The Beck Depression Inventory Second

Edition (BDI-II): Psychometric properties in

Icelandic student and patient populations
ÞÓRÐUR ÖRN ARNARSON, DANÍEL ÞÓR ÓLASON, JAKOB SMÁRI, JÓN FRIÐRIK
SIGURÐSSON
Nord J Psychiatry Downloaded from informahealthcare.com by University of Washington on 03/08/15

Arnarson ÞÖ, Ólason DÞ, Smári J, and Sigurðsson JF. The Beck Depression Inventory Second
Edition (BDI-II): Psychometric properties in Icelandic student and patient populations. Nord J
Psychiatry 2008;62:360
365. Oslo. ISSN 0803-9488.

The Beck Depression Inventory (BDI) is one of the most widely used self-report measures of
depression in both research and clinical practice. The Beck Depression Inventory Second
Edition (BDI-II) is the most recent version of the BDI. The objective of the present study was to
assess the psychometric foundations of the Icelandic translation of the BDI-II, adding to its
international knowledge base. Participants were in total 1454, 1206 students and 248 outpatient-
clinic patients. All students completed the BDI-II and a subgroup (n 142) completed
additional measures of anxiety and depression. The Mini-International Psychiatric Interview
(MINI) and the BDI-II were administrated to the patients. Convergent and divergent validity of
For personal use only.

the BDI-II were supported. It discriminated satisfactorily between patients diagnosed and those
not diagnosed with major depression. Confirmatory factor analyses revealed small differences
between various factor models of the BDI-II, derived from previous studies. However, a model
of three first-order factors (cognitive
affective
somatic) and one second-order factor (general
depression) offered an acceptable description of the item covariance structure for the BDI-II in
both samples. It is concluded that the psychometric properties of the Icelandic version of the
BDI-II are supported in patient and student populations.
’ BDI-II, Confirmatory factor analysis, Depression, Patient population, Student population.

Jakob Smári, Faculty of Social Science, University of Iceland, Reykjavik, Iceland, E-mail:
jakobsm@hi.is; Accepted 21 May 2007.

he Beck Depression Inventory (BDI) (1) is probably
T the most thoroughly researched and used self-report
measure of depression in both clinical and non-clinical
populations (2). It has been extensively used in research
on depression in both psychiatric and non-psychiatric
contexts, and its psychometric properties have generally
been strongly supported (2). The inventory has been
revised several times and the BDI-II is a new and
improved version of its predecessor (3). Several studies
of psychometric properties of the revised inventory have
been reported. Strong correlations have been found
between the BDI-II and previous versions of the
inventory, in both patient and student populations (3).
Coefficients alpha are also higher than for previous
versions of the inventory (4
6). Addressing convergent
and divergent validity of the inventory, Beck et al. (3)
investigated the correlation between the BDI-II and
several measures of anxiety and depression. Both types
of validity were supported, even though there was a
considerable correlation between the BDI-II and the
Beck Anxiety Inventory (BAI) (0.60). Other studies have
generally supported convergent validity of the BDI-II,
whereas divergent validity with regard to anxiety has
been moderate (4
8).
Factor analyses of the original BDI have revealed one
to seven factors depending on the population sampled
and the specific extraction method used. A three-factor
solution (Negative Attitudes Towards Self, Performance
Impairment and Somatic Disturbance), however, has
been the most frequently reported (2). Factor analyses of
the BDI-II in both student and patient populations have
also yielded somewhat varying results: often a two-factor
solution with either highly correlated affective
somatic
and cognitive factors or somatic and cognitive
affective
factors has been found (3, 4, 6, 7, 9
11). In at least two
studies, however, a three-factor solution (affective

cognitive
somatic) has been supported (5, 12); although
similar to the two factor solutions, a high correlation
between the cognitive and affective factors suggest
limited discriminated validity (11).

# 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As) DOI: 10.1080/08039480801962681

The original BDI has known a very wide international
proliferation. It has been used in countless studies in
different non-English versions (2). The BDI-II also exists
in various non-English versions and its validity has been
supported in studies using these versions (13
15).
There are numerous studies that attest to the useful-
ness of the BDI for diagnostic discrimination (2). Even
though this needs of course more empirical studies, there
are reasons to believe that the BDI-II performs at least
equally well in measuring the seriousness of depression
and short-term changes in depression, as well as in the
screening for depression (16).
While the original BDI has been thoroughly investi-
gated and used in the Nordic countries (e.g. 17, 18), no
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published psychometric studies of the BDI-II in these
countries are known to the authors. This is unfortunate
given the central role of the BDI (and now the BDI-II) in
depression research. In the present study, the psycho-
metric properties of the Icelandic version of the BDI-II
are investigated, addressing primarily its convergent,
divergent and concurrent validity, as well as the factorial
structure of the measure in a student and a patient
population. It is important for future use of the instru-
ment to test if there is a reasonable comparability of
factor structure between the American and the Icelandic
For personal use only.
versions. In this study, we therefore tested four different
factor models derived from previous studies of the BDI-
II, and compared in a confirmatory factor analysis.
These analyses included a one-factor model, two
alternative two-factor models (affective
somatic versus
cognitive; cognitive
affective versus somatic) and a
second-order factor model with three first-order factors
(cognitive, affective, somatic) and a one second-order
factor (general depression).
Material and Methods
Participants
Participants were in total 1454. Of these 1206 were
students (72% female) with an average age of 24 years
(standard deviation, s6.0) and 248 were outpatient-
clinic patients (82% female) participating in a study of
non-specific cognitive
behavioural therapy in general
health care. The average age of the patient group was
40 years (s13.5).
Measures
The Beck Depression Inventory Second Edition (BDI-II)
is a self-report measure of depression. Twenty-one
symptoms of depression are rated on a 4-point scale
(0
3), within the time frame of the past 2 weeks. It is
suggested in the BDI-II handbook (3) that the main
factors of the inventory are a cognitive and a somatic
factor, and that some items can shift between factors
depending on which population samples represent.
These are called emotional or affective items (crying
NORD J PSYCHIATRY ×VOL 62×NO 5×2008
THE BDI-II: PSYCHOMETRIC PROPERTIES IN ICELANDIC POPULATIONS
for example). The inventory had earlier been translated
into Icelandic by the permission of the publisher and
then back-translated to ensure accuracy.
The Beck Anxiety Inventory (BAI) is a self-report
measure of anxiety and consists of 21 statements
concerning symptoms of anxiety experienced during
the past week (19). In the present study, the coefficient
alpha of the BAI was 0.91.
The Center for Epidemiological Studies Depression
Scale (CES-D) is a self-report measure of depression
with 20 items concerning symptoms of depression
during the past week (20). In the present study, the
coefficient alpha of the CES-D was 0.86.
The Penn State Worry Questionnaire (PSWQ) is a self-
report measure of worry (21). In the present study, the
coefficient alpha of the PSWQ was 0.93.
The Hospital Anxiety and Depression Scale (HADS) is
a self-report measure of anxiety and depression (22).
There are 14 questions*seven items measure anxiety
and another seven items depression. The HADS-anxiety
scale in this study had a coefficient alpha of 0.78, the
HADS-depression scale 0.77.
The Mini-International Neuropsychiatric Interview
(MINI) is a short structured interview of mental
disorders according to the diagnostic criteria of the
DSM-IV and the ICD-10 (23). MINI permits among
other things to assess whether a major depressive episode
is present. MINI has not been extensively studied, but
earlier versions have shown excellent reliability (24).
Procedure
Participants in the patient group were undergoing a non-
specific cognitive
behavioural group therapy. The focus
of the therapy was on depression and anxiety. The
patients were referred to therapy by general practitioners
if they thought that the patients fulfilled criteria for
emotional disorders of any kind. In order to be eligible
for the therapy, the person had to be 18 years or older.
Exclusion criteria were a present alcohol or drug abuse
problem, psychosis or subnormal intelligence. Nine
psychologists from the division of psychiatry at the
Landspitali-University Hospital administered the BDI-
II and the MINI. They had all been trained in
administering the instruments. The students filled in
the BDI-II during class. A subgroup of 142 of the
students filled in the BAI, CES-D, PSWQ and HADS in
addition to the BDI-II during class hour. Finally, the
BDI-II was administered twice to 57 students of the
student group with 1
2 weeks in between. The adminis-
tration of the BDI-II and other instruments to the
students was conducted in class and there was an effort
made to ensure that there was a sufficient space provided
between students to increase privacy during responding.
361
 ÞÖ ARNARSON ET AL.
Analyses
All analyses were conducted with SPSS, except the
confirmatory factor analyses that were conducted with
EQS 6.1 (26, 27). A signal detection analysis was
conducted for the BDI-II with regard to the diagnosis
of major depression episode with the MINI. A ‘‘receiver
operating characteristics’’ (ROC) curve, which plots
sensitivity versus specificity for every possible cut-off
point, was obtained (25). Youden’s index was used to
evaluate the optimal cut-off point (sensitivity
specificity 1.00) (18).
Confirmatory factor analysis (CFA) was conducted
independently for the patient and student samples. Four
different factorial models were tested. Firstly, the fit for
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a simple one-factor model (model 1*one factor) where
all items loaded on the same factor was tested. Secondly,
the two-factor model (model 2*somatic/affective
cog-
nitive) reported in the BDI-II manual (3) for psychiatric
outpatients was tested, with items related to somatic and
affective symptoms loading on the same factor and items
related to cognitive symptoms loading on the second
factor. Thirdly, an alternative two-factor model (model
3*cognitive/affective
somatic) was tested. In this
model, items for the S-factor were ‘‘loss of energy’’,
For personal use only.
‘‘changes in sleeping pattern’’, ‘‘changes in appetite’’,
‘‘concentration difficulty’’ and ‘‘tiredness or fatigue’’.
The remaining 16 items comprised the CA-factor (9, 11).
Factors for both two-factor models were allowed to
correlate. Finally, a model with three first-order factors
(cognitive, affective, somatic) and one second-order
factor (general depression) (model 4*general depres-
sion) was tested. The three first-order factors were
regressed on the second-order factor (general depres-
sion).
All models were tested with maximum likelihood
estimation using the EQS 6.1 procedure for covariance
structure models (27). Following the recommendation of
Hu & Bentler (28) and MacCallum & Austin (29),
different goodness-of-fit tests were used to evaluate the
fit of the models. In addition to chi-square, the
comparative fit index (CFI; 26), the standardized root
mean square residual (SRMR; 26) and the root mean
square error of approximation (RMSEA; 30) were used.
The range for the CFI is between 0 and 1, and values in
Table 1. Pearson correlations of the BDI-II, BAI, PSWQ, HADS and CES-D.
BAI PSWQ
BDI-II 0.60* 0.61*
BDI-II, Beck Depression Inventory Second Edition; BAI, Beck Anxiety Inventory; PSWQ, Penn State Worry Questionnaire; HADS-A, Hospital
Anxiety and Depression Scale*Anxiety; HADS-D, Hospital Anxiety and Depression Scale*Depression; CES-D, Center for Epidemiological
Studies Depression Scale.
n 142.
*P B0.01.
362
the mid-90s or higher with a cut-off value close to 0.08
for the SRMR are taken to indicate an acceptable fit to
the data (28). RMSEA values less than 0.5 indicate a
close fit to the model, values between 0.08 and 0.05 are
an acceptable fit, and values greater than 0.10 a poor fit
(30). The Akaike information criterion (AIC; 31) was
also calculated. The AIC index evaluates both the
measure of fit and model complexity and is useful to
compare models that are not nested. Models with
smaller values of AIC indicate a better fit in a cross-
validation between models (32).
Results
Means and standard deviation of the BDI-II
Mean and standard deviation of the BDI-II for the
student data (n1206) was 8.80 (s7.82) and the
patients 21.25 (s12.16). These means are quite similar
to those reported for college students (12.56, s 9.93)
and psychiatric outpatients (22.45, s 12.75) in the BDI-
II manual (3).
Internal consistency
The internal consistency of the BDI-II was very
satisfactory for both students (a0.91) and patients
(a0.93). The test
retest reliability of the BDI-II for
1
2 weeks was again very good, r 0.89, and is similar to
what is reported by Beck et al. (3).
Validity
Pearson correlation coefficients were calculated between
the BDI-II and BAI, HADS-A, HADS-D, PSWQ and
CES-D. The correlation coefficients are reported in
Table 1.
The BDI-II has high correlations with the CES-D and
the HADS-D, indicating good convergent validity. A
comparison of dependent correlations (33) indicated that
when these two correlations were compared with the
correlations of the BDI-II with BAI, PSWQ and HADS-
A, the former were in all cases except one significantly
higher than the latter (P B0.05). The exception was the
comparison between the correlations of the BDI-II with
HADS-D and HADS-A (P B0.10). These results indi-
cate at least moderate divergent validity.
HADS-A HADS-D CES-D
0.65* 0.71* 0.81*
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 THE BDI-II: PSYCHOMETRIC PROPERTIES IN ICELANDIC POPULATIONS

Confirmatory factor analysis
Prior to the CFA, items were screened for deviation from
the normal distribution. Skewness and kurtosis values
for all items were adequate for patients but seven items
had high skewness and kurtosis values in the student
data. Different data transformation methods were ap-
plied to these items in effort to reduce their deviation
from non-normality, and logarithmic transformation
reduced skewness considerably for all items except
suicidal thoughts. Further examination of the multi-
variate normality in the two data sets revealed consider-
able multivariate skewness in the student data
(normalize coefficient 121.09) but not in the patient
data (normalize coefficient 13.08). Therefore, fit in-
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models and the value of AIC was considerably lower for
model 4 than for any of the other models in the student
data.
Similar results were obtained for the patients (and the
differences in fit indices were in general very modest).
None of the models achieved adequate fit according to
the criteria from Hu & Bentler (28), but the fit indices
for the second-order model (model 4) suggested a
slightly better fit than for the one- and two-factor
models. Similarly, for the student data the AIC index
suggests that the fit is also slightly better for the second-
order model (model 4) than the other three models.
Table 3 presents the standardized factor loadings for
the second-order model (model 4) for both students and

dexes (except SRMR) for all models for the student data
were corrected with the Satorra
Bentler scaled statistics
(26, 34). Preliminary analysis with EQS 6.1 Lagrange
multiplier test suggested that fit could be substantially
improved for all models by permitting the residuals of
one pair of items (‘‘loss of energy’’ with ‘‘tiredness or
fatigue’’) to correlate. The semantic similarity between
these two items is obvious and strong association
between them has previously been reported (11). The
correlated residuals for these two items were therefore
For personal use only.
patients. All items loaded significantly on the specified
factor and values ranged between 0.46 and 0.75 for
students and between 0.45 and 0.77 for patients. Factor
loadings on the second-order factor (general depression)
were all above 0.90 for both data sets
Signal detection
A signal detection analysis was conducted for the BDI-II
with regard to diagnosis of major depression episode with
the MINI. A ROC curve was obtained. In all, 104 out of
247 patients (diagnostic status of one patient uncertain)

specified for all models in both data sets.

The summary of results for the CFA for both students
and patients data is presented in Table 2. The chi-square
test was significant for all models within both datasets
but that is to be expected for models with large degrees
of freedom and relatively large sample size (26, 35).
Examining the remaining fit indices for the student data
suggest that model 1 (one-factor solution) offers the
poorest and model 4 (three-factor solution) the best fit
to the data. Although the difference in values of CFA,
SRMR and RMSEA is modest between all four models,
they were slightly better for model 4. Additionally,
the AIC index offers comparison between non-nested
were diagnosed with a major depressive episode. The
BDI-II discriminated well between those patients with
and without MD (AUC 0.87; 95% confidence interval
0.82
0.91). The ROC can be seen in Fig. 1.
The Youden’s index representing the optimal cut-off is
obtained for the value 20/21. At this point sensitivity is
0.82 and specificity 0.75.
Discussion
In this study, the psychometric properties of the
Icelandic version of the BDI-II were for the most part
found very satisfactory and in most respects comparable

Table 2. Summary of goodness-of-fit indices for students and patients.

Fit indices
2
Models tested x CFI SRMR RMSEA 90% CI AIC

Students (n 1206)
Model 1*one-factor 561.69** (df188) 0.92 0.039 0.041 0.037
0.044 185.69
Model 2*SA
C 444.97** (df187) 0.95 0.034 0.034 0.030
0.038 70.98
Model 3*CA
S 495.24** (df187) 0.94 0.037 0.037 0.033
0.041 121.24
Model 4*general depression 398.66** (df186) 0.96 0.032 0.031 0.027
0.035 26.66
Patients (n248)
Model 1*one-factor 382.72** (df188) 0.92 0.051 0.065 0.055
0.074 6.72
Model 2*SA
C 356.15** (df187) 0.93 0.049 0.061 0.051
0.070 17.85
Model 3*CA
S 363.54** (df187) 0.92 0.049 0.062 0.052
0.071 10.46
Model 4*general depression 341.99** (df186) 0.93 0.048 0.058 0.048
0.068 30.01

CFI, comparative fit index; SRMR, standardized root mean square residual; RMSEA, root mean square error of approximation; CI, confidence
interval; AIC, Akaike information criterion; SA
C, somatic/affective
cognitive; CA
S, cognitive/affective
somatic.
**PB0.001.

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 ÞÖ ARNARSON ET AL.

Table 3. Standardized loadings for the second-order model for student and patient data.

Studentsa Patientsb
Item C A S h2 C A S h2

Sadness 0.65 0.43 0.67 0.45

Pessimism 0.65 0.43 0.72 0.52
Past failure 0.62 0.39 0.68 0.46
Loss of pleasure 0.65 0.42 0.76 0.57
Guilty feelings 0.60 0.36 0.71 0.50
Punishment feelings 0.50 0.25 0.55 0.30
Self-dislike 0.75 0.56 0.71 0.51
Self-criticalness 0.65 0.42 0.75 0.56
Suicidal thoughts or wishes 0.46 0.21 0.51 0.26
Crying 0.53 0.28 0.61 0.37
Agitation 0.59 0.35 0.60 0.36
Loss of interest 0.55 0.29 0.74 0.55
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Indecisiveness 0.65 0.42 0.77 0.59

Worthlessness 0.66 0.43 0.79 0.62
Loss of energy 0.68 0.46 0.69 0.47
Changes in sleeping pattern 0.51 0.26 0.45 0.20
Irritability 0.56 0.31 0.56 0.31
Changes in appetite 0.52 0.27 0.60 0.36
Concentration difficulty 0.66 0.43 0.70 0.49
Tiredness or fatigue 0.67 0.45 0.65 0.42
Loss of interest in sex 0.49 0.24 0.45 0.21
Factor loadings on the secondary factor*general depression 0.91 0.92 0.98 * 0.95 0.94 0.96 *

C, cognitive; A, affective; S, somatic; h2, item communality.

For personal use only.

a
n1064; bn248.

with the original American version. Means and standard
deviations for both students and patients were similar to
those reported in previous studies of comparable groups
(3). Both internal consistency reliability and test
retest
reliability were acceptable. Convergent validity was
supported by strong correlations of the BDI-II in a
Fig. 1. Sensitivity and specificity of the Beck Depression
Inventory Second Edition (BDI-II) for depression.
student sample with the HADS-D and especially with
the CES-D. Divergent validity was similarly supported,
as correlations with measures of anxiety were signifi-
cantly lower. There are, however, substantial correlations
between the BDI-II and self-report measures of anxiety,
as has been found in previous research with the BDI-II
and other depression measures (3.5).
Signal detection analysis revealed that the BDI-II
differentiates well between patients with and without
major depression according to the MINI. Sensitivity
and specificity are jointly maximized when depression
is predicted at the score of 20/21 on the BDI-II. In
comparison with Scandinavian studies of the BDI in
clinical populations (18), this cut-off is higher than the
14/15 score that has been recommended. It has to be
borne in mind though that Beck (3) suggests that scores
on BDI-II are about 3 points higher than for BDI at the
middle of the distribution and that this difference
increases at the higher end.
In the present study, in a confirmatory factor analysis,
three different factor models of BDI-II were examined
based on previous research as well as a four-factor model
of three first-order factors and a second-order factor
named general depression. All the models showed a
reasonable fit to the data and the differences between
them were unimpressive. Interestingly, however, the
second-order model (model 4) showed a slightly better
fit than the other three models. The support for a second-
order factor based on highly correlated first-order factors

364 NORD J PSYCHIATRY×VOL 62 ×NO 5 ×2008

 THE BDI-II: PSYCHOMETRIC
similarly supports the use of the BDI-II total score. The
second-order model of the inventory seems, however,
14.
also to imply that subscales representing the cognitive,
somatic and affective symptom domains might be viable.
15.
A note of caution is, however, in order: primarily there is,
in spite of overall similarities across studies of the BDI-II,
inconsistencies with regard to the factorial composition 16.
of individual items; secondly the correlations between
factors in both two and three factor models are very high,
17.
and thus divergent validity of factors is not likely to be
high. Our recommendation is therefore for the time being
18.
to use the BDI-II mainly as a single score instrument.
The present study indicates that the BDI-II functions
adequately in a Nordic context and has similar properties
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19.
as the American original. The results of the confirmatory
factor analyses seem to support the use of the inventory 20.
as a single depression measure as well as to suggest the
possibility of taking systematically notice of the cogni- 21.
tive, somatic and even affective facets in the BDI-II.
22.
Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the 23.
content and writing of the paper.
24.
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