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Behaviour Research and Therapy 38 (2000) 311318

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Use of the Beck Depression Inventory-II with depressed geriatric inpatients


Robert A. Steer a,*, David J. Rissmiller a, Aaron T. Beck b
a

Department of Psychiatry, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Stratford, NJ, 08084-1350, USA b Beck Institute for Cognitive Therapy and Research, Bala Cynwyd, PA, USA Received 8 February 1999; received in revised form 10 March 1999

Abstract To provide information about the clinical utility of the Beck Depression Inventory-II (BDI-II) [Beck, A.T., Steer, R.A., & Brown, G.K. (1996b). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation] with geriatric inpatients, the BDI-II was administered to 130 psychiatric inpatients who were 55 years old or above and who were diagnosed with principal DSM-IV major depressive disorders (MDD) (N = 85, 65%) or adjustment disorders with depressed mood (N = 45, 35%). The internal consistency of the BDI-II was high (coecient alpha=0.90), and its total score was not signicantly related to sex, age, or ethnicity. An iterated maximum-likelihood factor analysis found the Cognitive and Noncognitive dimensions which have been reported for the BDI-II by Steer and coworkers (Steer R.A., Ball R., Ranieri W.F., & Beck A.T. (1999). Dimensions of the Beck Depression Inventory-II in clinically depressed outpatients. Journal of Psychopathology and Behavioral Assessment, 55, 117128) in a younger sample of clinically depressed psychiatric outpatients. The mean BDI-II total score of the 85 geriatric inpatients with MDD was also comparable to that of 42 younger (54 years old) inpatients with MDD. The results were discussed as supporting the use of the BDI-II with clinically depressed geriatric inpatients. # 2000 Elsevier Science Ltd. All rights reserved.
Keywords: Depression; Geriatric; Inpatients; BDI-II=Beck Depression Inventory-II

* Corresponding author. Tel.: +1-609-566-6290; fax: +1-609-566-6030. E-mail address: steer@umdnj.edu (R.A. Steer). 0005-7967/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 9 9 ) 0 0 0 6 8 - 6

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1. Introduction The amended Beck Depression Inventory (BDI-IA; Beck & Steer, 1993b) is one of the most widely used instruments for measuring the severity of self-reported depression in adolescents and adults (Piotrowski, 1996), and its reliability and validity have been established across a broad spectrum of clinical populations (Beck, Steer & Garbin, 1988). The eectiveness of the BDI-IA for assessing the severity of depression in geriatric psychiatric inpatients (Brand & Clingempeel, 1992) and outpatients (Kogan, Kabaco, Hersen & Vanhasselt, 1994; Olin, Schneider, Eaton, Zemansky & Pollock, 1992) has been reported to be comparable to that aorded by instruments which were especially developed for older adults, such as the Geriatric Depression Scale (Yesavage et al., 1983). In 1996, the BDI-IA was upgraded to the Beck Depression Inventory-II (BDI-II; Beck, Steer & Brown, 1996b) to make its symptom content more consonant with the diagnostic criteria for major depressive disorders (MDD) that are described in the American Psychiatric Association's (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th ed., (DSM-IV). To date, the clinical utility of the BDI-II for measuring self-reported depression in geriatric inpatients who have been diagnosed with unipolar depressions has not been studied. The overall psychometric characteristics of the BDI-II and the BDI-IA are similar for psychiatric outpatients in general. For example, Beck, Steer, Ball and Ranieri (1996a) found that the Cronbach coecient alphas of the BDI-II and the BDI-IA were, respectively, 0.91 and 0.89 in 140 outpatients who were diagnosed with various DSM-IV psychiatric disorders. The Pearson productmoment correlations of both instruments' total scores for these outpatients with sex, ethnicity, age, the diagnosis of a mood disorder, and the Beck Anxiety Inventory (Beck & Steer, 1993a) were within a hundredth of 1 point of each other for the same variables. However, the mean BDI-II total score was approximately 2 points higher than it was for the BDI-IA and approximately one more symptom on average was endorsed on the BDI-II than it was on the BDI-IA. In the normative sample of 500 outpatients with various psychiatric disorders who were studied by Beck et al. (1996b), the BDI-II was described as being composed of two positively correlated dimensions reecting a Noncognitive (SomaticAective) factor represented by somatic symptoms, such as Loss of Energy, and aective symptoms, such as Irritability, and a Cognitive factor composed of psychological symptoms, such as Self-Dislike and Worthlessness. To ascertain whether these two dimensions would be found in 210 adult (r18 year old) outpatients who were diagnosed with DSM-IV depressive disorders and whose mean age was 41.29 (SD=15.25) years old, Steer, Ball, Ranieri and Beck (1999) performed a series of exploratory and conrmatory factor analyses and concluded that the BDI-II represented two rst-order Noncognitive and Cognitive factors which, in turn, reected a second-order dimension of self-reported depression. The primary purpose of the present study was to determine whether the Noncognitive (SomaticAective) and Cognitive dimensions that Steer et al. (1999) had identied in clinically depressed outpatients would also be found in a sample of clinically depressed geriatric inpatients. The study also wished to determine whether the mean BDI-II total score of geriatric inpatients who were diagnosed with MDD would be comparable to the mean BDI-II total score of a younger (54 years old) sample of psychiatric inpatients who were also diagnosed

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with MDD. Steer et al. (1999) had found that younger clinically depressed outpatients scored higher on the BDI-II than older clinically depressed outpatients did.

2. Methods

2.1. Samples 2.1.1. Older adults The geriatric sample consisted of 50 (38%) male and 80 (62%) female older adult (r55 years old) inpatients who were consecutively admitted to an acute, senior-adult mental-health service in an urban general hospital. The sample was restricted to inpatients who were diagnosed with principal DSM-IV disorders in which there was a unipolar depressive component. It is important to note that the recruitment of inpatients continued until at least 50 male geriatric inpatients had completed BDI-IIs to assure that there would be a sucient number of inpatients of both sexes if subsequent analyses indicated that the mean BDI-II total scores of the men and women signicantly diered. Such a mean dierence might indicate that separate statistical analyses would have to be performed for each sex. There were 121 (93%) Whites and nine (7%) African Americans. The mean age was 74.89 (SD=7.45) years old. As previously stated, the present sample was restricted to consecutive admissions who were diagnosed with principal DSM-IV disorders in which there was a unipolar depressive component. All of the inpatients were diagnosed by a psychiatrist (DAR) who was board certied in geriatric psychiatry and who was actively involved in teaching psychiatric residents and medical students how to derive DSM-IV diagnoses. However, no interjudge agreement study was conducted with respect to his diagnoses. Because no interjudge agreement study was conducted, we decided to classify the inpatients into the following broad, principal diagnostic groups for descriptive purposes; there were 85 (65%) [17 single- and 68 recurrent-episode] MDD and 45 (35%) adjustment disorders with depressed mood. 2.1.2. Younger adults For comparative purposes, a separate sample of younger adult (r18 and 54 years old) inpatients was included in the study. The sample was composed of 16 (38%) male and 26 (62%) female inpatients who were consecutively admitted to the general psychiatric service of the same hospital from which the geriatric sample was drawn. This sample was admitted during the same time interval that the geriatric inpatients had been and was restricted to inpatients who were only diagnosed with principal DSM-IV MDD disorders. The sample was limited to inpatients with MDD because this disorder reects the diagnostic criteria that the BDI-II was specically upgraded for. There were 29 (69%) Whites, eight (19%) African Americans, four (10%) Puerto Rican Americans, and one (2%) Asian American. The mean age was 41.31 (SD=8.36) years old. There were eight (14%) with single-episode MDD and 36 (86%) with recurrent-episode MDD.

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2.2. Procedure The patients were administered the printed version of the BDI-II within 48 h of admission during a standardized psychiatric evaluation that was completed by every patient. The present study was conducted with the approval of our Institutional Review Board. 3. Results 3.1. Overall severity The mean total score of the BDI-II for the 130 geriatric inpatients was 24.56 (SD=12.75), and the coecient alpha was 0.89. This mean value indicates that the overall level of depression in the sample was moderate according to the diagnostic ranges presented by Beck et al. (1996b). Coecient alphas between 0.80 and 0.89 are described by Cicchetti (1994) as good for clinical purposes. The mean BDI-II total scores of the 50 geriatric men and 80 women were, respectively, 23.18 (SD=12.86) and 25.42 (SD=12.68). These means were comparable, t(128)=0.98, ns. The mean ages of the men (M = 75.12, SD=7.89) and women (M = 74.75, SD=7.20) were not statistically dierent, t(128)=0.27, ns. The mean BDI-II total scores of the 121 Whites and nine African Americans were, respectively, 24.52 (SD=12.59) and 25.11 (SD=15.59). These means were also comparable, t(128)=0.13, ns. The correlation of the BDI-II total scores with age (years) was 0.05 and not signicant, t(128)=0.54. The mean BDI-II score of 31.47 (SD=9.86) for the 85 geriatric inpatients with MDD was approximately 2.7 times higher than the mean BDI-II score of 11.51 (SD=4.97) for the 45 geriatric inpatients with adjustment disorders with depressed mood, Welch's t '(128)=15.24, p < 0.001. 3.2. Dimensions To test whether the BDI-II symptom ratings of the 130 geriatric inpatients represented two correlated rst-order factors as Steer et al. (1999) had found in clinically depressed outpatients, we performed an iterated maximum-likelihood factor analysis with the 21 symptom ratings of the geriatric patients. A maximum-likelihood factor analysis was chosen because the BDI-II symptoms were rated by a sample of geriatric inpatients, and we wished to estimate what the factors might be for the population of such inpatients. This is also the type of factor analysis that Steer et al. (1999) had performed, and its choice thus facilitated direct comparisons between their and our factor-analytic results. A Promax rotation was employed because we assumed from previous research ndings (Beck et al., 1996b; Steer et al., 1999) that positively correlated factors would be found. We ascertained whether sex and age might have to be controlled for by calculating the canonical correlations of sex and age with the set of 21 BDI-II ratings. Because there were only nine African Americans in the present sample, we did not calculate a canonical correlation with respect to ethnicity. The canonical correlation for sex was 0.37, Wilks' lambda=0.87, F(21, 106)=0.78, ns., and the canonical correlation for age was 0.41, Wilks' lambda=0.84,

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F(21, 106)=0.99, ns. Because the set of 21 BDI-II ratings was not signicantly related to sex or age, neither variable was controlled for in evaluating the interrelationships among the 21 BDIII symptom ratings. To estimate whether the 21 BDI-II items belonged together psychometrically, Kaiser's Measure of Sampling Adequacy (Dziuban & Shirkey, 1974) was calculated and yielded a value of 0.90. According to Kaiser (1970), such a value indicated that the present intercorrelation matrix was ``marvelously'' appropriate for factor analysis. Cattell's (1966) scree test was initially used to ascertain the number of factors to extract based on the plot of the magnitudes of the consecutive principal-component eigenvalues. The rst six consecutive eigenvalues were 7.03, 2.02, 1.13, 1.05, 1.00, and 0.87. The scree plot suggested that a two factor solution was plausible. The goodness-of-t test for the maximum-likelihood factor analysis conrmed that

Table 1 Promax-rotated maximum-likelihood factor standardized regression coecients of the Beck Depression Inventory-II for depressed geriatric inpatientsa Symptom Sadness Pessimism Past Failure Loss of Pleasure Guilty Feelings Punishment Feelings Self-Dislike Self-Criticalness Suicidal Thoughts Crying Agitation Loss of Interest Indecisiveness Worthlessness Loss of Energy Changes in Sleeping Irritability Changes in Appetite Concentration Diculty Tiredness or Fatigue Loss of Interest in Sex % Common % Total Factors I. Non cognitive II. Cognitive
a b

I 0.52b 0.54 0.00 0.43 0.16 0.17 0.22 0.09 0.05 0.07 0.42 0.43 0.28 0.33 0.81 0.31 0.35 0.58 0.56 0.68 0.48 50.4 18.8 I 0.52

II 0.29 0.15 0.66 0.27 0.77 0.63 0.45 0.67 0.44 0.39 0.18 0.33 0.58 0.40 0.19 0.29 0.16 0.23 0.24 0.09 0.02 49.6 18.4 Correlation between factors II

h2 0.51 0.41 0.44 0.38 0.49 0.32 0.35 0.40 0.22 0.18 0.29 0.44 0.58 0.40 0.53 0.27 0.20 0.25 0.52 0.41 0.22 100.0 37.2

N = 130. Salient regression coecients r0.35 are in italic.

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two common factors statistically exhausted all of the signicant covariation among the 21 ratings, w 2 (169, N = 130)=152.84, ns. The factor pattern matrix of the standardized regression coecients loading on the two Promax-rotated maximum-likelihood factors is presented in Table 1. The 11 salient (r0.35) coecients for the rst factor are for Sadness, Pessimism, Loss of Pleasure, Agitation, Loss of Interest, Loss of Energy, Irritability, Changes in Appetite, Concentration Diculty, Tiredness or Fatigue, and Loss of Interest in Sex. Because Loss of Energy and Tiredness or Fatigue had the highest loadings on the rst factor, and these two symptoms also had high loadings on Beck et al.'s (1996b) and Steer et al.'s (1999) Noncognitive factors, we considered the present factor to be reecting this dimension. Cattell, Balcar, Horn and Nesselroade's (1969) improved salient variable similarity index, s index, was calculated to estimate how well the present Noncognitive factor matched that found by Steer et al. (1999). The s index was 0.86, a value which indicated that the salient symptom composition of our factor was comparable to theirs, p < 0.001. Of their 10 salient symptoms, nine of our 11 salient symptoms matched theirs. Table 1 shows the second factor's nine salient (r0.35) symptoms are for Past Failure, Guilty Feelings, Punishment Feelings, Self-Dislike, Self-Criticalness, Suicidal Thoughts or Wishes, Crying, Indecisiveness, and Worthlessness. With the exception of Crying, the other eight salient symptoms are cognitive or psychological in nature. Therefore, this factor was interpreted as reecting the Cognitive dimension that Beck et al. (1996b) and Steer et al. (1999) had found in outpatients. The s index between our and Steer et al.'s (1999) Cognitive factors was 0.84 and again indicated that the salient symptom composition of our factor was comparable to theirs, p < 0.001. Eight of our nine salient symptoms matched eight of their 10 salient symptoms. As Table 1 demonstrates, the Noncognitive and Cognitive factors were moderately correlated, r = 0.52, p < 0.001. This correlation was comparable to the correlation of 0.57 between these same factors that was found by Steer et al. (1999), z = 0.63, ns. 3.3. Sample comparison Because the BDI-II was specically developed to address DSM-IV criteria for MDD, a t test for independence was performed to compare the mean BDI-II total scores of the 85 geriatric inpatients with MDD to those of the 42 younger inpatients with MDD. The mean BDI-II total scores for the two respective groups were 31.47 (SD=9.86) and 32.69 (SD=12.02). Both means were comparable, t(125)=0.61, ns.

4. Discussion The overall pattern of results supports the use of the BDI-II with clinically depressed geriatric inpatients. The coecient alpha of 0.89 indicated that the BDI-II possessed high internal consistency with the geriatric inpatients and fell within the range of coecient alphas that the BDI-II has been reported as having in outpatient psychiatric samples (Beck et al., 1996a,b; Steer et al., 1999). The Noncognitive (SomaticAective) and Cognitive dimensions of the BDI-II that were rst identied by Beck et al. (1996b) for psychiatric outpatients in general

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and by Steer et al. (1999) in clinically depressed outpatients were also found in clinically depressed geriatric inpatients. In their review of 25 years' worth of factor analyses of the BDI-IA, Beck et al. (1988) concluded that the total number of BDI-IA factors that was extracted and symptom compositions of the resultant factors were dependent upon the types of clinical samples being studied. In contrast, the BDI-II has consistently been found to yield two factors representing Noncognitive and Cognitive aspects of self-reported depression in adolescent (Steer, Kumar, Ranieri,& Beck, 1998) and adult (Beck et al., 1996a,b) psychiatric outpatients with various DSM-IV disorders, adult psychiatric outpatients with DSM-IV depressive disorders (Steer et al., 1999), and now geriatric inpatients with MDD or adjustment disorder with depressed mood. The present results support Beck et al.'s (1996b) contention about aective symptoms, such as Crying, shifting from one dimension to another depending on the background and diagnostic compositions of samples being studied. Crying saliently (r0.35) loaded in the present study on the Cognitive factor as it did in Steer et al.'s (1999) factor analysis, instead of on the Noncognitive factor as it had in Beck et al.'s (1996b) factor analysis. In the present study, Pessimism loaded on the Noncognitive factor rather than on the Cognitive factor as it had in both Beck et al.'s (1996b) and Steer et al.'s (1999) studies. For clinically depressed geriatric inpatients, hopelessness or pessimism about the future was more associated with negative aective and somatic symptomatology than it was with negative beliefs and cognitions. However, future research will have to ascertain whether the shift in the Pessimism symptom from saliently loading on the Cognitive factor to the Noncognitive factor was attributable to dierences in the mean ages of the patients that were sampled or simply to a dierence between the inpatient and outpatient statuses of the samples. The age (years) of the geriatric inpatients was not signicantly correlated with overall severity of self-reported depression as measured by the BDI-II. Contrary to Steer et al.'s (1999) nding that the BDI-II total scores of younger clinically depressed outpatients were higher than those of older clinically depressed outpatients, the mean BDI-II total scores of the 85 geriatric inpatients with MDD and the 42 younger inpatients with MDD were comparable. Furthermore, there were no signicant mean BDI-II total-score dierences with respect to sex or ethnicity as categorized as White versus African American. Previous studies have consistently found that the BDI-II was not signicantly related to ethnicity in adolescent and adult outpatients (Beck et al., 1996a,b; Steer et al., 1998, 1999), but the mean BDI-II total scores of adolescent and adult female outpatients tend to be at least 3 points higher than those of adolescent and adult male outpatients (Beck et al., 1996 a, b; Steer et al., 1998, 1999). We did not ascertain whether the BDI-II discriminated patients with single-episode and recurrent-episode MDD because no interjudge reliability study was conducted with respect to the psychiatrist's specic diagnoses. However, the BDI-II did dierentiate geriatric inpatients with MDD from those who had been diagnosed with adjustment disorders with depressed mood. The mean BDI-II total score of the inpatients with MDD was approximately 2.7 times higher than that of the inpatients with adjustment disorders with depressed mood. Obviously, future research needs to ascertain how eectively the BDI-II dierentiates among specic DSM-IV mood disorders. The clinical utility of the BDI-II should be studied in a variety of dierent clinical

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populations. The present geriatric sample was drawn from patients who were admitted to a specialized psychiatric unit serving older adults with acute mental-health problems that was located in an urban general hospital. Given that the present sample was 93% White, it is obvious that patients attracted to this specialized psychiatric service were not representative of the urban environment in which the hospital was located. References
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