective and performance difficul- al., 1984; Ansseau et al., 1986; Cluydts et al., 1987),ties, self-denigration, and physiological disturbances. whereas other researchers find no significant relation-This solution differs in important respects from the ship between the post-dexamethasone DST-statusstructure summarized in several reviews and was and self-report depression scales (e.g., Post et al.,supported by confirmative factor analysis in the 1985; Norman et al., 1985). The presence of astudy by Startup et al. (1992) in a sample of 139 personality disorder in depressive patients is general-DSM-III major depressive patients. ly associated with a less favourable effect for

In an effort to address this critical gap in the BDI pharmacological (Black et al., 1988; Reich, 1990;research, the present study investigates the psycho- Shea et al., 1992; Sato et al., 1993; Brophy, 1994)metric properties of the BDI in a unipolar depressive and psychotherapeutic interventions (Shea et al.,inpatient population, diagnosed according to the 1992). In the study of Sanderson et al. (1992)DSM-III (APA, 1980) classification by means of the dysthymic and major depressed patients with aStructured Clinical Interview for DSM-III ((SCID), personality disorder obtained higher BDI scoresSpitzer et al., 1985). This study focuses on the compared with the depressed patients without afollowing aspects of construct validity: (1) the diagnosis of a personality disorder.examination of the factor structure of the BDI and In summary, the present study aims to investigatethe development and psychometric evaluation of and elucidate the reliability and construct validity offactor analytically generated subscales; (2) the abili- the BDI in an inpatient unipolar depressive popula-ty of the BDI to differentiate between subtypes of tion.depressive disorders, diagnosed according to theDSM-III classification (APA, 1980); and the relation-ship of the BDI (3) with the outcome of the 2. MethodDexamethasone Suppression Test (DST), which isconsidered as a biological state-marker for major 2.1. Subjectsdepression (Carrol, 1980; Maes et al., 1986, 1989);and (4) with the diagnosis of a DSM-III(-R) per- All subjects were inpatients admitted to the psy-sonality disorder. The BDI intends to measure de- chiatric ward of the Antwerp University Hospital

C.K.W. Schotte et al. / Journal of Affective Disorders 46 (1997) 115 –125 117

(U.Z.A.) between 1986 and 1994. This psychiatric et al., 1979) and of the 17-item semi-structuredward is a 30-bed short-term unit (with a mean length version of the Hamilton Depression Rating Scaleof stay of approximately 1 month) that specializes in (HDRS; Williams, 1988). However, Item 3 (Genitalthe diagnosis and treatment of adult affective and symptoms) of the HDRS was not rated as most of theneurotic symptomatology. Most of the patients are patients seemed to be rather reluctant or uncomfort-from the Antwerp region and are referred by general able to answer this question during the interview.practitioners and psychiatrists. Consequently, the score on this item was not used in

The subject sample consisted of 338 patients computing the overall HDRS score.diagnosed as unipolar depressive patients and classi- The level of subjectively experienced anxiety wasfied according to DSM-III as follows. (1) MIN, assessed with the Dutch version of the State-Traitminor depression: dysthymic disorder (DSM-III code Anxiety Inventory (STAI; Van Der Ploeg et al.,300.40; n 5 41) and adjustment disorder with de- 1980).pressed mood (DSM-III code 309.00; n 5 52) were The BDI and STAI were routinely administratedlabelled as minor depression (n 5 93). (2) MAJ, 4–6 days after admission, whereas the patients weresimple major depression (code 296.X2; n 5 152). (3) interviewed with the SCID and HDRS after 7–9MEL/PSY (n 5 93), major depression with melan- days. Raters were blind with respect to the BDI andcholia (296.X3; n 5 79) or psychotic features STAI results; interview and self-report instruments(296.X4; n 5 14). The diagnoses were obtained with were administered in the morning to avoid the effectsthe SCID interview (Spitzer et al., 1985). The use of of diurnal variation.the DSM-III classification was preferred above Seven days after admission blood was drawn afterDSM-III-R (APA, 1987): the main raison was the an overnight fast at 8:00 a.m. for the assays ofdissatisfaction of the present authors with the defini- baseline cortisol; on the same day patients ingested 1tion of melancholia in the DSM-III-R (Maes et al., mg dexamethasone at 11:00 p.m.; the next day at1990, 1992). The DSM-IV (APA, 1994) conceptuali- 8:00 a.m. after an overnight fast, blood was sampledsation of melancholic depression returned to the for the determination of the postdexamethasoneDSM-III definition: consequently, the depression cortisol values. The methods for the assessment ofdiagnoses in the present study are in line with the the cortisol values are described elsewhere (Maes etrecent DSM-IV classification. al., 1986, 1989): an 8:00 a.m. postdexamethasone

Clinical DSM-III(-R) Axis II diagnoses were cortisol value $ 3.5 mg/dl defined cortisol non-obtained at the end of the hospitalisation period. suppression.These Axis II diagnoses were categorised as follows: Only patients with the following DSM-III unipolar(1) positive diagnosis of a DSM-III(-R) personality affective diagnoses were included: dysthymic disor-disorder (n 5 157); (2) absence of a personality der, adjustment disorder with depressed mood, sim-diagnosis (n 5 135); and (3) no Axis II data (n 5 15) ple major depression, major depression with melan-or diagnosis deferred on Axis II (n 5 31). The cholia, and major depression with psychotic features.unstructured clinical diagnosis of the DSM-III(-R) Patients with bipolar, organic mental, or nonaffectivepersonality disorders is associated with a low re- psychotic disorders were excluded. Patients wereliability (Mellsop et al., 1982); therefore we did not free of antidepressive medication during at least 7retain the specific personality disorders diagnoses, days. Routine blood plasma tests, urine analyses, andbut used the dichotomisation absence /presence of neurological examinations showed no majorany personality disorder diagnosis in our analyses. pathologies.This clinical diagnosis is a team diagnosis thatapproaches the LEAD procedure (Spitzer, 1983). 2.3. Statistics

2.2. Procedure Correlations between variables are expressed bymeans of Pearson’s product-moment coefficient.

Depression severity was assessed by means of Analyses of variance were used to assess groupDutch translations of the BDI (BDI-R version, Beck mean differences: for a posteriori comparisons be-


tween groups we used the statistically rather con- 3.1. Factorial structure of the BDI´servative Scheffe test, which offers a good protection

against the increased a error rate due to the multiple The scree test revealed the possibility of a two- orpost-hoc comparisons. a three-factor solution. Table 2 presents the varimax-

Factor analysis (principal component analysis) is rotated principal components of these two solutions.applied in order to investigate the underlying struc- The two-factor solution accounted for 45% of theture of the instruments. Cattell’s scree test was variance. Four items loaded significantly on bothutilized for determining the optimal number of factors. Items 1–9, 11, 13, and 14 loaded saliently onfactors (Zwick and Velicer, 1982), which were the first factor, whereas the remaining BDI itemsretained for subsequent orthogonal varimax rotation. loaded on the second factor. Thus, the first factor is

represented by the cognitive items, reflecting anegative self-view, together with the items on depre-ssive mood, pessimism, irritability, suicidal ideation,

3. Results and indecisiveness. The second factor contains thesomatic items of the BDI, together with the items on

Table 1 summarizes the demographic data for the social withdrawal and work inhibition. Consequently,338 depressive patients in this study. Both age and the two-factor solution reflects the psychologicalHDRS scores differed significantly between the versus somatic dichotomisation in the BDI, with thedepressive subgroups. The correlation between the first factor representing the psychological /cognitivetotal score of the BDI and the HDRS was 0.36 dimension and the second factor containing the(P , 0.001, n 5 310), whereas the correlation of the somatic /vegetative items.BDI with the STAI-State was 0.73 (P , 0.001; n 5 The three-factor solution explained 51% of the282). total variance. The largest first factor is heteroge-

The BDI scores did not differ significantly be- neous in content and represents several aspects oftween male and female patients (F(1,311) 5 3.48, depressive symptomatology: this component revealedP 5 0.06) and were not associated with age (r 5 2 salient loadings for the items reflecting anhedonia0.01, P 5 0.78, n 5 313) nor with educational level, (items 4, 21, 12), inhibition (items 15 and 13),as indicated by the number of years of schooling pessimism (item 2), somatic dysfunctioning (items(r 5 2 0.03, P 5 0.65, n 5 267). Neither the marital 17 and 20), and mood (items 1 and 11). Westatus nor the presence /absence of occupational interpreted this factor as ‘Anhedonia / Inhibition’ onactivities influenced significantly the BDI scores. the hand of the items with the highest loadings. The

Cronbach’s coefficient a (Cronbach, 1951) was second factor is more homogeneous in content: the0.91, suggesting a high internal consistency of the items loading on this component mainly reflect theBDI. self-denigratory cognitive items: this factor is la-

Table 1Demographic characteristics of the unipolar depression sample

Depression sample Index No. Sex ratio: Age, mean HDRS, mean% female (S.D.) (S.D.)

Total sample — 338 73 46.2 (13.6) 20.1 (6.1)Minor depression MIN 93 73 43.0 (13.6) 14.3 (4.2)Major depression MAJ 152 78 44.9 (13.1) 20.3 (3.9)Melancholic major depression MEL/PSY 93 67 51.6 (13.0) 25.6 (5.3)(n 5 79) or with psychoticfeatures (n 5 14)

Univariate analyses of variance between the depression samples: age, F(2,335) 5 11.2, P , 0.0001; HDRS, F(2,331) 5 150.5, P , 0.0001.


Table 2Principal component structure of the BDI after varimax rotation in the unipolar depressed inpatient population (n 5 313): the two- andthree-component structure

BDI-items Two-factor solution Three-factor solution2 a 2 aFactor 1 Factor 2 h Factor 1 Factor 2 Factor 3 h

1 Mood 0.53 0.45 0.48 0.52 0.482 Pessimism 0.54 0.47 0.51 0.66 0.563 Sense of failure 0.76 0.63 0.66 0.634 Lack of satisfaction 0.56 0.51 0.58 0.71 0.645 Guilty feeling 0.77 0.59 0.78 0.646 Sense of punishment 0.72 0.52 0.73 0.547 Self-hate 0.77 0.59 0.77 0.638 Self accusations 0.75 0.57 0.71 0.599 Suicidal ideas 0.58 0.39 0.45 0.45 0.4110 Crying spells 0.25 0.46 0.3911 Irritability 0.45 0.31 0.48 0.3312 Social withdrawal 0.47 0.52 0.49 0.64 0.5213 Indecisiveness 0.52 0.45 0.50 0.4514 Body image 0.55 0.46 0.48 0.4715 Work inhibition 0.59 0.49 0.67 0.5216 Sleep disturbance 0.48 0.23 0.61 0.3917 Fatigability 0.65 0.51 0.60 0.5118 Loss of appetite 0.64 0.44 0.54 0.4819 Weight loss 0.53 0.28 0.78 0.6220 Somatic preoccupation 0.62 0.39 0.57 0.4121 Loss of libido 0.53 0.36 0.65 0.44Eigenvalue 5.57 3.95 4.59 4.19 1.89% Variance 26.54 18.81 45.35 21.86 19.96 9.01 50.83

Only loadings $ 0.45 are presented.a 2h indicates the communalities of the items.

belled as ‘Negative Selfconcept’. The third factor is factor or items with non-salient loadings were notlabelled as ‘Somatic Complaints’ because of its retained for the subscale construction (Kline, 1993).salient loadings for the items 19, 16, and 18. The ‘psychological’ subscale is labelled ‘BDIPSY’

and contains nine items (items 3, 5–9, 11, 13, and14). The BDIPSY subscale consists mainly of the

3.2. Factor analytically generated BDI subscales self-derogatory cognitive items, together with theitems on suicidal ideation, irritability, and indecisive-

The three-factor solution contained a first com- ness. The internal consistency of the subscale wasponent which was heterogeneous in content and a 0.86, as measured by Cronbach’s a. The BDIPSYthird component with only three items; the latter subscale correlates weakly with the age of theprovides in an internal inconsistent subscale (Cron- subjects (r 5 2 0.16, P 5 0.003), but the scores arebach’s a 5 0.54) Therefore, we selected the two- not significantly associated with the gender of ourfactor solution for the development of the BDI inpatients (F(1,317) 5 3.54, P 5 0.06).subscales: this factor solution represents the psycho- The ‘somatic’ subscale is labelled as ‘BDISOM’logical / somatic dichotomisation in the BDI. For the and consists of seven items (items 15–21). Thesecreation of the two subscales we retained only the items represent the symptoms of sleep disorders,items with salient loadings ( $ 0.45) on one single fatigue, loss of appetite and weight, somatic preoccu-factor: items with high loadings on more than one pation, loss of libido, and inhibition of work and


activities. The Cronbach a of the BDISOM subscale 3.4. Relationship of the BDI with DST and DSM-is 0.73; this subscale correlates weakly with age III(-R) Axis II(r 5 2 0.22, P , 0.001) and significant effects ofgender (F(1,319) 5 4.05, P 5 0.05), with female Table 4 presents the results of the analyses ofpatients obtaining higher scores, are noticed. variance with the BDI, BDISOM, and BDIPSY

subscales as dependent variables and, respectively,the DST response and the DSM-III(-R) diagnosis of

3.3. The BDI and the DSM-III subtypology of any personality disorder as independent variables.depression Neither the BDI total score nor the BDIPSY

subscale score revealed any significant effects for theTable 3 presents the results of the analyses of DST suppression /non-suppression response. Patients

´variance and post hoc Scheffe tests with the BDI, with a positive diagnosis of a DSM-III(-R) personali-BDIPSY, and BDISOM subscales as the dependent ty disorder had significantly higher BDI andvariables and the minor, major, and melancholic / BDIPSY scores than the depressive patients withoutpsychotic diagnostic depression subgrouping as the an Axis II diagnosis. On the other hand, an inverseindependent variable. relationship is observed for the somatic BDISOM

The analyses of variance indicated significant subscale: the BDISOM scores were significantlyeffects of the diagnostic grouping on the scores of higher in the non-suppressor group, but were notthe BDI and the two subscales; this interaction was significantly associated with the DSM-III(-R) per-

´less obvious for the BDIPSY subscale. The Scheffe sonality disorder diagnosis.post hoc tests revealed that the BDI and theBDISOM scores differentiated significantly betweenthe three diagnostic depression subgroups; the 4. DiscussionBDIPSY scores revealed only significant differencesbetween the minor depressive and the melancholic / In modern psychometrics (e.g., Kline, 1993; Silva,psychotic depression subgroups. 1993) the validity of a psychological test is inter-

Table 3´Results of the analyses of variance (ANOVA) and Scheffe post hoc tests for the BDI, BDIPSY and BDISOM scores with the DSM-III

unipolar depressive categories as independent variables

DSM-III diagnostic group ANOVA

MIN (n 5 93) MAJ (n 5 152) MEL/PSY (n 5 93) F df P ,

BDIMean 22.13 26.79 31.52 13.30 2,310 0.00001S.D. 11.25 11.81 12.35Index 2,3 1,3 1,2BDIPSYMean 8.52 9.84 10.88 3.59 2,316 0.03S.D. 5.55 5.96 5.90Index 3 1BDISOMMean 8.03 10.14 11.86 19.73 2,318 0.000001S.D. 3.87 4.10 4.12Index 2,3 1,3 1,2

´Index: results of the Scheffe post-hoc test (P , 0.05). Only significant differences between the diagnostic groups are indicated. Index 1 refersto significantly different from MIN; 2 refers to different from MAJ; 3 refers to different from MEL/PSY.


Table 4Results of the analyses of variance (ANOVA) for the BDI, BDIPSY and BDISOM scores with (a) the outcome of the DexamethasoneSuppression Test and (b) the presence of a DSM-III(-R) Axis II personality disorder diagnosis as independent variables

DST outcome ANOVA DSM-III(-R) Axis II diag-nosis ANOVA

Suppression Non-suppression F df P Absent Present F df P(n 5 234) (n 5 86) (n 5 135) (n 5 157)

BDIMean 26.16 28.30 1.83 1293 0.18 24.41 29.56 12.49 1,270 0.0005S.D. 11.92 12.44 11.34 12.48BDIPSYMean 9.67 9.83 0.04 1299 0.84 8.46 11.29 17.14 1,273 0.00005S.D. 5.83 5.83 5.11 6.06BDISOMMean 9.67 11.14 7.34 1301 0.007 9.59 10.58 3.68 1,277 0.06S.D. 4.17 4.38 4.31 4.31

preted within the frame of the construct validity: of anxiety (Dobson, 1985): this result was alsoMessick (1989) considers the validity of a test obtained in our study. The Negative and Positive‘‘ . . . as an integrated evaluative judgement of the Affect Theory (Watson and Tellegen, 1985), and itsdegree to which empirical evidence and theoretical successor, the Tripartite Model (Clark et al., 1994;rationales support the adequacy and appropriateness Watson et al., 1995a,b) offer a theoretical frameworkof inferences and actions based on test scores . . . ’’. in which the observed strong relationship is ex-The present study focuses on the construct validity of plained by the fact that anxiety as well as depressionthe BDI and is one of the first studies that aims to self-report scales are strong markers of Negativeelucidate what exactly the BDI measures in a Affect.population of depressive inpatients. Factor analysis is a technique which is particularly

Firstly, consistent with the literature (e.g., Beck et relevant for construct validity research (e.g., Schotteal., 1988), we found a high index of internal et al., 1996). In the present study we detectedconsistency for the BDI. The present study detected meaningful two- and three-factor solutions.no significant relationships in depressed subjects The three-factor solution contained a first com-between the BDI and sociodemographic variables ponent ‘Anhedonia / Inhibition’ that corresponds wellsuch as age, sex, education, marital status, occupa- with the ‘Cognitive-Affective and Performance Dif-tional activity. ficulties’ factor, obtained by Steer et al. (1987a) in a

There was a weak correlation between the BDI major depressive outpatient population. However,and the HDRS (i.e., r 5 0.36), which reflects the item 20 ‘Somatic Preoccupations’ in the presentdifferent measurement approaches of the interview study loaded saliently on the first factor, whereas inand self-report methods. Both methods correspond the study by Steer and collaborators this item loadedonly to some extent and each has particular advan- on the third component. The second factor wastages and disadvantages such as costs, specificity, labelled as ‘Negative Selfconcept’ and correspondsand potential bias (Paykel and Norton, 1986). A well with the ‘Cognitive Distortions’ factor in themultiple assessment strategy, in which interview and Steer et al. (1987a) study. Differences between bothself-report are utilised is strongly recommended for studies are noted for items 9 and 10: item 9 (Suicidalresearch and clinical purposes (Paykel and Norton, Ideas) in the present study loads saliently on the first1986; Steer et al., 1987a). On the other hand, self- two factors, whereas in the Steer et al. study thisreport measures of depression are generally highly item loaded only on the first factor. Item 10 (Cryingand significantly correlated with self-report measures Spells) failed to load saliently in the study by Steer


et al., whereas in our study this item is represented on a continuum of depression severity. The BDI is aon the second factor. The third factor is labelled in dimensional measure of depression severity and isboth studies as ‘Somatic Complaints’. In summary: not an appropriate instrument for categorical deci-the three-factor solution in our depressive inpatient sions on the presence of a depressive nosologicalpopulation corresponded with the solution, obtained disorder. Categorical evaluations need to be doneby Steer et al. (1987b) in a major depressive with categorical instruments such as the SCID or theoutpatient population and suggests that the BDI Inventory to Diagnose Depression (IDD);measures the following three dimensions in depres- Zimmerman et al., 1986). Although several authorssive populations: (1) depressive mood, anhedonia, recognize this important distinction (e.g., Gibbons etand inhibition of activities, (2) negative selfconcept, al., 1985; Kendall et al., 1987; Wetzler et al., 1991),and (3) somatic /vegetative features. there is a tendency in depression research to establish

The two-factor solution reflected the psychologi- categorical decisions on dimensional instrumentscal / somatic dichotomisation in the BDI, and corre- such as the BDI (e.g., Oliver and Simmons, 1984,sponds with results obtained by Louks et al. (1989) 1985; Kutcher and Marton, 1989) and to report onand Steer et al. (1992). These authors labelled a first the relative high sensitivity but low specificity of thefactor, consisting of the first 13 or 14 items as BDI for specific nosological disorders. The BDI‘Cognitive-Affective’ and a second factor, consisting cutoff-score . 9 is often used to decide on theof the last six or seven items as ‘Somatic-Per- presence of a depressive disorder (e.g., Shaw et al.,formance’ or ‘Vegetative’. 1985; Steer et al., 1986; Kendall et al., 1987; Rabkin

Based on this two-factor solution, we developed and Klein, 1987). However, the appropriateness ofthe psychological /cognitive BDIPSY subscale and the various BDI cutoff-score ranges depends on thethe somatic /vegetative subscale BDISOM. Both nature of the sample. Together with Prud’hommesubscales obtained acceptable indexes of internal and Baron (1993) we emphasize that the BDI scoreconsistency. is not a valid categorical diagnostic indicator of

This study is one of the rare studies which clinical depression.examined the discriminant or differential validity of Nevertheless, in the light of the construct validitythe BDI in a DSM-III-diagnosed depression popula- of the BDI it is important that the scores of the BDItion. This population was subdivided in minor, reflect the hierarchy in depression severity, which ismajor, and melancholic /psychotic depression diag- implemented in the DSM-III classification. Thenostic subgroups. clinical criteria and descriptions of the DSM-III

However, when investigating this important aspect (APA, 1980) indicate an increasing severity of illnessof the construct validity we need to consider the fact from the minor (i.e., dysthymic and adjustmentthat the BDI is an instrument, designed for the disorder with depressed mood) over the major to-dimensional measurement of depression severity. wards the melancholic or psychotic depressionsThe BDI measures syndrome depression, which is a (Maes et al., 1986; Williams and Spitzer, 1982). Theconstellation of signs and symptoms, and which can present study found significant effects for the BDI,be present in secondary ways in non-affective psy- for the BDISOM, and—to a lesser extent—for thechiatric disorders (Kendall et al., 1987). Schotte BDIPSY scales. We found that the BDI and(1996) distinguishes between two diagnostic levels BDISOM scores differentiated significantly betweenof measurement in the area of the descriptive diag- the three depression subgroups; the BDIPSY sub-nostic assessment of depression: the categorical and scores discriminated only significantly between thedimensional levels of assessment. The aim of mea- minor and melancholic /psychotic groups.surement in the categorical diagnostic level is to Furthermore, significant effects of the DSTdecide if the symptom profile of a person corre- (non-)suppression response were only noticed for thesponds with the in- and exclusion criteria for a BDISOM subscale, whereas significant effects of thediagnostic category. For the dimensional assessment DSM-III(-R) diagnosis of a personality disorder werethe central aim is to rank the severity of a person’s observed for the BDI and BDIPSY, but not for thesymptom profile, expressed by means of a test score, BDISOM scores.


The significant association of the BDI and support and generalize the present findings, thisBDISOM scores with the classification of the minor, study generally supports the construct validity of themajor and melancholic /psychotic subtypes is an BDI and emphasizes the potential diagnostic utilityargument in favour of their construct validity. The of the self-report measurement of somatic /vegetativelack of differentiation between the depression sub- symptoms for the assessment of depression severitygroups of the cognitive modality, as measured with in depressive populations.the BDIPSY subscale, is consistent with the researchwith the Automatic Thoughts Questionnaire (ATQ;Hollon and Kendall, 1980). The ATQ scores did not Acknowledgementsdifferentiate between endogenous and non-endogen-ous depressive subjects (Eaves and Rush, 1984), nor This study was supported by a doctoral grant forbetween minor and major depressions (Schotte et al., the first author from the National Fund for Scientific1991) or between uni- and bipolar depressions Research (N.F.W.O.), Brussels, Belgium.(Hollon et al., 1986). These findings suggest thatnegative cognitions, as measured by self-report ques-tionnaires, can be considered as state-dependent

Referencesconcomitants of syndrome depression, independentof nosological or etiological factors.

American Psychiatric Association, 1980. DSM-III: Diagnostic andThe observed relations between the BDI subscalesStatistical Manual of Mental Disorders, 3rd ed. APA, Washing-and the DST outcome are consistent with the find-ton, DC.

ings reported in the Gastpar et al. (1992) multi- American Psychiatric Association, 1987. DSM-III-R: Diagnosticcenter study. These authors reported that DST sup- and Statistical Manual of Mental Disorders, 3rd ed., revised.

APA, Washington, DC.pression was best predicted by the cognitive symp-American Psychiatric Association, 1994. DSM-IV: Diagnostic andtom ‘ideas of insufficiency’; non-suppression was

Statistical Manual of Mental Disorders, 4th ed. APA, Washing-weakly associated with somatic depression symp-ton, DC.

toms such as weight-loss and sleep disorders. Ansseau, M., von Frenckel, R., Franck, G., Geenen, V., Legros,The self-report assessment of the negative cogni- J.J., 1986. Dexamethasone suppression test and MMPI scales.

Neuropsychobiology 16, 68–71.tions, as measured with the BDIPSY scale, was—inBeck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J.,contrast with the BDISOM subscale—significantly

1961. An inventory for measuring depression. Arch. Gen.associated with the clinical diagnosis of a DSM-IIIPsychiatry 4, 53–63.

(-R) personality disorder. Beck, A.T., Rush, A., Shaw, B.F., Emery, G., 1979. CognitiveIn summary, we found some arguments pointing at Therapy of Depression. Guilford Press, New York.

psychometric weaknesses of the BDI—and depres- Beck, A.T., Steer, R.A., Garbin, M.G., 1988. Psychometricproperties of the Beck Depression Inventory: twenty-five yearssion self-report scales in general—such as the weakof evaluation. Clin. Psychol. Rev. 8, 77–100.convergent validity with respect to the HDRS and

Black, D.W., Bell, S., Hulbert, J., Nasrallah, A., 1988. Thethe inadequate divergent validity, as indicated in the importance of Axis II in patients with major depression. Apresent study by the high correlation between the controlled study. J. Affect. Disord. 14, 115–122.BDI and the STAI. Brophy, J.J., 1994. Personality disorder, symptoms and dexa-

methasone suppression in depression. J. Affect. Disord. 31,On the other hand, we found evidence for the19–27.factorial and differential validity of the BDI in a

Carrol, B.J., 1980. Clinical application of neuroendocrine researchdiagnosed depressive inpatient population. Further- in depression. In: van Praag H.M. et al. (Eds.), Handbook ofmore, the present study indicates that the self-report Biological Psychiatry, Part III. Marcel Dekker, New York. pp.of the somatic modality in the BDI—in contrast with 179–193.

Clark, D.A., Steer, R.A., Beck, A.T., 1994. Common and specificthe self-report of the psychological /cognitivedimensions of self-reported anxiety and depression: implica-modality—shows a closer relationship with the de-tions for the cognitive and tripartite models. J. Abnorm.

pression construct, as evidenced by the associations Psychol. 103, 645–654.with the DSM-III classification and with the DST Cluydts, R., De Roeck, J.M.J., Beckham, B.J., 1987. Psychologi-outcome. Although further research is necessary to cal correlates of the dexamethasone supression test response


and of the shortened REM sleep latency in depressed outpati- Messick, S., 1989. Validity. In: Linn, R.L. (Ed.), EducationalMeasurement, 3rd ed. Macmillan and Collier Macmillan, Newents. Acta Psychiat. Belg. 87, 317–324.York, p. 13.Cronbach, L.J., 1951. Coefficient alpha and the internal structure

Norman, W.H., Keitner, G.I., Miller, I.W., 1985. MMPI, personali-of tests. Psychometrika 16, 297–334.ty dysfunction and the dexamethasone suppression test inDobson, K.S., 1985. The relationship between anxiety and depres-major depression. J. Affect. Disord. 9, 97–101.sion. Clin. Psychol. Rev. 5, 307–324.

Oliver, J.M., Simmons, M.E., 1984. Depression as measured byEaves, G., Rush, A.J., 1984. Cognitive patterns in symptomaticthe DSM-III and the Beck Depression Inventory in a unselectedand remitted unipolar depression. J. Abnorm. Psychol. 93,adult population. J. Consult. Clin. Psychol. 52, 892–898.31–40.

Oliver, J.M., Simmons, M.E., 1985. Affective disorders andGastpar, M., Golsdorf, U., Abou-Saleh, M.T., Ngo-Khac, T.,depression as measured by the Diagnostic Interview Schedule

1992. Clinical correlates of response to DST. The Dexa-and the Beck Depression Inventory in an unselected adult

methasone Suppression Test in depression: a World Healthpopulation. J. Clin. Psychol. 41, 469–477.

Organisation Collaborative study. J. Affect. Disord. 26, 17–24.Paykel, E.S., Norton, K.R.W., 1986. Self-report and clinical

Gibbons, R.D., Clark, D.C., von Ammon Cavanaugh, S., Davis, interview in the assessment of depression. In: Sartorius, N.,J.M., 1985. Application of modern psychometric theory in Bann, T.A. (Eds.), Assessment of Depression. Springer-Verlag,psychiatric research. J. Psychiatr. Res. 19, 43–55. Heidelberg, pp. 356–366.

Hollon, S.D., Kendall, P.C., 1980. Cognitive self-statements in Post, R.D., Alford, C.E., Baker, N.J., Franks, R.D., House, R.M.,depression: development of an Automatic Thoughts Ques- Jackson, A.M., Petersen, J.L., 1985. Comparison of self-reportstionnaire. Cognitive Ther. Res. 4, 383–395. and clinicians’ ratings of unipolar depression. Psychol. Rep.

Hollon, S.D., Kendall, P.C., Lumry, A., 1986. Specificity of 57, 479–483.depressotypic cognitions in clinical depression. J. Abnorm. Prud’homme, L., Baron, P., 1993. Utility of the Beck DepressionPsychol. 95, 52–59. Inventory in clinical research: some additional data. Rev. Eur.

Holsboer, F., 1992. The hypothalamic-pituitary-adreno-cortical Psychol. Appl. 43, 311–314.system. In: Paykel, E.S. (Ed.), Handbook of Affective Dis- Rabkin, J.G., Klein, D.F., 1987. The clinical measurement oforders. Guilford Press, New York. pp. 267–287. depressive disorders. In: Marsella et al. (Eds.), The Measure-

Kendall, P.C., Hollon, S.D., Beck, A.T., Hammen, C.L., Ingram, ment of Depression. Wiley & Sons, New York, pp. 30–86.R.E., 1987. Issues and recommendations regarding use of the Reich, J.H., 1990. Effect of DSM-III personality disorders onBeck Depression Inventory. Cognitive Ther. Res. 11, 289–299. outcome of tricyclic antidepressant-treated non-psychotic out-

Kline, P., 1993. The Handbook of Psychological Testing. Rout- patients with major or minor depressive disorder. Psychiatryledge, London. Res. 32, 175–181.

Kutcher, S.P., Marton, P., 1989. Utility of the Beck Depression Sanderson, W.C., Wetzler, S., Beck, A.T., Betz, F., 1992. Preval-Inventory with psychiatrically disturbed adolescent outpatients. ence of personality disorders in patients with major depressionCan. J. Psychiatry 34, 107–109. and dysthymia. Psychiatry Res. 42, 93–99.

Louks, J., Hayne, C., Smith, J., 1989. Replicated factor structure Sangal, R., Correa, E.I., DePaulo, J.R., 1984. Depression andof the Beck Depression Inventory. J. Nerv. Ment. Dis. 177, anxiety inventories, and the dexamethasone suppression test.473–479. Biol. Psychiatry 19, 1207–1213.

Maes, M., De Ruyter, M., Hobin, P., Suy, E., 1986. The Sato, T., Sakado, K., Sato, S., 1993. Is there any specificdexamethasone suppression test, the Hamilton Depression personality disorder or personality disorder cluster that worsensRating Scale and the DSM-III depression categories. J. Affect. the short-term treatment outcome of major depression?. ActaDisord. 10, 207–214. Psychiat. Scand. 88, 342–349.

Maes, M., Vandewoude, M., Schotte, C., Cosyns, P., 1989. Results Schotte, C., 1996. Descriptive diagnostic assessment of unipolarof the 8 a.m. Dexamethasone Suppression Test constitute a depressive disorders. Unpublished doctoral dissertation, Freesuitable tool for confirming the diagnosis of melancholia. University of Brussels (V.U.B), Brussels, Belgium.Neuropsychobiology 22, 26–32. Schotte, C., Maes, M., Claes, M., D’Hondt, P., Cosyns, P., 1991.

Maes, M., Cosyns, P., Maes, L., D’hondt, P., Schotte, C., 1990. Cognitive assessment of depression: clinical validation of theClinical subtypes of unipolar depression: Part I. A validation of Dutch ATQ-30. Tijdschr. Klin. Psychol. 21, 123–134.the vital and nonvital clusters. Psychiatry Res. 34, 29–41. Schotte, C.K.W., Maes, M., Cluydts, R., Cosyns, P., 1996. Effects

Maes, M., Maes, L., Schotte, C., Cosyns, P., 1992. A clinical and of affective-semantic mode of item presentation in balancedbiological validation of the DSM-III melancholia diagnosis in self-report scales: biased construct validity of the Zung self-men: results of pattern recognition methods. J. Psychiatr. Res. rating depression scale. Psychol. Med. 26, 1161–1168.26, 183–196. Shaw, B.F., Vallis, T.M., McCabe, S.B., 1985. The assessment of

Meador-Woodruff, J.H., Greden, J.F., Grunhaus, L., Haskett, R.F., the severity and symptom patterns in depression. In: Beckham,1988. Dexamethasone suppression test status and severity of E.E., Leber, W.R. (Eds.), Handbook of Depression. The Dorseydepression. Biol. Psychiatry 24, 693–696. Press, Homewood, IL, pp. 372–407.

Mellsop, G., Varghese, F., Joshua, S., Hicks, H., 1982. The Shea, M.T., Widiger, T.A., Klein, M.H., 1992. Comorbidity ofreliability of Axis II of DSM-III. Am. J. Psychiatry 139, personality disorders and depression: implications for treat-1360–1361. ment. J. Consult. Clin. Psychol. 60, 857–868.


Silva, F., 1993. Psychometric Foundations and Behavioral Assess- Watson, D., Tellegen, A., 1985. Toward a consensual constructionment, Sage Publications, Newbury Park, CA, USA. of mood. Psychol. Bull. 98, 219–235.

Spitzer, R.L., 1983. Psychiatric diagnosis: are clinicians still Watson, D., Weber, K., Assenheimer, J.S., Clark, L.A., Strauss,necessary?. Comp. Psychiatry 24, 399–411. M.E., McCormick, R.A., 1995a. Testing a tripartite model: I.

Spitzer, R.L., Williams, J.B.W., Gibbon, M., 1985. Structured Evaluating the convergent and discrimant validity of anxietyClinical Interview for DSM-III Patient Version. Biometrics and depression symptoms scales. J. Abnorm. Psychol. 104,Research Department, New York State Psychiatric Institute, 3–14.New York. Watson, D., Clark, L.A., Weber, K., Assenheimer, J.S., Strauss,

Startup, M., Rees, A., Barkham, M., 1992. Components of major M.E., McCormick, R.A., 1995b. Testing a tripartite model: II.depression examined via the Beck Depression Inventory. J. Exploring the symptom structure of anxiety and depression inAffect. Disord. 26, 251–259. student, adult, and patient samples. J. Abnorm. Psychol. 104,

Steer, R.A., Beck, A.T., Garrison, B., 1986. Applications of the 15–25.Beck Depresssion Inventory. In: Sartorius, N., Bann, T.A. Weckowitz, T.E., Muir, W., Cropley, A.J., 1967. A factor analysis(Eds.), Assessment of Depression. Springer-Verlag, Heidelberg, of the Beck Inventory of Depression. J. Consult. Psychol. 31,pp. 123–142. 23–28.

Steer, R.A., Beck, A.T., Riskind, J.H., Brown, G., 1987. Relation- Wetzler, H.M., van Praag, H.M., Katz, M.M., 1991. Diagnosingships between the Beck Depression Inventory and the Hamilton depression: a two-tier approach. In: Feighner, J.P., Boyer, W.F.Psychiatric Rating Scale for Depression in depressed outpati- (Eds.), Diagnosis of Depression. Wiley and Sons, Chichester,ents. J. Psychopathol. Behav. Assess. 9, 327–339. UK, pp. 65–78.

Steer, R.A., Beck, A.T., Brown, G., Berchick, R.J., 1987. Self- Williams, J.B.W., 1988. A structured interview guide for thereported depressive symptoms that differentiate recurrent-epi- Hamilton Depression Rating Scale. Arch. Gen. Psychiatry 45,sode major depression from dysthymic disorders. J. Clin. 742–747.Psychol. 43, 246–250. Williams, J.B.W., Spitzer, R.L., 1982. Research diagnostic criteria

Steer, R.A., Iguchi, M.Y., Platt, J.J., 1992. Use of the revised Beck and DSM-III. Arch. Gen. Psychiatry 39, 1283–1289.Depression Inventory with intravenous drug users not in Zimmerman, M., Coryell, W., Corenthal, C., Wilson, S., 1986. Atreatment. Psychol. Addict. Behav. 6, 225–232. self-report scale to diagnose major depressive disorder. Arch.

Van Der Ploeg, H.M., Defares, P.B., Spielberger, C.D., 1980. ZBV Gen. Psychiatry 43, 1076–1081.A Dutch-language adaptation of the Spielberger state-trait Zwick, W.R., Velicer, W.F., 1982. Factors influencing four rules foranxiety inventory. Swets and Zeitlinger, Lisse, The Nether- determining the number of components to retain. Multivar.lands. Behav. Res. 17, 253–269.

Watkins, C.E., Campbell, V.L., Nieberding, R., Hallmark, R.,1995. Contemporary practice of psychological assessment byclinical psychologists. Prof. Psychol. Res. Pract. 26, 54–60.

Documents

Construct validity of the Beck Depression Inventory in a depressive population