Brief report
The validity of the Beck Depression Inventory-Short Form as a screening and diagnostic instrument for moderate and severe depression in medical inpatients

https://doi.org/10.1016/j.jad.2004.12.011Get rights and content

Abstract

Objective

To examine the concurrent validity of the Beck Depression Inventory-Short Form (BDI-SF) to detect moderate and severe depressive episodes according to the International Classification of Diseases, 10th edition (ICD-10) criteria in inpatients with heterogeneous medical conditions and to set cut-off scores for its use in medical wards.

Methods

One hundred and fifty-five patients [53% female; mean age (±S.D.)=49.5 (±17) years; mean number of years of education (±S.D.)=6 (±4) years] consecutively admitted to the adult medical wards in a General Hospital were interviewed during the first 72 h of hospitalization. The Clinical Interview Schedule [CIS] was used to make ICD-10 psychiatric diagnoses. All patients completed the BDI-SF. A “receiver operating characteristics” (ROC) curve was obtained and the sensitivity, specificity, positive and negative predictive values were calculated for different cut-off points of the BDI-SF.

Results

High sensitivity and negative predictive value (NPV) were obtained with a cut-off score of 9/10 (sensitivity=100%, specificity=83.1%, NPV=100%). High sensitivity and positive predictive value (PPV) were obtained with a cut-off score of 13/14 (sensitivity=93.5%, specificity=96%, PPV=85.3%). The area under the ROC curve was 98.4% (95% Confidence Interval=0.97–1.00).

Conclusions

The BDI-SF is a valid instrument for detecting moderate and severe depression in medical inpatients. For screening purposes, a 9/10 cut-off score is indicated, but if a high specificity is desired, a 13/14 cut-off score is warranted.

Introduction

Depression in medical inpatients is an underrecognized and undertreated condition (Koenig et al., 1997). It has been shown that depression in this population is associated with increased morbidity, mortality and health care costs (Frasure-Smith et al., 2000).

The Beck Depression Inventory (BDI) (Beck et al., 1961) is one of the most widely used self-rating scales for measuring depression (Richter et al., 1998). Beck and Steer proposed that this scale could be divided in two subscales: the cognitive-affective (items 1 to 13) and the somatic-performance (items 14 to 21) (Beck and Steer, 1993). They recommended the use of the cognitive-affective subscale alone [the so-called BDI short-form (BDI-SF)] to assess depression in the medically ill and suggested that scores higher than 10 are associated with moderate and severe depressive syndromes.

The soundness of the psychometric properties of the BDI has already been fully demonstrated in community and clinical samples (Foelker et al., 1987, Scogin et al., 1988, Leahy, 1992, Bennett et al., 1997, Richter et al., 1998, Gesztelyi et al., 1999, Green et al., 2001, Strik et al., 2001). However, there is some concern regarding the use of the complete scale in patients with specific medical conditions since symptoms caused by the physical illness may affect the BDI somatic items (Lustman et al., 1997, Lykouras et al., 1998, Sliwinski et al., 1998, Leentjens et al., 2000). These studies demonstrated that the optimal cut-off scores may be different for these populations and that they depend on the research purposes (screening or diagnosis). We found only one study reporting the validity measures for different cut-off scores of the BDI-SF in medical inpatients (Cathebras et al., 1994). In a sample of French medical inpatients whose depression was diagnosed according to the DSM-III criteria, Cathebras et al. demonstrated that a cut-off point of 7/8 yielded a high sensitivity (95.5%) at the cost of a high rate of false-positives (43%). In contrast, the cut-off of 12/13 showed a high specificity (90.1%) at the cost of a low sensitivity (63.5%). They found that the best trade-off between sensitivity and specificity (86.4%; 81.8%) was the cut-off of 9/10. Using this cut-off point, the BDI showed a high negative predictive value (93.8%) and a positive predictive value of 65.5%.

The purpose of this study was to examine the concurrent validity of the Beck Depression Inventory-Short Form (BDI-SF) to detect moderate and severe depressive episodes according to the International Classification of Diseases, 10th edition (ICD-10) criteria in inpatients with heterogeneous medical conditions and to set cut-off scores for its use in medical wards.

Section snippets

Methods

One hundred and ninety patients consecutively admitted to the adult medical wards of the University Hospital of the Federal University of Rio de Janeiro (Brazil) were recruited for the study. Thirty-five patients were excluded because they were referred from the surgical wards, were discharged before completing 72 h in the ward or had a medical illness or cognitive impairment severe enough to preclude psychiatric interview and psychological testing. After signing an informed consent, the

Results

Fig. 1 displays the results in the form of a ROC curve. The area under the ROC curve was 98.4% (95% Confidence Interval=0.97–1.00).

When a cut-off point of 9/10 was used, all depressed patients were detected, but there was a high rate of false positives, 40.4% (21 patients without depression were “cases”, according to the BDI). When a cut-off point of 13/14 was used, there was a low rate of false positives (14.7%), but 2 depressed patients were not detected. The sensitivity, specificity, PPV and

Discussion

To our knowledge, this was the first study to evaluate the concurrent validity of the BDI-SF with the ICD-10 criteria for moderate and severe depressive episodes in medical inpatients. We found that the cut-off score of 10/11 recommended by Beck and Steer (1993), for the BDI-SF discriminated depressed medical inpatients with a relatively small rate of overall misclassification (19 patients). However, this cut-off yielded a sensitivity of 96.8%, meaning that 3 patients out of 100 would not be

Acknowledgments

This work was supported by CAPES, CNPq, and FAPERJ/Brazil.

References (24)

  • D. Goldberg et al.

    A standardized psychiatric interview for use in community surveys

    Br. J. Prev. Soc. Med.

    (1970)
  • C. Gorenstein et al.

    Validation of a Portuguese version of the Beck Depression Inventory and the State-Trait Anxiety Inventory in Brazilian subjects

    Braz. J. Med. Biol. Res.

    (1996)
  • Cited by (233)

    • Development and validation of heart failure-specific quality-of-life measurement tool in India

      2023, American Heart Journal Plus: Cardiology Research and Practice
    View all citing articles on Scopus
    View full text