Utility of the Beck Depression Inventory with Clinic-Referred Adolescents JAVAD H. KAS HAN I, M. D .. F. R.C. P .(Cl , DAN IEL D. SHERMAN, M .A . , DAVID R. PARK ER , M .ED., N .C.C., AND JOH N c. REIbf; PH.D .

Abstract. Thi s study reports on the utiliz ation of the Beck Depression Inventory (BOI) and the Diagnostic Interview for Children and Adolesce nts (OICA) in a sample of 100 clinic referred adolescents. Results indicate that the BOI efficiently identified and diffe rentiated dep ressed from nondepressed adolescen ts. In addition. greater levels of dep ressive symptomato logy and depre ssive disorder were found in girls . Reasons for these genera l sex differe nces are discussed . and it is co ncluded that a psycho logical ex planation appears more promising than exis ting biological explan ations . J . Am . Acad . Child Adolesc. Psychiatry . 1990 , 29 . 2:278- 282. Key Wor ds : adolescent , measurement of dep ression. outpatient. According to previ ou s researc h , assessment devices measuring the severity of depress ive symptomatology are desirable because of their sensitivity in differentiating depressed from nond epr essed individuals (Kazdin , 1981 ; Faulstich et a!., 1986). With this idea in mind , the present investigation will foc us upon the efficie nt identification of depression in a sample of outpatient ado lesce nts . Studies addressi ng the etiology, assess ment , and treatm ent of adolescent depression abou nd, co ntributing to a rich and sophisticated co nceptualization of the phenomena (Kashani and Sherma n, 1989). Acco mpany ing this grow th has come the need for an expe dient, co st-effec tive means of identifying depress ive phenomena within this popul ation . Preliminary work in this area has bee n perfor med using the Beck Depression Invent ory (BDI) (Beck et al., 1961) with psy chiatrica lly hospitalized ado lesce nts (Strober et a!., 1981). Strober et al. (1981) note d that " the BOI is a psychometrically sound descriptive instrument with potential usefulness in co llecting clinica l data on depress ive symptom profiles in psychiatrically disturbed adolescents and in evaluating the efficiency of treatment modalities applied to this population , " (p. 483). The present stud y will expand upon the work of Strober et a!. (1981) in two distinct ways. First, while Strober used the adult version of a structured diagnostic interview Sched ule for Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer, 1978), the present investigation benefits from the inclu sion of a structured interv iew specifically designed for use with chi ldre n and ado lesce nts (Diagnostic Interview for Children and Adolescent s [OIC A]) (Herjanic and Reich , 1982). Second , Strober's sa mple co nsisted of inpatie nts , whereas outpa tient ado lesce nts comprised the sample for this study .

In addition to ex panding upon the work of Strob er, the present investigation will also explore sex differences in adolescent depre ssion . Previous research on adult s yields conflicting information regarding sex differences on the BDI. For instance , Beck (1972), Schnurr et a!. (1976), Doru s and Senay (19 80), Nielsen and Williams (1980) , Knight (1984), and Oliver and Simmons ( 1985) have all report ed higher mean BOI scores in women than in men. On the other hand, Schwab et a!. (196 7) and Plumb and Holl and (1977) have reported no significant differences bet ween sex and BOI scores. The frequency of depression in prepubert al children has been reported to be similar in both mal es and females (Kashani and Sher man, 1989). However , with increas ing age, the prevalence of both depressive symptoms and depressive disorders becom es grea ter in girls than in boys (e .g ., Rutt er , 1986a). To illustrate , using a brief self-report measure in a com munit y sample of ado lesce nts, Kand el and Davies ( 1982) found grea ter depressive symptoma tology in gi rls than in boys. Similarly , the use of structured interviews with a com munity sam ple of adolescents enabled Kashani et a!. ( 1987) to find greater dep ressive disorder in girls than in boys. The auth ors were not able , however, to locate data addressing sex differences in depressive disorders among clinically referred ado lesce nts and will consequently explore the generality of this finding in the present sample .

Experimental Hypotheses Th e hypoth eses of the present study can now be addressed . First , based upon the wor k of Stro ber et a!. ( 198 1), it was predicted that the BOI should exhibit good discriminant validity in separating depress ed from nond ep ressed adolesce nts. Second , sex differences in depressive sym ptomatol ogy and in dep ressive disorder sho uld be grea ter among the girls than amo ng the boys.

Accepted October 24. 1989. Dr . Kashani is Prof essor of Psychiatry. Psychology . Pediatrics. and Medicine . and Director of Child and Adolescent Services at MidMissouri Mental Health Center. Dani el Sherman is a Ph .D . candidate ill Clinical Psychology . Dr. Reid is Prof essor of Biostatistics. All are at the University of Missouri-Columbia . David Parker is Clinical Director of Comprehensive HUll/ali Services , Inc .. ill Columbia. Missouri. Request reprints fr om Dr . Kashani, University of Missouri-Columbia. Department ofPsychiatry. 3 Hospital Drive. Columbia. MO 6520 1. 0890 -8567/90/2902-0278$02 .00/0 © t 990 by the American Academy of Child and Adolescent Psych iatry .

Method One-hundred and two 13- to 18-year-old s who atte nded an outpatient' ' counseling ce nter" were included in the present investigation . Data from two rando mly se lec ted subjec ts were discarded to pare the final sample size to I00 ado lescents . Of these , 47 were boys and 53 were girls . Th e mean age of this gro up was 14 .78 years (SO = 1.80). In addi tio n, the sample includ ed 13 black , 82 white, two America n 278

BECK DEPRESSION INVENTORY TAIJLE

I. Corrected Item-Total Correlation for the Blrlfrom a

Sample of 100 Referred Adolescents BOI I BOI 2 BOI 3 BOI 4 BOI 5 B0I6 BOI 7 BOI 8 B0I9 BOI 10 BOI II

0.60 0.62 0.51 0.58 0.39 0.14 0.62 0.39 0.54 0.36 0.41

BOI 12 BOI 13 BOI 14 BOI 15 BOI 16 BOII7 BOI 18 BOI 19 BOI 20 B0I21

0.42 0.61 0.60 0.66 0.30 0.64 0.56 0.20 0.39 0.24

Indian, and three biracial adolescents. Subjects were consecutive admissions to a free-standing, private, nonprofit agency located in a midwestern town of approximately 65,000 persons. The majority of adolescents were referred by a group home placement program with the remainder coming from parents, self-referrals, and the schools. Their families were of predominantly lower socioeconomic status, and approximately 50% of the adolescents were wards of the court. Upon presentation to the agency, adolescents completed the revised 21-item BDI (Beck et aI., 1979). They were subsequently interviewed by two individuals who were blind to the BDI results. In all interviews both the BDI and DlCA were completed on the same day. The interviewers were master's level staff who had benefited from extensive training in the administration of the DICA. The interviewers continually monitored each other's performance and reported diagnostic discrepancies (of which none occurred) to a consulting psychiatrist (J. H. K.). After training, no further attempt was made to assess and maximize diagnostic reliability. The DICA is a structured interview used to diagnose common psychiatric disorders in children and adolescents, according to DSM-1I1 criteria. While diagnoses were calculated according to the computer algorithm proposed by Herjanic et al. (1975), one minor modification was made. Criteria for attention deficit disorder were refined to more accurately reflect DSM-1I1 criteria for this disorder (E. Weiner, personal communication, 1985). The sample included the following diagnostic groups: attention deficit disorder (N = 10), oppositional disorder (N = 12), conduct disorder (N = 37), alcohol or substance abuse (N = 32), depression (major depressive disorder; N = 31), mania (N = 8), anxiety disorder (N = 41), bulimia (N = 1), and somatization complaints (N = 3). Twenty-two adolescents had only one disorder diagnosed, 23 had two, 16 had three, 9 had four, 4 had five, and 4 had six disorders diagnosed. The mean number of diagnoses per adolescent was 1.9; all diagnoses were based upon DSM-1I1 criteria. Results The BDI results did not correlate significantly with age, = 0.07, p > 0.05. The coefficient alpha estimate of internal consistency was 0.87. Item total score correlations ranged from 0.14 to 0.66 (see Table 1) and parallel r (100)

l.Am.Acad. Child Adolesc. Psychiatry. 29:2, March 1990

the findings of Strober et al. (1981) who likewise found a wide range of item-total correlations for individual BDI items. The average item-total product-moment correlation was 0.48 (Fisher's transformation). According to clinical researchers (Beck and Beamesderfer, 1974; Costello and Angold, 1988), cutting scores are determined by the purpose for which an inventory is being used. In the present investigation the authors were interested in screening efficiency, which is composed of sensitivity and specificity. The choice of an optimal cutting score was derived from data plotted in a receiver operating characteristic curve. A cutting score of 16 and above was chosen to designate moderate to severe clinical depression in the sampie. Interestingly, Strober et al. (1981) used the same cutting score in their study. The use of this cutting score permitted correct classification of 75% of the sample (9% were false positives and 16% were false negatives). While sensitivity was relatively low (48% in this sample compared with Strober's value of 80%), specificity was similar in both studies (87% here compared with Strober's value of 81%). The positive predictive value was 63% and the negative predictive value was 79%; the corresponding values for Strober et al. (1981) were 59% and 92%, respectively. Patients with a DlCA diagnosis of depression differed from nondepressed patients in total BDI score, 17.32 (SD = 12.11) versus 10.04 (SD = 8.02), respectively, t = 3.06 [df = 42.3 using Satterthwaite's approximation for degrees of freedom using 4funequal variances], p < 0.004, and endorsed higher severity ratings on 12 of the 21 items (see Table 2). The Bonferroni p-level for these 21 tests would be 0.0024. These results suggest that the BDI possesses a fair degree of discriminant validity. A greater proportion of girls (42% or 22 of 53) than boys (19% or 9 of 47) were depressed (X 2 = 5.28, df = 1, p = 0.016). The mean BDI score for males was 10.09 (SD = 8.54), and the mean for females was 14.26 (SD = 10.84). The difference between these groups was significant (t = 2.12, df = 98, p = 0.04). The mean Beck depression scores of the 22 DICA depressed and the 31 nondepressed girls were 20.86 (SD = 12.16) and 9.58 (SD = 6.75), respectively. These two means were significantly different (t = 3.94, df = 30.2 using Satterthwaite's approximation, p = 0.(004). The mean BDI scores of the 9 DICA depressed and the 38 nondepressed boys were 8.67 (SD = 6.54) and 10.42 (SD = 8.99), respectively. The depressed and nondepressed boys' BDI scores did not differ significantly. There were also no significant differences between BDI scores of nondepressed boys (mean 10.42) and nondepressed girls (mean 9.58). Because of the difference between girls and boys on the BDl, individual BDI item responses were analyzed to examine intersex differences in reported symptom severity (see Table 3). Significant intersex differences were obtained on approximately half the items. Without exception, each of these differences indicated greater symptom severity in the girls than in the boys. Girls reported feeling greater affective blunting and greater vegetative symptomatology than boys. For instance, the girls feel greater sadness, hopelessness, failure, and less enjoyment from previously pleasurable ac279

KASHANI ET AL. T ABL E

2. Beck Depression Item Scores Broken DOlI'n by Depression Status (Depressed from a Sample of 100 Ref erred Adolescents

BD! Item I 2 3 4 5 6 7 8 9 10 II 12 13 14 15 16 17 18 19 20 21

Nondepressed

Feel sad Discouraged abou t future Feel like a failure Enjoy activities less Feel guilty Feel punished Disappointed in self Self-blame Suici dal thought s Increa sed crying Irritation Less interested in people Difficulty with decisio ns Worr y over appearance Amotiv ation Sleep disturbance Easily fatigued Worse appetite Weight loss Somatic preoccupations Loss of interest in sex

0.56 0.24 0.52 0.48 0 .36 0.98 0.45 0.44 0 .32 0.94 0.73 0 .36 0.55 0.23 0.42 0.79 0.52 0 .39 0.41 0.44 0.37

tivities than the boys . More over , the girls reported more worryi ng about personal attractiveness and more thoughts about killing themselves than the boys . With respect to vegetat ive symptoms, the girls reported increased fatigue , decreased appetite , and decreased interes t in sex when compared with the boys. The girls also reported greater weight loss; however, it is unclear whether this weight loss represe nts a vegetative symptom or simply the desire to control weight through dieting . Discussion At first blush , the sensitivity of the BDl appears to be disappointingly low. However , it is possible that the nature and composition of our sample contributed to the lower sensitivity of the BD!. For instance, a diagnosis of conduct disorder is associated with increa sed BDI score s and the present samp le contained more of such cases than that of Strober et a!. (198 1) (37% in this study vs . 28% in Strober' s) . Increased comorbi dity represents a second possib le contributor to the lower relative sensitivity in this samp le. As previo usly mentioned, the mean number of diagnoses per adolescent was 1.9 . Strober et al . (1981) did not present data on diagnostic overlap . Third, eigh t times as many adolesce nts in the presen t sample had an anxiety disorder and four times as many had somatizatio n complaints relative to Strober's sample . There is evidence of higher BDl scores associated with these diagnostic groups which might also have added to the total error variance in Beck Depression scores and subseq uently lowered the sensitivity of the BDl in detecting depression in this sample. Nevertheless, the discordance amo ng BDl and DlCA ratings of depression in approximately one quarter of the cases should be viewed positively . More specifically , "if it were

280

, Depressed

1.21 0.77 1.03 0.93 0.4 3 1.31 0.97 0.79 0.67 1.57 0.83 0.47 0.90 1.03 0.87 0.93 1.00 0.83 0.63 0.40 0.50

I'S .

Nondepressed )

( value

p value

- 2.49 - 2.58 - 2.66 - 2.35 - 0 .45 -1.16 -2.40 - 1.95 -2 .34 -2 .28 -0 .5 1 - 0. 7 1 - 1.69 -3 .32 -2 .48 -0 .73 - 2.40 -2 . 11 - 1.24 0.24 -0.73

0 .017 0.014 0.0 09 0.021 NS NS 0 .021 0 .054 0.02 1 0.025 NS NS NS 0.002 0. 0 15 NS 0.021 0.041 NS NS NS

really possible to identify all true cases and true nonca ses using a brief self-report questionnaire, large areas of diagnostic psychiatry would be redundant. It is unrealistic to expect this level of accuracy," (Costello and Angold, 1988, pp. 729-730) . Furthermore, the BDl was originally designed to supplement rather than to supp lant clinical assessment. More specifically , the BDI was desig ned to asses s the level of symptom severity; it was never intended to generate categorical (i.e. , depre ssed, nondepressed) information . These considerations in com bination with the authors ' emphasi s upon gather ing screeni ng data in an efficient manner further affirm the utility of the BDl as a valuable descriptive instrument with applicability to inpatient and outpatie nt adolescents. The finding of greater depressive symptomatology and a higher prevalence of depressive disorder in girls than in boys is cons istent with recent studies on the epidemiology of adolescent depression (Rutter, 1986a; Kasha ni et al ., 1987) . More specifically, the freque ncy of depression in prepuberty is roughly equa l for boys and girls . However, in comm unity samples, the prevalence of depre ssive symptoms and depressive disorders becomes higher in girls than in boys. The results of this investigation extend these developmental differences to a clinically referred samp le . Also interesting is the finding that the BDl differentiated Dl CA depresse d from nondepressed girls but failed to differentiate DlCA depressed from nondepres sed boys . Thi s finding implies that the BDl may be a more useful depression screen in adolescent girls than boys in a clinically referred samp le. Although the reasons for a difference in freq uency of depressio n and depressive symptoms are not clearly understood, severa l expla nations have been proposed . Among them are biological, social, and psychological fac tors l. Am .A cad . Child Ado/esc. Psychiatry . 29:2 . Ma rch 1990

BECK DEPRESSION INVENTORY TABLE

3. Beck Depression Item Scores Broken Down by Sex from a Sample of 100 Referred Adolescents Sex

BOI Item

Boys

Girls

t value

p value

1 2 3 4 5 6 7 8 9 10

0.50 0.23 0.42 0. 36 0.40 1.09 0.49 0.57 0.28 1.02 0.72 0.36 0.57 0.1 3 0.49 0.83 0.36 0.28 0.28 0.5 1 0.24

1.00 0.57 0.92 0.87 0.37 1.08 0.73 0.52 0.57 1.24 0.80 0.43 0.73 0.82 0.63 0.84 0.96 0.77 0.67 0.35 0.57

-2 .35 -2 . 16 - 2.74 - 3.00 0.26 0.02 -1 .40 0.27 -2 . 13 - 0.86 -0.37 - 0.50 -0 .82 - 3.96 -0.84 -0 .04 - 3.95 -3 .07 -2.45 - 1.13 - 2.04

0.02 1 0.036 0.007 0.004 NS NS NS NS 0.036 NS NS NS NS 0.000 NS NS 0.000 0.003 0.016 NS 0.044

II

12 13 14 15 16 17 18 19 20 21

Feel sad Discoura ged about futur e Feel like a failure Enjoy activities less Feel guilty Feel punished Disappointed in self Self-blame Suicidal thoughts Increased crying Irritation Less interested in people Difficulty with decision s Worry over appearance Amotivation Sleep disturbance Easily fatigued Worse appetite Weight loss Somatic preoccupat ions Loss of interest in sex

(Weissman and Klerman , 1977; Rutter , 1986b). Research derived from the multifactorial model of disease transmission does not support the notion that a woman 's greater predispo sition to depression is genetically determined. However , the possibility exists that genetic factors may be involved in endocrine system functionin g which may be associated with penetrance of the disorder (Merikangas et al. , 1985). According to a social status explanation , disadvantages inherent in a woman 's social role account for sex difference s in depression. A demonstration of the detrimental effects of marriage for women would support this view. That is, disadvantages associated with a woman's role in marriage are said to include increased role restriction, inadequate role structure, and boredom . Consistent with this perspective is research demonstrating a protecti ve effect of marriage (against general psychopathology) for males and a detrimental effect for females (Weissman and Klerrnan, 1977). It is plausible that social role inequities develop prior to the changes that manifest themselves in marital role differences . In fact, such difference s may develop during adolescence as well. An appealing psychological explanation involves females' greater suscepti bility to learned helplessness (Abramson et aI. , 1978). According to this view , girls are more likely to display a helpless attributional style than boys . More specifically, girls tend to attribute failure outcomes to a lack of ability whereas boys attribute failure to a lack of effort . Children employing unstable factors (e.g. , effort) as explan ations for the causes of failure persist in the face of failure and often show subsequent performan ce increments (Dweck and Reppucci, 1973). Conversely , children attributing failure to relatively stable causes (e.g., abill.Am .Acad. Child Adolesc.Psychiatry, 29:2. March 1990

ity) manifest the cognitive , affective , and motivational deficits known as "helplessness deficit s." There is evidence that these sex differenc es in explaining failure performance derive from differential performance feedback received in the school setting (Dweck et aI., 1978). Because of differential feedback received from teachers, boys learn to view negative feedb ack as uninform ative of their intellectual perform ance and as more attributable to decreased motivation than to low ability. In contrast, girls learn that negative feedb ack is both informative of intellectual performance and better explained in terms of diminished ability, rather than motivation (Dweck et al., 1978). Interestingly, boys and girls exhibit a reversal in helplessness deficits when failure feedback is delivered by peers, illustrating the crucial role played by teacher feedback in the development of these sex differences (Dweck and Bush, 1976). This research can be extended by improving upon the limitations of this investigation. For instance, both the BDI and DICA were administered without an attempt to assess and maximize diagnostic reliabilit y. Second , because the group of adolescents in this study represents a skewed sample, generalizations should be made cautiously. Future research can address this limitation by replicating these findings in different catchment areas throughout the country. Third, the finding of greater symptom severity ratings among adolescent girls than among boys deserves further investigation . More specifically, the biological, social, and psychological factors that were explored in the discussion section refers to global sex difference s in depression. However , the present results indicate that the bulk of the sex difference in BDI scores was confined to the group of depressed girls. Therefore , studies addres sing learned helplessness and din281

KASHANI ET AL.

ical depression from a developmental perspective may contribute to this endeavor. Additional research on the cognitive and biological contributions to this difference also appear to be warranted .

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