ORIGINAL ARTICLE
Using the Persian-Language Version of the Beck Depression Inventory–II (BDI-II-Persian) for the Screening of Depression in Students Sasan Vasegh, MD* and Nafiseh Baradaran, MD† Abstract: Early identification and treatment of depression can prevent the development of the full depressive episode and its consequences. Although the Beck Depression Inventory–II is among the most widely used tools for measuring depression, there are relatively few studies that empirically confirm any cutoff points for screening depression among university students. Our subjects were 400 students from Ilam University (Iran). On the basis of a diagnostic interview checklist, the subjects were differentiated whether they were major depressive syndrome positive (MDS+) (i.e., fulfill criteria A and C of major depressive episode Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria) or significant depression positive (SD+) (having depressed mood or anhedonia that caused significant distress or dysfunction). According to receiver operating characteristic curves obtained, the cutoff point of 22 or greater was the most suitable to screen MDS, whereas for screening milder but clinically significant depression (i.e., having depressed mood or anhedonia that caused significant distress or dysfunction), the cutoff point of 14 or greater was the best. Key Words: Beck Depression Inventory–II, students, Iran (J Nerv Ment Dis 2014;202: 738–744)
D
epression and depressive symptoms are common among various populations, including university and college students. For example, in the study of Furr et al. (2001), a total of 53% of the sample students stated that they experienced depression and 9% reported that they considered committing suicide since beginning college. Moreover, although the prevalence of depression may resemble the general population upon entering the university, it may rise significantly year after year in some student populations, including medical and law students (Dammeyer and Nunez, 1999; Rosal et al., 1997). Depressive disorders can cause serious dysfunction in depressed populations, including suicidal thoughts and/or attempts, interpersonal problems, educational and work problems, and others. Appreciating the fact that approximately 50% of patients having their first episode of major depressive disorder showed significant depressive symptoms beforehand (Sadock and Sadock, 2007), early identification and treatment of early symptoms may prevent the development of the full depressive episode and its consequences. The Beck Depression Inventory (BDI) is among the most widely used tools for measuring depression in various countries, including Iran (Ghassemzadeh et al., 2005). It has been shown to have good reliability and validity for screening and measuring depression among different populations, including college students (Bonilla et al., 2004; Canals et al., 2001; Nu’man, 2001; Penley et al., 2003; Sprinkle et al., 2002; Steer et al., 1999, 1998; Storch et al.,
*Iran University of Medical Sciences, Tehran; and †Jondishapur University of Medical Sciences, Ahvaz, Khuzestan Province, Islamic Republic of Iran. This study was conducted as a university thesis. Send reprint requests to Sasan Vasegh, MD, No 7, The 4th Western Andisheh Alley, The Main Andisheh Street, Shahid Beheshti Street, Tehran 1569715611, Islamic Republic of Iran. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20210–0738 DOI: 10.1097/NMD.0000000000000183
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2004; Tashakkori et al., 1989; Viljoen et al., 2003; Weeks and Heimberg, 2005; Whisman et al., 2000). Unfortunately, although Beck and Beamesderfer (1974) previously suggested some BDI cutoff points for screening depression, there are relatively few studies that empirically confirm these or any other cutoff points, leading to difficulties in specificity and discriminant validity (Nezu et al., 1986). Actually in Iran, as far as we know, there has been no study to empirically determine cutoff points of the BDI for screening depression in any population. As a result, there are considerable variations in the reported prevalence of depression in Iran (Sadeghirad et al., 2010). Although some studies report the prevalence of major depressive disorder to be relatively high (4.1%; Sadeghirad et al., 2010), a more accurate and extensive study using a structured clinical interview among a national representative sample reported it to be relatively low (2.98%; Mohammadi et al., 2005). Our study is the first of its kind among university students in Iran and can help better estimate the prevalence of and/or determine a more efficient screening of depression in this population.
METHODS Subjects Subjects were students of Ilam Medical University and Ilam University who were approached conveniently and consented to participate in the study. Ilam is the central city of the Ilam Province west of Iran, near the Iran-Iraq border. No other inclusion criteria were considered.
Procedure After being informed about the study process and giving consent, the subjects completed a demographic questionnaire and the BDI and then participated in a semistructured diagnostic interview conducted by a trained general practitioner (GP), who was blinded to the BDI result. In the diagnostic interview, the GP completed a checklist based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria of the major depressive episode (MDE) (Appendix 1). The authors then used receiver operating characteristic (ROC) curves to determine suitable cutoff point(s) of the BDI for diagnosis of depression.
Instruments Persian-Language Version of the BDI-II The BDI-II was first introduced in 1996 for measuring depression (Beck et al., 1996) and has been widely used since then in various populations. It contains 21 sets of sentences, each including 4 sentences describing the subject's condition, and the subjects should mark the sentence that more precisely describes their condition in the previous week “including today.” The four sentences are scored from 0 to 3, yielding a test score range from 0 to 63, with higher scores indicating more depression. The BDI-II has been shown to have acceptable psychometric properties in psychiatric and nonpsychiatric populations in various countries and has been translated into many different languages, including Persian (Ghassemzadeh et al., 2005). We used the
The Journal of Nervous and Mental Disease • Volume 202, Number 10, October 2014
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The Journal of Nervous and Mental Disease • Volume 202, Number 10, October 2014
TABLE 1. Age and BDI-II–Persian Scores of 400 Male and Female Students in the Sample Age Sex
n
Female 261 Male 139
BDI-II–Persian Score
Mean (Standard Deviation) Mean (Standard Deviation) 22.65 (2.59) 24.05 (3.18)
15.89 (11.10) 13.79 (13.54)
Persian (Farsi) translation of the BDI-II previously studied in Iran, obtained by repeated translation and back-translation of the original questionnaire (Ghassemzadeh et al., 2005).
DSM-IV-TR Depression Diagnostic Checklist We created a checklist questionnaire based on the DSM-IV-TR criteria A and C for MDE (Appendix 1). To estimate the reliability of the checklist, a pilot study was conducted with 20 of the students. The students participated in a semistructured interview conducted by two GP interviewers under the supervision of a psychiatrist. The interviewers independently completed the checklist to diagnose the students who had depression (see below). Although there were discrepancies regarding individual criteria, the two interviewers showed 100% correlation in diagnosing the depressed students (as defined below). One reason may be that, although the two interviewers independently completed separate checklists for each student, both were present in each other's interview sessions so that no student would need to be interviewed twice.
BDI in Students
In addition, because it may be suitable to screen for significant depressive signs and symptoms even lower than the MDE threshold, we defined being significant depression positive (SD+) as having depressed mood or anhedonia that caused significant distress or dysfunction (Appendix 1). Using the ROC curves, the authors used the above-mentioned results of the semistructured interview as the criterion standard against which the BDI-II–Persian results were evaluated. In an ROC curve, sensitivity of each cutoff score of a test (here, BDI-II–Persian) for diagnosis of a defined disorder (here, depression) is plotted on the y axis, and “1-specificity” for the same score is plotted on the x axis. The closer the area under the ROC curve is to 1, the more useful is the “test” for differentiating subjects with from subjects without a disease. The ROC curve yields sensitivity and specificity for each cutoff score of the test, which are used to offer the best cutoff point. Sensitivity of a cutoff point is the portion of disease-positive subjects who are also test positive (i.e., their scores are equal to or higher than True‐positive TP the defined cutoff point) Sensitivity ¼ True‐positive þ false‐negative ¼ Dþ . Thus, a test with higher sensitivity can diagnose a higher portion of the subjects with a disease, and fewer subjects will be missed. 1-Specificity is the portion of disease-negative subjects who are test positive (i.e., their scores are equal to or higher than the defined cut FP off point) 1−Specificity ¼ False‐positive . Thus, a test with lower 1¼ D− D− specificity allows for fewer false-positive diagnoses, and fewer normal subjects will be mistakenly marked as having the disease. Therefore, the best cutoff point (assuming the equal importance of not missing and not false-diagnosing the subjects) would be that which has the highest sensitivity and the lowest 1-specificity. We used Youden's index (Youden, 1950) to calculate such a cutoff point: Youden's index = sensitivity + (1-specificity). The most suitable cutoff point would be the one with the maximum Youden's index.
Statistical Analyses On the basis of the diagnostic interview, the subjects were diagnosed if they fulfill MDE criteria A and C. These subjects were defined as major depressive syndrome positive (MDS+), that is, having depressive signs and symptoms described in DSM-IV- TR criterion A of MDE that caused significant distress or dysfunction. According to DSM-IV-TR, the minimum duration of MDE is 2 weeks, but the Persian-language version of the BDI-II (BDI-II–Persian) asks about depressive symptoms in the last week, so we also defined MDS+–1 week (MDS1w+) as those who fulfilled MDE criteria A and C for at least 1 week.
A total of 400 students were approached, completed the BDI-II– Persian, and participated in a semistructured interview, of which 261 (65.3%) were women and 139 (34.8%) were men. The mean (standard deviation) age was 23(2.8)years, and the age range was from 18 to 36 years. The mean (standard deviation) BDI-II–Persian score was 15.16(12.03), and its range was from 00.00 to 53.00. Table 1 shows the mean age and BDI-II–Persian score for the male and female students separately.
FIGURE 1. ROC curve of the BDI for diagnosis of MDS1w.
FIGURE 2. ROC curve of the BDI for diagnosis of MDS2w.
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TABLE 2. Sensitivity, Specificity, and Youden's Index for Various Cutoff Points of the BDI for Diagnosis of MDS1w Positive If ≥
FIGURE 3. ROC curve of the BDI for diagnosis of SD.
According to the results of the semistructured interview, 38 (9.5%) of the sample were MDS+, 42 (10.5%) of the subjects were MDS1w+, and 229 (57.3%) were SD+. The corresponding ROC curves as well as the table of sensitivities, specificities, and Youden’s indices for each cutoff point follow (Figs. 1–3, Tables 2–4). The areas under the ROC curves (0.919 for MDS1w, 0.913 for MDS, and 0.890 for SD) imply that BDI-II–Persian is good in screening each of these depressive syndromes. Table 5 shows the cutoff points of BDI-II–Persian with maximum Youden indices for the diagnosis of MDS1w, MDS, and SD according to the tables and figures. As Table 5 implies, according to our study, the cutoff point of 22 or greater would be the most suitable to diagnose MDE symptoms, whether 1 week or 2 weeks is considered as the minimal episode length. Of the 400 students in our sample, 108 had BDI-II–Persian scores of greater than or equal to 22. Using this cutoff point, approximately 87% of the patients with MDS were correctly diagnosed, but approximately 20% of those who are not MDS+ were falsely diagnosed to be MDS+. The sensitivity (0.868) and specificity (0.793) both were good and acceptable. The sensitivity (0.775) and specificity (0.883) for screening SD by the cutoff point of 14 or greater were good and acceptable too. Of the 400 students in our sample, 193 had BDI-II–Persian scores of greater than or equal to 14. Psychological and/or psychiatric consultation was offered and recommended to all of these students.
DISCUSSION The BDI has long been used for measurement of depression; the higher the score is, the worse the depression. However, compared with many articles studying the psychometric properties of the BDI, there are much fewer articles empirically studying the BDI for screening of clinically significant depression to find suitable cutoff points. Some such studies will follow. Holocomb et al. (1996) used the BDI among 105 pregnant women. They used a structured interview according to the NIMH Diagnostic Interview Schedule–version III to diagnose current depression according to DSM-III. Using a cutoff score of greater than 16, the sensitivity of the BDI to detect current depression was 0.83, and the specificity was 0.89. Yeung et al. (2002b) administered the Chinese version of the BDI (CBDI) to 503 Chinese-Americans in primary care. The results were compared with those of a standard semistructured interview. They found that an empirically determined cutoff score of 13 or greater 740
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0.5 1.5 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9.5 10.5 11.5 12.5 13.5 14.5 15.5 16.5 17.5 18.5 19.5 20.5 21.5 22.5 23.5 24.5 25.5 26.5 27.5 28.5 29.5 30.5 31.5 32.5 33.5 34.5 35.5 36.5 37.5 39 40.5 41.5 42.5 43.5 44.5 46 47.5 49 50.5 51.5 52.5 54
Sensitivity
Specificity
Youden's Index
1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 0.976 0.952 0.905 0.905 0.905 0.881 0.881 0.857 0.810 0.786 0.762 0.738 0.714 0.667 0.643 0.619 0.595 0.571 0.476 0.452 0.429 0.405 0.381 0.357 0.333 0.286 0.262 0.238 0.214 0.119 0.095 0.071 0.048 0.024 0.024 0.000
0.067 0.115 0.159 0.187 0.235 0.288 0.324 0.360 0.405 0.433 0.486 0.506 0.556 0.578 0.603 0.640 0.656 0.698 0.729 0.757 0.774 0.802 0.821 0.852 0.872 0.894 0.913 0.922 0.925 0.927 0.944 0.953 0.955 0.958 0.964 0.966 0.978 0.983 0.983 0.983 0.983 0.983 0.989 0.989 0.994 0.994 0.994 0.994 0.994 0.997 1.000
0.067 0.115 0.159 0.187 0.235 0.288 0.324 0.360 0.405 0.433 0.486 0.506 0.556 0.578 0.603 0.616 0.608 0.603 0.634 0.662 0.655 0.683 0.678 0.662 0.658 0.656 0.651 0.636 0.592 0.570 0.563 0.548 0.526 0.434 0.416 0.395 0.383 0.364 0.340 0.316 0.269 0.245 0.227 0.203 0.113 0.089 0.065 0.042 0.018 0.021 0.000
Bold data are the cutoff point with the maximum Youden’s Index.
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The Journal of Nervous and Mental Disease • Volume 202, Number 10, October 2014
BDI in Students
TABLE 3. Sensitivity, Specificity, and Youden's Index for Various Cutoff Points of the BDI for Diagnosis of MDS2w
TABLE 4. Sensitivity, Specificity, and Youden's Index for Various Cutoff Points of the BDI for Diagnosis of SD
Positive If ≥
Positive If ≥
0.5 1.5 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9.5 10.5 11.5 12.5 13.5 14.5 15.5 16.5 17.5 18.5 19.5 20.5 21.5 22.5 23.5 24.5 25.5 26.5 27.5 28.5 29.5 30.5 31.5 32.5 33.5 34.5 35.5 36.5 37.5 39 40.5 41.5 42.5 43.5 44.5 46 47.5 49 50.5 51.5 52.5 54
Sensitivity
Specificity
Youden's Index
1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 0.974 0.947 0.895 0.895 0.895 0.868 0.868 0.842 0.789 0.789 0.763 0.737 0.737 0.684 0.658 0.632 0.605 0.579 0.474 0.447 0.421 0.395 0.395 0.368 0.342 0.316 0.289 0.263 0.237 0.132 0.105 0.079 0.053 0.026 0.026 0.000
0.066 0.113 0.157 0.185 0.232 0.285 0.320 0.356 0.401 0.428 0.481 0.500 0.550 0.572 0.597 0.633 0.649 0.691 0.721 0.749 0.765 0.793 0.812 0.843 0.865 0.887 0.906 0.917 0.920 0.923 0.939 0.948 0.950 0.953 0.959 0.961 0.972 0.981 0.981 0.981 0.983 0.983 0.989 0.989 0.994 0.994 0.994 0.994 0.994 0.997 1.000
0.066 0.113 0.157 0.185 0.232 0.285 0.320 0.356 0.401 0.428 0.481 0.500 0.550 0.572 0.597 0.607 0.596 0.586 0.616 0.644 0.633 0.661 0.654 0.632 0.654 0.650 0.643 0.654 0.604 0.581 0.571 0.553 0.529 0.427 0.406 0.382 0.367 0.376 0.349 0.323 0.299 0.272 0.252 0.226 0.126 0.099 0.073 0.047 0.020 0.023 0.000
Bold data are the cutoff point with the maximum Youden’s Index.
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0.5 1.5 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9.5 10.5 11.5 12.5 13.5 14.5 15.5 16.5 17.5 18.5 19.5 20.5 21.5 22.5 23.5 24.5 25.5 26.5 27.5 28.5 29.5 30.5 31.5 32.5 33.5 34.5 35.5 36.5 37.5 39 40.5 41.5 42.5 43.5 44.5 46 47.5 49 50.5 51.5 52.5 54
Sensitivity
Specificity
Youden's Index
0.996 0.996 0.987 0.983 0.969 0.952 0.943 0.926 0.878 0.856 0.821 0.812 0.769 0.755 0.729 0.681 0.655 0.590 0.550 0.507 0.480 0.445 0.415 0.358 0.323 0.293 0.262 0.245 0.231 0.223 0.192 0.179 0.170 0.148 0.135 0.127 0.105 0.096 0.092 0.087 0.079 0.074 0.061 0.057 0.031 0.026 0.022 0.017 0.013 0.009 0.000
0.135 0.234 0.316 0.368 0.450 0.538 0.602 0.655 0.684 0.713 0.778 0.807 0.854 0.883 0.901 0.918 0.924 0.936 0.947 0.947 0.953 0.965 0.971 0.971 0.971 0.982 0.988 0.988 0.988 0.988 0.988 0.994 0.994 0.994 0.994 0.994 0.994 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
0.131 0.230 0.303 0.351 0.419 0.490 0.545 0.581 0.562 0.569 0.599 0.619 0.623 0.638 0.630 0.599 0.579 0.526 0.497 0.454 1.433 0.410 0.386 0.329 1.294 0.275 0.250 0.233 0.219 0.211 0.180 0.173 0.164 0.143 0.129 0.121 0.099 0.096 0.092 0.087 0.079 0.074 0.061 0.057 0.031 0.026 0.022 0.017 0.013 0.009 0.000
Bold data are the cutoff point with the maximum Youden’s Index.
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TABLE 5. Cutoff Points of the BDI That Have Maximum Youden's Indices for the Diagnosis of MDES1w, MDES2w, and SD
Canals J, Blade J, Carbajo G, Domenech-L L (2001) The Beck Depression Inventory: Psychometric characteristics and usefulness in nonclinical adolescents. Eur J Psychol Assess. 17:63–68.
Clinical Syndrome
BDI Cutoff Point
Sensitivity
Specificity
Dammeyer MM, Nunez N (1999) Anxiety and depression among law students: Current knowledge and future directions. Law Hum Behav. 23:55–73.
21.5 21.5 13.5
0.881 0.868 0.755
0.802 0.793 0.883
Furr SR, Westefeld JS, McConnell GN, Jenkins JM (2001) Suicide and depression among college students: A decade later. Prof Psychol Res Pract. 32:97–100.
MDES1w MDES2w SD
for the CBDI has good sensitivity (0.78) and specificity (0.91) for diagnosing depression. In another similar article, Yeung et al. (2002a) approached a total of 815 Chinese-Americans in a primary care clinic, of whom 503 completed the CBDI, administered and read to them by a native-speaking research assistant. The Structured Clinical Interview for DSM-III-R Patient Version was used as the standard for evaluating the sensitivity and the specificity of the CBDI. This time, they found that the CBDI with the cutoff score of 16 or greater had good sensitivity (0.79) and specificity (0.91) for diagnosis of depression among Chinese-Americans in a primary care clinic. Sprinkle et al. (2002) used the BDI-II and the MDE portion of the Structured Clinical Interview for DSM-IV Axis I Disorders among a sample of 137 students receiving treatment at a university counseling center. They proposed a BDI-II cutoff score of 16, with a sensitivity rate of 84% and a false-positive rate of 18% in identifying depressed mood. Viinamäki et al. (2004) used the 21-item BDI and the Structured Clinical Interview for DSM-III-R among a sample of 127 treatmentseeking outpatients twice with a 2-year interval to screen whether the patient had a current episode of major depressive disorder. They proposed a BDI cutoff score of 15, with a sensitivity of 0.83 and a specificity of 0.81 as suitable in identifying MDE in different phases of MDD. It can be concluded from the aforementioned studies that suitable cutoff points of the BDI for screening of depression are different among different populations and depend on the methodology used to diagnose depression.
CONCLUSIONS The BDI-II–Persian can be a suitable tool to screen and diagnose depression. Its use is relatively easy and fast, but suitable cutoff points to diagnose depression have seldom resulted from empirical studies. According to our study, the cutoff point of 22 or greater was the most suitable to screen MDE symptoms among university students and for screening milder but clinically significant depression (i.e., having depressed mood or anhedonia that caused significant distress or dysfunction; Appendix 1); the cutoff point of 14 or greater was the best.
DISCLOSURES This study was funded by the authors. The authors declare no conflict of interest.
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BDI in Students
If yes, A5a1: Was psychomotor agitation or retardation present almost every day in the current episode? Yes □ No □ A5a2: How long is the approximate duration of the current psychomotor agitation or retardation according to the subject's report? (Write in days or weeks or months) _______
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APPENDIX 1 A Checklist for Diagnosis of Depression Based on the DSM-IV-TR MDE Criteria
Criterion A A1a: Does the subject have depressed mood? Yes □ No □ For example, ask the subject, “Have you recently felt sadness or emptiness or felt like crying?” If yes, A1a1: Was the depressed mood present most of the day, almost every day in the current episode? Yes □ No □ A1a2: How long is the approximate duration of the current depressive mood? (Write in days or weeks or months) _______ A2a: Does the subject have anhedonia? For example, ask the subject, “Have you recently felt that you do not feel pleasure from almost any activity? Or your interest has been significantly diminished in almost any activity?” Yes □ No □ If yes, A2a1: Was anhedonia present most of the day, almost every day in the current episode? Yes □ No □ A2a2: How long is the approximate duration of the current anhedonia? (Write in days or weeks or months) _______ A3a: Has the subject's weight increased or decreased by at least 5% during the last month? Yes □ No □ A3a1: Did the subject's weight increase or decrease because of dieting? Yes □ No □ A3b: Has the subject's appetite increased or decreased significantly during the current episode? Yes □ No □ If yes, A3b1: Was significantly increased or decreased appetite present almost every day in the current episode? Yes □ No □ A3b2: How long is the approximate duration of the current significant increase or decrease in appetite? (Write in days or weeks or months) _______ A4a: Does the subject report significant insomnia or hypersomnia? Yes □ No □ If yes, A4a1: Was significant insomnia or hypersomnia present almost every day in the current episode? Yes □ No □ A4a2: How long is the approximate duration of the current significant insomnia or hypersomnia? (Write in days or weeks or months) _______ A5a: Does the subject show signs and symptoms of psychomotor agitation (for example, complains about restlessness and wiggles or cannot sit still or plays a lot with his/her clothes or hair) or psychomotor retardation (for example, speaks slowly or has delayed response or retarded body movements)? Yes □ No □ © 2014 Lippincott Williams & Wilkins
A6a: Does the subject report fatigue or loss of energy? (For example, ask the subject, “Do you feel severe tiredness or loss of energy?”) Yes □ No □ If yes, A6a1: Was fatigue or loss of energy present almost every day in the current episode? Yes □ No □ A6a2: How long is the approximate duration of the current fatigue or loss of energy according to the subject's report? (Write in days or weeks or months) _______ A7a: Does the subject have a worthlessness feeling? (For example, ask the subject, “Do you feel worthless? Do you think you are an inadequate or weak person?”) Yes □ No □ If yes, A7a1: Was the worthlessness feeling present almost every day in the current episode? Yes □ No □ A7a2: How long is the approximate duration of the current worthlessness feeling according to the subject's report? (Write in days or weeks or months) _______ A7b: Does the subject have excessive guilt feeling (not merely self-reproach or guilt about being sick)? (For example, ask the subject, “Do you think you are a bad or sinful person? Do you think you have committed unforgivable or great sins?”) Yes □ No □ If yes, A7b1: Was the guilt feeling present almost every day in the current episode? Yes □ No □ A7b2: How long is the approximate duration of the current guilt feeling according to the subject's report? (Write in days or weeks or months) _______ A8a: Does the subject report diminished ability to think? Yes □ No □ If yes, A8a1: Was diminished ability to think present almost every day in the current episode? Yes □ No □ A8a2: How long is the approximate duration of the current diminished ability to think according to the subject's report? (Write in days or weeks or months) _______ A8b: Does the subject report diminished ability to concentrate? Yes □ No □ If yes, A8b1: Was diminished ability to concentrate present almost every day in the current episode? Yes □ No □ A8b2: How long is the approximate duration of the current diminished ability to concentrate? (Write in days or weeks or months) _______ A8c: Does the subject report indecisiveness? Yes □ No □ If yes, A8c1: Was indecisiveness present almost every day in the current episode? Yes □ No □ A8c2: How long is the approximate duration of the current indecisiveness according to the subject's report? (Write in days or weeks or months) _______ A9a: Does the subject have recurrent thoughts of death these days? (For example, ask the subject, “Do you think a lot about death/ dying these days? Are you only afraid of death, or do you think a lot about other aspects of death too?”) Yes □ No □ www.jonmd.com
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If yes, A9a1: How long is the approximate duration of the current thoughts of death according to the subject's report? (Write in days or weeks or months) _______ A9b: Does the subject report recent recurrent suicidal ideation? Yes □ No □ If yes, A9b1: How long was the recent recurrent suicidal ideation present? (Write in days or weeks or months) _______ A9c: Does the subject report a specific suicidal plan or attempted suicide in the recent episode? Yes □ No □
Criterion C C1: Clinically significant distress. How much distress did the aforementioned problems cause to the subject? (For example, ask the subject, “We spoke about several problems and symptoms. Could you please say how much you think you have suffered from these problems, such as sadness? Little? Moderate? Very much? Very little?”) 1. Almost none □ 2. Little but significant □ 3. Moderate □ 4. Severe □ C2: Clinically significant dysfunction. How much dysfunction did the aforementioned problems cause to the subject's important areas of functioning such as social, occupational, familial, or educational areas? (The interviewer must examine all areas carefully and answer according to his/her own opinion.) 1. Almost none □ 2. Little but significant □ 3. Moderate □ 4. Severe □
Questions to Be Completed After the Interview A1: Depressed mood Does the subject fulfill criterion A1? (A1a Yes and A1a1 Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A2: Anhedonia Does the subject fulfill criterion A2? (A2a Yes and A2a1 Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A3: Weight and appetite Does the subject fulfill criterion A3? ([A3a Yes and A3a1 No] or [A3b Yes and A3b1 Yes]) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □
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A4: Sleep Does the subject fulfill criterion A4? (A4a Yes and A4a1 Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A5: Psychomotor Does the subject fulfill criterion A5? (A5a Yes and A5a1 Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A6: Fatigue or loss of energy Does the subject fulfill criterion A6? (A6a Yes and A6a1 Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A7: Worthlessness or excessive guilt feeling Does the subject fulfill criterion A7? ([A7a Yes and A7a1 Yes] or [A7b Yes and A7b1 Yes]) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A8: Diminished ability to think or concentrate, or indecisiveness Does the subject fulfill criterion A8? ([A8a Yes and A8a1 Yes] or [A8b Yes and A8b1 Yes] or [A8c Yes and A8c1 Yes]) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A9: Recurrent thoughts of death, or recurrent suicidal ideation, or a suicidal attempt or a specific plan Does the subject fulfill criterion A9? (A9a Yes, or A9b Yes, or A9c Yes, or A9d Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ Does the subject fulfill criterion A based on the above-mentioned nine questions? ([A1 Yes or A2 Yes] and [at least four other criteria from A1 to A9, Yes]) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ Does the subject fulfill criterion C? ([C1 moderate or severe] or [C2 moderate or severe]) Yes □ No □ Is the subject MDS+? (Both of the above-mentioned questions Yes for at least 2 weeks) Yes □ No □ Is the subject MDS1w+? (Both of the above-mentioned questions Yes for at least 1 week) Yes □ No □ Is the subject SD+? ([A1a Yes or A2a Yes] and [(C1≥2) or (C2 ≥ 2)]) Yes □ No □
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Using the Persian-Language Version of the Beck Depression Inventory–II (BDI-II-Persian) for the Screening of Depression in Students Sasan Vasegh, MD* and Nafiseh Baradaran, MD† Abstract: Early identification and treatment of depression can prevent the development of the full depressive episode and its consequences. Although the Beck Depression Inventory–II is among the most widely used tools for measuring depression, there are relatively few studies that empirically confirm any cutoff points for screening depression among university students. Our subjects were 400 students from Ilam University (Iran). On the basis of a diagnostic interview checklist, the subjects were differentiated whether they were major depressive syndrome positive (MDS+) (i.e., fulfill criteria A and C of major depressive episode Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria) or significant depression positive (SD+) (having depressed mood or anhedonia that caused significant distress or dysfunction). According to receiver operating characteristic curves obtained, the cutoff point of 22 or greater was the most suitable to screen MDS, whereas for screening milder but clinically significant depression (i.e., having depressed mood or anhedonia that caused significant distress or dysfunction), the cutoff point of 14 or greater was the best. Key Words: Beck Depression Inventory–II, students, Iran (J Nerv Ment Dis 2014;202: 738–744)
D
epression and depressive symptoms are common among various populations, including university and college students. For example, in the study of Furr et al. (2001), a total of 53% of the sample students stated that they experienced depression and 9% reported that they considered committing suicide since beginning college. Moreover, although the prevalence of depression may resemble the general population upon entering the university, it may rise significantly year after year in some student populations, including medical and law students (Dammeyer and Nunez, 1999; Rosal et al., 1997). Depressive disorders can cause serious dysfunction in depressed populations, including suicidal thoughts and/or attempts, interpersonal problems, educational and work problems, and others. Appreciating the fact that approximately 50% of patients having their first episode of major depressive disorder showed significant depressive symptoms beforehand (Sadock and Sadock, 2007), early identification and treatment of early symptoms may prevent the development of the full depressive episode and its consequences. The Beck Depression Inventory (BDI) is among the most widely used tools for measuring depression in various countries, including Iran (Ghassemzadeh et al., 2005). It has been shown to have good reliability and validity for screening and measuring depression among different populations, including college students (Bonilla et al., 2004; Canals et al., 2001; Nu’man, 2001; Penley et al., 2003; Sprinkle et al., 2002; Steer et al., 1999, 1998; Storch et al.,
*Iran University of Medical Sciences, Tehran; and †Jondishapur University of Medical Sciences, Ahvaz, Khuzestan Province, Islamic Republic of Iran. This study was conducted as a university thesis. Send reprint requests to Sasan Vasegh, MD, No 7, The 4th Western Andisheh Alley, The Main Andisheh Street, Shahid Beheshti Street, Tehran 1569715611, Islamic Republic of Iran. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20210–0738 DOI: 10.1097/NMD.0000000000000183
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2004; Tashakkori et al., 1989; Viljoen et al., 2003; Weeks and Heimberg, 2005; Whisman et al., 2000). Unfortunately, although Beck and Beamesderfer (1974) previously suggested some BDI cutoff points for screening depression, there are relatively few studies that empirically confirm these or any other cutoff points, leading to difficulties in specificity and discriminant validity (Nezu et al., 1986). Actually in Iran, as far as we know, there has been no study to empirically determine cutoff points of the BDI for screening depression in any population. As a result, there are considerable variations in the reported prevalence of depression in Iran (Sadeghirad et al., 2010). Although some studies report the prevalence of major depressive disorder to be relatively high (4.1%; Sadeghirad et al., 2010), a more accurate and extensive study using a structured clinical interview among a national representative sample reported it to be relatively low (2.98%; Mohammadi et al., 2005). Our study is the first of its kind among university students in Iran and can help better estimate the prevalence of and/or determine a more efficient screening of depression in this population.
METHODS Subjects Subjects were students of Ilam Medical University and Ilam University who were approached conveniently and consented to participate in the study. Ilam is the central city of the Ilam Province west of Iran, near the Iran-Iraq border. No other inclusion criteria were considered.
Procedure After being informed about the study process and giving consent, the subjects completed a demographic questionnaire and the BDI and then participated in a semistructured diagnostic interview conducted by a trained general practitioner (GP), who was blinded to the BDI result. In the diagnostic interview, the GP completed a checklist based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria of the major depressive episode (MDE) (Appendix 1). The authors then used receiver operating characteristic (ROC) curves to determine suitable cutoff point(s) of the BDI for diagnosis of depression.
Instruments Persian-Language Version of the BDI-II The BDI-II was first introduced in 1996 for measuring depression (Beck et al., 1996) and has been widely used since then in various populations. It contains 21 sets of sentences, each including 4 sentences describing the subject's condition, and the subjects should mark the sentence that more precisely describes their condition in the previous week “including today.” The four sentences are scored from 0 to 3, yielding a test score range from 0 to 63, with higher scores indicating more depression. The BDI-II has been shown to have acceptable psychometric properties in psychiatric and nonpsychiatric populations in various countries and has been translated into many different languages, including Persian (Ghassemzadeh et al., 2005). We used the
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The Journal of Nervous and Mental Disease • Volume 202, Number 10, October 2014
TABLE 1. Age and BDI-II–Persian Scores of 400 Male and Female Students in the Sample Age Sex
n
Female 261 Male 139
BDI-II–Persian Score
Mean (Standard Deviation) Mean (Standard Deviation) 22.65 (2.59) 24.05 (3.18)
15.89 (11.10) 13.79 (13.54)
Persian (Farsi) translation of the BDI-II previously studied in Iran, obtained by repeated translation and back-translation of the original questionnaire (Ghassemzadeh et al., 2005).
DSM-IV-TR Depression Diagnostic Checklist We created a checklist questionnaire based on the DSM-IV-TR criteria A and C for MDE (Appendix 1). To estimate the reliability of the checklist, a pilot study was conducted with 20 of the students. The students participated in a semistructured interview conducted by two GP interviewers under the supervision of a psychiatrist. The interviewers independently completed the checklist to diagnose the students who had depression (see below). Although there were discrepancies regarding individual criteria, the two interviewers showed 100% correlation in diagnosing the depressed students (as defined below). One reason may be that, although the two interviewers independently completed separate checklists for each student, both were present in each other's interview sessions so that no student would need to be interviewed twice.
BDI in Students
In addition, because it may be suitable to screen for significant depressive signs and symptoms even lower than the MDE threshold, we defined being significant depression positive (SD+) as having depressed mood or anhedonia that caused significant distress or dysfunction (Appendix 1). Using the ROC curves, the authors used the above-mentioned results of the semistructured interview as the criterion standard against which the BDI-II–Persian results were evaluated. In an ROC curve, sensitivity of each cutoff score of a test (here, BDI-II–Persian) for diagnosis of a defined disorder (here, depression) is plotted on the y axis, and “1-specificity” for the same score is plotted on the x axis. The closer the area under the ROC curve is to 1, the more useful is the “test” for differentiating subjects with from subjects without a disease. The ROC curve yields sensitivity and specificity for each cutoff score of the test, which are used to offer the best cutoff point. Sensitivity of a cutoff point is the portion of disease-positive subjects who are also test positive (i.e., their scores are equal to or higher than True‐positive TP the defined cutoff point) Sensitivity ¼ True‐positive þ false‐negative ¼ Dþ . Thus, a test with higher sensitivity can diagnose a higher portion of the subjects with a disease, and fewer subjects will be missed. 1-Specificity is the portion of disease-negative subjects who are test positive (i.e., their scores are equal to or higher than the defined cut FP off point) 1−Specificity ¼ False‐positive . Thus, a test with lower 1¼ D− D− specificity allows for fewer false-positive diagnoses, and fewer normal subjects will be mistakenly marked as having the disease. Therefore, the best cutoff point (assuming the equal importance of not missing and not false-diagnosing the subjects) would be that which has the highest sensitivity and the lowest 1-specificity. We used Youden's index (Youden, 1950) to calculate such a cutoff point: Youden's index = sensitivity + (1-specificity). The most suitable cutoff point would be the one with the maximum Youden's index.
Statistical Analyses On the basis of the diagnostic interview, the subjects were diagnosed if they fulfill MDE criteria A and C. These subjects were defined as major depressive syndrome positive (MDS+), that is, having depressive signs and symptoms described in DSM-IV- TR criterion A of MDE that caused significant distress or dysfunction. According to DSM-IV-TR, the minimum duration of MDE is 2 weeks, but the Persian-language version of the BDI-II (BDI-II–Persian) asks about depressive symptoms in the last week, so we also defined MDS+–1 week (MDS1w+) as those who fulfilled MDE criteria A and C for at least 1 week.
A total of 400 students were approached, completed the BDI-II– Persian, and participated in a semistructured interview, of which 261 (65.3%) were women and 139 (34.8%) were men. The mean (standard deviation) age was 23(2.8)years, and the age range was from 18 to 36 years. The mean (standard deviation) BDI-II–Persian score was 15.16(12.03), and its range was from 00.00 to 53.00. Table 1 shows the mean age and BDI-II–Persian score for the male and female students separately.
FIGURE 1. ROC curve of the BDI for diagnosis of MDS1w.
FIGURE 2. ROC curve of the BDI for diagnosis of MDS2w.
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RESULTS
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TABLE 2. Sensitivity, Specificity, and Youden's Index for Various Cutoff Points of the BDI for Diagnosis of MDS1w Positive If ≥
FIGURE 3. ROC curve of the BDI for diagnosis of SD.
According to the results of the semistructured interview, 38 (9.5%) of the sample were MDS+, 42 (10.5%) of the subjects were MDS1w+, and 229 (57.3%) were SD+. The corresponding ROC curves as well as the table of sensitivities, specificities, and Youden’s indices for each cutoff point follow (Figs. 1–3, Tables 2–4). The areas under the ROC curves (0.919 for MDS1w, 0.913 for MDS, and 0.890 for SD) imply that BDI-II–Persian is good in screening each of these depressive syndromes. Table 5 shows the cutoff points of BDI-II–Persian with maximum Youden indices for the diagnosis of MDS1w, MDS, and SD according to the tables and figures. As Table 5 implies, according to our study, the cutoff point of 22 or greater would be the most suitable to diagnose MDE symptoms, whether 1 week or 2 weeks is considered as the minimal episode length. Of the 400 students in our sample, 108 had BDI-II–Persian scores of greater than or equal to 22. Using this cutoff point, approximately 87% of the patients with MDS were correctly diagnosed, but approximately 20% of those who are not MDS+ were falsely diagnosed to be MDS+. The sensitivity (0.868) and specificity (0.793) both were good and acceptable. The sensitivity (0.775) and specificity (0.883) for screening SD by the cutoff point of 14 or greater were good and acceptable too. Of the 400 students in our sample, 193 had BDI-II–Persian scores of greater than or equal to 14. Psychological and/or psychiatric consultation was offered and recommended to all of these students.
DISCUSSION The BDI has long been used for measurement of depression; the higher the score is, the worse the depression. However, compared with many articles studying the psychometric properties of the BDI, there are much fewer articles empirically studying the BDI for screening of clinically significant depression to find suitable cutoff points. Some such studies will follow. Holocomb et al. (1996) used the BDI among 105 pregnant women. They used a structured interview according to the NIMH Diagnostic Interview Schedule–version III to diagnose current depression according to DSM-III. Using a cutoff score of greater than 16, the sensitivity of the BDI to detect current depression was 0.83, and the specificity was 0.89. Yeung et al. (2002b) administered the Chinese version of the BDI (CBDI) to 503 Chinese-Americans in primary care. The results were compared with those of a standard semistructured interview. They found that an empirically determined cutoff score of 13 or greater 740
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0.5 1.5 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9.5 10.5 11.5 12.5 13.5 14.5 15.5 16.5 17.5 18.5 19.5 20.5 21.5 22.5 23.5 24.5 25.5 26.5 27.5 28.5 29.5 30.5 31.5 32.5 33.5 34.5 35.5 36.5 37.5 39 40.5 41.5 42.5 43.5 44.5 46 47.5 49 50.5 51.5 52.5 54
Sensitivity
Specificity
Youden's Index
1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 0.976 0.952 0.905 0.905 0.905 0.881 0.881 0.857 0.810 0.786 0.762 0.738 0.714 0.667 0.643 0.619 0.595 0.571 0.476 0.452 0.429 0.405 0.381 0.357 0.333 0.286 0.262 0.238 0.214 0.119 0.095 0.071 0.048 0.024 0.024 0.000
0.067 0.115 0.159 0.187 0.235 0.288 0.324 0.360 0.405 0.433 0.486 0.506 0.556 0.578 0.603 0.640 0.656 0.698 0.729 0.757 0.774 0.802 0.821 0.852 0.872 0.894 0.913 0.922 0.925 0.927 0.944 0.953 0.955 0.958 0.964 0.966 0.978 0.983 0.983 0.983 0.983 0.983 0.989 0.989 0.994 0.994 0.994 0.994 0.994 0.997 1.000
0.067 0.115 0.159 0.187 0.235 0.288 0.324 0.360 0.405 0.433 0.486 0.506 0.556 0.578 0.603 0.616 0.608 0.603 0.634 0.662 0.655 0.683 0.678 0.662 0.658 0.656 0.651 0.636 0.592 0.570 0.563 0.548 0.526 0.434 0.416 0.395 0.383 0.364 0.340 0.316 0.269 0.245 0.227 0.203 0.113 0.089 0.065 0.042 0.018 0.021 0.000
Bold data are the cutoff point with the maximum Youden’s Index.
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The Journal of Nervous and Mental Disease • Volume 202, Number 10, October 2014
BDI in Students
TABLE 3. Sensitivity, Specificity, and Youden's Index for Various Cutoff Points of the BDI for Diagnosis of MDS2w
TABLE 4. Sensitivity, Specificity, and Youden's Index for Various Cutoff Points of the BDI for Diagnosis of SD
Positive If ≥
Positive If ≥
0.5 1.5 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9.5 10.5 11.5 12.5 13.5 14.5 15.5 16.5 17.5 18.5 19.5 20.5 21.5 22.5 23.5 24.5 25.5 26.5 27.5 28.5 29.5 30.5 31.5 32.5 33.5 34.5 35.5 36.5 37.5 39 40.5 41.5 42.5 43.5 44.5 46 47.5 49 50.5 51.5 52.5 54
Sensitivity
Specificity
Youden's Index
1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 0.974 0.947 0.895 0.895 0.895 0.868 0.868 0.842 0.789 0.789 0.763 0.737 0.737 0.684 0.658 0.632 0.605 0.579 0.474 0.447 0.421 0.395 0.395 0.368 0.342 0.316 0.289 0.263 0.237 0.132 0.105 0.079 0.053 0.026 0.026 0.000
0.066 0.113 0.157 0.185 0.232 0.285 0.320 0.356 0.401 0.428 0.481 0.500 0.550 0.572 0.597 0.633 0.649 0.691 0.721 0.749 0.765 0.793 0.812 0.843 0.865 0.887 0.906 0.917 0.920 0.923 0.939 0.948 0.950 0.953 0.959 0.961 0.972 0.981 0.981 0.981 0.983 0.983 0.989 0.989 0.994 0.994 0.994 0.994 0.994 0.997 1.000
0.066 0.113 0.157 0.185 0.232 0.285 0.320 0.356 0.401 0.428 0.481 0.500 0.550 0.572 0.597 0.607 0.596 0.586 0.616 0.644 0.633 0.661 0.654 0.632 0.654 0.650 0.643 0.654 0.604 0.581 0.571 0.553 0.529 0.427 0.406 0.382 0.367 0.376 0.349 0.323 0.299 0.272 0.252 0.226 0.126 0.099 0.073 0.047 0.020 0.023 0.000
Bold data are the cutoff point with the maximum Youden’s Index.
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0.5 1.5 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9.5 10.5 11.5 12.5 13.5 14.5 15.5 16.5 17.5 18.5 19.5 20.5 21.5 22.5 23.5 24.5 25.5 26.5 27.5 28.5 29.5 30.5 31.5 32.5 33.5 34.5 35.5 36.5 37.5 39 40.5 41.5 42.5 43.5 44.5 46 47.5 49 50.5 51.5 52.5 54
Sensitivity
Specificity
Youden's Index
0.996 0.996 0.987 0.983 0.969 0.952 0.943 0.926 0.878 0.856 0.821 0.812 0.769 0.755 0.729 0.681 0.655 0.590 0.550 0.507 0.480 0.445 0.415 0.358 0.323 0.293 0.262 0.245 0.231 0.223 0.192 0.179 0.170 0.148 0.135 0.127 0.105 0.096 0.092 0.087 0.079 0.074 0.061 0.057 0.031 0.026 0.022 0.017 0.013 0.009 0.000
0.135 0.234 0.316 0.368 0.450 0.538 0.602 0.655 0.684 0.713 0.778 0.807 0.854 0.883 0.901 0.918 0.924 0.936 0.947 0.947 0.953 0.965 0.971 0.971 0.971 0.982 0.988 0.988 0.988 0.988 0.988 0.994 0.994 0.994 0.994 0.994 0.994 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
0.131 0.230 0.303 0.351 0.419 0.490 0.545 0.581 0.562 0.569 0.599 0.619 0.623 0.638 0.630 0.599 0.579 0.526 0.497 0.454 1.433 0.410 0.386 0.329 1.294 0.275 0.250 0.233 0.219 0.211 0.180 0.173 0.164 0.143 0.129 0.121 0.099 0.096 0.092 0.087 0.079 0.074 0.061 0.057 0.031 0.026 0.022 0.017 0.013 0.009 0.000
Bold data are the cutoff point with the maximum Youden’s Index.
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TABLE 5. Cutoff Points of the BDI That Have Maximum Youden's Indices for the Diagnosis of MDES1w, MDES2w, and SD
Canals J, Blade J, Carbajo G, Domenech-L L (2001) The Beck Depression Inventory: Psychometric characteristics and usefulness in nonclinical adolescents. Eur J Psychol Assess. 17:63–68.
Clinical Syndrome
BDI Cutoff Point
Sensitivity
Specificity
Dammeyer MM, Nunez N (1999) Anxiety and depression among law students: Current knowledge and future directions. Law Hum Behav. 23:55–73.
21.5 21.5 13.5
0.881 0.868 0.755
0.802 0.793 0.883
Furr SR, Westefeld JS, McConnell GN, Jenkins JM (2001) Suicide and depression among college students: A decade later. Prof Psychol Res Pract. 32:97–100.
MDES1w MDES2w SD
for the CBDI has good sensitivity (0.78) and specificity (0.91) for diagnosing depression. In another similar article, Yeung et al. (2002a) approached a total of 815 Chinese-Americans in a primary care clinic, of whom 503 completed the CBDI, administered and read to them by a native-speaking research assistant. The Structured Clinical Interview for DSM-III-R Patient Version was used as the standard for evaluating the sensitivity and the specificity of the CBDI. This time, they found that the CBDI with the cutoff score of 16 or greater had good sensitivity (0.79) and specificity (0.91) for diagnosis of depression among Chinese-Americans in a primary care clinic. Sprinkle et al. (2002) used the BDI-II and the MDE portion of the Structured Clinical Interview for DSM-IV Axis I Disorders among a sample of 137 students receiving treatment at a university counseling center. They proposed a BDI-II cutoff score of 16, with a sensitivity rate of 84% and a false-positive rate of 18% in identifying depressed mood. Viinamäki et al. (2004) used the 21-item BDI and the Structured Clinical Interview for DSM-III-R among a sample of 127 treatmentseeking outpatients twice with a 2-year interval to screen whether the patient had a current episode of major depressive disorder. They proposed a BDI cutoff score of 15, with a sensitivity of 0.83 and a specificity of 0.81 as suitable in identifying MDE in different phases of MDD. It can be concluded from the aforementioned studies that suitable cutoff points of the BDI for screening of depression are different among different populations and depend on the methodology used to diagnose depression.
CONCLUSIONS The BDI-II–Persian can be a suitable tool to screen and diagnose depression. Its use is relatively easy and fast, but suitable cutoff points to diagnose depression have seldom resulted from empirical studies. According to our study, the cutoff point of 22 or greater was the most suitable to screen MDE symptoms among university students and for screening milder but clinically significant depression (i.e., having depressed mood or anhedonia that caused significant distress or dysfunction; Appendix 1); the cutoff point of 14 or greater was the best.
DISCLOSURES This study was funded by the authors. The authors declare no conflict of interest.
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Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani N (2005) Psychometric properties of a Persian-language version of the Beck Depression Inventory Second Edition: BDI-II–Persian. Depress Anxiety. 185–192. Holocomb WL, Stone LS, Lustman PJ, Gavard JA, Mostello DJ (1996) Screening for depression in pregnancy: Characteristics of the Beck Depression Inventory. Obstet Gynecol. 88:1021–1025. Mohammadi MR, Davidian H, Noorbala AA, Malekafzali H, Naghavi HR, Pouretemad HR, Yazdi SA, Rahgozar M, Alaghebandrad J, Amini H, Razzaghi EM, Mesgarpour B, Soori H, Mohammadi M, Ghanizadeh A (2005) An epidemiological survey of psychiatric disorders in Iran. Available from http:// www.cpementalhealth.com/content/1/1/16. Accessed February 2014. Clin Pract Epidemiol Ment Health. 1:16. Nezu AM, Nezu CM, Nezu VA (1986) Depression, general distress, and causal attributions among university students. J Abnorm Psychol. 95:184–186. Nu’man MM (2001) Psychometric properties of the Beck Depression Inventory–II with university students in Bahrain. J Pers Assess. 77:568–579. Penley JA, Wiebe JS, Nwosu A (2003) Psychometric properties of the Spanish Beck Depression Inventory–II in a medical sample. Psychol Assess. 15:569–577. Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR (1997) A longitudinal study of students’ depression at one medical school. Acad Med. 72:452–456. Sadeghirad B, Haghdoost AA, Amin-Esmaeili M, Shahsavand E, Ghaeli P, RahimiMovaghar A, Talebian E, Pourkhandani A, Noorbala AA, Esmat B (2010) Epidemiology of major depressive disorder in Iran: A systematic review and metaanalysis. Int J Prev Med. 1:81–91. Sadock BJ, Sadock VA (2007) Depression and bipolar disorder. In Sadock BJ, Sadock VA (Eds), Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (10th ed, pp 527–562). Philadelphia: Lippincott Williams & Wilkins. Sprinkle SD, Lurie D, Insko SL, Atkinson G, Jones GL, Logan AR, Bissada NN (2002) Criterion validity, severity cut scores, and test-retest reliability of the Beck Depression Inventory–II in a university counseling center sample. J Couns Psychol. 49:381–385. Steer RA, Ball R, Ranieri WF, Beck AT (1999) Dimensions of the Beck Depression Inventory–II in clinically depressed outpatients. J Clin Psychol. 55:117–128. Steer RA, Kumar G, Ranieri WF, Beck AT (1998) Use of the Beck Depression Inventory–II with adolescent psychiatric outpatients. J Psychopathol Behav Assess. 20:127–137. Storch EA, Roberti JW, Roth DA (2004) Factor structure, concurrent validity, and internal consistency of the Beck Depression Inventory–Second Edition in a sample of college students. Depress Anxiety. 19:187–189. Tashakkori A, Barefoot J, Mehryar AH (1989) What does the Beck Depression Inventory measure in college students?; evidence from a non-Western culture. J Clin Psychol. 45:595–602. Viinamäki H, Tanskanen A, Onkalampi K, Oivumaa-Honkanen H, Aatainen K, Austio O, Intikka J (2004) Is the Beck Depression Inventory suitable for screening major depression in different phases of the disease? Nord J Psychiatry. 58:49–53. Viljoen JL, Iverson GL, Griffiths S, Woodward TS (2003) Factor structure of the Beck Depression Inventory–II in a medical outpatient sample. J Clin Psychol Med Settings. 10:289–291.
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Yeung A, Howarth S, Chan R, Sonawalla S, Nierenberg A, Fava M (2002a) Use of the Chinese version of the Beck Depression Inventory for screening of depression in primary care. J Nerv Ment Dis. 190:94–99. Yeung A, Neault N, Sonawalla S, Fava M, Nierenberg A (2002b) Screening for major depression in Asian-Americans: A comparison of the Beck and the Chinese Depression Inventory. Acta Psychiatr Scand. 105:252–257.
BDI in Students
If yes, A5a1: Was psychomotor agitation or retardation present almost every day in the current episode? Yes □ No □ A5a2: How long is the approximate duration of the current psychomotor agitation or retardation according to the subject's report? (Write in days or weeks or months) _______
Youden WJ (1950) Index for rating diagnostic tests. Cancer. 3:32–35.
APPENDIX 1 A Checklist for Diagnosis of Depression Based on the DSM-IV-TR MDE Criteria
Criterion A A1a: Does the subject have depressed mood? Yes □ No □ For example, ask the subject, “Have you recently felt sadness or emptiness or felt like crying?” If yes, A1a1: Was the depressed mood present most of the day, almost every day in the current episode? Yes □ No □ A1a2: How long is the approximate duration of the current depressive mood? (Write in days or weeks or months) _______ A2a: Does the subject have anhedonia? For example, ask the subject, “Have you recently felt that you do not feel pleasure from almost any activity? Or your interest has been significantly diminished in almost any activity?” Yes □ No □ If yes, A2a1: Was anhedonia present most of the day, almost every day in the current episode? Yes □ No □ A2a2: How long is the approximate duration of the current anhedonia? (Write in days or weeks or months) _______ A3a: Has the subject's weight increased or decreased by at least 5% during the last month? Yes □ No □ A3a1: Did the subject's weight increase or decrease because of dieting? Yes □ No □ A3b: Has the subject's appetite increased or decreased significantly during the current episode? Yes □ No □ If yes, A3b1: Was significantly increased or decreased appetite present almost every day in the current episode? Yes □ No □ A3b2: How long is the approximate duration of the current significant increase or decrease in appetite? (Write in days or weeks or months) _______ A4a: Does the subject report significant insomnia or hypersomnia? Yes □ No □ If yes, A4a1: Was significant insomnia or hypersomnia present almost every day in the current episode? Yes □ No □ A4a2: How long is the approximate duration of the current significant insomnia or hypersomnia? (Write in days or weeks or months) _______ A5a: Does the subject show signs and symptoms of psychomotor agitation (for example, complains about restlessness and wiggles or cannot sit still or plays a lot with his/her clothes or hair) or psychomotor retardation (for example, speaks slowly or has delayed response or retarded body movements)? Yes □ No □ © 2014 Lippincott Williams & Wilkins
A6a: Does the subject report fatigue or loss of energy? (For example, ask the subject, “Do you feel severe tiredness or loss of energy?”) Yes □ No □ If yes, A6a1: Was fatigue or loss of energy present almost every day in the current episode? Yes □ No □ A6a2: How long is the approximate duration of the current fatigue or loss of energy according to the subject's report? (Write in days or weeks or months) _______ A7a: Does the subject have a worthlessness feeling? (For example, ask the subject, “Do you feel worthless? Do you think you are an inadequate or weak person?”) Yes □ No □ If yes, A7a1: Was the worthlessness feeling present almost every day in the current episode? Yes □ No □ A7a2: How long is the approximate duration of the current worthlessness feeling according to the subject's report? (Write in days or weeks or months) _______ A7b: Does the subject have excessive guilt feeling (not merely self-reproach or guilt about being sick)? (For example, ask the subject, “Do you think you are a bad or sinful person? Do you think you have committed unforgivable or great sins?”) Yes □ No □ If yes, A7b1: Was the guilt feeling present almost every day in the current episode? Yes □ No □ A7b2: How long is the approximate duration of the current guilt feeling according to the subject's report? (Write in days or weeks or months) _______ A8a: Does the subject report diminished ability to think? Yes □ No □ If yes, A8a1: Was diminished ability to think present almost every day in the current episode? Yes □ No □ A8a2: How long is the approximate duration of the current diminished ability to think according to the subject's report? (Write in days or weeks or months) _______ A8b: Does the subject report diminished ability to concentrate? Yes □ No □ If yes, A8b1: Was diminished ability to concentrate present almost every day in the current episode? Yes □ No □ A8b2: How long is the approximate duration of the current diminished ability to concentrate? (Write in days or weeks or months) _______ A8c: Does the subject report indecisiveness? Yes □ No □ If yes, A8c1: Was indecisiveness present almost every day in the current episode? Yes □ No □ A8c2: How long is the approximate duration of the current indecisiveness according to the subject's report? (Write in days or weeks or months) _______ A9a: Does the subject have recurrent thoughts of death these days? (For example, ask the subject, “Do you think a lot about death/ dying these days? Are you only afraid of death, or do you think a lot about other aspects of death too?”) Yes □ No □ www.jonmd.com
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If yes, A9a1: How long is the approximate duration of the current thoughts of death according to the subject's report? (Write in days or weeks or months) _______ A9b: Does the subject report recent recurrent suicidal ideation? Yes □ No □ If yes, A9b1: How long was the recent recurrent suicidal ideation present? (Write in days or weeks or months) _______ A9c: Does the subject report a specific suicidal plan or attempted suicide in the recent episode? Yes □ No □
Criterion C C1: Clinically significant distress. How much distress did the aforementioned problems cause to the subject? (For example, ask the subject, “We spoke about several problems and symptoms. Could you please say how much you think you have suffered from these problems, such as sadness? Little? Moderate? Very much? Very little?”) 1. Almost none □ 2. Little but significant □ 3. Moderate □ 4. Severe □ C2: Clinically significant dysfunction. How much dysfunction did the aforementioned problems cause to the subject's important areas of functioning such as social, occupational, familial, or educational areas? (The interviewer must examine all areas carefully and answer according to his/her own opinion.) 1. Almost none □ 2. Little but significant □ 3. Moderate □ 4. Severe □
Questions to Be Completed After the Interview A1: Depressed mood Does the subject fulfill criterion A1? (A1a Yes and A1a1 Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A2: Anhedonia Does the subject fulfill criterion A2? (A2a Yes and A2a1 Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A3: Weight and appetite Does the subject fulfill criterion A3? ([A3a Yes and A3a1 No] or [A3b Yes and A3b1 Yes]) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □
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A4: Sleep Does the subject fulfill criterion A4? (A4a Yes and A4a1 Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A5: Psychomotor Does the subject fulfill criterion A5? (A5a Yes and A5a1 Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A6: Fatigue or loss of energy Does the subject fulfill criterion A6? (A6a Yes and A6a1 Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A7: Worthlessness or excessive guilt feeling Does the subject fulfill criterion A7? ([A7a Yes and A7a1 Yes] or [A7b Yes and A7b1 Yes]) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A8: Diminished ability to think or concentrate, or indecisiveness Does the subject fulfill criterion A8? ([A8a Yes and A8a1 Yes] or [A8b Yes and A8b1 Yes] or [A8c Yes and A8c1 Yes]) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ A9: Recurrent thoughts of death, or recurrent suicidal ideation, or a suicidal attempt or a specific plan Does the subject fulfill criterion A9? (A9a Yes, or A9b Yes, or A9c Yes, or A9d Yes) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ Does the subject fulfill criterion A based on the above-mentioned nine questions? ([A1 Yes or A2 Yes] and [at least four other criteria from A1 to A9, Yes]) For at least 1 week Yes □ No □ For at least 2 weeks Yes □ No □ Does the subject fulfill criterion C? ([C1 moderate or severe] or [C2 moderate or severe]) Yes □ No □ Is the subject MDS+? (Both of the above-mentioned questions Yes for at least 2 weeks) Yes □ No □ Is the subject MDS1w+? (Both of the above-mentioned questions Yes for at least 1 week) Yes □ No □ Is the subject SD+? ([A1a Yes or A2a Yes] and [(C1≥2) or (C2 ≥ 2)]) Yes □ No □
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