Analysis of the psychometric properties of the Spanish version of the Beck Depression Inventory in Argentina

Psychiatry Research 79 Ž1998. 277]285

Analysis of the psychometric properties of the Spanish version of the Beck Depression Inventory in Argentina Silvia Bonicatto a,U , Amanda Mary Dew b , Juan Jose Soriaa b

a Fundacion Argentina, FUNDONAR, La Plata, Argentina ´ Oncologica ´ Western Psychiatric Institute and Clinic, Uni¨ ersity of Pittsburgh, Pittsburgh, PA, USA

Received 18 December 1996; received in revised form 9 July 1997; accepted 27 August 1997

Abstract Increased international collaboration in clinical trials has created a need for cross-culturally valid instruments to assess quality of life and behavioral disorders. Cross-cultural studies of depressive symptomatology, in particular, must be preceded by an exhaustive study of the psychometric properties of the instruments, to ensure the validity of the comparison. In this article, we examine the validity, reliability and factor structure of the Spanish version of the Beck Depression Inventory ŽBDI. in a random stratified sample of 608 community residents in Argentina. Our findings indicate that this version of the BDI is psychometrically strong and appropriate for use in Argentina, and we suggest that it is suitable for assessing depressive symptomatology in Spanish speakers. Q 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: BDI; Cross-cultural; Psychometric

1. Introduction The Beck Depression Inventory ŽBDI. is one of the most widely used measures of depressive symptoms, both in adolescents and adults ŽBeck and Steer, 1993a.. The original version of this self-report instrument was introduced in 1961

U

Corresponding author. Tel.: q54 21 253406; fax: q54 21 253406.

ŽBeck et al., 1961. and later revised Ž1971. at the Center for Cognitive Therapy ŽCCT. of the University of Pennsylvania Medical School. Beck Ž1970. defined depression as ‘an abnormal state of the organism manifested by signs or symptoms such as low subjective mood, pessimistic and nihilistic attitudes, loss of spontaneity and specific vegetative signs’. The BDI was developed to assess this state and was derived from clinical observations and descriptions of symptoms observed frequently in depressed psychiatric

0165-1781r98r$19.00 Q 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0165-1781Ž98.00047-X

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patients and infrequently in non-depressed psychiatric patients ŽBeck et al., 1988.. These observations were consolidated in 21 symptoms and attitudes Žcategories., which are rated according to severity. The categories Žitems. were chosen to assess only the severity of depression and were not intended to reflect the etiology of illness ŽBeck and Steer, 1993a.. Although the BDI was designed primarily for patient populations, and was not developed as a screening instrument, it has been widely used for this purpose ŽGallagher et al., 1983; Steer et al., 1986; Teri, 1982.. Its usefulness in non-psychiatric patient groups and community samples depends, essentially, on the psychometric properties of the test across these different groups. A review of these properties in different samples and countries was published by Beck Ž1970., and focused on studies published between 1961 and June 1986; these studies included English as well as nonEnglish versions of the BDI. The inventory has been translated into many languages and, across languages, it has generally shown high levels of internal consistency reliability, test]retest reliability, and construct and criterion validity. Psychometric aspects of the Spanish version of the BDI were described by Conde et al. Ž1976. in a sample from Spain, and the results were reported to have been highly satisfactory. However, we have been unable to locate any report that examined the reliability, validity and underlying factor structure of this instrument in any other Spanish-speaking population. This is an important omission in the literature because demonstration of satisfactory psychometric properties in one country does not guarantee that a measure will possess equally high validity and reliability in all countries where the same language is spoken. Important differences in conceptualization and expression of depressive symptoms may exist between cultures, despite their shared language. These differences, in turn, are recognized to have important but often unidentified effects on an instrument’s psychometric properties. Thus, although scale items may be equivalent in literal meaning across populations, they can be valued or conceptualized in different senses across groups with the same language but different cultures or

‘ways of life’. Because of these cross-cultural differences, it is essential to adapt the instrument and reestablish its psychometric criteria ŽAlonso et al., 1994; Bonicatto and Soria, 1996; Bonicatto et al., in press.. In the case of the Spanish version of the BDI, psychometric evaluation has been completed in only one Spanish-speaking country ŽSpain.. Moreover, this country is a European one, essentially isolated from other Spanish speakers. The vast majority of Spanish speakers in the world are in South and Central America. Historically, the cultural differences between Spain and the Spanish speaking countries of the Americas began from the earliest days of colonization. Although the American countries had ties with Spain for long periods, their language, religion, and social institutions were slowly melded into a different and new culture Žcalled ‘criolla’ by many authors., a mix of the Spanish culture and language with the preexisting cultures of America ŽUslar Pietri, 1992.. In this article, we argue that cross-cultural studies using depression symptom questionnaires must be preceded by extensive study of the psychometric properties of the instruments to ensure that they have not changed and that direct comparisons between countries will be valid. The aim of the work is to examine the reliability, validity and factor structure of the Spanish version of the BDI, in order to determine the feasibility of using it to measure depression in the Argentine population and to be able to carry on cross-cultural studies of depressive symptomatology in the future. Since there is evidence that the expression and meaning of somatic complaints are different in Hispanic populations than in populations of European heritage ŽEscobar et al., 1983; Guarnaccia et al., 1990; Mezzich and Rabb, 1980., we selected the BDI as a particularly important and appropriate instrument to evaluate in this regard. The BDI places relatively less emphasis on somatic complaints and instead focuses on cognitive and affective symptoms ŽGotlib and Cane, 1989.. These latter symptoms appear to be expressed relatively more similarly across Spanish-speaking and English-speaking cultural groups ŽGuarnaccia et al., 1990..

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2. Material and methods 2.1. Instruments 2.1.1. BDI The Spanish version of the BDI wQ 1982, 1993, The Psychological Corporation, and used by Conde et al. Ž1976.x was employed. We initially selected a small sample of individuals Ž n s 12. in order to pre-test the Spanish version to determine the broad suitability of item wording for the Argentine population. These persons were individually administered the BDI by an interviewer who, after a random number of answers, would ask the question: ‘what do you mean?’ thus ensuring that the item was understood as having a meaning equivalent to that of the source item ŽEnglish.. We found no evidence that respondents had difficulty understanding the items or scale instructions. The BDI asks respondents to describe themselves ‘for the past week, including today’ ŽSacco, 1981.. The inventory includes 21 categories of symptoms of depression, and each item consists of a group of four statements, from which one must be selected. These statements reflect increasing severity of distress and are scored along a four-point scale ranging from 0 Žlittle or no distress. to 3 Žsevere distress.. The total scale score is obtained by summing the 21 items, yielding a total score that can range from 0 to 63. Cut-off scores are often used to categorize levels of depression, and the choice of cut-points on the BDI should be based on the sample and clinical rationale for utilizing the instrument. Nevertheless, cut-off scores that have been used in US community-based samples to identify broad categories of distress are as follows: scores from 0 to 9 are considered to reflect minimal symptomatology; scores of 10]16 indicate mild depression; scores of 17]29 indicate moderate depression; and scores of 30]63 indicate severe depression ŽBeck and Steer, 1993a.. 2.1.2. Cross-¨ alidation instruments Two measures were utilized. The first, the Symptom Checklist-90 ŽSCL90. is a 90-item selfreport symptom inventory that was designed to

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indicate psychological symptom patterns in community, medical and psychiatric respondents ŽDerogatis, 1994.. The SCL90 has nine primary symptom dimensions and three global indices of distress, and was translated and standardized for the Argentine population by our group ŽBonicatto and Soria, 1996.. The results of our study indicated acceptable reliability and validity levels. In the current investigation, the Depression ŽDEP. subscale of the SCL90 was administrated to the participants in order to study the concurrent validity of the BDI; we used the SCL90 subscale because it is the only other measure of depressive symptomatology that has been standardized for Argentina ŽBonicatto et al., in press.. The SCL90 customarily asks respondents to describe themselves for the ‘last 2 weeks’. For the present analyses, since the BDI focuses on symptoms during the past week, we modified the SCL90 instructions so that the respondent focused only on ‘the last week including today’. The second cross-validation instrument was the Beck Hopelessness Scale ŽBHS; Beck and Steer, 1993b., a 20-item scale developed to assess the extent of negative attitudes about the future as perceived by adolescents and adults ŽSacco, 1981.. We used the Spanish version distributed and copyrighted by The Psychological Corporation Ž1993., and pre-tested the questionnaire in the same way that we did with the BDI. No problems were observed in the comprehension of the questions or the scoring method. Each item of the BHS consists of a true]false statement about the future Že.g. ‘I look forward to the future with hope and enthusiasm’.. The final score is obtained by summing the items, with higher scores indicating greater hopelessness. This score can range from 0 to 20. Internal consistency reliability of the BHS in the present sample was 0.82. 3. Subjects and procedures Between September 1995 and January 1996, the BDI, the DEP subscale of the SCL90-R and the BHS were administered to individuals from La Plata, a large city of Buenos Aires Province ŽArgentina.. The participants Ž N s 608. were selected by the stratified random sampling method

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with socioeconomic level as the stratifying factor. Sociodemographic characteristics obtained for each respondent included age, sex, educational level and income. Subjects averaged 42.62 years of age ŽS.D.s 16.51; range s 20]75., 46.7% were male Ž n s 284. and 38% were high-school graduates. Income was stratified in three categories by grouping the 10 income levels determined by the INDEC ŽInstituto Nacional de Estadistica y Censos.. Dollar-for-dollar comparisons between US and Argentine income levels are inappropriate because the costs of living differ between the two countries. We have thus grouped the 10 income levels in our sample into three broad levels. Level 1 includes persons who have only the minimal income necessary for daily living Ž- $800 per month; 44.4% of the sample.. Level 2 corresponds to low middle class Ž$801]1600 per month; 31.7% of the sample.. Level 3 represents all persons above these two categories Ž23.8% of the sample.. None of the respondents were receiving psychiatric treatment at the time of evaluation. Only a few persons Ž n s 14. refused to participate in the study. The participants were requested to fill out each measure themselves Žpaper and pencil.. The three instruments were introduced by trained interviewers who explained the instructions in a brief and easy manner, and remained accessible to respondents to answer any questions. The individuals were interviewed at home or at their workplace. The mean time of administration for the BDI ranged from 5 to 8 min, similar to the mean time of administration for the BHS. The DEP subscale of the SCL90 was completed within 2]3 min. 4. Analysis Reliability was assessed through internal consistency, which is a function of both the number of items and their correlation within a scale measuring a particular construct ŽCronbach, 1951.. The most extensively used coefficient to estimate internal consistency is Cronbach’s a coefficient, which is a multipoint variation of the Kuder] Richardson 20 formula and is the average of all possible split-half reliability estimates adjusted to the original number of items.

Validity was assessed in three ways: Ž1. concurrent validity, by correlation with another measure of depression; Ž2. construct validity, by correlation with another instrument designed to measure a similar but distinct component of affect; and Ž3. criterion validity, by examining hypothesized differences in scale scores between different groups of individuals. 1. Concurrent validity: We correlated z-scores from the BDI in our sample Ž N s 608. with respondent’s z-scores from the DEP subscale of the SCL90. 2. Construct validity: Accorded to Nunnally, a measure of a construct must be related strongly to measures of other similar constructs of interest in order to demonstrate construct validity ŽNunnally, 1969.. Beck et al. Ž1974. hypothesized a strong association between depression and hopelessness. Thus, after determining that the BHS had an acceptable level of internal consistency reliability in our sample ŽCronbach’s a s 0.82., we correlated respondents’ standardized scores on the two instruments. 3. Criterion validity: In order to demonstrate criterion validity, we hypothesized that there should be differences in BDI scores between men and women, across age groups, and between different levels of education and income, because these are characteristics that are each known to be strongly associated with self-reported depressive symptom levels. To the extent that the instrument is valid, then, we would expect similarly strong differences in the present sample. Under this hypothesis, the highest scores were expected in women, in younger persons, and in those with lower education and income levels, since these groups are typically found to have higher depression scores than their counterparts ŽBeck and Beamesderfer, 1974; Blumenthal, 1975; Comstock and Helsing, 1976; Derogatis et al., 1977; Dew, in press; Turner et al., 1995.. We performed a principal component analysis with varimax rotation on the set of 21 items in the

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Table 1 Reliability } statistics for items and total scale score BDI item

Mean

S.D.

Item-total correlation

Male

Female

Total sample

Male

Female

Total sample

Male

Female

Total sample

1. Sadness 2. Pessimism 3. Sense of failure 4. Dissatisfaction 5. Guilt 6. Punishment 7. Self-dislike 8. Self-accusations 9. Suicidal ideas 10. Crying 11. Irritability 12. Social withdrawal 13. Indecisiveness 14. Body image change 15. Work difficulty 16. Insomnia 17. Fatigability 18. Loss of appetite 19. Weight loss 20. Somatic preoccupation 21. Loss of libido

0.29 0.36 0.27 0.50 0.24 0.24 0.15 0.41 0.14 0.43 0.80 0.43 0.61 0.27 0.53 0.49 0.51 0.19 0.10 0.37

0.42 0.39 0.32 0.52 0.32 0.28 0.23 0.55 0.20 0.51 0.81 0.38 0.55 0.44 0.45 0.60 0.71 0.31 0.21 0.49

0.36 0.38 0.30 0.51 0.28 0.26 0.19 0.48 0.17 0.47 0.80 0.40 0.58 0.36 0.49 0.55 0.62 0.26 0.16 0.43

0.55 0.67 0.61 0.66 0.54 0.59 0.37 0.60 0.40 0.88 0.96 0.64 0.76 0.67 0.72 0.71 0.63 0.47 0.35 0.57

0.66 0.70 0.61 0.71 0.56 0.61 0.48 0.62 0.44 0.84 1.00 0.63 0.76 0.77 0.64 0.78 0.81 0.69 0.50 0.65

0.61 0.69 0.61 0.68 0.55 0.60 0.43 0.62 0.43 0.86 0.98 0.64 0.76 0.73 0.68 0.75 0.73 0.60 0.44 0.62

0.46 0.35 0.44 0.55 0.40 0.45 0.47 0.43 0.21 0.28 0.32 0.46 0.53 0.39 0.40 0.43 0.52 0.38 0.31 0.49

0.70 0.51 0.50 0.60 0.44 0.48 0.55 0.43 0.38 0.45 0.39 0.41 0.50 0.47 0.52 0.52 0.66 0.47 0.40 0.46

0.62 0.44 0.48 0.57 0.42 0.47 0.53 0.43 0.32 0.37 0.36 0.42 0.50 0.45 0.45 0.49 0.61 0.45 0.38 0.48

0.28

0.54

0.42

0.63

0.94

0.82

0.42

0.40

0.41

Statistics for total scale score

7.59

9.23

8.46

6.44

7.98

7.34

Male 0.84 0.73

Female 0.88 0.84

Total sample 0.87 0.80

Cronbach’s a Spearman]Brown

BDI, in order to further examine the patterns of relationships among scale items and determine whether subscales could be identified. 5. Results 5.1. Reliability Table 1 shows descriptive statistics for BDI items and the total scale score Žmean and standard deviation., and the item-total correlation. As shown in the table all individual scale items were positively correlated with the total scale score Žcorrelations ranging from 0.32 to 0.62.. Internal consistency for the BDI in our sample

was high ŽCronbach’s a s 0.87. and was within the range reported across 15 studies of non-psychiatric samples from primarily North American and European locales Žrange s 0.73]0.92; Beck et al., 1988. The internal consistency reliability was uniform across age groups, educational level, and income levels, with only a slight tendency toward lower reliability among males in all the groups ŽTable 2.. The high internal reliability of the BDI was also evident when the complete sample was randomly split into two equal subsamples ŽCronbach’s a s 0.88 for both subsamples.. Other indicators were equally robust in supporting the reliability of the BDI; for example, an alternative analysis of

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Table 2 Reliability } Cronbach’s a coefficient of the BDI by selected demographic variables and gender Subgroup

All subjects Age groups 20]30 31]45 46]60 60]75 Income levels Level 1 Žlow. Level 2 Level 3 Žhigh. Educational levels Level 1 Žlow. Level 2 Level 3 Žhigh.

Males

Table 3 Distribution of frequencies of the cut-off scores by gender Symptoms

Male Ž%. n s 284

Female Ž%. n s 324

Global Ž%.

0]9 Žminimal. 10]16 Žmild. 17]29 Žmoderate. 30]63 Žsevere.

69.6 19.3 10.7 0.4

61.2 21.6 14.2 3.0

65.1 20.4 12.5 2.0

Females

Ž n.

a coefficient

Ž n.

a coefficient

284

0.84

324

0.88

81 76 71 56

0.82 0.87 0.84 0.82

101 90 79 54

0.87 0.90 0.85 0.88

118 89 7

0.86 0.80 0.81

152 104 68

0.88 0.88 0.86

91 104 89

0.85 0.84 0.90

100 127 97

0.90 0.84 0.86

the data by the Spearman]Brown corrected split-half correlations also shows high reliability levels Žmale, 0.73; female, 0.84; global, 0.80.. The analysis of the mean total scale score distribution in our study shows that 85.5% of the global sample had scores of 16 or lower Žmale, 88.9%; female, 82.8%., which is consistent with the fact that our sample is a non-psychiatric one. The distribution of the cut-off scores for gender and the overall sample is shown in Table 3. 5.2. Validity Ž1. Concurrent validity: We correlated z-scores from the BDI with the DEP subscale of the SCL90. The results showed a strong and significant positive correlation between the two measures ŽPearson’s r s 0.68; P- 0.000.. Ž2. Construct validity: We correlated respondents’ standardized scores on the BHS with their BDI scores and found a moderately strong positive correlation between the two inventories ŽPearson’s r s 0.43; P- 0.000.. The size of this correlation was, as hypothesized, smaller than the correlation between the BDI and our other measure of depressive symptomatology. Ž3. Criterion validity: Under our hypothesis, the

highest scores were expected in women, in younger persons, and in those with lower education and income levels. As shown in Table 4, the hypothesis was supported for gender, education and income levels; analyses of variance examining these effects indicated statistically significant differences for each of these characteristics. Although BDI levels varied significantly by age as well, the pattern of findings was more complex, with lower symptoms among the 46]69-year age group than in other age groups. 5.3. Factor analysis Results of the principal component analysis on the set of 21 items indicated that the first unrotated factor accounted for the largest proportion of the variance Ž28.7%., although the second factor accounted for some additional variability Ž7.4%.. Examination of the scree plot of percent variance by number of extracted factors indicated that remaining factors did not make sizable contributions to the latent structure of the BDI in our sample ŽTabachnick and Fidell, 1989.. The degree of drop-off in explained variance between the first and all subsequent factors indicates that the scale has one overriding dimension, reflecting overall depression severity. However, varimax rotation suggests that the scale might usefully be considered to have two subscales in our Argentine sample. The 21 items’ loadings on the first unrotated factor, ranged from 0.39 to 0.69 with a median of 42.9. Thus, all were contributing similarly to this dimension of overall depression severity. The rotated two-factor solution indicated two subscales: Factor 1 ŽF1. represents a cognitive]affective di-

S. Bonicatto et al. r Psychiatry Research 79 (1998) 277]285 Table 4 Criterion validity } differences among mean BDI scores between sex, age, income and educational level ŽANOVA one-way.

Sex Male Female Age F 30 31]45 46]60 G 61 Educational level Primary school High school College Income Level 1 Level 2 Level 3 U

Mean

S.D.

F Žd.f..

7.71 9.23

6.48 7.98

0.53U Ž1,606.

8.00 8.38 7.54 10.92

6.89 7.84 6.52 7.94

5.22UU Ž3,604.

10.24 8.50 6.77

8.59 6.86 6.06

10.82UU Ž2,605.

10.01 7.48 7.10

8.03 6.74 6.25

10.55UU Ž2,605.

P- 0.01, UU P- 0.001.

mension and the 10 items loading highly Ž) 0.30. on it included those pertaining to feeling of sadness, pessimism, guilt, sense of failure, lack satisfaction, sense of punishment, self-hate, self-accusations, suicidal ideas and social withdrawal. Factor 2 ŽF2. reflects somatic symptomatology and the items loading highly Ž) 0.30. on it pertained to irritability, crying spells, indecisiveness, body image, work inhibition, insomnia, fatigability, anorexia, weight loss, somatic and libido. Each of the two rotated factors were analyzed regarding their internal consistency reliability. Cronbach’s a coefficient was relatively strong for each ŽF1, 0.80; F2, 0.80. To determine the generalizability, or replicability, of the principal components solution, we randomly split the original sample into two subsamples and repeated the analysis in each. The results closely resembled the results for the total sample. 6. Discussion We analyzed the psychometric properties of the Spanish version of the revised BDI in a popula-

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tion-based sample of La Plata, Argentina Ž N s 608.. With regard to reliability, the BDI had acceptable levels of internal consistency, as assessed by Cronbach’s a coefficient and Spearman]Brown corrected split-half correlations. All of the items were significantly and strongly correlated with the total scale score. These results are generally comparable to those obtained by Beck et al. Ž1961. for the English version of the BDI, and later by Conde et al. Ž1976. in a study carried out in Spain, with the Spanish version, on 250 normal, 46 depressed and 15 alcoholic adults ŽSpearman]Brown reliability: 0.93., and suggest that the items are relatively homogeneous and that they are all measuring the same psychological construct. We also found the internal consistency reliability to be uniform across major demographic subgroups Žgender, age groups, educational and income levels. and in two randomly split halves of the sample. The analysis of the score distributions shows that 82.9% of the total sample had scores lower than 16, which is the cut-off score for detecting possible depression in normal populations ŽBeck et al., 1961.. This large proportion in the ‘non-depressed’ range is consistent with the non-psychiatric nature of our sample. The validity analysis included three components. In terms of concurrent validity, we found a high correlation between the BDI and the DEP subscale of the SCL90 Ž0.68.. In terms of construct validity, the BDI showed a moderately strong positive association with reported hopelessness Ž0.43., which is hypothesized to be associated with, but distinct from depression. Beck et al. Ž1974. found similar levels of associations between these two measures. Finally, for criterion validity, we hypothesized that depression symptom scores would be higher in women, younger persons and those with low educational level and low socioeconomic level, because these characteristics are known to be strongly associated with self-reported depression. While we did find such effects for gender, education and socioeconomic level, this pattern was not completely confirmed for age. Specifically, although respondents in the oldest age group had higher BDI scores than younger persons, middle-aged respondents had lower scores than expected.

284

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Finally, we used principal components analysis to examine whether reliable subscales could be identified for our sample. Our findings suggest that, while the items as a group all appear to tap the basic construct of depression, there were two identifiable item subgroups. The first represented the cognitive]affective aspect of depression, and factor two reflected somatic symptomatology. The factor structure of the BDI has been considered in several reports. Pichot et al. Ž1964. extracted four factors, and Cropley and Weckowicz Ž1966. reported three factors in patient samples. Tashakkori et al. Ž1989. suggested a five-factor structure in a non-patient population. Finally, Beck and Steer Ž1993a. reported that the number of factors extracted depends upon the clinical and non-clinical characteristics of the samples being studied. Nevertheless, one consistency across these studies, including ours, is the identification of a somatic dimension separate from one or more cognitive and affective dimensions ŽRounsaville et al., 1977; Shaw et al., 1979.. In summary, in a time of increased crosscultural research and international collaboration, the need for instruments applicable across different countries is becoming more important. If we consider high levels of depressive symptomatology and diagnosable depression as major conditions affecting the majority of persons at least once during their lifetimes, it is absolutely essential to ascertain that the instrument selected to evaluate distress in this area is highly reliable and valid. Our findings indicate that the Spanish version of the revised BDI is psychometrically strong and appropriate for use in Argentina. Since the scale has now been examined in two Spanishspeaking cohorts } in Argentina and in Spain } which differ culturally and geographically, we suggest that it is likely to be appropriate for assessing depressive symptomatology in a variety of populations of Spanish speakers. However, since Latin American countries differ in their populations’ cultural mix, further research will be required to clarify the impact of cultural differences over and above shared Spanish language. Furthermore, it will be critical in future work to examine scales such as the BDI in relation to diagnostic assessments of depressive-related psychiatric disorders

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