- Email: [email protected]
The Talbieh Brief Distress Inventory: A brief instrument to measure psychological distress among immigrants
The Talbieh Brief Distress Inventory: A Brief Instrument to Measure Psychological Distress Among Immigrants M i c h a e l Ritsner, J o n a t h a n R a b i n o w i t z , a n d M i c h a e l S l y u z b e r g
The purpose of this study was to develop and test the Talbieh Brief Distress Inventory (TBDI), a 24-item selfreport questionnaire that measures psychological distress among immigrants. The TBDI combines items from the Brief Symptom Inventory (BSI) and the Psychiatric Epidemiology Research Interview Demoralization Scale (PERI-D). It includes a global score and six scales (obsessiveness, hostility, sensitiveness, depression, anxiety, and paranoid ideation). A convenience sample of 966 recent immigrants to Israel from the former Soviet Union were asked to complete a Russianlanguage version of the BSI and PERI-D as part of a study on immigrants' psychological adjustment. The TBDI is a combination of 13 items from the BSI and 11 items from the PERI-D. Items for inclusion were based on results of a separate factor analysis for the BSI and
PERI-D and removal of repetitive items. We compared the total score with the total PERI-D and BSl and developed gender-specific cutoff points of caseness for the TBDI by comparison to known PERI-D and BSI cutoff points. We also checked for reliability using Cronbach's a. The TBDI correlated highly with the PERI-D (r = .93) and with the BSI (r = ,82). Reliability of the scales and the overall instrument ranged from Cronbach's a of .60 to .89. TBDI caseness cutoff points were in close agreement with the BSI and PERI-D as reflected by K scores that ranged from .66 to .79. The TBDI is a promising instrument for screening populations for psychological distress and symptomatology. It is available in English, Hebrew, and Russian. Copyright © 1995by W.B. Saunders Company
TH INCREASED immigration in many parts of the world, there has been a concomitant interest in studying and treating psychological distress among immigrants. Due to the lack of instruments designed specifically for this population, studies have used instruments that were not developed for studying immigrants. These instruments included various measures of generalized psychological distress and symptomatology such as the Psychiatric Epidemiology Research Interview Demoralization Scale (PERI-D), 1-3 Symptom Checklist-90 (SCL-90) 4,5 and its short form, Brief Symptom Inventory (BSI), 6 Midtown Psychiatric Impairment Index, 7 Center for Epidemiological Studies Depression Scale, 7,s Cornell Medical Index--Health Questionnaire, 9 Bradburn Morale Scale, 1° General Health Questionnaire, n and Self-Reporting Questionnaire. 12 The lack of one tailor-made instrument has sometimes led to the need to use more than one instrument. This can be time-consuming and generally disconcerting when screening large nonclini-
cal populations. We therefore sought to develop a brief instrument that would provide a reliable and valid measure of both and could be compared with norms and caseness cutoff points of existing instruments. Our particular area of interest was in screening large groups of immigrants as an outgrowth of our studies of immigrants in Israel, where one tenth of the population are immigrants who arrived over the last 5 years primarily from the former Soviet Union. In our community psychiatric epidemiology study of immigrants, we initially included the PERI-D 13 to measure demoralization and the BS114,15to measure specific symptoms. We sought to develop a brief instrument that would provide an adequate measure of both. After using these instruments to screen almost 1,000 immigrants, we constructed a short version that encompasses items from both. The PERI-D is a 27-item instrument developed by Dohrenwend et al. 16 that measures demoralization. Demoralization has been defined as a predicament for which the person sees no solution. 17The PERI-D was designed to tap demoralization and includes items common to rating scales measuring anxiety, depressive, and psychosomatic symptoms. 13,16,1s It is composed of fixed-format items about the frequency of psychological complaints in the past year. Responses are given on a five-point scale ranging from "never" (weighted as 0) to "very often" (weighted as 4). It is scored by adding
W
From the Psychiatric Epidemiology Research Unit, Talbieh Mental Health Center, Jerusalem; and Bar-llan University, Ramat-Gan, Israel. Address reprint requests to Jonathan Rabinowitz, D.S.W., School of Social Work, Bar-Ilan, University Ramat-Gan, lsrael. Copyright © 1995 by W.B. Saunders Company 0010-440X/95/3606-0002503.00/0
448
Comprehensive Psychiatry, Vol. 36, No. 6 (November/December), 1995: pp 448-453
TALBIEH BRIEF DISTRESS INVENTORY
449
Table 1. TBDI Mean -+ SD Values and Cronbach ¢=Coefficients for Males and Females (nonpatient immigrant sample) Males (n = 398) Scale
Females (n = 568)
Mean -+ SD
c~
1.20 +- .83
.62
1.42 -+ .87
.97 -+ .80 .87 +- .70
.62 .57
1.15 _+ .81 1.00 -+ .80
Anxiety (3 items) Paranoid ideation (3 items)
1.55 -+ .90 1.04 + .90
.78 .60
2.04 + .95 1.09 -+ .90
Depression (7 items)
1.42 -+ .87
.86
Total score (24 items)
1.18 -+ .66
.88
Obsessiveness (3 items) Hostility (3 items) Sensitivity (4 items)
responses to the 27 items and dividing by the number of completed items, t9 The higher the PERI-D score, the more demoralization. Reliability and validity tests of the PERI-D in the United States and Israel have shown satisfactory results, t6 It has been widely used in Israel. 2,3,2°-22High sensitivity and specificity levels have been reported. 23 The BSI is a shortened version of the betterknown Hopkins SCL-90.14A5 It is a 53-item self-report inventory. Subjects respond on a five-point Likert format from "not at all troubled b y . . . during the last year" to "troubled a lot by . . . in the last year" to a list of psychological symptoms. Analysis of BSI scores supplies quantitative indices of severity of distress and profiles that correspond to standard clinical syndromes. A Russian-language version of the BSI was available from previous studies. 24,25 Reliability and validity tests of the BSI have shown satisfactory results. Reliability of nine symptoms and three global indices has been tested for internal consistency that ranged from ot .71 to .80. Test-retest coefficients ranged from
t Test
Mean _+SD
c~
t
P
.65
3.93
.000
.57 .66
3.30 2.60
.001 .009
.79 .62
7.91 0.72
.000 .47
1.74 -+ .90
.86
5.38
.0go
1.43 -+ .71
.89
5.33
.000
.68 to .90. There are high correlations (lowest, .92) between symptom dimensions of the SCL-90 and the BSI. 14,15 The PERI-D and BSI have been used in social, psychiatric, and epidemiological studies of immigrants in different languages, including Russian. 5,26,27 METHOD We selected 11 of 27 PERI-D items and 13 of 53 items from the BSI that best tapped psychological distress. Items for inclusion were based on results of a separate factor analysis for the BSI and PERI-D. In each case, items on the primary factor were chosen. A few additional items were removed because they were repetitious in content and highly correlated. The 24 selected items were used to create a total score that is the sum of all items divided by the number of completed items, and six scales (obsessiveness, hostility, sensitivity, depression, anxiety, and paranoid ideation). All items were scored from low (0) to high (4). Talbieh Brief Distress Inventory (TBDI) items, source of items, and scale compositions are included in Appendix 1.
Subjects The PERI-D and BSI were administered to a convenience sample of 966 non-psychiatric-patient immigrants aged 18 to 87 in Jerusalem, Tel-Aviv, and Beer-Sheva
Table 2. Correlation of BSI Dimensions and TBDI Scales TBDI Scales BSl Dimensions
Obsessiveness
Hostility
Sensitiveness
Depression
Anxiety
Paranoid Ideation
Somatization Obsessive-compulsive Interpersonal sensitivity
.52 .87 .58
.43 .55 .55
.49 .64 .84
.49 .60 .59
.49 .53 .52
.44 .62 .60
Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism General Severity Index
.58 .62 .47 .44 .44 .48 ,72
.59 .66 .79 .37 .46 .46 .74
.67 .63 .55 .47 .69 .58 .78
.74 .67 .49 .41 .48 .50 .72
.60 .70 .50 .39 .41 .42 .66
.72 .74 .52 .44 .73 .58 .79
NOTE. N = 918; 46 missing on at least one scale. All correlations with significance, P < .001.
450
RITSNER, RABINOWITZ, AND SLYUZBERG
Table 3. Correlation of TBDI Scales TBDI Scales
Obsessiveness
Hostility
Sensitiveness
Depression
Anxiety
Hostility
.53
Sensitiveness
.56
.54
Depression
.59
.57
.57
Anxiety Paranoid ideation
.53 .52
.56 .55
.53 .62
.73 .60
1 .52
General score
.75
.75
.78
.90
.81
Paranoid Ideation
1 1 1 1 .77
NOTE. N = 918; 46 missing on at least one scale. Significance for all correlations, P < .001.
between 1991 and 1993. Respondents were from typical gathering places for these immigrants, e.g., professional retraining courses, temporary accommodations at hotels, social services for immigrants, and Hebrew-language instruction courses. At each site, data were collected from approximately 75% of the immigrants present. Respondents were 39.3 _+ 12.9 years old (mean -+ SD). Approximately 54% had immigrated within 12 months of study, 41.7% within 1 to 2 years, and 3.9% within 25 to 30 months. The mean time in Israel was 12.5 _+ 7.8 months. The male to female ratio was 1:1.4. Approximately 67% were married, 12.8% single, 19.3% divorced and widowed, and 1% unknown. Approximately 79.4% were university graduates, 13.4% were graduates of vocational training, 5.0% were high school graduates, and 2.2% had grade school education. Results were analyzed using descriptive statistics and analysis of variance to compare men and women. Reliability of scales was examined using Cronbach's ct. The uniqueness of scales was examined by studying Pearson productmoment correlations between scales. Convergent validity of the instrument as a measure of psychological distress was measured by studying correlations of TBDI scale scores to PERI-D and BSI scores of respondents. We compared distribution of the total score with total PERI-D and BSI scores and developed gender-specific cutoff points for TBDI caseness by comparing with known PERI-D and BSI cutoff points by using sequential steps. Table 4. Sensitivity and Specificity of TBDI Risk for Demoralization as Compared With PERI-D Demoralization Cutoff Points and BSl Caseness Cutoff Points TBDI Risk for Demoralization (%) Males (n = 397) No Parameter
No.
Females (n = 569)
Yes %
No.
%
No No.
Yes %
No.
The TBDI total score correlated highly with the PERI-D (r = .93) and with the BSI (r = .82). The correlation of the PERI-D and BSI was .82. The mean -+ SD and reliability of the scales and total score for males and females are presented in Table 1. There are significant differences between males and females, with the exception of paranoid ideation. All Cronbach et values are greater than .56 and many approximately .75, suggesting high internal consistency. The miss-
Comparison of Three Instruments
8O
/ :/ / :i:j
4o~/ :...:1II ~
:./
%
PERI-D demoralization* No 202 84.2 38 15.8 248 91.2 24 8.8 Yes 9 5.7 148 94.3 35 11.8 262 88.2 BSI casenessl" No 167 77 50 23.0 272 85.8 45 14.2 Yes 17 9.4 163 90.6 36 14.3 216 85.7 *For males, K = .76; for females, K = .79. TFor males, K = .66; for females, K = .71.
RESULTS
"// / 11to20 r 31to40 I 51to60 I 71 to' 80 I 0 to 10 21 to 30 41 to 50 61 to 70 81 to 90 Cummulative Percent
Fig 1. Comparison of PERI-D {---), BSI ( - - ) , and TBDI ('"") total scores.
TALBIEH BRIEF DISTRESS INVENTORY
451
ing number of responses was less than 15 for all variables. Table 2 presents correlations between the BSI dimensions and the TBDI scales. Correlations between the TBDI and corresponding BSI items were high, ranging from .70 to .87. It should be noted that although BSI somatization, phobic anxiety, and psychoticism scales were not included in the TBDI, there is a high correlation between them and the TBDI. Table 3 presents correlations between TBDI items. There is a moderately high correlation between scales, yet no two scales are correlated to an extent that would suggest duplication. As expected, all scales are highly correlated with the general score. Table 4 presents the agreement on caseness between the TBDI and BSI and PERI-D as reflected by K scores. We used PERI-D demoralization cutoff points of 1.23 for males and 1.51 for females2°,21 (based on Shrout et al.23). Based on our analysis comparing distribution of the PERI-D and its cutoff point with that of the TBDI, we found that the best cutoff point on the TBDI for males is 1.23, and for females, 1.27. Using a similar procedure, we developed TBDI cutoff points in relation to the BSI. For males, the cutoff point is 1.15, and for females, 1.39. Psychopathology caseness cutoff points of the BSI are a Global Severity Index of .58 for males and .78 for females. 14,15 There is good agreement on easeness (Table 4). Overall, the PERI-D and its cutoff points present more
agreement than the BSI and its cutoff points, as reflected by higher K values. If the cost of underidentifying is greater than for overidentifying, then for males the BSI cutoff point should be used, and for females the PERI-D cutoff point should be used. Figure 1 shows cumulative distribution of the three measures, which have been rescaled on a 0 to 100 scale. TBDI is between the other two instruments. DISCUSSION
Using a combination of an empirical and a qualitative approach, we were able to eliminate 56 of 80 items on the two instruments and obtain almost identical results. In practice, this reduces administration time considerably, which is likely to increase response rate and result in other savings in conducting studies. The results suggest that the TBDI is a promising instrument for screening immigrant populations for psychological distress and symptomatology, and that it can possibly replace the 53-item BSI and the 27-item PERI-D. We are in the process of replicating this study on different populations of immigrants. These include immigrants from Ethiopia, adolescent immigrants from the former Soviet Union, and immigrants who are in outpatient treatment at community mental health centers. This will enable us to test robustness of this instrument.
APPENDIX 1. TBDI Instructions given: Below is a list of problems and complaints that people sometimes have. Read each one carefully, and select one of the numbered choices that best describe HOW MUCH DISCOMFORT THAT PROBLEM HAS CAUSED YOU DURING THE PAST MONTH INCLUDING TODAY. Place that number on the line to the right of the problems. Please do not skip any items, and print your number clearly. Items from the BSl Choice for questions: 0--Not at all; 1 - - A little bit; 2--Moderately; 3~Quite a bit; 4~Extremely I. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Trouble remembering things Feeling easily annoyed or irritated Pains in heart or chest Feeling that most people cannot be trusted Temper outbursts that you could not control Feeling lonely even when you are with people Your feelings being easily hurt Feeling that people are unfriendly or dislike you Difficulty making decisions Getting into frequent arguments Others not giving you proper credit for your achievements Feelings of worthlessness Feelings of guilt
BSI item number 5 6 7 10 13 14 20 21 27 46 48 50 53
452
RITSNER, RABINOWlTZ, AND SLYUZBERG APPENDIX
1. T B D I (CONT'D)
Items from the PERI-D For the following items, these choices are given: 4---Very often; 3~fairly often; 2--sometimes; 1---almost never; 0~never. PERI-D item number 14. During the past month, how often have you had attacks of sudden fear or panic? 3 15. During the past month, how often have you been bothered by feelings of sadness or depressiorr~feeling blue? 5 16. During the past month, how often have you been bothered by nervousness, being fidgety or tense? 6 17. During the past month, how often have you felt useless? 9 18. During the past month, how often have you felt anxious? 11 19. During the past month, how often have you felt that nothing turns out for you the way you want it to, would you say.... 14 20. During the past month, how often have you felt completely hopeless about everything, would you say. . . . 15 21. During the past month, how often have you felt completely helpless? 17 22. During the past month, how often have you had times when you couldn't help wondering if anything was worthwhile any more? 18 23. During the past month, how often have you had trouble concentrating or keeping your mind on what you were doing? 22 24. In general, how satisfied have you been with yourself during the last year?: 0~Very satisfied; 1--somewhat satisfied; 3---somewhat dissatisfied; 4~very dissatisfied. 26 Scales Items Obsessiveness 1,9, 23 Hostility 2, 5, 10 Sensitivity 7, 8, 12, 13 Depression 15, 17, 19, 20, 21, 22, 24 Anxiety 14, 16, 18 Paranoid ideation 4, 6, 11
ACKNOWLEDGMENT
We thank A. Ponizovsky, A. Factourovich, and K. Levin for participating in data collection. We are grateful to Professor Y. Ginath (Director of Talbieh Mental Health Center) for his support at all stages of the study, REFERENCES
1. Kohn R, Flaherty JA, Levav. Somatic symptoms among older Soviet immigrants: an exploratory study. Int J Soc Psychiatry 1989;35:350-360. 2. Flaherty JA, Kohn R, Levav I, Birz S. Demoralization in Soviet-Jewish immigrants to the United States and Israel. Compr Psychiatry 1988;29:588-597. 3. Zilber N, Lerner Y. Psychological distress among recent immigrants from the former Soviet Union to Israel: I. Mediating factors. Psychol Med. In press. 4. Roskin M. Psychosocial transitions: an emotional health comparison. Int J Soc Psychiatry 1986;32:39-47. 5. Westermeyer J, Neider J, Vang TF. Migration and mental health among Hmong refugees: association of pre and postmigration factors with self-rating scales. J Nerv Ment Dis 1983;171:92-96. 6. Aroian KJ, Pastdaughter CA. Multiple-method, cross cultural assessment of psychological distress. Image J Nurs School 1989;21:90-93. 7. Kuo W. Theories of migration and mental health: an empirical testing of Chinese-Americans. Soc Sci Med 1976; 10:297-306. 8. Vega WA, Kolody B, Valle JR, Hough R. Depressive symptoms and their correlates among immigrant Mexican women in the United States. Soc Sci Med 1986;22:645-652. 9. Sayil I. Psychiatric problems of Turkish labourers in Holland. Int J Soc Psychiatry 1984;30:267-273. 10. Lipson J, Meleis G, Afaf I. Methodological issues in research with immigrants. Med Anthropol 1989; 12:103-115. 11. Fichter MM, Elton M, Diallina M, Koptagel IG,
Fthenakis WE, Weyerer S. Mental illness in Greek and Turkish adolescents. Eur Arch Psychiatry Neurol Sci 1988; 237:125-134. 12. Upadhyaya A, Creed F, Upadhyaya M. Psychiatric morbidity among mothers attending well-baby clinic: a cross-cultural comparison. Acta Psychiatr Scand 1990;81:148151. 13. Dohrenwend BP, Shrout PE, Galdys E, Mendelsohn FS. Nonspecific psychological distress and other dimensions of psychopathology. Arch Gen Psychiatry 1980;37:12291236. 14. Derogatis LR, Spenser PM. The Brief Symptom Inventory (BSI): Administration, Scoring and Procedures Manual. Baltimore, MD: Johns Hopkins University School Medicine, 1982. 15. Derogatis LR, Melisavatos N. The Brief Symptom Inventory: an introductory report. Psychol Med 1983;3:595605. 16. Dohrenwend BP, Levav I, Shrout PE. Screening scales from the Psychiatric Epidemiology Research Interview (PERI). In: Weissman MM, Myers JK, Ross CE (eds): Community Surveys of Psychiatric Disorders. New Brunswick, NJ: Rutgers University Press, 1986:349. 17. Frank J. Persuasion and Healing. Baltimore, MD: Johns Hopkins University Press, 1973. 18. Levav I, Gilboa S, Ruiz F. Demoralization and gender differences in kibbutz. Psychol Med 1991;21:10191028. 19. Shrout PE, Lyons M, Dohrenwend BP, Skodal AlE,
TALBIEH BRIEF DISTRESS INVENTORY
Solomon M, Kass F. Changing time frames on symptom inventories: effects of the Psychiatric Epidemiology Research Interview. J Consult Clin Psychol 1988;56:267-272. 20. Fennig S, Levav I. Demoralization and social supports among Holocaust survivors. J Nerv Ment Dis 1991;179: 167-172. 21. Gilboa S, Levav I, Gilboa L, Ruiz F. The epidemiology of demoralization in a kibbutz. Acta Psychiatr Scand 1990;82:60-64. 22. Lerner J, Zilber N. Psychological distress among recent immigrants from the former Soviet Union to Israel: II. The effect of the Gulf War. Psychol Med. In press. 23. Shrout PE, Dohrenwend BP, Levav I. A discriminat rule for screening cases of diverse diagnostic type: preliminary results. J Consult Clin Psychol 1986;54:314-319.
453
24. Epstein A. The impact of time in Israel and Jewish identity on the psychological adjustment of recent Soviet immigrants to Israel [dissertation]. New York, NY: Yeshiva University, 1992. 25. Mirsky J, Ginath Y, Perl E, Ritsner M. A psychological profile of Jewish late adolescents in the USSR: a pre-immigration study. Isr J Psychiatry Relat Sci 1992;29:150158. 26. Roskin M, Dasberg H. On the validity of the Symptom Checklist (SCL-90): a comparison of diagnostic selfrating in general practice patients and normals based on the Hebrew version. Int J Soc Psychiatry 1983;29:225-230. 27. Simoes M, Binder J. Socio-psychiatric field study among Portuguese emigrants in Switzerland. Soc Psychiatry 1980;15:1-7.
The purpose of this study was to develop and test the Talbieh Brief Distress Inventory (TBDI), a 24-item selfreport questionnaire that measures psychological distress among immigrants. The TBDI combines items from the Brief Symptom Inventory (BSI) and the Psychiatric Epidemiology Research Interview Demoralization Scale (PERI-D). It includes a global score and six scales (obsessiveness, hostility, sensitiveness, depression, anxiety, and paranoid ideation). A convenience sample of 966 recent immigrants to Israel from the former Soviet Union were asked to complete a Russianlanguage version of the BSI and PERI-D as part of a study on immigrants' psychological adjustment. The TBDI is a combination of 13 items from the BSI and 11 items from the PERI-D. Items for inclusion were based on results of a separate factor analysis for the BSI and
PERI-D and removal of repetitive items. We compared the total score with the total PERI-D and BSl and developed gender-specific cutoff points of caseness for the TBDI by comparison to known PERI-D and BSI cutoff points. We also checked for reliability using Cronbach's a. The TBDI correlated highly with the PERI-D (r = .93) and with the BSI (r = ,82). Reliability of the scales and the overall instrument ranged from Cronbach's a of .60 to .89. TBDI caseness cutoff points were in close agreement with the BSI and PERI-D as reflected by K scores that ranged from .66 to .79. The TBDI is a promising instrument for screening populations for psychological distress and symptomatology. It is available in English, Hebrew, and Russian. Copyright © 1995by W.B. Saunders Company
TH INCREASED immigration in many parts of the world, there has been a concomitant interest in studying and treating psychological distress among immigrants. Due to the lack of instruments designed specifically for this population, studies have used instruments that were not developed for studying immigrants. These instruments included various measures of generalized psychological distress and symptomatology such as the Psychiatric Epidemiology Research Interview Demoralization Scale (PERI-D), 1-3 Symptom Checklist-90 (SCL-90) 4,5 and its short form, Brief Symptom Inventory (BSI), 6 Midtown Psychiatric Impairment Index, 7 Center for Epidemiological Studies Depression Scale, 7,s Cornell Medical Index--Health Questionnaire, 9 Bradburn Morale Scale, 1° General Health Questionnaire, n and Self-Reporting Questionnaire. 12 The lack of one tailor-made instrument has sometimes led to the need to use more than one instrument. This can be time-consuming and generally disconcerting when screening large nonclini-
cal populations. We therefore sought to develop a brief instrument that would provide a reliable and valid measure of both and could be compared with norms and caseness cutoff points of existing instruments. Our particular area of interest was in screening large groups of immigrants as an outgrowth of our studies of immigrants in Israel, where one tenth of the population are immigrants who arrived over the last 5 years primarily from the former Soviet Union. In our community psychiatric epidemiology study of immigrants, we initially included the PERI-D 13 to measure demoralization and the BS114,15to measure specific symptoms. We sought to develop a brief instrument that would provide an adequate measure of both. After using these instruments to screen almost 1,000 immigrants, we constructed a short version that encompasses items from both. The PERI-D is a 27-item instrument developed by Dohrenwend et al. 16 that measures demoralization. Demoralization has been defined as a predicament for which the person sees no solution. 17The PERI-D was designed to tap demoralization and includes items common to rating scales measuring anxiety, depressive, and psychosomatic symptoms. 13,16,1s It is composed of fixed-format items about the frequency of psychological complaints in the past year. Responses are given on a five-point scale ranging from "never" (weighted as 0) to "very often" (weighted as 4). It is scored by adding
W
From the Psychiatric Epidemiology Research Unit, Talbieh Mental Health Center, Jerusalem; and Bar-llan University, Ramat-Gan, Israel. Address reprint requests to Jonathan Rabinowitz, D.S.W., School of Social Work, Bar-Ilan, University Ramat-Gan, lsrael. Copyright © 1995 by W.B. Saunders Company 0010-440X/95/3606-0002503.00/0
448
Comprehensive Psychiatry, Vol. 36, No. 6 (November/December), 1995: pp 448-453
TALBIEH BRIEF DISTRESS INVENTORY
449
Table 1. TBDI Mean -+ SD Values and Cronbach ¢=Coefficients for Males and Females (nonpatient immigrant sample) Males (n = 398) Scale
Females (n = 568)
Mean -+ SD
c~
1.20 +- .83
.62
1.42 -+ .87
.97 -+ .80 .87 +- .70
.62 .57
1.15 _+ .81 1.00 -+ .80
Anxiety (3 items) Paranoid ideation (3 items)
1.55 -+ .90 1.04 + .90
.78 .60
2.04 + .95 1.09 -+ .90
Depression (7 items)
1.42 -+ .87
.86
Total score (24 items)
1.18 -+ .66
.88
Obsessiveness (3 items) Hostility (3 items) Sensitivity (4 items)
responses to the 27 items and dividing by the number of completed items, t9 The higher the PERI-D score, the more demoralization. Reliability and validity tests of the PERI-D in the United States and Israel have shown satisfactory results, t6 It has been widely used in Israel. 2,3,2°-22High sensitivity and specificity levels have been reported. 23 The BSI is a shortened version of the betterknown Hopkins SCL-90.14A5 It is a 53-item self-report inventory. Subjects respond on a five-point Likert format from "not at all troubled b y . . . during the last year" to "troubled a lot by . . . in the last year" to a list of psychological symptoms. Analysis of BSI scores supplies quantitative indices of severity of distress and profiles that correspond to standard clinical syndromes. A Russian-language version of the BSI was available from previous studies. 24,25 Reliability and validity tests of the BSI have shown satisfactory results. Reliability of nine symptoms and three global indices has been tested for internal consistency that ranged from ot .71 to .80. Test-retest coefficients ranged from
t Test
Mean _+SD
c~
t
P
.65
3.93
.000
.57 .66
3.30 2.60
.001 .009
.79 .62
7.91 0.72
.000 .47
1.74 -+ .90
.86
5.38
.0go
1.43 -+ .71
.89
5.33
.000
.68 to .90. There are high correlations (lowest, .92) between symptom dimensions of the SCL-90 and the BSI. 14,15 The PERI-D and BSI have been used in social, psychiatric, and epidemiological studies of immigrants in different languages, including Russian. 5,26,27 METHOD We selected 11 of 27 PERI-D items and 13 of 53 items from the BSI that best tapped psychological distress. Items for inclusion were based on results of a separate factor analysis for the BSI and PERI-D. In each case, items on the primary factor were chosen. A few additional items were removed because they were repetitious in content and highly correlated. The 24 selected items were used to create a total score that is the sum of all items divided by the number of completed items, and six scales (obsessiveness, hostility, sensitivity, depression, anxiety, and paranoid ideation). All items were scored from low (0) to high (4). Talbieh Brief Distress Inventory (TBDI) items, source of items, and scale compositions are included in Appendix 1.
Subjects The PERI-D and BSI were administered to a convenience sample of 966 non-psychiatric-patient immigrants aged 18 to 87 in Jerusalem, Tel-Aviv, and Beer-Sheva
Table 2. Correlation of BSI Dimensions and TBDI Scales TBDI Scales BSl Dimensions
Obsessiveness
Hostility
Sensitiveness
Depression
Anxiety
Paranoid Ideation
Somatization Obsessive-compulsive Interpersonal sensitivity
.52 .87 .58
.43 .55 .55
.49 .64 .84
.49 .60 .59
.49 .53 .52
.44 .62 .60
Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism General Severity Index
.58 .62 .47 .44 .44 .48 ,72
.59 .66 .79 .37 .46 .46 .74
.67 .63 .55 .47 .69 .58 .78
.74 .67 .49 .41 .48 .50 .72
.60 .70 .50 .39 .41 .42 .66
.72 .74 .52 .44 .73 .58 .79
NOTE. N = 918; 46 missing on at least one scale. All correlations with significance, P < .001.
450
RITSNER, RABINOWITZ, AND SLYUZBERG
Table 3. Correlation of TBDI Scales TBDI Scales
Obsessiveness
Hostility
Sensitiveness
Depression
Anxiety
Hostility
.53
Sensitiveness
.56
.54
Depression
.59
.57
.57
Anxiety Paranoid ideation
.53 .52
.56 .55
.53 .62
.73 .60
1 .52
General score
.75
.75
.78
.90
.81
Paranoid Ideation
1 1 1 1 .77
NOTE. N = 918; 46 missing on at least one scale. Significance for all correlations, P < .001.
between 1991 and 1993. Respondents were from typical gathering places for these immigrants, e.g., professional retraining courses, temporary accommodations at hotels, social services for immigrants, and Hebrew-language instruction courses. At each site, data were collected from approximately 75% of the immigrants present. Respondents were 39.3 _+ 12.9 years old (mean -+ SD). Approximately 54% had immigrated within 12 months of study, 41.7% within 1 to 2 years, and 3.9% within 25 to 30 months. The mean time in Israel was 12.5 _+ 7.8 months. The male to female ratio was 1:1.4. Approximately 67% were married, 12.8% single, 19.3% divorced and widowed, and 1% unknown. Approximately 79.4% were university graduates, 13.4% were graduates of vocational training, 5.0% were high school graduates, and 2.2% had grade school education. Results were analyzed using descriptive statistics and analysis of variance to compare men and women. Reliability of scales was examined using Cronbach's ct. The uniqueness of scales was examined by studying Pearson productmoment correlations between scales. Convergent validity of the instrument as a measure of psychological distress was measured by studying correlations of TBDI scale scores to PERI-D and BSI scores of respondents. We compared distribution of the total score with total PERI-D and BSI scores and developed gender-specific cutoff points for TBDI caseness by comparing with known PERI-D and BSI cutoff points by using sequential steps. Table 4. Sensitivity and Specificity of TBDI Risk for Demoralization as Compared With PERI-D Demoralization Cutoff Points and BSl Caseness Cutoff Points TBDI Risk for Demoralization (%) Males (n = 397) No Parameter
No.
Females (n = 569)
Yes %
No.
%
No No.
Yes %
No.
The TBDI total score correlated highly with the PERI-D (r = .93) and with the BSI (r = .82). The correlation of the PERI-D and BSI was .82. The mean -+ SD and reliability of the scales and total score for males and females are presented in Table 1. There are significant differences between males and females, with the exception of paranoid ideation. All Cronbach et values are greater than .56 and many approximately .75, suggesting high internal consistency. The miss-
Comparison of Three Instruments
8O
/ :/ / :i:j
4o~/ :...:1II ~
:./
%
PERI-D demoralization* No 202 84.2 38 15.8 248 91.2 24 8.8 Yes 9 5.7 148 94.3 35 11.8 262 88.2 BSI casenessl" No 167 77 50 23.0 272 85.8 45 14.2 Yes 17 9.4 163 90.6 36 14.3 216 85.7 *For males, K = .76; for females, K = .79. TFor males, K = .66; for females, K = .71.
RESULTS
"// / 11to20 r 31to40 I 51to60 I 71 to' 80 I 0 to 10 21 to 30 41 to 50 61 to 70 81 to 90 Cummulative Percent
Fig 1. Comparison of PERI-D {---), BSI ( - - ) , and TBDI ('"") total scores.
TALBIEH BRIEF DISTRESS INVENTORY
451
ing number of responses was less than 15 for all variables. Table 2 presents correlations between the BSI dimensions and the TBDI scales. Correlations between the TBDI and corresponding BSI items were high, ranging from .70 to .87. It should be noted that although BSI somatization, phobic anxiety, and psychoticism scales were not included in the TBDI, there is a high correlation between them and the TBDI. Table 3 presents correlations between TBDI items. There is a moderately high correlation between scales, yet no two scales are correlated to an extent that would suggest duplication. As expected, all scales are highly correlated with the general score. Table 4 presents the agreement on caseness between the TBDI and BSI and PERI-D as reflected by K scores. We used PERI-D demoralization cutoff points of 1.23 for males and 1.51 for females2°,21 (based on Shrout et al.23). Based on our analysis comparing distribution of the PERI-D and its cutoff point with that of the TBDI, we found that the best cutoff point on the TBDI for males is 1.23, and for females, 1.27. Using a similar procedure, we developed TBDI cutoff points in relation to the BSI. For males, the cutoff point is 1.15, and for females, 1.39. Psychopathology caseness cutoff points of the BSI are a Global Severity Index of .58 for males and .78 for females. 14,15 There is good agreement on easeness (Table 4). Overall, the PERI-D and its cutoff points present more
agreement than the BSI and its cutoff points, as reflected by higher K values. If the cost of underidentifying is greater than for overidentifying, then for males the BSI cutoff point should be used, and for females the PERI-D cutoff point should be used. Figure 1 shows cumulative distribution of the three measures, which have been rescaled on a 0 to 100 scale. TBDI is between the other two instruments. DISCUSSION
Using a combination of an empirical and a qualitative approach, we were able to eliminate 56 of 80 items on the two instruments and obtain almost identical results. In practice, this reduces administration time considerably, which is likely to increase response rate and result in other savings in conducting studies. The results suggest that the TBDI is a promising instrument for screening immigrant populations for psychological distress and symptomatology, and that it can possibly replace the 53-item BSI and the 27-item PERI-D. We are in the process of replicating this study on different populations of immigrants. These include immigrants from Ethiopia, adolescent immigrants from the former Soviet Union, and immigrants who are in outpatient treatment at community mental health centers. This will enable us to test robustness of this instrument.
APPENDIX 1. TBDI Instructions given: Below is a list of problems and complaints that people sometimes have. Read each one carefully, and select one of the numbered choices that best describe HOW MUCH DISCOMFORT THAT PROBLEM HAS CAUSED YOU DURING THE PAST MONTH INCLUDING TODAY. Place that number on the line to the right of the problems. Please do not skip any items, and print your number clearly. Items from the BSl Choice for questions: 0--Not at all; 1 - - A little bit; 2--Moderately; 3~Quite a bit; 4~Extremely I. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Trouble remembering things Feeling easily annoyed or irritated Pains in heart or chest Feeling that most people cannot be trusted Temper outbursts that you could not control Feeling lonely even when you are with people Your feelings being easily hurt Feeling that people are unfriendly or dislike you Difficulty making decisions Getting into frequent arguments Others not giving you proper credit for your achievements Feelings of worthlessness Feelings of guilt
BSI item number 5 6 7 10 13 14 20 21 27 46 48 50 53
452
RITSNER, RABINOWlTZ, AND SLYUZBERG APPENDIX
1. T B D I (CONT'D)
Items from the PERI-D For the following items, these choices are given: 4---Very often; 3~fairly often; 2--sometimes; 1---almost never; 0~never. PERI-D item number 14. During the past month, how often have you had attacks of sudden fear or panic? 3 15. During the past month, how often have you been bothered by feelings of sadness or depressiorr~feeling blue? 5 16. During the past month, how often have you been bothered by nervousness, being fidgety or tense? 6 17. During the past month, how often have you felt useless? 9 18. During the past month, how often have you felt anxious? 11 19. During the past month, how often have you felt that nothing turns out for you the way you want it to, would you say.... 14 20. During the past month, how often have you felt completely hopeless about everything, would you say. . . . 15 21. During the past month, how often have you felt completely helpless? 17 22. During the past month, how often have you had times when you couldn't help wondering if anything was worthwhile any more? 18 23. During the past month, how often have you had trouble concentrating or keeping your mind on what you were doing? 22 24. In general, how satisfied have you been with yourself during the last year?: 0~Very satisfied; 1--somewhat satisfied; 3---somewhat dissatisfied; 4~very dissatisfied. 26 Scales Items Obsessiveness 1,9, 23 Hostility 2, 5, 10 Sensitivity 7, 8, 12, 13 Depression 15, 17, 19, 20, 21, 22, 24 Anxiety 14, 16, 18 Paranoid ideation 4, 6, 11
ACKNOWLEDGMENT
We thank A. Ponizovsky, A. Factourovich, and K. Levin for participating in data collection. We are grateful to Professor Y. Ginath (Director of Talbieh Mental Health Center) for his support at all stages of the study, REFERENCES
1. Kohn R, Flaherty JA, Levav. Somatic symptoms among older Soviet immigrants: an exploratory study. Int J Soc Psychiatry 1989;35:350-360. 2. Flaherty JA, Kohn R, Levav I, Birz S. Demoralization in Soviet-Jewish immigrants to the United States and Israel. Compr Psychiatry 1988;29:588-597. 3. Zilber N, Lerner Y. Psychological distress among recent immigrants from the former Soviet Union to Israel: I. Mediating factors. Psychol Med. In press. 4. Roskin M. Psychosocial transitions: an emotional health comparison. Int J Soc Psychiatry 1986;32:39-47. 5. Westermeyer J, Neider J, Vang TF. Migration and mental health among Hmong refugees: association of pre and postmigration factors with self-rating scales. J Nerv Ment Dis 1983;171:92-96. 6. Aroian KJ, Pastdaughter CA. Multiple-method, cross cultural assessment of psychological distress. Image J Nurs School 1989;21:90-93. 7. Kuo W. Theories of migration and mental health: an empirical testing of Chinese-Americans. Soc Sci Med 1976; 10:297-306. 8. Vega WA, Kolody B, Valle JR, Hough R. Depressive symptoms and their correlates among immigrant Mexican women in the United States. Soc Sci Med 1986;22:645-652. 9. Sayil I. Psychiatric problems of Turkish labourers in Holland. Int J Soc Psychiatry 1984;30:267-273. 10. Lipson J, Meleis G, Afaf I. Methodological issues in research with immigrants. Med Anthropol 1989; 12:103-115. 11. Fichter MM, Elton M, Diallina M, Koptagel IG,
Fthenakis WE, Weyerer S. Mental illness in Greek and Turkish adolescents. Eur Arch Psychiatry Neurol Sci 1988; 237:125-134. 12. Upadhyaya A, Creed F, Upadhyaya M. Psychiatric morbidity among mothers attending well-baby clinic: a cross-cultural comparison. Acta Psychiatr Scand 1990;81:148151. 13. Dohrenwend BP, Shrout PE, Galdys E, Mendelsohn FS. Nonspecific psychological distress and other dimensions of psychopathology. Arch Gen Psychiatry 1980;37:12291236. 14. Derogatis LR, Spenser PM. The Brief Symptom Inventory (BSI): Administration, Scoring and Procedures Manual. Baltimore, MD: Johns Hopkins University School Medicine, 1982. 15. Derogatis LR, Melisavatos N. The Brief Symptom Inventory: an introductory report. Psychol Med 1983;3:595605. 16. Dohrenwend BP, Levav I, Shrout PE. Screening scales from the Psychiatric Epidemiology Research Interview (PERI). In: Weissman MM, Myers JK, Ross CE (eds): Community Surveys of Psychiatric Disorders. New Brunswick, NJ: Rutgers University Press, 1986:349. 17. Frank J. Persuasion and Healing. Baltimore, MD: Johns Hopkins University Press, 1973. 18. Levav I, Gilboa S, Ruiz F. Demoralization and gender differences in kibbutz. Psychol Med 1991;21:10191028. 19. Shrout PE, Lyons M, Dohrenwend BP, Skodal AlE,
TALBIEH BRIEF DISTRESS INVENTORY
Solomon M, Kass F. Changing time frames on symptom inventories: effects of the Psychiatric Epidemiology Research Interview. J Consult Clin Psychol 1988;56:267-272. 20. Fennig S, Levav I. Demoralization and social supports among Holocaust survivors. J Nerv Ment Dis 1991;179: 167-172. 21. Gilboa S, Levav I, Gilboa L, Ruiz F. The epidemiology of demoralization in a kibbutz. Acta Psychiatr Scand 1990;82:60-64. 22. Lerner J, Zilber N. Psychological distress among recent immigrants from the former Soviet Union to Israel: II. The effect of the Gulf War. Psychol Med. In press. 23. Shrout PE, Dohrenwend BP, Levav I. A discriminat rule for screening cases of diverse diagnostic type: preliminary results. J Consult Clin Psychol 1986;54:314-319.
453
24. Epstein A. The impact of time in Israel and Jewish identity on the psychological adjustment of recent Soviet immigrants to Israel [dissertation]. New York, NY: Yeshiva University, 1992. 25. Mirsky J, Ginath Y, Perl E, Ritsner M. A psychological profile of Jewish late adolescents in the USSR: a pre-immigration study. Isr J Psychiatry Relat Sci 1992;29:150158. 26. Roskin M, Dasberg H. On the validity of the Symptom Checklist (SCL-90): a comparison of diagnostic selfrating in general practice patients and normals based on the Hebrew version. Int J Soc Psychiatry 1983;29:225-230. 27. Simoes M, Binder J. Socio-psychiatric field study among Portuguese emigrants in Switzerland. Soc Psychiatry 1980;15:1-7.