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See discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/8157458 The Hamilton Depression Rating Scale: Has the Gold Standard Become a Lead Weight? ARTICLE in AMERICAN JOURNAL OF PSYCHIATRY · JANUARY 2005 Impact Factor: 12.3 · DOI: 10.1176/appi.ajp.161.12.2163 · Source: PubMed CITATIONS 458 READS 2,176 4 AUTHORS, INCLUDING: R. Michael Bagby University of Toronto 347 PUBLICATIONS 16,312 CITATIONS SEE PROFILE Andrew G Ryder Concordia University Montreal 78 PUBLICATIONS 2,268 CITATIONS SEE PROFILE Available from: R. Michael Bagby Retrieved on: 19 December 2015 Am J Psychiatry 161:12, December 2004 2163 Reviews and Overviews http://ajp.psychiatryonline.org The Hamilton Depression Rating Scale: Has the Gold Standard Become a Lead Weight? R. Michael Bagby, Ph.D. Andrew G. Ryder, M.A. Deborah R. Schuller, M.D. Margarita B. Marshall, B.Sc. Objective: The Hamilton Depression Rat- ing Scale has been the gold standard for the assessment of depression for more than 40 years. Criticism of the instrument has been increasing. The authors review studies pub- lished since the last major review of this in- strument in 1979 that explicitly examine the psychometric properties of the Hamil- ton depression scale. The authors’ goal is to determine whether continued use of the Hamilton depression scale as a measure of treatment outcome is justified. Method: MEDLINE was searched for stud- ies published since 1979 that examine psychometric properties of the Hamilton depression scale. Seventy studies were identified and selected, and then grouped into three categories on the basis of the major psychometric properties exam- ined—reliability, item-response character- istics, and validity. Results: The Hamilton depression scale’s internal reliability is adequate, but many scale items are poor contributors to the measurement of depression severity; oth- ers have poor interrater and retest reliabil- ity. For many items, the format for re- sponse options is not optimal. Content validity is poor; convergent validity and discriminant validity are adequate. The factor structure of the Hamilton depres- sion scale is multidimensional but with poor replication across samples. Conclusions: Evidence suggests that the Hamilton depression scale is psychomet- rically and conceptually flawed. The breadth and severity of the problems mil- itate against efforts to revise the current instrument. After more than 40 years, it is time to embrace a new gold standard for assessment of depression. (Am J Psychiatry 2004; 161:2163–2177) The Hamilton Depression Rating Scale (1) was devel- oped in the late 1950s to assess the effectiveness of the first generation of antidepressants and was originally pub- lished in 1960. Although Hamilton (1) recognized that the scale had “room for improvement” (p. 56) and that further revision was necessary, the scale quickly became the stan- dard measure of depressio.

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See discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/8157458 The Hamilton Depression Rating Scale: Has the Gold Standard Become a Lead Weight? ARTICLE in AMERICAN JOURNAL OF PSYCHIATRY · JANUARY 2005 Impact Factor: 12.3 · DOI: 10.1176/appi.ajp.161.12.2163 · Source: PubMed CITATIONS 458 READS 2,176 4 AUTHORS, INCLUDING: R. Michael Bagby University of Toronto 347 PUBLICATIONS 16,312 CITATIONS SEE PROFILE
Andrew G Ryder ConcordiaUniversity Montreal 78 PUBLICATIONS 2,268 CITATIONS SEE PROFILE Available from: R. Michael Bagby Retrieved on: 19 December 2015 Am J Psychiatry 161:12, December 2004 2163 Reviews and Overviews http://ajp.psychiatryonline.org The Hamilton Depression Rating Scale: Has the Gold Standard Become a Lead Weight? R. Michael Bagby, Ph.D. Andrew G. Ryder, M.A. Deborah R. Schuller, M.D. Margarita B. Marshall, B.Sc. Objective: The Hamilton Depression Rat- ing Scale has been the gold standard for the assessment of depression for more than 40
years. Criticism of the instrument has been increasing. The authors review studies pub- lished since the last major review of this in- strument in 1979 that explicitly examine the psychometric properties of the Hamil- ton depression scale. The authors’ goal is to determine whether continued use of the Hamilton depression scale as a measure of treatment outcome is justified. Method: MEDLINE was searched for stud- ies published since 1979 that examine psychometric properties of the Hamilton depression scale. Seventy studies were identified and selected, and then grouped into three categories on the basis of the major psychometric properties exam- ined—reliability, item-response character- istics, and validity. Results: The Hamilton depression scale’s internal reliability is adequate, but many scale items are poor contributors to the measurement of depression severity; oth- ers have poor interrater and retest reliabil- ity. For many items, the format for re- sponse options is not optimal. Content validity is poor; convergent validity and discriminant validity are adequate. The factor structure of the Hamilton depres- sion scale is multidimensional but with poor replication across samples. Conclusions: Evidence suggests that the Hamilton depression scale is psychomet- rically and conceptually flawed. The
breadth and severity of the problems mil- itate against efforts to revise the current instrument. After more than 40 years, it is time to embrace a new gold standard for assessment of depression. (Am J Psychiatry 2004; 161:2163–2177) The Hamilton Depression Rating Scale (1) was devel- oped in the late 1950s to assess the effectiveness of the first generation of antidepressants and was originally pub- lished in 1960. Although Hamilton (1) recognized that the scale had “room for improvement” (p. 56) and that further revision was necessary, the scale quickly became the stan- dard measure of depression severity for clinical trials of antidepressants (2, 3). The Hamilton depression scale has retained this function and is now the most commonly used measure of depression (3). Our objective in this arti- cle is to provide a review of the Hamilton depression scale literature published since the last major evaluation of its psychometric properties, more than 20 years ago (4). More recent reviews have appeared (3, 5–7), but they have not systematically examined the literature with regard to a broad range of measurement issues. Significant develop- ments in psychometric theory and practice have been made since the 1950s and need to be applied to instru- ments currently in use. We evaluate the Hamilton depres- sion scale in light of these current standards and conclude by presenting arguments for and against retaining, revis- ing, or rejecting the Hamilton depression scale as the gold standard for assessment of depression. Method Studies for the review were identified by means of MEDLINE searches for both “depression” and “Hamilton.” All studies pub-
lished during the period since the last major review ( January 1980 to May 2003) were considered. Studies selected for review had to be explicitly designed to evaluate empirically the psychometric properties of the instrument or to review conceptual issues re- lated to the instrument’s development, continued use, and/or shortcomings. At least 20 published versions of the Hamilton de- pression scale exist, including both longer and shortened ver- sions. This review was limited to studies that examined the origi- nal 17-item version, as the majority of the studies that evaluated the scale’s psychometrics used the 17-item version. Only a small number of studies evaluated other versions, and most of these versions contain the original 17 items. Seventy articles met the se- lection criteria and were categorized into three groups on the ba- sis of the major psychometric property examined—reliability, item response, and validity. Table 1 lists the articles included in the review. Results Reliability Clinician-rated instruments should demonstrate three types of reliability: 1) internal reliability, 2) retest reliability, and 3) interrater reliability. Cronbach’s alpha statistic (78) is used to evaluate internal reliability, and estimates ≥0.70 2164 Am J Psychiatry 161:12, December 2004
HAMILTON DEPRESSION SCALE http://ajp.psychiatryonline.org TABLE 1. Characteristics of Studies Examining the Psychometric Properties of the Hamilton Depression Rating Scalea % of Female Subjects Psychometric Properties Examined Study Year Language N Subjects Reliability Item Response Validity Aben et al. (8) 2002 Dutch 202 46 Stroke patients × Addington et al. (9) 1990 English 250 —b Schizophrenia inpatients × Addington et al. (10) 1996 English 112c 60 Schizophrenia inpatients × × Addington et al. (10) 1996 English 89d —b Schizophrenia inpatients × × Akdemir et al. (11) 2001 Turkish 94 66 Psychiatric patients × × Baca-García et al. (12) 2001 Spanish 1 100 Dysthymia outpatient × Bech (5) 1981 Danish 66 70 Depressed inpatients × × Bech et al. (13) 1992 Multilingual 1,128 —b Psychiatric patients × × Bech et al. (14) 2002 Danish 650 —b Psychiatric patients × × Berard and Ahmed (15) 1995 English 22 64 Elderly psychiatric outpatients × ×
Berrios and Bulbena- Villarasa (16) 1990 Castilian 1,204 59 Psychiatric outpatients × × Brown et al. (17) 1995 English 259 —b Medical outpatients × Carroll et al. (18) 1981 English 278 —b Depressed patients × Cicchetti and Prusoff (19) 1983 Time 1 English 86 —b Depressed outpatients × Time 2 English 81 —b Depressed outpatients × Craig et al. (20) 1985 English 32 0 Schizophrenia inpatients × × Daradkeh et al. (21) 1997 Arabic 73 58 Depressed inpatients × × Deluty et al. (22) 1986 English 70 39 Psychiatric inpatients × × Demitrack et al. (23) 1998 —b 85 66 Professionals/laypersons × Entsuah et al. (24) 2002 Sample 1 Multilingual 865 65 Psychiatric patients × Sample 2 Multilingual 757 64 Psychiatric patients × Sample 3 Multilingual 450 62 Psychiatric patients × Faries et al. (25) 2000 —b 1,658 —b Depressed outpatients × Feinberg et al. (26) 1981 English —b —b Depressed patients × Fleck et al. (27) 1995 French 60 77 Psychiatric outpatients × Fuglum et al. (28) 1996 Danish —b —b Depressed patients × × Gastpar and Gilsdorf (29) 1990 Multilingual 122 66 Depressed patients × Gibbons et al. (30) 1993 English 370 72 Psychiatric patients × × Gilley et al. (31) 1995 Sample 1 English 185 56 Alzheimer’s disease patients × × Sample 2 English 54 39 Comparsion subjects with normal cognition
× × Sample 3 English 57 37 Parkinson’s disease patients × × Gottlieb et al. (32) 1988 English 43 67 Neurological patients × × Gullion and Rush (33) 1998 English 324 67 Depressed patients × Hammond (34) 1998 English 100 74 Elderly medical patients × Hooijer et al. (35) 1991 Flemish 56 —b Mental health professionals × Hotopf et al. (36) 1998 English 49 65 Primary care patients × Kobak et al. (37) 1999 English 113 —b Psychiatric patients/community comparison subjects × × Koenig et al. (38) 1995 English 38 55 Elderly medical patients × Lambert et al. (39) 1986 —b 1,850 —b Psychiatric patients × Lambert et al. (40) 1988 English 13 31 Psychiatric inpatients/outpatients × Leentjens et al. (41) 2000 Dutch 63 37 Parkinson’s disease patients × Leung et al. (42) 1999 Chinese 93 56 Psychiatric inpatients × × McAdams et al. (43) 1996 English 101 23 Schizophrenia outpatients × Maier and Philipp (44) 1985 German 280 —b Psychiatric outpatients × Maier et al. (45) 1988 Sample 1 German 130 —b Psychiatric inpatients × × × Sample 2 German 48 —b Psychiatric inpatients × × × Maier et al. (46) 1988 German 130 —b Psychiatric inpatients × Marcos and Salamero (47) 1990 Spanish 234 76 Community
geriatric subjects × Meyer et al. (48) 2001 English 196 68 Medical outpatients × Middelboe et al. (49) 1994 Danish 36 64 Medical outpatients × Moberg et al. (50) 2001 English 20 70 Geriatric consultation/liaison patients × Mottram et al. (51) 2000 English 433 73 Elderly psychiatric referrals × Naarding et al. (52) 2002 Sample 1 Dutch 44 36 Stroke inpatients × Sample 2 Dutch 274 60 Alzheimer’s disease patients × Sample 3 Dutch 85 40 Parkinson’s disease patients × O’Brien and Glaudin (53) 1988 Sample 1 English 183 70 Psychiatric outpatients × Sample 2 English 182 70 Psychiatric outpatients × (continued) Am J Psychiatry 161:12, December 2004 2165 BAGBY, RYDER, SCHULLER, ET AL. http://ajp.psychiatryonline.org reflect adequate reliability (79, 80). The internal reliability of individual items is calculated by using corrected item- to-total correlation with Pearson’s r; items should have a correlation greater than 0.20 (79, 80). Retest reliability as- sesses the extent to which multiple administrations of the scale generate the same results. When scores on an instru- ment are expected to change in response to effective treat- ment, it is necessary to demonstrate that these scores re- main the same in the absence of treatment. Interrater
reliability assesses the extent to which multiple raters gen- erate the same result. Although Pearson’s r is often used to compute these estimates, the preferred method is the intraclass r (81), which allows for adjustment for agree- ment by chance. Estimates of retest and interrater reliabil- ity should be at a minimum of 0.70 (Pearson’s r) and 0.60 (intraclass r) (82). For retest reliability of scale items, Pear- son’s r >0.70 is considered acceptable (83). Internal Reliability Table 2 summarizes the results from studies examining internal reliability of the total Hamilton depression scale. Es- timates ranged from 0.46 to 0.97, and 10 studies reported es- timates ≥0.70. Table 3 summarizes the studies that exam- ined internal reliability at the item level. The majority of Hamilton depression scale items show adequate reliability. Six items met the reliability criteria in every sample (guilt, middle insomnia, psychic anxiety, somatic anxiety, gastro- intestinal, general somatic), and an additional five items met the criteria in all but one sample (depressed mood, suicide, early insomnia, late insomnia, work and interests, hypo- chondriasis). Loss of insight was the item with the most vari- able findings, suggesting a potential problem with this item. Interrater Reliability Total Hamilton depression scale interrater reliabilities are displayed in Table 2. Pearson’s r ranged from 0.82 to TABLE 1. Characteristics of Studies Examining the Psychometric Properties of the Hamilton Depression Rating Scalea (continued) % of
Female Subjects Psychometric Properties Examined Study Year Language N Subjects Reliability Item Response Validity O’Hara and Rehm (54) 1983 English 20 0 Depressed outpatients × Olsen et al. (55) 2003 Danish 91 74 Psychiatric and medical patients × Onega and Abraham (56) 1997 English 206 70 Geriatric psychiatric outpatients × Pancheri et al. (57) 2002 Italian 186 62 Depressed outpatients × × Paykel (58) 1990 Sample 1 English 101 —b Depressed inpatients × × Sample 2 English 118 —b Psychiatric outpatients × × Sample 3 English 167 —b General practice outpatients × × Potts et al. (59) 1990 English 694 74 Depressed outpatients × Ramos-Brieva and Cordero-Villafafila (60) 1988 Spanish 135 70 Depressed inpatients/outpatients × × Rehm and O’Hara (61) 1985 English 158 100 Community (symptomatic) subjects × × Reynolds and Kobak (62) 1995 English 357 59 Psychiatric outpatient/nonreferred community subjects ×
Riskind et al. (63) 1987 English 191 54 Psychiatric outpatients × × Santor and Coyne (64) 2001 Sample 1 English 316 —b Primary care outpatients × Sample 2 English 318 70 Depressed outpatients × Santor and Coyne (65) Sayer et al. (66) 2001 English 732 —b Depressed patients × 1993 English 114 61 Psychiatric inpatients × × Senra Rivera et al. (67) 2000 Castilian 52 65 Depressed patients × × Shain et al. (68) 1990 English 45 64 Depressed adolescent inpatients × Smouse et al. (69) 1981 English —b —b Depressed patients × Steinmeyer and Möller (70) 1992 German 223e 68 Psychiatric inpatients × Steinmeyer and Möller (70) 1992 German 174f 68 Psychiatric inpatients × Strik et al. (71) 2001 Sample 1 Dutch 156 0 Medical patients × × Sample 2 Dutch 50 100 Medical patients × × Teri and Wagner (72) 1991 English 75 68 Alzheimer’s patients × Thase et al. (73) 1983 English 147 100 Depressed outpatients × × Thompson et al. (74) 1998 English 242 100 Psychiatric referrals × Whisman et al. (75) 1989 English 70 100 Depressed outpatients × × Williams (76) 1988 English 23 65 Psychiatric inpatients × Zheng et al. (77) 1988 Chinese 329 47 Psychiatric inpatients/outpatients × × a Studies were published between January 1980 and May 2003 and identified by means of a MEDLINE search for both
“depression” and “Hamilton.” b Not reported. c Number of subjects providing data at time 1. d Number of subjects providing follow-up data 3 months after admission. e Number of subjects providing baseline (i.e., pretreatment) data. f Number of subjects providing endpoint (week 6) data after treatment with either paroxetine or amitriptyline. 2166 Am J Psychiatry 161:12, December 2004 HAMILTON DEPRESSION SCALE http://ajp.psychiatryonline.org 0.98, and the intraclass r ranged from 0.46 to 0.99. Some investigators provided evidence that the skill level or ex- pertise of the interviewer and the provision of structured queries and scoring guidelines affect reliability (19, 23, 35, 54). Across studies, the best estimate mean of interrater re- liability for studies reporting higher levels of interviewer skill and use of expert raters, structured queries, and scor- ing guidelines did not statistically differ from that for other studies (z=0.81, n.s.). At the individual item level, interrater reliability is poor for many items. Cicchetti and Prusoff (19) assessed reli- ability before treatment initiation and 16 weeks later at trial end. Only early insomnia was adequately reliable be- fore treatment, and only depressed mood was adequately reliable after treatment. Thirteen items had coefficients
<0.50 before treatment, and 11 items had coefficients <0.50 after treatment. Rehm and O’Hara (61) performed a similar analysis with data from two samples. Six items showed adequate reliability in the first sample (early in- somnia, middle insomnia, late insomnia, somatic anxiety, gastrointestinal, loss of libido), as did 10 in the second sample (depressed mood, guilt, suicide, early insomnia, middle insomnia, late insomnia, work/interests, psychic anxiety, somatic anxiety, gastrointestinal). Loss of insight showed the lowest interrater agreement in both samples. Craig et al. (20) found that only one item, work/interests, had adequate interrater reliability. Moberg et al. (50) re- ported that nine items demonstrated adequate reliability when the standard Hamilton depression scale was admin- istered (depressed mood, guilt, suicide, early insomnia, late insomnia, agitation, psychic anxiety, hypochondria- sis, loss of insight), but all items showed adequate reliabil- ity when the scale was administered with interview guide- lines. Potts et al. (59) demonstrated that a single omnibus coefficient can mask specific problems. Using a structured interview version of the Hamilton depression scale, they TABLE 2. Studies Reporting Reliability Estimates for the Total 17-Item Hamilton Depression Rating Scalea Study Year Internal Reliability (Cronbach’s alpha) Interrater Reliability (Pearson’s r) Interrater Reliability (Intraclass r)
Retest Reliability (Pearson’s r) Addington et al. (9) 1990 0.82 Addington et al. (10) 1996 0.93 Akdemir et al. (11) 2001 0.75 0.87–0.98b 0.85 Baca-García et al. (12) 2001 0.97 Cicchetti and Prusoff (19) 1983 Time 1 0.46 Time 2 0.82 Craig et al. (20) 1985 0.95 Deluty et al. (22) 1986 0.96 Demitrack et al. (23) 1998 0.65–0.79b Fuglum et al. (28) 1996 0.86 0.81 Gastpar and Gilsdorf (29) 1990 0.48 Gilley et al. sample 1 (31) 1995 0.92 Gottlieb et al. (32) 1988 0.99 Hammond (34) 1998 0.46 Kobak et al. (37) 1999 0.91 0.98 Koenig et al. (38) 1995 0.97 Leung et al. (42) 1999 0.94 Maier et al. (45) 1988 Sample 1 0.70 Sample 2 Time 1 0.72 Time 2 0.70 McAdams et al. (43) 1996 0.77 Meyer et al. (48) 2001 0.57–0.80b Middelboe et al. (49) 1994 0.75 O’Hara and Rehm (54) 1983
Expert raters 0.91 Novice raters 0.76 Pancheri et al. (57) 2002 0.90 Potts et al. (59) 1990 0.82 0.92 Ramos-Brieva and Cordero-Villafafila (60) 1988 0.72 Rehm and O’Hara (61) 1985 Study 1 0.76 0.78–0.91b Study 2 0.91–0.96b Reynolds and Kobak (62) 1995 0.92 0.96 Riskind et al. (63) 1987 0.73 Shain et al. (68) 1990 0.97 Teri and Wagner (72) 1991 0.65–0.97b Whisman et al. (75) 1989 0.85 Williams (76) 1988 0.81 Zheng et al. (77) 1988 0.71 0.92 a Estimates are from studies published between January 1980 and May 2003 that measured psychometric properties of the Hamilton depression scale. Studies were identified by means of a MEDLINE search for both “depression” and “Hamilton.” b Range over multiple pairs of raters. Am J Psychiatry 161:12, December 2004 2167 BAGBY, RYDER, SCHULLER, ET AL. http://ajp.psychiatryonline.org found an overall intraclass coefficient of 0.92; however, two trained psychiatrists differed at least 20% of the time
in their ratings of psychic anxiety, psychomotor agitation, and psychomotor retardation, and they differed by at least two points 15% of the time in their ratings of loss of libido. The ratings of trained raters disagreed with the psychia- trists’ ratings on psychomotor agitation (50% of the time), hypochondriasis (60%), loss of libido (90%), and loss of energy (100%). Retest Reliability Retest reliability for the Hamilton depression scale ranged from 0.81 to 0.98 (Table 2). Retest reliability at the item level (Table 3) ranged from 0.00 to 0.85. Williams (76) argued in favor of using structured interview guides to boost item and total scale reliability and developed the Structured Interview Guide for the Hamilton Depression Rating Scale. This effort increased the mean retest reliabil- ity across individual items to 0.54, although only four items met the criteria for adequate reliability (depressed mood, early insomnia, psychic anxiety, and loss of libido). Item Characteristics Content and scaling. Standard psychometric practice dictates that items within an instrument should measure a single symptom and contain response options linked to increasing or decreasing amounts of that symptom. Each item is assumed to contribute equally to the total score or be backed with evidence in support of differential weight- ing. These criteria are not consistently met by using the current scaling procedure or the options for rating symp- toms. Although improperly scaled items can cause prob- lems in quantitative measurement, evaluation of item scaling takes place first at a qualitative level. Some Hamil- ton depression scale items measure single symptoms along a meaningful continuum of severity; many do not.
The item assessing depressed mood includes a combina- tion of affective, behavioral, and cognitive features, such as gloomy attitude, pessimism about the future, subjective feeling of sadness, and tendency to weep. The general so- matic symptoms item, which is also symptomatically het- erogeneous, includes feelings of heaviness, diffuse back- ache, and loss of energy. Headache is coded only as part of somatic anxiety along with such symptoms as indigestion, palpitations, and respiratory difficulties. Genital symp- toms for women entail loss of libido and menstrual distur- bances. The problems inherent in the heterogeneity of these rating descriptors reduce the potential meaningful- ness of these items, a problem exacerbated if the different components of an item actually measure multiple con- structs and thus measure different effects. Most items on the Hamilton depression scale at least are scaled so that increasing scores represent increasing se- verity. It is less clear whether the anchors used for different scores on certain items actually assess the same underly- ing construct/syndrome. This ambiguity is most obvious for severity ratings involving psychotic features. The feel- ings of guilt item, for example, is graded as follows: 0=ab- sent, 1=self-reproach, 2=ideas of guilt or rumination over past errors or sinful deeds, 3=present illness is a punish- ment, and 4=hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations. A patient with guilt-themed hallucinations may be more se- verely ill than a patient who has nonpsychotic guilty feel- ings, but is he/she feeling more guilt? The psychotic fea- tures may instead represent a qualitatively different construct/syndrome associated with more severe illness. Similarly, the hypochondriasis item progresses through bodily self-absorption (rated 1) and preoccupation with health (rated 2) before switching to querulous attitude
(rated 3) and then again to hypochondriacal delusions (rated 4). These item-scoring anchors violate basic mea- surement principles, because nominal scaling and ordinal scaling are combined in a single item. Although Hamilton (1) explained the rationale for the inclusion of both 3-point and 5-point items, the argument was not made on the grounds of differential weighting. Hamilton believed that certain items would be difficult to anchor dimensionally and therefore assigned them fewer response options. The end result is that certain items con- tribute more to the total score than others. Contrasting psychomotor retardation and psychomotor agitation, for example, reveals that a severe manifestation of the former contributes 4 points, whereas an equally severe manifes- tation of the latter contributes 2 points. Similarly, some- one who weeps all the time can contribute 3 or 4 points on depressed mood, whereas someone who feels tired all the time can contribute only 2 points on the general somatic symptoms item. Item Response Analysis A psychiatric rating scale should measure a single psy- chopathological construct (i.e., an illness or syndrome) and be composed of items that adequately cover a range of symptoms that are consistently associated with the syn- drome. Item response theory, a method used increasingly in the evaluation and construction of psychometric in- struments, permits empirical evaluation of these pre- mises. It is important to note that this method was not available when the original Hamilton depression scale was developed, although some researchers more recently used this method to evaluate this instrument. According to item response theory, a scale and its constituent items may have good reliability estimates but still fail to meet item re-
sponse theory criteria. For example, if a depression scale were composed only of items measuring mild depression, the instrument would have great difficulty distinguishing between moderate and severe cases of depression, as both would be characterized by high scores on all items. This is- sue is particularly pressing in studies of clinical change; not only is a wide range of severity often represented in this research, but individual patients are expected to move 2168 Am J Psychiatry 161:12, December 2004 HAMILTON DEPRESSION SCALE http://ajp.psychiatryonline.org along this continuum as they improve. Continued use of items insensitive to change underestimates the strength of actual treatment effects and makes it necessary to have larger samples to demonstrate that an effect is statistically significant. Falsely identifying patients as not having changed represents an additional source of “noise” and weakens the “signal” of a true treatment effect. A prag- matic implication of such lack of sensitivity is that new compounds shown to be promising in the laboratory may appear spuriously ineffective in clinical trials. A related issue concerns the extent to which a severity score actually measures a single unidimensional syn- drome. To summarize a syndrome with a single score re- quires a precise understanding of what that score repre- sents. The implicit assumption is that the severity score represents a single dimension (84); if depression is hetero- geneous, interpretation of a single summed score is un- clear. If, for example, items assessing psychological and
physical symptoms were only loosely related, a single score would not distinguish between two potentially dif- ferent groups of depressed patients—one group whose symptoms were primarily psychological and another group with primarily vegetative symptoms. Any effects of an intervention targeting only one of these aspects would be harder to detect. Gibbons et al. (85) presented a strategy for identifying a unidimensional set of items from a psychiatric rating scale and evaluating the extent to which these items adequately measure the full range of depression severity. Subse- quently, a subset of Hamilton depression scale items that would measure a single dimension of depression across a wide range of severity was developed (30). This subset in- cluded depressed mood, which was sensitive at low levels; work/interests, psychic anxiety, and loss of libido, which were sensitive at mild levels; somatic anxiety, psychomo- tor agitation, and guilt, which were sensitive at moderate levels; and suicide, which was sensitive at severe levels. These items were proposed as a psychometrically stronger form of the full Hamilton depression scale. Santor and Coyne (64, 65) used item response theory to examine the functioning of the full Hamilton depression scale and its individual items. In one of these studies (65) they examined individual Hamilton depression scale item performance in a combined sample of primary care pa- tients and depressed patients from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. One expects different item ratings at TABLE 3. Studies Reporting Item Reliability Estimates for the 17-Item Hamilton Depression Rating Scalea
Scale Item Reliability Measure and Study Year Depressed Mood Guilt Suicide Early Insomnia Middle Insomnia Late Insomnia Work/ Interests Internal reliabilityb Berrios and Bulbena-Villarasa (16) 1990 Sample 1 0.32 0.24 0.26 0.25 0.32 0.31 0.39 Sample 2 0.37 0.38 0.40 0.23 0.37 0.42 0.33 Gastpar and Gilsdorf (29) 1990 Time 1 0.10 0.22 –0.04 0.04 0.22 0.13 0.09 Time 2 0.65 0.39 0.50 0.44 0.46 0.53 0.73 Paykel (58) 1990 Sample 1 0.52 0.31 0.31 0.24 0.21 0.38 0.59 Sample 2 0.42 0.38 0.47 0.27 0.34 0.30 0.58 Sample 3 0.52 0.41 0.49 0.34 0.35 0.34 0.59 Rehm and O’Hara (61) 1985 0.63 0.26 0.47 0.40 0.41 0.37 0.46 Interrater reliabilityc
Cicchetti and Prusoff (19) 1983 Time 1 0.37 0.18 0.59 0.76 0.57 0.42 0.33 Time 2 0.72 0.37 0.64 0.57 0.45 0.49 0.64 Moberg et al. (50)d 2001 Standard administration 0.90 0.80 0.90 0.61 0.39 0.89 0.50 Interview guidelines 0.96 0.83 0.81 0.97 0.78 0.89 0.87 Rehm and O’Hara (61)e 1985 Above median split 0.61 0.39 0.49 0.74 0.79 0.72 0.56 Below median split 0.84 0.82 0.92 0.91 0.79 0.92 0.73 Retest reliabilityf Akdemir et al. (11) 2001 0.61 0.78 0.67 0.69 0.79 0.76 0.73 Williams (76) 1988 0.80 0.63 0.64 0.80 0.62 0.30 0.54 a Estimates are from studies published between January 1980 and May 2003 that measured psychometric properties of the Hamilton depres- sion scale. Studies were identified by means of a MEDLINE search for both “depression” and “Hamilton.” b Correlation of item scores with total scores. An uncorrected Pearson’s r>0.20 was considered significant. Significant correlations are shown in boldface type. OK Following on from the previous. Short podcast This is another one looking at scales for depression so another famous scale that's used for measuring depression has been for a long time Hamilton depression rating scale factors for one so. Yes it uses. To evaluate. And to depression medications still. So let's take a look at this article this is this is another article. That has a good foundation study in this case of the Hamilton scale. So. Again your. Introduction here. Around one has been the gold
standard for the assessment of depression for 2 years when this was published which of us was. 15. And 50 years. And. Life the infected person in the entry This was also developed a much earlier actually in the late 1950 S. to assess the effectiveness of the 1st generation of antidepressants it was a vision we published in 1960 so again it was it was not developed to measure depression and clients so much as to measure the effectiveness of antidepressant medications. And. It's now. That the most commonly used measure of depression so there are some there often issues come by the minute. Related to the fact that this that perhaps. This scale. Was developed by now conceptualize ation of depression might have been something different from one of his today all right so the last major review was found 950 of this I'm not sure if you show me 2003 so this is. Update 201517 items will question is on the sky right of Sky question. Section and let's take a look at the reliability of the Hamilton so we've got some. Information here. And looking reasonably good this is kind of putting together a list of many studies. Saying. If you know you know what information was contained within. You in those studies and. So it's talking about reliability and some statistics being used to cases are. So. In terms of internal life of the sea. The estimates range from point 462.97.97 courses 5 fabulous to the excellent point 46 it's a little bit. On the low and. But point 7 is his closer to accept to be the best we're looking for really his point 8 while high. Interests are a liability and this is this is a very important type of reliability this means. That you know because this is what happens in real life creations. Are using. In this case the Hamilton depression scale are they. Getting the same result. When they use this chaos and other clinicians so the pieces are here ranged from point A to point 98 that was good very good. But the individual item level so that was really the whole sky off here the size of the individual lots of novel into a survival using whole for many items and so that's. How some calls for concern. So here. This is the board state psychiatric rating scale should measure a single psycho form of psychopathological
construct. You know. What we refer to. In the medical model we use as an illness or a syndrome and whether they are actually medical illnesses is another matter. Mentioned in the other. Video and become part of items that adequately cover a range of symptoms that are consistently associated with the syndrome so again we're coming back to the fact that. This scale is. Whether or not they come back to the question should say whether or not this scale. Catches depression as it is currently conceptualize this currently conceptualize. Her to death Nowadays the D.S.M. 5. We've already talked about whether or not the D.S.M. itself is valid and reliable. But that's what we take history. As the standard and so on a depression scale is then measure it against it's ability it's the ability of the scale is measured in terms of. How well it's able to capture what we know we conceptualize depression per the D.S.M. diagnostic criteria so here it's this paragraph here it's reasonable to ask whether this instrument catches depression as it is currently conceptualize several symptoms contained within the how time scale and not official D.S.M. diagnostic criteria although they are recognizes speech is associated with depression for example psyche XYZZY or other symptoms including included I don't and scale for example loss of inside hypochondriasis the link with depression is more tenuous war critically important features of D.S.M. for depression are often buried within more complex items and sometimes in all kinds of toll so it could be a problem since we are obliged in practice to use the D.S.M.. We need we need to VO to use in a major scale that's going to give us. A score that tells us whether or not the client has depression as it is defined in the D.S.M.. And no explicit assessment of feelings of worthlessness. OK she's something there in the D.S.M. knowledge. Doesn't capture. All right so anyway. Let's take a look at 2. So this was the conclusion or one of the confluence of this particular study was that the Hamilton depression scale is measuring concepts in a depression that is now several decades old and that is at best partly related to the operationalize ation of depression in D.S.M. 4 so maybe even
be. Further removed from how the D.S.M. 5 sexualizes depression. Huge difference between D.S.M. $4.00 and $5.00. But nevertheless it's a concern. So then we take a look. Now. And think. So we can see how these 2 scales are. Different from each other even though they. May be same thing. Well 1st of all the number of items is different. Here. If we look at the way that. Both in both scales we add up the total score you see here that the. Back to Persian inventory. It says the cutoff of. 0 to 13 is minimal depression was this there's no score that tells you no depression. I see interesting whereas at least I have also and. You can not be depressed with a house. And then $8.00 to $12.00 when the House of depression is doubtful and Miles Wilder and severe. Which kind of sort of seems to equate to a mild more drip sit here on. The. The Bay It's the same word to use but whether it's. They are made the same meaning in terms of actual depressed state in the plan or less. Matter. But also what you can see here is some of the. Items have effectively a different $1080.00 in the houses scale whereas as we've mentioned previously we're talking about a bank that each He chides in his weighted equally So these these since we're adding the total score these items. Can these 4 from 0 to 2. Kind of have less weighting than those that are. Rated from 0 to 4. We should give that one for depressed mood as you can give this some new initiatives on. Maximum 2 So anyway that the the scales are different and so. The question is are they how they measuring the same thing and we've looked at the lives of the few who did see off the top of them in those elevations studies and so that would be what we're trying to make a decision as to which scale we're going to use. Those And those would be the deciding factor is the size things like practical things like ease of use and so on. And of course you where if we're planning to. Major Depression say in. Children. The wording of the question say. I think that. Well one would have to consider whether the would be is going to be understood as it's meant to be understood by a child this is an adult. So you eat what for your for your assignment. Let's say they say you choose. Depression
chosen depression is on of your clients main problems so then you can use. Something like Google Scholar through V.F.S. universe and you can search for depression scale see what comes out or depression in Tory and you probably get lots of hits. Back and. Saw So the 1st step is to find scales. That seethes if they are. Potentially useful for what you want to do. Then go for validation studies of those particular scales once you got some of the scales and you go to whittle this down to 2 scales per problem so if you chosen depression you need to have 2 scales you could even use that back in the house and compare those 2. But again I ask you not to use the validation studies that I've presented these videos but find some feel. Free So for each scale you have to find 2. Validation studies so to fit in this case you need 2 for the bank and 2 for the Hamilton OK and you look at the. Reliability of booty statistics and used those and things like ease of use. To argue that OK I'm going to select the best because blah blah blah on the. Hamilton because all and give your reasons in terms of statistics and other factors that. Make that a better choice to go client OK All right you also have. Some work on this in your discussion board aside for this much. So. International Journal of Mental Health Nursing (2007) 16, 108 – 115 doi: 10.1111/j.1447-0349.2007.00453.x © 2007 Australian College of Mental Health Nurses Inc. Feature Article Measuring melancholy: A critique of the Beck Depression Inventory and its use in mental health nursing Brad Hagen
School of Health Sciences, The University of Lethbridge, Lethbridge, Alberta, Canada ABSTRACT: The Beck Depression Inventory (BDI) is one of the most commonly used depression measurement instruments. Mental health nurses often utilize the BDI to assess the level of depression in clients, and to monitor the effectiveness of treatments such as antidepressants and electroconvulsive therapy. Despite the widespread use of the BDI in both clinical practice and research, there is surprisingly little nursing literature critically examining the BDI or its use by mental health nurses. This paper reviews the origins, purpose, and format of the BDI, discusses some of the strengths and limitations of the BDI, and concludes with some implications for mental health nursing. KEY WORDS: Beck Depression Inventory, depression, mental health, psychiatric nursing, psychometrics. Blackwell Publishing AsiaMelbourne, AustraliaINMInternational Journal of Mental Health Nursing1445-8330© 2007 Australian College of Mental Health Nurses Inc.? 2007162108115Original ArticleBECK DEPRESSION INVENTORYB. HAGEN Correspondence: Brad Hagen, School of Health Sciences, The University of Lethbridge, 4401 University Drive, Lethbridge, AB T1K 3M4, Canada. Email: [email protected] Brad Hagen, RN, PhD. Accepted May 2006.
Mental health nurses are often encouraged to use psychi- atric/psychological measurement instruments in their nursing practice, and the Beck Depression Inventory (BDI; Beck et al. 1996) is one of the most commonly used instruments that mental health nurses are likely to encounter and use in their practice (Demyttenaere & De Fruyt 2003). The majority of current psychiatric nursing textbooks discuss the BDI, and in one commonly used textbook, the BDI is described as ‘. . . a quick but reliable and valid measure of the extent to which depression may be present’ (Kneisl et al. 2004; p. 169). Indeed, in the first author’s own local health region, where he supervises nursing students in mental health clinical settings, nurses commonly use the BDI to assess the level of depression in patients, and to monitor the effectiveness of treatments such as antidepressants and electroconvulsive therapy. Yet despite the common use of the BDI by mental health nurses, there is little or no nursing literature crit- ically examining the BDI, or its use by mental health nurses. Therefore, the purpose of this paper is to provide a critical discussion of the BDI, and its use by mental health nurses. To this end, the author will briefly review the origins, purpose, and format of the BDI, discuss some of the strengths and limitations of the BDI, and conclude with some implications for mental health nursing. ORIGINS, PURPOSE, AND FORMAT OF THE BDI As Demyttenaere and De Fruyt (2003) have described in their review of depression rating scales, depression rating scales were first developed in the late 1950s as part of the overall psychopharmacology revolution, whereby psycho- logical theories of depression gave way to commercially
driven biochemical theories of depression. They go on to note that ‘. . . with the advent of antidepressant drugs, rating scales were needed to measure the severity of the depressive disorder and the changes during therapy’ (Demyttenaere & De Fruyt 2003; p. 61), and there are now more than 100 depression rating scales in existence. While there are many available depression rating scales, the BDI, a self-administered scale first developed in 1961 tgomory Highlight tgomory Highlight BECK DEPRESSION INVENTORY 109 © 2007 Australian College of Mental Health Nurses Inc. (Beck et al. 1961), has risen to prominence as one of the most widely used depression rating scales (Dozois & Covin 2004). Beck et al. (1961) developed the original BDI as a 21- item inventory to measure the severity of depressive symptoms, and based the 21 items on Beck’s observations of the symptoms and attitudes of depressed persons seen in the context of therapy. Beck has claimed that the BDI does not reflect any particular theory of depression, and merely reflects the observed symptoms of persons who are depressed (Beck et al. 1996). While the first version of the BDI was shown to be reasonably robust in terms of psychometric properties, increasing concerns were raised concerning the instrument’s validity vis-à-vis the
DSM-IV standard for diagnosing depression (American Psychiatric Association 1994). Consequently, Beck et al. created a second revised version of the BDI (BDI-II) in 1996 (Beck et al. 1996). The main changes made to develop the BDI-II primarily reflected increased com- patibility with the DSM-IV, and included the changing of certain items, dropping of other items, and changes to certain response options and time frames (Beck et al. 1996; Dozois et al. 1998). From this point forwards in this manuscript, the authors will use the term ‘BDI’ to refer to this most recent version of the instrument, the BDI-II. The BDI is typically self-administered, requires only about 5–10 min to complete, and can be used with per- sons aged 13 years and up (Dozois & Covin 2004). Each one of the 21 items in the BDI is rated on a scale of 0– 3, and scores from all items are tallied to obtain a total possible score, ranging from 0 and 63, with higher scores reflecting greater severity of depressive symptomatology. Scores between 0 and 13 are interpreted as ‘minimal’ depression, scores between 14 and 19 as ‘mild’ depres- sion, scores of 20–28 as ‘moderate’ depression, and scores of 29–63 as ‘severe’ depression (Beck et al. 1996; Dozois & Covin 2004). Interestingly, it appears that with the possible exception of a score of 0, there are no score grouping to be interpreted as ‘no depression’. STRENGTHS OF THE BDI Strengths of the BDI include the ease of administration and scoring of the BDI, its widespread use, and the results of psychometric testing of the reliability and valid- ity of the BDI. Ease of administering and scoring the BDI
One of the principle advantages of the BDI is its ease of administration and scoring (Dozois & Covin 2004). Indeed, the BDI generally only takes less than 10 min to complete, and is easily scored and interpreted. Conse- quently, the BDI has become one of the most widely used psychological tests, has been translated into many lan- guages, and has been employed in more than 2000 empir- ical studies (Barroso & Sandelowski 2001; Dozois & Covin 2004; Richter et al. 1998). Psychometric testing of the BDI Reliability of the BDI Although more reliability testing has been completed on the original BDI than the BDI-II, both are considered to be generally quite reliable (Dozois et al. 1998; Richter et al. 1998). The original manual for the BDI-II reported high internal consistency, with a coefficient alpha of 0.93 for college students, and 0.92 for psychiatric outpatients (Beck et al. 1996). More recently, Dozois and Covin (2004) reviewed 13 studies reporting reliability data on the BDI-II since 1996, and reported an average coeffi- cient alpha of 0.91. Less information is available on the test–retest reliability of the BDI-II, although the original manual reports a 1-week test–retest reliability coefficient of 0.93 with 26 psychiatric outpatients (Beck et al. 1996). As Dozois and Covin (2004) have cautioned, however, test–retest reliability is difficult to interpret on a measure that is supposed to both reliably measure depression and detect changes in depression due to treatment. For example, at least one group of researchers have sug- gested that the BDI may not be reliable for longer peri- ods of time in non-clinical samples, after finding that BDI scores declined by 40% over 2 months in a non- clinical sample (Ahava et al. 1998). Such a significant downward drift in BDI scores in non-clinical samples
clearly poses a threat to the instrument’s ability to reli- ably detect changes in depression due to treatment alone. Validity of the BDI Dozois and Covin (2004) have asserted that while the BDI is comparable to the original BDI in terms of reli- ability, the BDI-II is ‘. . . a clearly superior instrument in terms of its validity’ (p. 53). Such claims for the higher validity of the BDI-II are made on a number of levels. To begin with, the content validity and the face validity of the BDI-II are argued to be very high, because the items in the BDI-II now closely mirror the standard DSM-IV diagnostic criteria for depression (Dozois & Covin 2004; Richter et al. 1998). The convergent validity of the BDI- II has also been reported, and the BDI-II appears to correlate fairly well with other depression rating scales, tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight
tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight 110 B. HAGEN © 2007 Australian College of Mental Health Nurses Inc. such as the original BDI-I (r = 0.93), the Hamilton Rating Scale for depression (r = 0.71), and the Beck Hopeless- ness Scale (r = 0.68) (Dozois & Covin 2004). The level of discriminate validity for the BDI is less clear. For example, while Richter et al. (1998) have con- cluded that the BDI ‘. . . discriminates reliably between depressives and non-depressives’ (p. 162), Dozois and Covin (2004) came to the opposite conclusion, stating that the BDI-II does not differentiate well between depressed and non-depressed persons. Furthermore, it has been noted that the BDI-II correlates highly with other mea- sures of anxiety, and may not be able to reliably distin- guish between depression and other affective states such as anxiety (Dozois & Covin 2004). Finally, it has been suggested that the BDI-II contains a reasonably stable factor structure (Beck et al. 1996;
Dozois & Covin 2004). When the BDI-II was first released, Beck et al. (1996) reported a two-factor solu- tion: somatic-affective and cognitive symptoms within a psychiatric outpatient sample, and cognitive-affective and somatic symptoms with a college student sample. Other researchers have since found generally similar two-factor structures in other studies using college students (Dozois et al. 1998) and primary care medical patients (Arnau et al. 2001). It should be noted, however, that in their review of the BDI, Richter et al. (1998) concluded that the tacit factorial validity of the BDI is in fact controver- sial, and that subtle but possibly important differences exist in the factor structure of the BDI, depending upon the kinds of subjects that complete the BDI. In summary, the main support for the BDI appears to lie in its ease of use, widespread utilization, very good internal reliability, high content validity when compared with the DSM-IV criteria for depression, good conver- gent validity with other similar depression rating scales, and a somewhat stable factor structure. LIMITATIONS OF THE BDI While the BDI is well-known and widely used by mental health nurses, and while the BDI has several strengths, there is little critical discussion in the nursing literature of some of the potential limitations of the use of the BDI in general, or by mental health nurses in particular. Some of the potential limitations of the BDI include: issues related to norms (including potential bias issues); prob- lems with the wording, ordering, and weighting of the BDI items; potential gender biases; theoretical issues with the BDI; potentially inappropriate uses of the BDI; and validity issues related to the DSM-IV criteria for depression, upon which the BDI is based.
Norms and bias issues The BDI has no actual large population norms per se, so it is difficult to determine if any given individual’s level of depression, as determined by the BDI, is ‘normal’ in any sense of the word. Instead, the interpretation of the BDI is referenced to criterion based on the original standard- ized sample of 500 persons (317 women and 183 men) in the Eastern United States (Beck et al. 1996). Based on this sample, the authors of the manual for the BDI-II offered cut-off score criterion or guidelines to distinguish between minimal, mild, moderate, and severe amounts of depression. However, while the total possible scores range from 0 to 63, the scoring of the scale is very ‘bottom heavy’. That is, the mean score for severely depressed persons in the standardized sample (32.96) is approxi- mately half-way along the range of total possible scores, and anyone who scores anywhere from 29 to 63 is con- sidered to be ‘severely’ depressed (Beck et al. 1996). As several authors have noted, the original sample upon which the BDI-II was standardized was predomi- nantly Caucasian, and is greatly misrepresentative of the US population at large (Dozois & Covin 2004; Richter et al. 1998). Obviously, this kind of sample also renders the BDI generally misrepresentative of other countries and cultures (Dozois & Covin 2004), and fails to capture the many different cultural factors influencing how depression is experienced by different ethnic and cultural groups (Falicov 2003). Finally, women tend to score higher on the BDI than men (Beck et al. 1996) and items on the BDI such as ‘crying’ may contain a gender bias, and may hold very different meanings for men as opposed to women (Barroso & Sandelowski 2001). Item-related issues
There are also several problems with the way that items contained in the BDI are worded, ordered, and weighted. To begin with, several authors (Barroso & Sandelowski 2001; Demyttenaere & De Fruyt 2003; Richter et al. 1998) have noted that the BDI item response options, most of which contain some combination of negatively and positively worded options, can be very confusing and misleading for persons taking the BDI. In addition, the responses are only ordinal-level data, with unequal inter- vals between options, yet are tallied up, analysed, and reported as if they are ratio-level data (Burns & Grove 2001). There is also a tendency for responses on each item to score quite low. That is, although potential scores for each item range from 0 to 3, studies in non-clinical (stu- dent) samples typically report average scores below 1, and even psychiatric samples mean item scores rarely exceed values of 2 (Richter et al. 1998). tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight
tgomory Highlight tgomory Highlight BECK DEPRESSION INVENTORY 111 © 2007 Australian College of Mental Health Nurses Inc. The BDI also has an obvious consistency in the order- ing of responses, as each response is ordered from least to most depressed. Therefore, several authors have noted that the obvious ordering of answers in the BDI may lead to responses reflective of faking, social desirability, and/ or defensiveness, as opposed to depression per se (Bar- roso & Sandelowski 2001; Dozois & Covin 2004). This problem is compounded by the BDI’s high face validity, which makes it easy for subjects to guess which of the items are reflective of greater or lesser depression. Finally, there is the problem of item weighting within the BDI. As Healy (1997) has noted, the creators of the BDI arbitrarily decided that the total BDI depression score would be generated by simply adding the individual scores for each of the 21 items. This kind of scoring system raises the issue of whether or not it is legitimate to simply add dissimilar items to produce a total score, and subsequently assume that the total score actually ‘means’ something (this process is called reification, and shall be addressed further in this paper). This scoring process also raises the issue of whether or not each added item in the BDI should have equal weighting in relation to the other items. Healy (1997) has commented on this
problem, and has noted that ‘. . . many clinicians had dif- ficulties with the idea that items of very different meaning could simply be summed. Should early morning awaken- ing be counted in the same balance as guilt or suicidality?’ (p. 98). Yet despite such criticisms, all items of the BDI continue to be treated as if they are of equal importance in determining a person’s level of depression, and the creators of the BDI have offered no justification for such a stance. Theoretical issues with the BDI There are a number of important theoretical limitations with the BDI as well. First and foremost is the problem with the supposedly atheoretical nature of the BDI. That is, although the creators of the BDI maintain that the BDI merely reflects the symptoms and attitudes typically found in persons with depression – and does not reflect any theoretical assumptions about depression (Beck et al. 1996; Dozois & Covin 2004) – other authors have chal- lenged this claim of theoretical neutrality. Demyttenaere and De Fruyt (2003), for example, have noted that the BDI clearly reflects a distinctly cognitive–behavioural perspective. This perspective is not surprising, given that Beck et al. were primarily responsible for the creation of cognitive therapy. Healy (1997) has also observed that it is probably more than coincidence that the BDI is partic- ularly well-suited for evaluating cognitive–behavioural therapy, and that it would be very difficult for a person who has gone through cognitive therapy not to recognize many of the terms and language used in the BDI. There- fore, the assertion that the BDI is theoretically neutral of bias-free is simply not true, nor should this necessarily be surprising. As Jensen and Hoagwood (1997) have emphasized:
. . . it should be noted that all clinicians – indeed, all human beings – bring theory-laden perspectives and con- ceptual filters to their assessment and diagnostic approaches with a given patient. They differ principally in the explicitness, rigidity and awareness of their biases (p. 235). Perhaps one of the most important source of bias found within the BDI is reflected in what the architects of the BDI chose not to include as items in the tool. For example, the BDI focuses exclusively on negative symp- tomatology – such as sadness, guilt, and feeling like a failure – and no positive experiences symptoms are included, despite research suggesting that positive mood may well be superior to negative mood in predicting outcomes from depression (Demyttenaere & De Fruyt 2003). In addition, the creators of the BDI chose to dis- regard large areas of interpersonal functioning, and many of the factors which determine quality of life for individ- uals (Healy 1997). Finally, Beck et al. have selected items for the BDI that clearly reflect a theoretical stance whereby the problem (i.e. depression) is seen to lie within the individual. By focusing exclusively on symptoms or problems inside the person, the BDI explicitly disregards all the multitude of factors and problems external to the individual that may be clearly impacting his or her level of depression, such as unemployment, discrimination and/or domestic violence (Crowe 2000; Jensen & Hoag- wood 1997). Lastly, the BDI exhibits the theoretical problem of reification, or the tendency to view abstract concepts as actual entities. That is, the creators of the BDI would have us believe that the simple process of adding up the answers to 21 questions about various symptoms and atti- tudes allows us to measure, with a single number, the
quantity of a reliably identifiable ‘thing’ called depression, as if we were measuring the weight or height of an indi- vidual. Yet as Gould (1996) has pointed out, measuring and reifying such concepts as ‘depression’ and ‘intelli- gence’, as if they have a definite existence of their own, can be very misleading. Not only can such reification oversimplify complex and multifaceted experiences like depression, but such reification also disregards the large extent to which such concepts are socially created and defined, and fail to actually reflect any clearly tangible and tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight
tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight 112 B. HAGEN © 2007 Australian College of Mental Health Nurses Inc. unambiguous entities, such as height, weight, or hyper- tension (Sarbin 1997). Inappropriate uses of the BDI Additional concern has also been raised regarding the use of potentially controversial ‘spin-offs’ of the BDI, as well as the manner in which the BDI is being increasingly used to ‘screen’ for depression. With regards to spin-offs, Dozois and Covin (2004) have noted the increasing use of controversial spin-offs of the BDI, such as the ‘short form’ of the BDI (Furlanetto, Mendlowicz & Romildo 2005). The increasing use of such spin-offs, because of their comparative lack of psychometric testing and estab- lished norms, only further compounds the overall issues of reliability and validity of the BDI and other depression rating scales.
Furthermore, increasing numbers of clinicians, includ- ing nurses, are beginning to use the BDI as a depression ‘screening tool’, particularly now that the BDI-II closely mirrors the DSM diagnostic criteria for depression (Lasa et al. 2000). However, despite the fact that the creators of the BDI specifically specified that the BDI was not to be used as a diagnostic tool, and was to only be used as a measurement of depressive symptom severity (Beck et al. 1996; Dozois & Covin 2004), the demarcation lines between measuring symptoms of depression, diagnosing depression, and screening for depression have never been clear, and are becoming even less clear. In particular, it was never conceptually clear why the BDI – an instru- ment apparently able to measure the quantity of depres- sion – could not actually determine the presence of depression or not (i.e. diagnosis it), particularly when so many of the BDI items used to measure depression symp- toms were so similar to the same DSM-IV diagnostic criteria for depression. Despite this logical inconsistency, the BDI is increasingly being used not only to measure depression, but to detect or diagnosis it as well (Lasa et al. 2000), despite a lack of clear validation for doing so (Beck et al. 1996). Validity issues and the DSM When Beck et al. attempted to increase the validity of the BDI by making the BDI-II more closely mirror DSM-IV diagnostic criteria for depression (Beck et al. 1996), they also further reinforced the common assumption that the DSM-IV offers the most valid definition and description of the experience of depression. By doing so, however, they not only overlooked considerable criticism of the way that the DSM-IV authors categorize depression, but also inherited many of the limitations of the DSM-IV descrip- tion of depression (Beutler & Malik 2002; Crowe 2000;
Donald 2001; Eriksen & Kress 2005; Jensen & Hoagwood 1997; Sarbin 1997). Therefore, any examination of the limitations of depression scales like the BDI must also include an examination of the limitations of the DSM-IV criteria. These limitations include issues of reliability and validity of the DSM-IV, and issues of DSM-IV value judgements and biases. Issues of the reliability and validity of the DSM-IV While many mental health clinicians simply take the reli- ability and validity of the DSM-IV system for granted, closer examination often finds the reliability and validity of the DSM-IV wanting. In fact, the reliability of the diagnosis of major depression is quite poor, and research- ers have reported kappa coefficients for the diagnosis of depression as low as 0.25 (Parker 2005). As Beutler and Malik (2002) have observed, this inadequate level of diag- nostic reliability is not surprising, given the ambiguous and complex set of guidelines that the authors of the DSM-IV created to diagnosis depression. In fact, the DSM-IV criteria for depression literally allow for several hundred possible different patterns or clusters of symp- toms, all of which can still all meet the DSM-IV diag- nostic criteria for depression (American Psychiatric Association 1994). Given the myriad of symptom patterns which can qual- ify for a DSM-IV diagnosis of depression, the DSM-IV diagnosis of depression suffers not only from reliability problems, but from considerable validity problems as well. For example, all forms of depression share great overlap with numerous other psychiatric diagnosis con- tained within the DSM-IV, and depression is found to be comorbid in 60% of general psychiatric patients, and in 40% of patients diagnosed with anxiety disorders (Beutler
& Malik 2002). In addition, another key indicator of diag- nostic validity – that different diagnoses would respond differently and predictably to prescribed treatments – is also lacking. That is, both the natural and treatment his- tories of persons with a diagnosis of depression are noto- riously hard to predict (Parker 2005). Furthermore, a wide variety of treatments with entirely different theoret- ical explanations – including antidepressants, different forms of counselling, electroconvulsive therapy, St. John’s Wort, exercise, and placebo – all have nearly identical efficacy levels, seriously challenging the diagnostic con- struct of depression implicitly contained within the BDI (Parker 2005). Value judgements and biases within the DSM As opposed to other medical diagnoses, the diagnoses contained within the DSM-IV (including the diagnosis of tgomory Highlight tgomory Highlight BECK DEPRESSION INVENTORY 113 © 2007 Australian College of Mental Health Nurses Inc. depression) are not arrived at with the aid of laboratory tests or diagnostic imaging, but rely instead on a clinician’s judgement as to whether or not certain behaviours and symptoms, such as feelings of guilt or loss of concentra- tion, are present in certain prescribed patterns for certain prescribed periods of time (Eriksen & Kress 2005). These
prescriptions for what constitutes a diagnosis (or disorder) are in turn arrived at by consensus by committees and panels of psychiatric experts associated with the American Psychiatric Association (1994). Numerous authors have challenged this DSM diagnosis-by-consensus process, claiming that the pro- cess reflects not so much a scientific and objective pro- cess, but a process whereby the values and biases of the privileged few comprising ‘expert consensus’ panels become embedded in our society’s definitions of mental disorders (Beutler & Malik 2002; Eriksen & Kress 2005; Jensen & Hoagwood 1997; Kutchins & Kirk 1997; Sarbin 1997). Female scholars in particular (Caplan 1995; Crowe 2000; Russell 1986) have noted the preponderance of upper-middle and upper class men in DSM diagnostic expert committees, and have suggested that Western, male, and upper/middle class values strongly influence decisions regarding diagnoses such as depression, and how such diagnoses are applied. For example, using the standard DSM-IV criteria for depression, twice as many women are diagnosed with depression as men (Kuehner 2003), yet the role that many contextual factors – such as gender discrimination in society or the higher rates of sexual abuse and assault in girls and women – are rarely taken into account when diagnosing or measuring depres- sion (Whitfield 2003). This disregard of contextual factors reflects another bias inherent within the DSM-IV diagnosis of depression, the notion that mental disorders are located within indi- viduals. This tendency to locate mental disorders and problems inside individuals has important implications, as it can easily direct clinicians’ attention away from the social context of mental health issues. That is, numerous authors have argued forcibly that it is equally plausible –
and perhaps more appropriate – to suggest that it may well be our families, communities, and societies that deserve such labels as ‘depressed’, ‘disordered’ or ‘men- tally ill’, as opposed to individual persons (Crowe 2000; Jensen & Hoagwood 1997; Russell 1986; Sarbin 1997; Whitfield 2003). For example, a woman suffering from domestic violence and seeking assistance from the mental health system is likely to receive a psychiatric diagnosis of depression and/or post-traumatic stress disorder, and may be given instruments like the BDI to determine the extent of her ‘disorder’. Yet the real source of the woman’s problems – the perpetrator of the violence towards her – is typically given no corresponding psychiatric diagnosis (Eriksen & Kress 2005). SUMMARY AND CONCLUSIONS In summary, it has been shown that the BDI was created in the historical context of the rise of psychopharmacol- ogy and DSM nosological classification systems in the mental health care system, … I love class so this brief video is meant for helping you. Get started on your paper part one the literature if you feel like 1. 1 of the tasks that you have to carry out for the paper is to identify scales measures inventories questionnaires whatever you want to call them know this is the same thing. That you can use to measure the 2. Main problems that you identified for your client annual case summary OK so we're going to use the vector oppression inventory as an example I just go through this process of 1st of all finding a suitable scale and then. Use for validation studies research articles. That provide data supporting the reliability and the from the duty of the sky OK so this is the best depression inventories been very widely used for many years and just a quick point here see this. Indicates
that. There is a. Pharmaceutical company. Sponsoring this this. So this is the the P.D.I. to this 2nd version it contains 20 we we're looking at the $21.00 question version there is a shorter 13 question as a $21.00 question Asian and. There are 21 questions this is an explanation of what the scale consists of. Each answer scored on a scale of 0 to 3. And. This explaining the cutoff. Used to determine the Neville of depression the client has after completing this questionnaire of change from the original so they use it now 0 to 13 is minimal depression 1419 mild depression 2028 moderate depression 292638 severe depression so high in the The idea is that high a total scores indicate more severe depressive symptoms on U.C. scale. Another important thing in here is you see there is some instruction now. That that tells the person who's completing the. The scale the inventory. What they've got to do as an aside here when you create your yourself made scale which is another part of the assignment. Make sure that you give us a. Simple set of instructions on how to complete your selfmade. Scale OK. Back to this so anyway the back oppression him and Terry. Was. There is a link between this and the D.S.M.. Diagnosis of. Depressive Disorder which later became a major depressive disorder and. Beck has attempted to match the questions with the diagnostic criteria found in the D.S.M.. This raises an important question. Because the D.S.M. is not is not known for being scientifically valid or reliable. So this is. If it turns out not to be. Providing us with a scientific description of the real. Thing we call depression. Then that could impact the. The actual usefulness of meaningfulness of this kind of O.U.I. that's a whole different discussion practice that is a well used well known skull and it serves the purpose of being an example for how to you know. How to find a suitable scale and then to look to the scale world OK. Good research article. Which would constitute a validation study for this scale so you can see these different. These different. Categories. That according to back. Constitutes kind of a definition of depression these different things are aspects of depression according to back. So then you
have the book once once the person has completed the inventory they just. Add up that the score was. According to the cutoff given right with getting you determine the level of depression try OK So then let's go to validation studies that look at this. So this is. From the International Journal of mental health nursing so if you if you read and are working in a crisis stabilize a ship you need to have a correct receive facility your view if you alongside mental health nurses. So that you know we we have certain overlaps in the work that we do. So this is a critique of the P.D.I. and its use of mental health Nessie So just take a look at the important things that make this article a good validation study. So we see here just an introduction to a bit of background about the beady eye that it was. Just like you saw it has a corporate sponsor so it was. A pharmaceutical corporate sponsor but it was designed to. In a way to prove the efficacy of antidepressant drugs if you used to be before the person starts treatment you get a certain measure to depression and then you can use it to throughout treatment and in the end of treatment 2 you can. Theoretically. Measure the client's improvement. Using this scale. And here the article is talking about the relationship between banks scale and the. The D.S.M. and how they scale this very morning is did you find. To become this compatible as possible with the D.S.M.. Definition of this. This construct we call depression. So then the the article goes on to talk about the strengths of the B.V.I. easy to use in school and then we go on to this very important section here it starts talking about reliability so he hears that he's going to he's come to give us some confirmation Alpha's which is what we're looking for what if you file for us. And our phones are our 1st range between 0 and one and these schools are really very good. 0.93 for college students 0.92 for psychiatric outpatients. And I've. Met analysis a number of studies who were good average. 0.91 so these figures are great as far as a liability is concerned that. The. Meet the criteria would be advisable study. However these caution here. That one group of research is of suggested P.D.I. may not be reliable for longer periods of time in known
clinical samples after finding that Beady Eye schools declined by 40 percent of the 2 month long clinical sample. This was. A small role $170.00 Dorie as far as fix. Trees concerned but if. There is. A fair amount of evidence of its survival tool and look onto villages he is is the video I measuring depression is it measuring what we think it's measuring it measure with host to be measuring what it says it's. So. Here we sit here we see that according to these researches the contents of the face of the of the video to argue to be very high because the items of the video to now closely mirror the standard D.S.M. 4 this is written by the. Diagnostic criteria for depression so. That's where the kind of. 100 anyway. That the D.S.M. 4 is being taken as scientific fact here and so because the scale. Closely mirrors the diagnostic create criteria for depression in the D.S.M. 4 in this case. It's being being stated to her very high. Political. Problem is that the D.S.M. has not passed such. Rigorous test. And was different kinds of from the you hopefully will learned all about these and the. Videos about reliability and that see now the level of discriminative validity for the V.D.I. is less clear what that meaning is. Does it does it just is it able to discriminate between people who are actually depressed and people who are not depressed and so it doesn't seem to do so well there however if we take if we go the way of determining Flutie is if. We compare the results of the P.D.I. with the results of other depression scales other branches of depression and if they correlate highly then we can say that. These The fact that the case. Validates the the the I. Because. It also gives the same. The same kind of indications regarding depression as other well known well established measures of depression OK. So the summarizing then means for for the V.D.I. of his to lie his ease of use widespread utilize ation very good internal reliability high content validity when compared to the D.S.M. for criteria for depression good convergence for the other similar depression rating scales and a somewhat stable factor structure factor structure OK but that means factor structure actually if. You don't know about the causes of the
statistics. All right. Then it's it's important to. Note when you when you're looking for articles some of Asian studies it's important to note. What population the. The instrument being used was normed on right so in this case the V.D.I. says it has no actual launch population norms per se so it's difficult to determine if any given individual's level of depression as determined by the V.D.I. is normal in any sense of what word so that's kind of a problem. Yeah you know do you know the original sample from which the beady eye to a standardized was predominantly Caucasian and is greatly missed representative of the U.S. population at large so that you sometimes find is that. The. Sound poll. That it's used for. The cooks standardizing the. Scale the tree question whatever. We did with that population that it was normal and on what is not necessarily representative all of wider population or sometimes you know. A scale of only even. One of only big normed on male participants. Nobody else. Are exceptions so this these these kind of these kind of. Things can. Kind of come because of the defect. Here saying that women tend to score higher on the B.T.I. than men for this would be one of those and. That is suggested here that that may be because the because some off the items on the scale show gender bias. And also several problems with the way that I feel is content to be the word you wanted and waited. Because each of a few you go back to the scale itself each of the items have equal weight. Because you just you're just scoring each item and then adding up the total. But the question is. For example you do suicidal for soul wishes. Right is that really equivalent to something my changes in appetite for feeling tired on boss of interest in sex I mean devoted to those really. Quite to the extent that you could wait to the quickly the answer is obviously no so there is criticism on the V.D.I.. Then again then another another problem with any kind of questioning is the order in which the I'm too soft place because sometimes this can create. Test taking a moment such as. A person. Just hearing you sound as if several offers of notice you know that the obvious ordering of **** in the video I may need to response is
reflective of faking social desirability that is that person. Gives the answers that they think the person of mainstream test wants them to get. Laid off alternatively they don't want to be. Putin in a negative way so they get off of things that they think will make them look better and it's cetera All right so that's that's always something you have to consider that any question in. Order to attract just adding up the score is. And there's the bit about should early morning awakening be counted do the same balance as guilt or suicidality not as if they are of equal importance in determining determining a person's level to oppression. And. The creators of the video I have offered no justification for such a stance. The V.D.I. is supposedly a theoretical However it is linked to particular cognitive behavioral perspective as Fast 5 back to his colleagues and so. In that sense it's not a theoretical This is sort of it's sort of reflects back on. Views on this abstract called struck. The recall depression. So there is that there. Was specks no different from anybody else in very his own theory laden this fictive and concepts will filters. To his thought. Process. OK so other other criticisms say you can read. The whole story so thanks. To you have selected items that reflect a theoretical stance whereby the problem in this case depression is seen to live within the individual and. Neglect. The multitude of external factors that could be impacted person. Such as I believe and discrimination based You just search it searching for a. Problem because he's taking a certain way. Because this is very much a medical model you're depressed a. Chemical Imbalance is he is a myth. And you know more about this but just for us to say there is no. Scientific basis for most of this chemical balance theorizing. You know this stuff happens person's life is very likely to. Be what we call depression. It's not necessary to do the genes of. Biochemistry. I think. That's another home of the debate let's get back to the. Task at hand here. All right so. This isn't the point here that the V.D.I. exhibits the spiritual problem of reification with a tendency to view abstract concepts as actual entities that is the creation of the video I would have us believe
that the simple process of adding up the houses to 21 questions about various symptoms and I choose allows us to measure with a single number the quantity over and liability identifiable The whole question as if we were measuring the weight or height of an individual OK So this is so again. Down to the whole you know what is what are these so called mental health conditions. You know we're we develop the whole system of labeling and. Identifying labeling and treating these so-called mental illnesses as if things were made a whole nation who. Come to use the medical model and of course it's suits. The health insurance companies should sue speak pharma suits the OS of the system. Is really based on. Good science so the question. Of. Issues of alive if you do if you D.S.M. 4 this is a good article because it actually raises this point. After coefficients for the diagnosis of depression most point 25 so that this is this is a massive debate but it's important to recognize that this. So-called mental health or psychiatric Bible the D.S.M. 5 now. We take it as it is. As factual. But it's really a compilation of expert opinion. Does not or has not. To this point in time. Provided a scientific basis. And so. Their liability to important to remember. OK so. It. Could cost you. So that's that's that constitutes a very good excellent in fact awful Don't use this one though if you should if you decide to if you decide to use if you're if you one of your clients problems is depression and you want to use the victim Persian inventory that's fine but please find your own. Nation studies phone just use this one because part of this. Exercise that you know of one is choose to do research yourself you'll find plenty of other. Research articles on the V.D.I. OK that's it for now. So.

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  • 1. See discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/8157458 The Hamilton Depression Rating Scale: Has the Gold Standard Become a Lead Weight? ARTICLE in AMERICAN JOURNAL OF PSYCHIATRY · JANUARY 2005 Impact Factor: 12.3 · DOI: 10.1176/appi.ajp.161.12.2163 · Source: PubMed CITATIONS 458 READS 2,176 4 AUTHORS, INCLUDING: R. Michael Bagby University of Toronto 347 PUBLICATIONS 16,312 CITATIONS SEE PROFILE
  • 2. Andrew G Ryder ConcordiaUniversity Montreal 78 PUBLICATIONS 2,268 CITATIONS SEE PROFILE Available from: R. Michael Bagby Retrieved on: 19 December 2015 Am J Psychiatry 161:12, December 2004 2163 Reviews and Overviews http://ajp.psychiatryonline.org The Hamilton Depression Rating Scale: Has the Gold Standard Become a Lead Weight? R. Michael Bagby, Ph.D. Andrew G. Ryder, M.A. Deborah R. Schuller, M.D. Margarita B. Marshall, B.Sc. Objective: The Hamilton Depression Rat- ing Scale has been the gold standard for the assessment of depression for more than 40
  • 3. years. Criticism of the instrument has been increasing. The authors review studies pub- lished since the last major review of this in- strument in 1979 that explicitly examine the psychometric properties of the Hamil- ton depression scale. The authors’ goal is to determine whether continued use of the Hamilton depression scale as a measure of treatment outcome is justified. Method: MEDLINE was searched for stud- ies published since 1979 that examine psychometric properties of the Hamilton depression scale. Seventy studies were identified and selected, and then grouped into three categories on the basis of the major psychometric properties exam- ined—reliability, item-response character- istics, and validity. Results: The Hamilton depression scale’s internal reliability is adequate, but many scale items are poor contributors to the measurement of depression severity; oth- ers have poor interrater and retest reliabil- ity. For many items, the format for re- sponse options is not optimal. Content validity is poor; convergent validity and discriminant validity are adequate. The factor structure of the Hamilton depres- sion scale is multidimensional but with poor replication across samples. Conclusions: Evidence suggests that the Hamilton depression scale is psychomet- rically and conceptually flawed. The
  • 4. breadth and severity of the problems mil- itate against efforts to revise the current instrument. After more than 40 years, it is time to embrace a new gold standard for assessment of depression. (Am J Psychiatry 2004; 161:2163–2177) The Hamilton Depression Rating Scale (1) was devel- oped in the late 1950s to assess the effectiveness of the first generation of antidepressants and was originally pub- lished in 1960. Although Hamilton (1) recognized that the scale had “room for improvement” (p. 56) and that further revision was necessary, the scale quickly became the stan- dard measure of depression severity for clinical trials of antidepressants (2, 3). The Hamilton depression scale has retained this function and is now the most commonly used measure of depression (3). Our objective in this arti- cle is to provide a review of the Hamilton depression scale literature published since the last major evaluation of its psychometric properties, more than 20 years ago (4). More recent reviews have appeared (3, 5–7), but they have not systematically examined the literature with regard to a broad range of measurement issues. Significant develop- ments in psychometric theory and practice have been made since the 1950s and need to be applied to instru- ments currently in use. We evaluate the Hamilton depres- sion scale in light of these current standards and conclude by presenting arguments for and against retaining, revis- ing, or rejecting the Hamilton depression scale as the gold standard for assessment of depression. Method Studies for the review were identified by means of MEDLINE searches for both “depression” and “Hamilton.” All studies pub-
  • 5. lished during the period since the last major review ( January 1980 to May 2003) were considered. Studies selected for review had to be explicitly designed to evaluate empirically the psychometric properties of the instrument or to review conceptual issues re- lated to the instrument’s development, continued use, and/or shortcomings. At least 20 published versions of the Hamilton de- pression scale exist, including both longer and shortened ver- sions. This review was limited to studies that examined the origi- nal 17-item version, as the majority of the studies that evaluated the scale’s psychometrics used the 17-item version. Only a small number of studies evaluated other versions, and most of these versions contain the original 17 items. Seventy articles met the se- lection criteria and were categorized into three groups on the ba- sis of the major psychometric property examined—reliability, item response, and validity. Table 1 lists the articles included in the review. Results Reliability Clinician-rated instruments should demonstrate three types of reliability: 1) internal reliability, 2) retest reliability, and 3) interrater reliability. Cronbach’s alpha statistic (78) is used to evaluate internal reliability, and estimates ≥0.70 2164 Am J Psychiatry 161:12, December 2004
  • 6. HAMILTON DEPRESSION SCALE http://ajp.psychiatryonline.org TABLE 1. Characteristics of Studies Examining the Psychometric Properties of the Hamilton Depression Rating Scalea % of Female Subjects Psychometric Properties Examined Study Year Language N Subjects Reliability Item Response Validity Aben et al. (8) 2002 Dutch 202 46 Stroke patients × Addington et al. (9) 1990 English 250 —b Schizophrenia inpatients × Addington et al. (10) 1996 English 112c 60 Schizophrenia inpatients × × Addington et al. (10) 1996 English 89d —b Schizophrenia inpatients × × Akdemir et al. (11) 2001 Turkish 94 66 Psychiatric patients × × Baca-García et al. (12) 2001 Spanish 1 100 Dysthymia outpatient × Bech (5) 1981 Danish 66 70 Depressed inpatients × × Bech et al. (13) 1992 Multilingual 1,128 —b Psychiatric patients × × Bech et al. (14) 2002 Danish 650 —b Psychiatric patients × × Berard and Ahmed (15) 1995 English 22 64 Elderly psychiatric outpatients × ×
  • 7. Berrios and Bulbena- Villarasa (16) 1990 Castilian 1,204 59 Psychiatric outpatients × × Brown et al. (17) 1995 English 259 —b Medical outpatients × Carroll et al. (18) 1981 English 278 —b Depressed patients × Cicchetti and Prusoff (19) 1983 Time 1 English 86 —b Depressed outpatients × Time 2 English 81 —b Depressed outpatients × Craig et al. (20) 1985 English 32 0 Schizophrenia inpatients × × Daradkeh et al. (21) 1997 Arabic 73 58 Depressed inpatients × × Deluty et al. (22) 1986 English 70 39 Psychiatric inpatients × × Demitrack et al. (23) 1998 —b 85 66 Professionals/laypersons × Entsuah et al. (24) 2002 Sample 1 Multilingual 865 65 Psychiatric patients × Sample 2 Multilingual 757 64 Psychiatric patients × Sample 3 Multilingual 450 62 Psychiatric patients × Faries et al. (25) 2000 —b 1,658 —b Depressed outpatients × Feinberg et al. (26) 1981 English —b —b Depressed patients × Fleck et al. (27) 1995 French 60 77 Psychiatric outpatients × Fuglum et al. (28) 1996 Danish —b —b Depressed patients × × Gastpar and Gilsdorf (29) 1990 Multilingual 122 66 Depressed patients × Gibbons et al. (30) 1993 English 370 72 Psychiatric patients × × Gilley et al. (31) 1995 Sample 1 English 185 56 Alzheimer’s disease patients × × Sample 2 English 54 39 Comparsion subjects with normal cognition
  • 8. × × Sample 3 English 57 37 Parkinson’s disease patients × × Gottlieb et al. (32) 1988 English 43 67 Neurological patients × × Gullion and Rush (33) 1998 English 324 67 Depressed patients × Hammond (34) 1998 English 100 74 Elderly medical patients × Hooijer et al. (35) 1991 Flemish 56 —b Mental health professionals × Hotopf et al. (36) 1998 English 49 65 Primary care patients × Kobak et al. (37) 1999 English 113 —b Psychiatric patients/community comparison subjects × × Koenig et al. (38) 1995 English 38 55 Elderly medical patients × Lambert et al. (39) 1986 —b 1,850 —b Psychiatric patients × Lambert et al. (40) 1988 English 13 31 Psychiatric inpatients/outpatients × Leentjens et al. (41) 2000 Dutch 63 37 Parkinson’s disease patients × Leung et al. (42) 1999 Chinese 93 56 Psychiatric inpatients × × McAdams et al. (43) 1996 English 101 23 Schizophrenia outpatients × Maier and Philipp (44) 1985 German 280 —b Psychiatric outpatients × Maier et al. (45) 1988 Sample 1 German 130 —b Psychiatric inpatients × × × Sample 2 German 48 —b Psychiatric inpatients × × × Maier et al. (46) 1988 German 130 —b Psychiatric inpatients × Marcos and Salamero (47) 1990 Spanish 234 76 Community
  • 9. geriatric subjects × Meyer et al. (48) 2001 English 196 68 Medical outpatients × Middelboe et al. (49) 1994 Danish 36 64 Medical outpatients × Moberg et al. (50) 2001 English 20 70 Geriatric consultation/liaison patients × Mottram et al. (51) 2000 English 433 73 Elderly psychiatric referrals × Naarding et al. (52) 2002 Sample 1 Dutch 44 36 Stroke inpatients × Sample 2 Dutch 274 60 Alzheimer’s disease patients × Sample 3 Dutch 85 40 Parkinson’s disease patients × O’Brien and Glaudin (53) 1988 Sample 1 English 183 70 Psychiatric outpatients × Sample 2 English 182 70 Psychiatric outpatients × (continued) Am J Psychiatry 161:12, December 2004 2165 BAGBY, RYDER, SCHULLER, ET AL. http://ajp.psychiatryonline.org reflect adequate reliability (79, 80). The internal reliability of individual items is calculated by using corrected item- to-total correlation with Pearson’s r; items should have a correlation greater than 0.20 (79, 80). Retest reliability as- sesses the extent to which multiple administrations of the scale generate the same results. When scores on an instru- ment are expected to change in response to effective treat- ment, it is necessary to demonstrate that these scores re- main the same in the absence of treatment. Interrater
  • 10. reliability assesses the extent to which multiple raters gen- erate the same result. Although Pearson’s r is often used to compute these estimates, the preferred method is the intraclass r (81), which allows for adjustment for agree- ment by chance. Estimates of retest and interrater reliabil- ity should be at a minimum of 0.70 (Pearson’s r) and 0.60 (intraclass r) (82). For retest reliability of scale items, Pear- son’s r >0.70 is considered acceptable (83). Internal Reliability Table 2 summarizes the results from studies examining internal reliability of the total Hamilton depression scale. Es- timates ranged from 0.46 to 0.97, and 10 studies reported es- timates ≥0.70. Table 3 summarizes the studies that exam- ined internal reliability at the item level. The majority of Hamilton depression scale items show adequate reliability. Six items met the reliability criteria in every sample (guilt, middle insomnia, psychic anxiety, somatic anxiety, gastro- intestinal, general somatic), and an additional five items met the criteria in all but one sample (depressed mood, suicide, early insomnia, late insomnia, work and interests, hypo- chondriasis). Loss of insight was the item with the most vari- able findings, suggesting a potential problem with this item. Interrater Reliability Total Hamilton depression scale interrater reliabilities are displayed in Table 2. Pearson’s r ranged from 0.82 to TABLE 1. Characteristics of Studies Examining the Psychometric Properties of the Hamilton Depression Rating Scalea (continued) % of
  • 11. Female Subjects Psychometric Properties Examined Study Year Language N Subjects Reliability Item Response Validity O’Hara and Rehm (54) 1983 English 20 0 Depressed outpatients × Olsen et al. (55) 2003 Danish 91 74 Psychiatric and medical patients × Onega and Abraham (56) 1997 English 206 70 Geriatric psychiatric outpatients × Pancheri et al. (57) 2002 Italian 186 62 Depressed outpatients × × Paykel (58) 1990 Sample 1 English 101 —b Depressed inpatients × × Sample 2 English 118 —b Psychiatric outpatients × × Sample 3 English 167 —b General practice outpatients × × Potts et al. (59) 1990 English 694 74 Depressed outpatients × Ramos-Brieva and Cordero-Villafafila (60) 1988 Spanish 135 70 Depressed inpatients/outpatients × × Rehm and O’Hara (61) 1985 English 158 100 Community (symptomatic) subjects × × Reynolds and Kobak (62) 1995 English 357 59 Psychiatric outpatient/nonreferred community subjects ×
  • 12. Riskind et al. (63) 1987 English 191 54 Psychiatric outpatients × × Santor and Coyne (64) 2001 Sample 1 English 316 —b Primary care outpatients × Sample 2 English 318 70 Depressed outpatients × Santor and Coyne (65) Sayer et al. (66) 2001 English 732 —b Depressed patients × 1993 English 114 61 Psychiatric inpatients × × Senra Rivera et al. (67) 2000 Castilian 52 65 Depressed patients × × Shain et al. (68) 1990 English 45 64 Depressed adolescent inpatients × Smouse et al. (69) 1981 English —b —b Depressed patients × Steinmeyer and Möller (70) 1992 German 223e 68 Psychiatric inpatients × Steinmeyer and Möller (70) 1992 German 174f 68 Psychiatric inpatients × Strik et al. (71) 2001 Sample 1 Dutch 156 0 Medical patients × × Sample 2 Dutch 50 100 Medical patients × × Teri and Wagner (72) 1991 English 75 68 Alzheimer’s patients × Thase et al. (73) 1983 English 147 100 Depressed outpatients × × Thompson et al. (74) 1998 English 242 100 Psychiatric referrals × Whisman et al. (75) 1989 English 70 100 Depressed outpatients × × Williams (76) 1988 English 23 65 Psychiatric inpatients × Zheng et al. (77) 1988 Chinese 329 47 Psychiatric inpatients/outpatients × × a Studies were published between January 1980 and May 2003 and identified by means of a MEDLINE search for both
  • 13. “depression” and “Hamilton.” b Not reported. c Number of subjects providing data at time 1. d Number of subjects providing follow-up data 3 months after admission. e Number of subjects providing baseline (i.e., pretreatment) data. f Number of subjects providing endpoint (week 6) data after treatment with either paroxetine or amitriptyline. 2166 Am J Psychiatry 161:12, December 2004 HAMILTON DEPRESSION SCALE http://ajp.psychiatryonline.org 0.98, and the intraclass r ranged from 0.46 to 0.99. Some investigators provided evidence that the skill level or ex- pertise of the interviewer and the provision of structured queries and scoring guidelines affect reliability (19, 23, 35, 54). Across studies, the best estimate mean of interrater re- liability for studies reporting higher levels of interviewer skill and use of expert raters, structured queries, and scor- ing guidelines did not statistically differ from that for other studies (z=0.81, n.s.). At the individual item level, interrater reliability is poor for many items. Cicchetti and Prusoff (19) assessed reli- ability before treatment initiation and 16 weeks later at trial end. Only early insomnia was adequately reliable be- fore treatment, and only depressed mood was adequately reliable after treatment. Thirteen items had coefficients
  • 14. <0.50 before treatment, and 11 items had coefficients <0.50 after treatment. Rehm and O’Hara (61) performed a similar analysis with data from two samples. Six items showed adequate reliability in the first sample (early in- somnia, middle insomnia, late insomnia, somatic anxiety, gastrointestinal, loss of libido), as did 10 in the second sample (depressed mood, guilt, suicide, early insomnia, middle insomnia, late insomnia, work/interests, psychic anxiety, somatic anxiety, gastrointestinal). Loss of insight showed the lowest interrater agreement in both samples. Craig et al. (20) found that only one item, work/interests, had adequate interrater reliability. Moberg et al. (50) re- ported that nine items demonstrated adequate reliability when the standard Hamilton depression scale was admin- istered (depressed mood, guilt, suicide, early insomnia, late insomnia, agitation, psychic anxiety, hypochondria- sis, loss of insight), but all items showed adequate reliabil- ity when the scale was administered with interview guide- lines. Potts et al. (59) demonstrated that a single omnibus coefficient can mask specific problems. Using a structured interview version of the Hamilton depression scale, they TABLE 2. Studies Reporting Reliability Estimates for the Total 17-Item Hamilton Depression Rating Scalea Study Year Internal Reliability (Cronbach’s alpha) Interrater Reliability (Pearson’s r) Interrater Reliability (Intraclass r)
  • 15. Retest Reliability (Pearson’s r) Addington et al. (9) 1990 0.82 Addington et al. (10) 1996 0.93 Akdemir et al. (11) 2001 0.75 0.87–0.98b 0.85 Baca-García et al. (12) 2001 0.97 Cicchetti and Prusoff (19) 1983 Time 1 0.46 Time 2 0.82 Craig et al. (20) 1985 0.95 Deluty et al. (22) 1986 0.96 Demitrack et al. (23) 1998 0.65–0.79b Fuglum et al. (28) 1996 0.86 0.81 Gastpar and Gilsdorf (29) 1990 0.48 Gilley et al. sample 1 (31) 1995 0.92 Gottlieb et al. (32) 1988 0.99 Hammond (34) 1998 0.46 Kobak et al. (37) 1999 0.91 0.98 Koenig et al. (38) 1995 0.97 Leung et al. (42) 1999 0.94 Maier et al. (45) 1988 Sample 1 0.70 Sample 2 Time 1 0.72 Time 2 0.70 McAdams et al. (43) 1996 0.77 Meyer et al. (48) 2001 0.57–0.80b Middelboe et al. (49) 1994 0.75 O’Hara and Rehm (54) 1983
  • 16. Expert raters 0.91 Novice raters 0.76 Pancheri et al. (57) 2002 0.90 Potts et al. (59) 1990 0.82 0.92 Ramos-Brieva and Cordero-Villafafila (60) 1988 0.72 Rehm and O’Hara (61) 1985 Study 1 0.76 0.78–0.91b Study 2 0.91–0.96b Reynolds and Kobak (62) 1995 0.92 0.96 Riskind et al. (63) 1987 0.73 Shain et al. (68) 1990 0.97 Teri and Wagner (72) 1991 0.65–0.97b Whisman et al. (75) 1989 0.85 Williams (76) 1988 0.81 Zheng et al. (77) 1988 0.71 0.92 a Estimates are from studies published between January 1980 and May 2003 that measured psychometric properties of the Hamilton depression scale. Studies were identified by means of a MEDLINE search for both “depression” and “Hamilton.” b Range over multiple pairs of raters. Am J Psychiatry 161:12, December 2004 2167 BAGBY, RYDER, SCHULLER, ET AL. http://ajp.psychiatryonline.org found an overall intraclass coefficient of 0.92; however, two trained psychiatrists differed at least 20% of the time
  • 17. in their ratings of psychic anxiety, psychomotor agitation, and psychomotor retardation, and they differed by at least two points 15% of the time in their ratings of loss of libido. The ratings of trained raters disagreed with the psychia- trists’ ratings on psychomotor agitation (50% of the time), hypochondriasis (60%), loss of libido (90%), and loss of energy (100%). Retest Reliability Retest reliability for the Hamilton depression scale ranged from 0.81 to 0.98 (Table 2). Retest reliability at the item level (Table 3) ranged from 0.00 to 0.85. Williams (76) argued in favor of using structured interview guides to boost item and total scale reliability and developed the Structured Interview Guide for the Hamilton Depression Rating Scale. This effort increased the mean retest reliabil- ity across individual items to 0.54, although only four items met the criteria for adequate reliability (depressed mood, early insomnia, psychic anxiety, and loss of libido). Item Characteristics Content and scaling. Standard psychometric practice dictates that items within an instrument should measure a single symptom and contain response options linked to increasing or decreasing amounts of that symptom. Each item is assumed to contribute equally to the total score or be backed with evidence in support of differential weight- ing. These criteria are not consistently met by using the current scaling procedure or the options for rating symp- toms. Although improperly scaled items can cause prob- lems in quantitative measurement, evaluation of item scaling takes place first at a qualitative level. Some Hamil- ton depression scale items measure single symptoms along a meaningful continuum of severity; many do not.
  • 18. The item assessing depressed mood includes a combina- tion of affective, behavioral, and cognitive features, such as gloomy attitude, pessimism about the future, subjective feeling of sadness, and tendency to weep. The general so- matic symptoms item, which is also symptomatically het- erogeneous, includes feelings of heaviness, diffuse back- ache, and loss of energy. Headache is coded only as part of somatic anxiety along with such symptoms as indigestion, palpitations, and respiratory difficulties. Genital symp- toms for women entail loss of libido and menstrual distur- bances. The problems inherent in the heterogeneity of these rating descriptors reduce the potential meaningful- ness of these items, a problem exacerbated if the different components of an item actually measure multiple con- structs and thus measure different effects. Most items on the Hamilton depression scale at least are scaled so that increasing scores represent increasing se- verity. It is less clear whether the anchors used for different scores on certain items actually assess the same underly- ing construct/syndrome. This ambiguity is most obvious for severity ratings involving psychotic features. The feel- ings of guilt item, for example, is graded as follows: 0=ab- sent, 1=self-reproach, 2=ideas of guilt or rumination over past errors or sinful deeds, 3=present illness is a punish- ment, and 4=hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations. A patient with guilt-themed hallucinations may be more se- verely ill than a patient who has nonpsychotic guilty feel- ings, but is he/she feeling more guilt? The psychotic fea- tures may instead represent a qualitatively different construct/syndrome associated with more severe illness. Similarly, the hypochondriasis item progresses through bodily self-absorption (rated 1) and preoccupation with health (rated 2) before switching to querulous attitude
  • 19. (rated 3) and then again to hypochondriacal delusions (rated 4). These item-scoring anchors violate basic mea- surement principles, because nominal scaling and ordinal scaling are combined in a single item. Although Hamilton (1) explained the rationale for the inclusion of both 3-point and 5-point items, the argument was not made on the grounds of differential weighting. Hamilton believed that certain items would be difficult to anchor dimensionally and therefore assigned them fewer response options. The end result is that certain items con- tribute more to the total score than others. Contrasting psychomotor retardation and psychomotor agitation, for example, reveals that a severe manifestation of the former contributes 4 points, whereas an equally severe manifes- tation of the latter contributes 2 points. Similarly, some- one who weeps all the time can contribute 3 or 4 points on depressed mood, whereas someone who feels tired all the time can contribute only 2 points on the general somatic symptoms item. Item Response Analysis A psychiatric rating scale should measure a single psy- chopathological construct (i.e., an illness or syndrome) and be composed of items that adequately cover a range of symptoms that are consistently associated with the syn- drome. Item response theory, a method used increasingly in the evaluation and construction of psychometric in- struments, permits empirical evaluation of these pre- mises. It is important to note that this method was not available when the original Hamilton depression scale was developed, although some researchers more recently used this method to evaluate this instrument. According to item response theory, a scale and its constituent items may have good reliability estimates but still fail to meet item re-
  • 20. sponse theory criteria. For example, if a depression scale were composed only of items measuring mild depression, the instrument would have great difficulty distinguishing between moderate and severe cases of depression, as both would be characterized by high scores on all items. This is- sue is particularly pressing in studies of clinical change; not only is a wide range of severity often represented in this research, but individual patients are expected to move 2168 Am J Psychiatry 161:12, December 2004 HAMILTON DEPRESSION SCALE http://ajp.psychiatryonline.org along this continuum as they improve. Continued use of items insensitive to change underestimates the strength of actual treatment effects and makes it necessary to have larger samples to demonstrate that an effect is statistically significant. Falsely identifying patients as not having changed represents an additional source of “noise” and weakens the “signal” of a true treatment effect. A prag- matic implication of such lack of sensitivity is that new compounds shown to be promising in the laboratory may appear spuriously ineffective in clinical trials. A related issue concerns the extent to which a severity score actually measures a single unidimensional syn- drome. To summarize a syndrome with a single score re- quires a precise understanding of what that score repre- sents. The implicit assumption is that the severity score represents a single dimension (84); if depression is hetero- geneous, interpretation of a single summed score is un- clear. If, for example, items assessing psychological and
  • 21. physical symptoms were only loosely related, a single score would not distinguish between two potentially dif- ferent groups of depressed patients—one group whose symptoms were primarily psychological and another group with primarily vegetative symptoms. Any effects of an intervention targeting only one of these aspects would be harder to detect. Gibbons et al. (85) presented a strategy for identifying a unidimensional set of items from a psychiatric rating scale and evaluating the extent to which these items adequately measure the full range of depression severity. Subse- quently, a subset of Hamilton depression scale items that would measure a single dimension of depression across a wide range of severity was developed (30). This subset in- cluded depressed mood, which was sensitive at low levels; work/interests, psychic anxiety, and loss of libido, which were sensitive at mild levels; somatic anxiety, psychomo- tor agitation, and guilt, which were sensitive at moderate levels; and suicide, which was sensitive at severe levels. These items were proposed as a psychometrically stronger form of the full Hamilton depression scale. Santor and Coyne (64, 65) used item response theory to examine the functioning of the full Hamilton depression scale and its individual items. In one of these studies (65) they examined individual Hamilton depression scale item performance in a combined sample of primary care pa- tients and depressed patients from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. One expects different item ratings at TABLE 3. Studies Reporting Item Reliability Estimates for the 17-Item Hamilton Depression Rating Scalea
  • 22. Scale Item Reliability Measure and Study Year Depressed Mood Guilt Suicide Early Insomnia Middle Insomnia Late Insomnia Work/ Interests Internal reliabilityb Berrios and Bulbena-Villarasa (16) 1990 Sample 1 0.32 0.24 0.26 0.25 0.32 0.31 0.39 Sample 2 0.37 0.38 0.40 0.23 0.37 0.42 0.33 Gastpar and Gilsdorf (29) 1990 Time 1 0.10 0.22 –0.04 0.04 0.22 0.13 0.09 Time 2 0.65 0.39 0.50 0.44 0.46 0.53 0.73 Paykel (58) 1990 Sample 1 0.52 0.31 0.31 0.24 0.21 0.38 0.59 Sample 2 0.42 0.38 0.47 0.27 0.34 0.30 0.58 Sample 3 0.52 0.41 0.49 0.34 0.35 0.34 0.59 Rehm and O’Hara (61) 1985 0.63 0.26 0.47 0.40 0.41 0.37 0.46 Interrater reliabilityc
  • 23. Cicchetti and Prusoff (19) 1983 Time 1 0.37 0.18 0.59 0.76 0.57 0.42 0.33 Time 2 0.72 0.37 0.64 0.57 0.45 0.49 0.64 Moberg et al. (50)d 2001 Standard administration 0.90 0.80 0.90 0.61 0.39 0.89 0.50 Interview guidelines 0.96 0.83 0.81 0.97 0.78 0.89 0.87 Rehm and O’Hara (61)e 1985 Above median split 0.61 0.39 0.49 0.74 0.79 0.72 0.56 Below median split 0.84 0.82 0.92 0.91 0.79 0.92 0.73 Retest reliabilityf Akdemir et al. (11) 2001 0.61 0.78 0.67 0.69 0.79 0.76 0.73 Williams (76) 1988 0.80 0.63 0.64 0.80 0.62 0.30 0.54 a Estimates are from studies published between January 1980 and May 2003 that measured psychometric properties of the Hamilton depres- sion scale. Studies were identified by means of a MEDLINE search for both “depression” and “Hamilton.” b Correlation of item scores with total scores. An uncorrected Pearson’s r>0.20 was considered significant. Significant correlations are shown in boldface type. OK Following on from the previous. Short podcast This is another one looking at scales for depression so another famous scale that's used for measuring depression has been for a long time Hamilton depression rating scale factors for one so. Yes it uses. To evaluate. And to depression medications still. So let's take a look at this article this is this is another article. That has a good foundation study in this case of the Hamilton scale. So. Again your. Introduction here. Around one has been the gold
  • 24. standard for the assessment of depression for 2 years when this was published which of us was. 15. And 50 years. And. Life the infected person in the entry This was also developed a much earlier actually in the late 1950 S. to assess the effectiveness of the 1st generation of antidepressants it was a vision we published in 1960 so again it was it was not developed to measure depression and clients so much as to measure the effectiveness of antidepressant medications. And. It's now. That the most commonly used measure of depression so there are some there often issues come by the minute. Related to the fact that this that perhaps. This scale. Was developed by now conceptualize ation of depression might have been something different from one of his today all right so the last major review was found 950 of this I'm not sure if you show me 2003 so this is. Update 201517 items will question is on the sky right of Sky question. Section and let's take a look at the reliability of the Hamilton so we've got some. Information here. And looking reasonably good this is kind of putting together a list of many studies. Saying. If you know you know what information was contained within. You in those studies and. So it's talking about reliability and some statistics being used to cases are. So. In terms of internal life of the sea. The estimates range from point 462.97.97 courses 5 fabulous to the excellent point 46 it's a little bit. On the low and. But point 7 is his closer to accept to be the best we're looking for really his point 8 while high. Interests are a liability and this is this is a very important type of reliability this means. That you know because this is what happens in real life creations. Are using. In this case the Hamilton depression scale are they. Getting the same result. When they use this chaos and other clinicians so the pieces are here ranged from point A to point 98 that was good very good. But the individual item level so that was really the whole sky off here the size of the individual lots of novel into a survival using whole for many items and so that's. How some calls for concern. So here. This is the board state psychiatric rating scale should measure a single psycho form of psychopathological
  • 25. construct. You know. What we refer to. In the medical model we use as an illness or a syndrome and whether they are actually medical illnesses is another matter. Mentioned in the other. Video and become part of items that adequately cover a range of symptoms that are consistently associated with the syndrome so again we're coming back to the fact that. This scale is. Whether or not they come back to the question should say whether or not this scale. Catches depression as it is currently conceptualize this currently conceptualize. Her to death Nowadays the D.S.M. 5. We've already talked about whether or not the D.S.M. itself is valid and reliable. But that's what we take history. As the standard and so on a depression scale is then measure it against it's ability it's the ability of the scale is measured in terms of. How well it's able to capture what we know we conceptualize depression per the D.S.M. diagnostic criteria so here it's this paragraph here it's reasonable to ask whether this instrument catches depression as it is currently conceptualize several symptoms contained within the how time scale and not official D.S.M. diagnostic criteria although they are recognizes speech is associated with depression for example psyche XYZZY or other symptoms including included I don't and scale for example loss of inside hypochondriasis the link with depression is more tenuous war critically important features of D.S.M. for depression are often buried within more complex items and sometimes in all kinds of toll so it could be a problem since we are obliged in practice to use the D.S.M.. We need we need to VO to use in a major scale that's going to give us. A score that tells us whether or not the client has depression as it is defined in the D.S.M.. And no explicit assessment of feelings of worthlessness. OK she's something there in the D.S.M. knowledge. Doesn't capture. All right so anyway. Let's take a look at 2. So this was the conclusion or one of the confluence of this particular study was that the Hamilton depression scale is measuring concepts in a depression that is now several decades old and that is at best partly related to the operationalize ation of depression in D.S.M. 4 so maybe even
  • 26. be. Further removed from how the D.S.M. 5 sexualizes depression. Huge difference between D.S.M. $4.00 and $5.00. But nevertheless it's a concern. So then we take a look. Now. And think. So we can see how these 2 scales are. Different from each other even though they. May be same thing. Well 1st of all the number of items is different. Here. If we look at the way that. Both in both scales we add up the total score you see here that the. Back to Persian inventory. It says the cutoff of. 0 to 13 is minimal depression was this there's no score that tells you no depression. I see interesting whereas at least I have also and. You can not be depressed with a house. And then $8.00 to $12.00 when the House of depression is doubtful and Miles Wilder and severe. Which kind of sort of seems to equate to a mild more drip sit here on. The. The Bay It's the same word to use but whether it's. They are made the same meaning in terms of actual depressed state in the plan or less. Matter. But also what you can see here is some of the. Items have effectively a different $1080.00 in the houses scale whereas as we've mentioned previously we're talking about a bank that each He chides in his weighted equally So these these since we're adding the total score these items. Can these 4 from 0 to 2. Kind of have less weighting than those that are. Rated from 0 to 4. We should give that one for depressed mood as you can give this some new initiatives on. Maximum 2 So anyway that the the scales are different and so. The question is are they how they measuring the same thing and we've looked at the lives of the few who did see off the top of them in those elevations studies and so that would be what we're trying to make a decision as to which scale we're going to use. Those And those would be the deciding factor is the size things like practical things like ease of use and so on. And of course you where if we're planning to. Major Depression say in. Children. The wording of the question say. I think that. Well one would have to consider whether the would be is going to be understood as it's meant to be understood by a child this is an adult. So you eat what for your for your assignment. Let's say they say you choose. Depression
  • 27. chosen depression is on of your clients main problems so then you can use. Something like Google Scholar through V.F.S. universe and you can search for depression scale see what comes out or depression in Tory and you probably get lots of hits. Back and. Saw So the 1st step is to find scales. That seethes if they are. Potentially useful for what you want to do. Then go for validation studies of those particular scales once you got some of the scales and you go to whittle this down to 2 scales per problem so if you chosen depression you need to have 2 scales you could even use that back in the house and compare those 2. But again I ask you not to use the validation studies that I've presented these videos but find some feel. Free So for each scale you have to find 2. Validation studies so to fit in this case you need 2 for the bank and 2 for the Hamilton OK and you look at the. Reliability of booty statistics and used those and things like ease of use. To argue that OK I'm going to select the best because blah blah blah on the. Hamilton because all and give your reasons in terms of statistics and other factors that. Make that a better choice to go client OK All right you also have. Some work on this in your discussion board aside for this much. So. International Journal of Mental Health Nursing (2007) 16, 108 – 115 doi: 10.1111/j.1447-0349.2007.00453.x © 2007 Australian College of Mental Health Nurses Inc. Feature Article Measuring melancholy: A critique of the Beck Depression Inventory and its use in mental health nursing Brad Hagen
  • 28. School of Health Sciences, The University of Lethbridge, Lethbridge, Alberta, Canada ABSTRACT: The Beck Depression Inventory (BDI) is one of the most commonly used depression measurement instruments. Mental health nurses often utilize the BDI to assess the level of depression in clients, and to monitor the effectiveness of treatments such as antidepressants and electroconvulsive therapy. Despite the widespread use of the BDI in both clinical practice and research, there is surprisingly little nursing literature critically examining the BDI or its use by mental health nurses. This paper reviews the origins, purpose, and format of the BDI, discusses some of the strengths and limitations of the BDI, and concludes with some implications for mental health nursing. KEY WORDS: Beck Depression Inventory, depression, mental health, psychiatric nursing, psychometrics. Blackwell Publishing AsiaMelbourne, AustraliaINMInternational Journal of Mental Health Nursing1445-8330© 2007 Australian College of Mental Health Nurses Inc.? 2007162108115Original ArticleBECK DEPRESSION INVENTORYB. HAGEN Correspondence: Brad Hagen, School of Health Sciences, The University of Lethbridge, 4401 University Drive, Lethbridge, AB T1K 3M4, Canada. Email: [email protected] Brad Hagen, RN, PhD. Accepted May 2006.
  • 29. Mental health nurses are often encouraged to use psychi- atric/psychological measurement instruments in their nursing practice, and the Beck Depression Inventory (BDI; Beck et al. 1996) is one of the most commonly used instruments that mental health nurses are likely to encounter and use in their practice (Demyttenaere & De Fruyt 2003). The majority of current psychiatric nursing textbooks discuss the BDI, and in one commonly used textbook, the BDI is described as ‘. . . a quick but reliable and valid measure of the extent to which depression may be present’ (Kneisl et al. 2004; p. 169). Indeed, in the first author’s own local health region, where he supervises nursing students in mental health clinical settings, nurses commonly use the BDI to assess the level of depression in patients, and to monitor the effectiveness of treatments such as antidepressants and electroconvulsive therapy. Yet despite the common use of the BDI by mental health nurses, there is little or no nursing literature crit- ically examining the BDI, or its use by mental health nurses. Therefore, the purpose of this paper is to provide a critical discussion of the BDI, and its use by mental health nurses. To this end, the author will briefly review the origins, purpose, and format of the BDI, discuss some of the strengths and limitations of the BDI, and conclude with some implications for mental health nursing. ORIGINS, PURPOSE, AND FORMAT OF THE BDI As Demyttenaere and De Fruyt (2003) have described in their review of depression rating scales, depression rating scales were first developed in the late 1950s as part of the overall psychopharmacology revolution, whereby psycho- logical theories of depression gave way to commercially
  • 30. driven biochemical theories of depression. They go on to note that ‘. . . with the advent of antidepressant drugs, rating scales were needed to measure the severity of the depressive disorder and the changes during therapy’ (Demyttenaere & De Fruyt 2003; p. 61), and there are now more than 100 depression rating scales in existence. While there are many available depression rating scales, the BDI, a self-administered scale first developed in 1961 tgomory Highlight tgomory Highlight BECK DEPRESSION INVENTORY 109 © 2007 Australian College of Mental Health Nurses Inc. (Beck et al. 1961), has risen to prominence as one of the most widely used depression rating scales (Dozois & Covin 2004). Beck et al. (1961) developed the original BDI as a 21- item inventory to measure the severity of depressive symptoms, and based the 21 items on Beck’s observations of the symptoms and attitudes of depressed persons seen in the context of therapy. Beck has claimed that the BDI does not reflect any particular theory of depression, and merely reflects the observed symptoms of persons who are depressed (Beck et al. 1996). While the first version of the BDI was shown to be reasonably robust in terms of psychometric properties, increasing concerns were raised concerning the instrument’s validity vis-à-vis the
  • 31. DSM-IV standard for diagnosing depression (American Psychiatric Association 1994). Consequently, Beck et al. created a second revised version of the BDI (BDI-II) in 1996 (Beck et al. 1996). The main changes made to develop the BDI-II primarily reflected increased com- patibility with the DSM-IV, and included the changing of certain items, dropping of other items, and changes to certain response options and time frames (Beck et al. 1996; Dozois et al. 1998). From this point forwards in this manuscript, the authors will use the term ‘BDI’ to refer to this most recent version of the instrument, the BDI-II. The BDI is typically self-administered, requires only about 5–10 min to complete, and can be used with per- sons aged 13 years and up (Dozois & Covin 2004). Each one of the 21 items in the BDI is rated on a scale of 0– 3, and scores from all items are tallied to obtain a total possible score, ranging from 0 and 63, with higher scores reflecting greater severity of depressive symptomatology. Scores between 0 and 13 are interpreted as ‘minimal’ depression, scores between 14 and 19 as ‘mild’ depres- sion, scores of 20–28 as ‘moderate’ depression, and scores of 29–63 as ‘severe’ depression (Beck et al. 1996; Dozois & Covin 2004). Interestingly, it appears that with the possible exception of a score of 0, there are no score grouping to be interpreted as ‘no depression’. STRENGTHS OF THE BDI Strengths of the BDI include the ease of administration and scoring of the BDI, its widespread use, and the results of psychometric testing of the reliability and valid- ity of the BDI. Ease of administering and scoring the BDI
  • 32. One of the principle advantages of the BDI is its ease of administration and scoring (Dozois & Covin 2004). Indeed, the BDI generally only takes less than 10 min to complete, and is easily scored and interpreted. Conse- quently, the BDI has become one of the most widely used psychological tests, has been translated into many lan- guages, and has been employed in more than 2000 empir- ical studies (Barroso & Sandelowski 2001; Dozois & Covin 2004; Richter et al. 1998). Psychometric testing of the BDI Reliability of the BDI Although more reliability testing has been completed on the original BDI than the BDI-II, both are considered to be generally quite reliable (Dozois et al. 1998; Richter et al. 1998). The original manual for the BDI-II reported high internal consistency, with a coefficient alpha of 0.93 for college students, and 0.92 for psychiatric outpatients (Beck et al. 1996). More recently, Dozois and Covin (2004) reviewed 13 studies reporting reliability data on the BDI-II since 1996, and reported an average coeffi- cient alpha of 0.91. Less information is available on the test–retest reliability of the BDI-II, although the original manual reports a 1-week test–retest reliability coefficient of 0.93 with 26 psychiatric outpatients (Beck et al. 1996). As Dozois and Covin (2004) have cautioned, however, test–retest reliability is difficult to interpret on a measure that is supposed to both reliably measure depression and detect changes in depression due to treatment. For example, at least one group of researchers have sug- gested that the BDI may not be reliable for longer peri- ods of time in non-clinical samples, after finding that BDI scores declined by 40% over 2 months in a non- clinical sample (Ahava et al. 1998). Such a significant downward drift in BDI scores in non-clinical samples
  • 33. clearly poses a threat to the instrument’s ability to reli- ably detect changes in depression due to treatment alone. Validity of the BDI Dozois and Covin (2004) have asserted that while the BDI is comparable to the original BDI in terms of reli- ability, the BDI-II is ‘. . . a clearly superior instrument in terms of its validity’ (p. 53). Such claims for the higher validity of the BDI-II are made on a number of levels. To begin with, the content validity and the face validity of the BDI-II are argued to be very high, because the items in the BDI-II now closely mirror the standard DSM-IV diagnostic criteria for depression (Dozois & Covin 2004; Richter et al. 1998). The convergent validity of the BDI- II has also been reported, and the BDI-II appears to correlate fairly well with other depression rating scales, tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight
  • 34. tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight 110 B. HAGEN © 2007 Australian College of Mental Health Nurses Inc. such as the original BDI-I (r = 0.93), the Hamilton Rating Scale for depression (r = 0.71), and the Beck Hopeless- ness Scale (r = 0.68) (Dozois & Covin 2004). The level of discriminate validity for the BDI is less clear. For example, while Richter et al. (1998) have con- cluded that the BDI ‘. . . discriminates reliably between depressives and non-depressives’ (p. 162), Dozois and Covin (2004) came to the opposite conclusion, stating that the BDI-II does not differentiate well between depressed and non-depressed persons. Furthermore, it has been noted that the BDI-II correlates highly with other mea- sures of anxiety, and may not be able to reliably distin- guish between depression and other affective states such as anxiety (Dozois & Covin 2004). Finally, it has been suggested that the BDI-II contains a reasonably stable factor structure (Beck et al. 1996;
  • 35. Dozois & Covin 2004). When the BDI-II was first released, Beck et al. (1996) reported a two-factor solu- tion: somatic-affective and cognitive symptoms within a psychiatric outpatient sample, and cognitive-affective and somatic symptoms with a college student sample. Other researchers have since found generally similar two-factor structures in other studies using college students (Dozois et al. 1998) and primary care medical patients (Arnau et al. 2001). It should be noted, however, that in their review of the BDI, Richter et al. (1998) concluded that the tacit factorial validity of the BDI is in fact controver- sial, and that subtle but possibly important differences exist in the factor structure of the BDI, depending upon the kinds of subjects that complete the BDI. In summary, the main support for the BDI appears to lie in its ease of use, widespread utilization, very good internal reliability, high content validity when compared with the DSM-IV criteria for depression, good conver- gent validity with other similar depression rating scales, and a somewhat stable factor structure. LIMITATIONS OF THE BDI While the BDI is well-known and widely used by mental health nurses, and while the BDI has several strengths, there is little critical discussion in the nursing literature of some of the potential limitations of the use of the BDI in general, or by mental health nurses in particular. Some of the potential limitations of the BDI include: issues related to norms (including potential bias issues); prob- lems with the wording, ordering, and weighting of the BDI items; potential gender biases; theoretical issues with the BDI; potentially inappropriate uses of the BDI; and validity issues related to the DSM-IV criteria for depression, upon which the BDI is based.
  • 36. Norms and bias issues The BDI has no actual large population norms per se, so it is difficult to determine if any given individual’s level of depression, as determined by the BDI, is ‘normal’ in any sense of the word. Instead, the interpretation of the BDI is referenced to criterion based on the original standard- ized sample of 500 persons (317 women and 183 men) in the Eastern United States (Beck et al. 1996). Based on this sample, the authors of the manual for the BDI-II offered cut-off score criterion or guidelines to distinguish between minimal, mild, moderate, and severe amounts of depression. However, while the total possible scores range from 0 to 63, the scoring of the scale is very ‘bottom heavy’. That is, the mean score for severely depressed persons in the standardized sample (32.96) is approxi- mately half-way along the range of total possible scores, and anyone who scores anywhere from 29 to 63 is con- sidered to be ‘severely’ depressed (Beck et al. 1996). As several authors have noted, the original sample upon which the BDI-II was standardized was predomi- nantly Caucasian, and is greatly misrepresentative of the US population at large (Dozois & Covin 2004; Richter et al. 1998). Obviously, this kind of sample also renders the BDI generally misrepresentative of other countries and cultures (Dozois & Covin 2004), and fails to capture the many different cultural factors influencing how depression is experienced by different ethnic and cultural groups (Falicov 2003). Finally, women tend to score higher on the BDI than men (Beck et al. 1996) and items on the BDI such as ‘crying’ may contain a gender bias, and may hold very different meanings for men as opposed to women (Barroso & Sandelowski 2001). Item-related issues
  • 37. There are also several problems with the way that items contained in the BDI are worded, ordered, and weighted. To begin with, several authors (Barroso & Sandelowski 2001; Demyttenaere & De Fruyt 2003; Richter et al. 1998) have noted that the BDI item response options, most of which contain some combination of negatively and positively worded options, can be very confusing and misleading for persons taking the BDI. In addition, the responses are only ordinal-level data, with unequal inter- vals between options, yet are tallied up, analysed, and reported as if they are ratio-level data (Burns & Grove 2001). There is also a tendency for responses on each item to score quite low. That is, although potential scores for each item range from 0 to 3, studies in non-clinical (stu- dent) samples typically report average scores below 1, and even psychiatric samples mean item scores rarely exceed values of 2 (Richter et al. 1998). tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight
  • 38. tgomory Highlight tgomory Highlight BECK DEPRESSION INVENTORY 111 © 2007 Australian College of Mental Health Nurses Inc. The BDI also has an obvious consistency in the order- ing of responses, as each response is ordered from least to most depressed. Therefore, several authors have noted that the obvious ordering of answers in the BDI may lead to responses reflective of faking, social desirability, and/ or defensiveness, as opposed to depression per se (Bar- roso & Sandelowski 2001; Dozois & Covin 2004). This problem is compounded by the BDI’s high face validity, which makes it easy for subjects to guess which of the items are reflective of greater or lesser depression. Finally, there is the problem of item weighting within the BDI. As Healy (1997) has noted, the creators of the BDI arbitrarily decided that the total BDI depression score would be generated by simply adding the individual scores for each of the 21 items. This kind of scoring system raises the issue of whether or not it is legitimate to simply add dissimilar items to produce a total score, and subsequently assume that the total score actually ‘means’ something (this process is called reification, and shall be addressed further in this paper). This scoring process also raises the issue of whether or not each added item in the BDI should have equal weighting in relation to the other items. Healy (1997) has commented on this
  • 39. problem, and has noted that ‘. . . many clinicians had dif- ficulties with the idea that items of very different meaning could simply be summed. Should early morning awaken- ing be counted in the same balance as guilt or suicidality?’ (p. 98). Yet despite such criticisms, all items of the BDI continue to be treated as if they are of equal importance in determining a person’s level of depression, and the creators of the BDI have offered no justification for such a stance. Theoretical issues with the BDI There are a number of important theoretical limitations with the BDI as well. First and foremost is the problem with the supposedly atheoretical nature of the BDI. That is, although the creators of the BDI maintain that the BDI merely reflects the symptoms and attitudes typically found in persons with depression – and does not reflect any theoretical assumptions about depression (Beck et al. 1996; Dozois & Covin 2004) – other authors have chal- lenged this claim of theoretical neutrality. Demyttenaere and De Fruyt (2003), for example, have noted that the BDI clearly reflects a distinctly cognitive–behavioural perspective. This perspective is not surprising, given that Beck et al. were primarily responsible for the creation of cognitive therapy. Healy (1997) has also observed that it is probably more than coincidence that the BDI is partic- ularly well-suited for evaluating cognitive–behavioural therapy, and that it would be very difficult for a person who has gone through cognitive therapy not to recognize many of the terms and language used in the BDI. There- fore, the assertion that the BDI is theoretically neutral of bias-free is simply not true, nor should this necessarily be surprising. As Jensen and Hoagwood (1997) have emphasized:
  • 40. . . . it should be noted that all clinicians – indeed, all human beings – bring theory-laden perspectives and con- ceptual filters to their assessment and diagnostic approaches with a given patient. They differ principally in the explicitness, rigidity and awareness of their biases (p. 235). Perhaps one of the most important source of bias found within the BDI is reflected in what the architects of the BDI chose not to include as items in the tool. For example, the BDI focuses exclusively on negative symp- tomatology – such as sadness, guilt, and feeling like a failure – and no positive experiences symptoms are included, despite research suggesting that positive mood may well be superior to negative mood in predicting outcomes from depression (Demyttenaere & De Fruyt 2003). In addition, the creators of the BDI chose to dis- regard large areas of interpersonal functioning, and many of the factors which determine quality of life for individ- uals (Healy 1997). Finally, Beck et al. have selected items for the BDI that clearly reflect a theoretical stance whereby the problem (i.e. depression) is seen to lie within the individual. By focusing exclusively on symptoms or problems inside the person, the BDI explicitly disregards all the multitude of factors and problems external to the individual that may be clearly impacting his or her level of depression, such as unemployment, discrimination and/or domestic violence (Crowe 2000; Jensen & Hoag- wood 1997). Lastly, the BDI exhibits the theoretical problem of reification, or the tendency to view abstract concepts as actual entities. That is, the creators of the BDI would have us believe that the simple process of adding up the answers to 21 questions about various symptoms and atti- tudes allows us to measure, with a single number, the
  • 41. quantity of a reliably identifiable ‘thing’ called depression, as if we were measuring the weight or height of an indi- vidual. Yet as Gould (1996) has pointed out, measuring and reifying such concepts as ‘depression’ and ‘intelli- gence’, as if they have a definite existence of their own, can be very misleading. Not only can such reification oversimplify complex and multifaceted experiences like depression, but such reification also disregards the large extent to which such concepts are socially created and defined, and fail to actually reflect any clearly tangible and tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight
  • 42. tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight tgomory Highlight 112 B. HAGEN © 2007 Australian College of Mental Health Nurses Inc. unambiguous entities, such as height, weight, or hyper- tension (Sarbin 1997). Inappropriate uses of the BDI Additional concern has also been raised regarding the use of potentially controversial ‘spin-offs’ of the BDI, as well as the manner in which the BDI is being increasingly used to ‘screen’ for depression. With regards to spin-offs, Dozois and Covin (2004) have noted the increasing use of controversial spin-offs of the BDI, such as the ‘short form’ of the BDI (Furlanetto, Mendlowicz & Romildo 2005). The increasing use of such spin-offs, because of their comparative lack of psychometric testing and estab- lished norms, only further compounds the overall issues of reliability and validity of the BDI and other depression rating scales.
  • 43. Furthermore, increasing numbers of clinicians, includ- ing nurses, are beginning to use the BDI as a depression ‘screening tool’, particularly now that the BDI-II closely mirrors the DSM diagnostic criteria for depression (Lasa et al. 2000). However, despite the fact that the creators of the BDI specifically specified that the BDI was not to be used as a diagnostic tool, and was to only be used as a measurement of depressive symptom severity (Beck et al. 1996; Dozois & Covin 2004), the demarcation lines between measuring symptoms of depression, diagnosing depression, and screening for depression have never been clear, and are becoming even less clear. In particular, it was never conceptually clear why the BDI – an instru- ment apparently able to measure the quantity of depres- sion – could not actually determine the presence of depression or not (i.e. diagnosis it), particularly when so many of the BDI items used to measure depression symp- toms were so similar to the same DSM-IV diagnostic criteria for depression. Despite this logical inconsistency, the BDI is increasingly being used not only to measure depression, but to detect or diagnosis it as well (Lasa et al. 2000), despite a lack of clear validation for doing so (Beck et al. 1996). Validity issues and the DSM When Beck et al. attempted to increase the validity of the BDI by making the BDI-II more closely mirror DSM-IV diagnostic criteria for depression (Beck et al. 1996), they also further reinforced the common assumption that the DSM-IV offers the most valid definition and description of the experience of depression. By doing so, however, they not only overlooked considerable criticism of the way that the DSM-IV authors categorize depression, but also inherited many of the limitations of the DSM-IV descrip- tion of depression (Beutler & Malik 2002; Crowe 2000;
  • 44. Donald 2001; Eriksen & Kress 2005; Jensen & Hoagwood 1997; Sarbin 1997). Therefore, any examination of the limitations of depression scales like the BDI must also include an examination of the limitations of the DSM-IV criteria. These limitations include issues of reliability and validity of the DSM-IV, and issues of DSM-IV value judgements and biases. Issues of the reliability and validity of the DSM-IV While many mental health clinicians simply take the reli- ability and validity of the DSM-IV system for granted, closer examination often finds the reliability and validity of the DSM-IV wanting. In fact, the reliability of the diagnosis of major depression is quite poor, and research- ers have reported kappa coefficients for the diagnosis of depression as low as 0.25 (Parker 2005). As Beutler and Malik (2002) have observed, this inadequate level of diag- nostic reliability is not surprising, given the ambiguous and complex set of guidelines that the authors of the DSM-IV created to diagnosis depression. In fact, the DSM-IV criteria for depression literally allow for several hundred possible different patterns or clusters of symp- toms, all of which can still all meet the DSM-IV diag- nostic criteria for depression (American Psychiatric Association 1994). Given the myriad of symptom patterns which can qual- ify for a DSM-IV diagnosis of depression, the DSM-IV diagnosis of depression suffers not only from reliability problems, but from considerable validity problems as well. For example, all forms of depression share great overlap with numerous other psychiatric diagnosis con- tained within the DSM-IV, and depression is found to be comorbid in 60% of general psychiatric patients, and in 40% of patients diagnosed with anxiety disorders (Beutler
  • 45. & Malik 2002). In addition, another key indicator of diag- nostic validity – that different diagnoses would respond differently and predictably to prescribed treatments – is also lacking. That is, both the natural and treatment his- tories of persons with a diagnosis of depression are noto- riously hard to predict (Parker 2005). Furthermore, a wide variety of treatments with entirely different theoret- ical explanations – including antidepressants, different forms of counselling, electroconvulsive therapy, St. John’s Wort, exercise, and placebo – all have nearly identical efficacy levels, seriously challenging the diagnostic con- struct of depression implicitly contained within the BDI (Parker 2005). Value judgements and biases within the DSM As opposed to other medical diagnoses, the diagnoses contained within the DSM-IV (including the diagnosis of tgomory Highlight tgomory Highlight BECK DEPRESSION INVENTORY 113 © 2007 Australian College of Mental Health Nurses Inc. depression) are not arrived at with the aid of laboratory tests or diagnostic imaging, but rely instead on a clinician’s judgement as to whether or not certain behaviours and symptoms, such as feelings of guilt or loss of concentra- tion, are present in certain prescribed patterns for certain prescribed periods of time (Eriksen & Kress 2005). These
  • 46. prescriptions for what constitutes a diagnosis (or disorder) are in turn arrived at by consensus by committees and panels of psychiatric experts associated with the American Psychiatric Association (1994). Numerous authors have challenged this DSM diagnosis-by-consensus process, claiming that the pro- cess reflects not so much a scientific and objective pro- cess, but a process whereby the values and biases of the privileged few comprising ‘expert consensus’ panels become embedded in our society’s definitions of mental disorders (Beutler & Malik 2002; Eriksen & Kress 2005; Jensen & Hoagwood 1997; Kutchins & Kirk 1997; Sarbin 1997). Female scholars in particular (Caplan 1995; Crowe 2000; Russell 1986) have noted the preponderance of upper-middle and upper class men in DSM diagnostic expert committees, and have suggested that Western, male, and upper/middle class values strongly influence decisions regarding diagnoses such as depression, and how such diagnoses are applied. For example, using the standard DSM-IV criteria for depression, twice as many women are diagnosed with depression as men (Kuehner 2003), yet the role that many contextual factors – such as gender discrimination in society or the higher rates of sexual abuse and assault in girls and women – are rarely taken into account when diagnosing or measuring depres- sion (Whitfield 2003). This disregard of contextual factors reflects another bias inherent within the DSM-IV diagnosis of depression, the notion that mental disorders are located within indi- viduals. This tendency to locate mental disorders and problems inside individuals has important implications, as it can easily direct clinicians’ attention away from the social context of mental health issues. That is, numerous authors have argued forcibly that it is equally plausible –
  • 47. and perhaps more appropriate – to suggest that it may well be our families, communities, and societies that deserve such labels as ‘depressed’, ‘disordered’ or ‘men- tally ill’, as opposed to individual persons (Crowe 2000; Jensen & Hoagwood 1997; Russell 1986; Sarbin 1997; Whitfield 2003). For example, a woman suffering from domestic violence and seeking assistance from the mental health system is likely to receive a psychiatric diagnosis of depression and/or post-traumatic stress disorder, and may be given instruments like the BDI to determine the extent of her ‘disorder’. Yet the real source of the woman’s problems – the perpetrator of the violence towards her – is typically given no corresponding psychiatric diagnosis (Eriksen & Kress 2005). SUMMARY AND CONCLUSIONS In summary, it has been shown that the BDI was created in the historical context of the rise of psychopharmacol- ogy and DSM nosological classification systems in the mental health care system, … I love class so this brief video is meant for helping you. Get started on your paper part one the literature if you feel like 1. 1 of the tasks that you have to carry out for the paper is to identify scales measures inventories questionnaires whatever you want to call them know this is the same thing. That you can use to measure the 2. Main problems that you identified for your client annual case summary OK so we're going to use the vector oppression inventory as an example I just go through this process of 1st of all finding a suitable scale and then. Use for validation studies research articles. That provide data supporting the reliability and the from the duty of the sky OK so this is the best depression inventories been very widely used for many years and just a quick point here see this. Indicates
  • 48. that. There is a. Pharmaceutical company. Sponsoring this this. So this is the the P.D.I. to this 2nd version it contains 20 we we're looking at the $21.00 question version there is a shorter 13 question as a $21.00 question Asian and. There are 21 questions this is an explanation of what the scale consists of. Each answer scored on a scale of 0 to 3. And. This explaining the cutoff. Used to determine the Neville of depression the client has after completing this questionnaire of change from the original so they use it now 0 to 13 is minimal depression 1419 mild depression 2028 moderate depression 292638 severe depression so high in the The idea is that high a total scores indicate more severe depressive symptoms on U.C. scale. Another important thing in here is you see there is some instruction now. That that tells the person who's completing the. The scale the inventory. What they've got to do as an aside here when you create your yourself made scale which is another part of the assignment. Make sure that you give us a. Simple set of instructions on how to complete your selfmade. Scale OK. Back to this so anyway the back oppression him and Terry. Was. There is a link between this and the D.S.M.. Diagnosis of. Depressive Disorder which later became a major depressive disorder and. Beck has attempted to match the questions with the diagnostic criteria found in the D.S.M.. This raises an important question. Because the D.S.M. is not is not known for being scientifically valid or reliable. So this is. If it turns out not to be. Providing us with a scientific description of the real. Thing we call depression. Then that could impact the. The actual usefulness of meaningfulness of this kind of O.U.I. that's a whole different discussion practice that is a well used well known skull and it serves the purpose of being an example for how to you know. How to find a suitable scale and then to look to the scale world OK. Good research article. Which would constitute a validation study for this scale so you can see these different. These different. Categories. That according to back. Constitutes kind of a definition of depression these different things are aspects of depression according to back. So then you
  • 49. have the book once once the person has completed the inventory they just. Add up that the score was. According to the cutoff given right with getting you determine the level of depression try OK So then let's go to validation studies that look at this. So this is. From the International Journal of mental health nursing so if you if you read and are working in a crisis stabilize a ship you need to have a correct receive facility your view if you alongside mental health nurses. So that you know we we have certain overlaps in the work that we do. So this is a critique of the P.D.I. and its use of mental health Nessie So just take a look at the important things that make this article a good validation study. So we see here just an introduction to a bit of background about the beady eye that it was. Just like you saw it has a corporate sponsor so it was. A pharmaceutical corporate sponsor but it was designed to. In a way to prove the efficacy of antidepressant drugs if you used to be before the person starts treatment you get a certain measure to depression and then you can use it to throughout treatment and in the end of treatment 2 you can. Theoretically. Measure the client's improvement. Using this scale. And here the article is talking about the relationship between banks scale and the. The D.S.M. and how they scale this very morning is did you find. To become this compatible as possible with the D.S.M.. Definition of this. This construct we call depression. So then the the article goes on to talk about the strengths of the B.V.I. easy to use in school and then we go on to this very important section here it starts talking about reliability so he hears that he's going to he's come to give us some confirmation Alpha's which is what we're looking for what if you file for us. And our phones are our 1st range between 0 and one and these schools are really very good. 0.93 for college students 0.92 for psychiatric outpatients. And I've. Met analysis a number of studies who were good average. 0.91 so these figures are great as far as a liability is concerned that. The. Meet the criteria would be advisable study. However these caution here. That one group of research is of suggested P.D.I. may not be reliable for longer periods of time in known
  • 50. clinical samples after finding that Beady Eye schools declined by 40 percent of the 2 month long clinical sample. This was. A small role $170.00 Dorie as far as fix. Trees concerned but if. There is. A fair amount of evidence of its survival tool and look onto villages he is is the video I measuring depression is it measuring what we think it's measuring it measure with host to be measuring what it says it's. So. Here we sit here we see that according to these researches the contents of the face of the of the video to argue to be very high because the items of the video to now closely mirror the standard D.S.M. 4 this is written by the. Diagnostic criteria for depression so. That's where the kind of. 100 anyway. That the D.S.M. 4 is being taken as scientific fact here and so because the scale. Closely mirrors the diagnostic create criteria for depression in the D.S.M. 4 in this case. It's being being stated to her very high. Political. Problem is that the D.S.M. has not passed such. Rigorous test. And was different kinds of from the you hopefully will learned all about these and the. Videos about reliability and that see now the level of discriminative validity for the V.D.I. is less clear what that meaning is. Does it does it just is it able to discriminate between people who are actually depressed and people who are not depressed and so it doesn't seem to do so well there however if we take if we go the way of determining Flutie is if. We compare the results of the P.D.I. with the results of other depression scales other branches of depression and if they correlate highly then we can say that. These The fact that the case. Validates the the the I. Because. It also gives the same. The same kind of indications regarding depression as other well known well established measures of depression OK. So the summarizing then means for for the V.D.I. of his to lie his ease of use widespread utilize ation very good internal reliability high content validity when compared to the D.S.M. for criteria for depression good convergence for the other similar depression rating scales and a somewhat stable factor structure factor structure OK but that means factor structure actually if. You don't know about the causes of the
  • 51. statistics. All right. Then it's it's important to. Note when you when you're looking for articles some of Asian studies it's important to note. What population the. The instrument being used was normed on right so in this case the V.D.I. says it has no actual launch population norms per se so it's difficult to determine if any given individual's level of depression as determined by the V.D.I. is normal in any sense of what word so that's kind of a problem. Yeah you know do you know the original sample from which the beady eye to a standardized was predominantly Caucasian and is greatly missed representative of the U.S. population at large so that you sometimes find is that. The. Sound poll. That it's used for. The cooks standardizing the. Scale the tree question whatever. We did with that population that it was normal and on what is not necessarily representative all of wider population or sometimes you know. A scale of only even. One of only big normed on male participants. Nobody else. Are exceptions so this these these kind of these kind of. Things can. Kind of come because of the defect. Here saying that women tend to score higher on the B.T.I. than men for this would be one of those and. That is suggested here that that may be because the because some off the items on the scale show gender bias. And also several problems with the way that I feel is content to be the word you wanted and waited. Because each of a few you go back to the scale itself each of the items have equal weight. Because you just you're just scoring each item and then adding up the total. But the question is. For example you do suicidal for soul wishes. Right is that really equivalent to something my changes in appetite for feeling tired on boss of interest in sex I mean devoted to those really. Quite to the extent that you could wait to the quickly the answer is obviously no so there is criticism on the V.D.I.. Then again then another another problem with any kind of questioning is the order in which the I'm too soft place because sometimes this can create. Test taking a moment such as. A person. Just hearing you sound as if several offers of notice you know that the obvious ordering of **** in the video I may need to response is
  • 52. reflective of faking social desirability that is that person. Gives the answers that they think the person of mainstream test wants them to get. Laid off alternatively they don't want to be. Putin in a negative way so they get off of things that they think will make them look better and it's cetera All right so that's that's always something you have to consider that any question in. Order to attract just adding up the score is. And there's the bit about should early morning awakening be counted do the same balance as guilt or suicidality not as if they are of equal importance in determining determining a person's level to oppression. And. The creators of the video I have offered no justification for such a stance. The V.D.I. is supposedly a theoretical However it is linked to particular cognitive behavioral perspective as Fast 5 back to his colleagues and so. In that sense it's not a theoretical This is sort of it's sort of reflects back on. Views on this abstract called struck. The recall depression. So there is that there. Was specks no different from anybody else in very his own theory laden this fictive and concepts will filters. To his thought. Process. OK so other other criticisms say you can read. The whole story so thanks. To you have selected items that reflect a theoretical stance whereby the problem in this case depression is seen to live within the individual and. Neglect. The multitude of external factors that could be impacted person. Such as I believe and discrimination based You just search it searching for a. Problem because he's taking a certain way. Because this is very much a medical model you're depressed a. Chemical Imbalance is he is a myth. And you know more about this but just for us to say there is no. Scientific basis for most of this chemical balance theorizing. You know this stuff happens person's life is very likely to. Be what we call depression. It's not necessary to do the genes of. Biochemistry. I think. That's another home of the debate let's get back to the. Task at hand here. All right so. This isn't the point here that the V.D.I. exhibits the spiritual problem of reification with a tendency to view abstract concepts as actual entities that is the creation of the video I would have us believe
  • 53. that the simple process of adding up the houses to 21 questions about various symptoms and I choose allows us to measure with a single number the quantity over and liability identifiable The whole question as if we were measuring the weight or height of an individual OK So this is so again. Down to the whole you know what is what are these so called mental health conditions. You know we're we develop the whole system of labeling and. Identifying labeling and treating these so-called mental illnesses as if things were made a whole nation who. Come to use the medical model and of course it's suits. The health insurance companies should sue speak pharma suits the OS of the system. Is really based on. Good science so the question. Of. Issues of alive if you do if you D.S.M. 4 this is a good article because it actually raises this point. After coefficients for the diagnosis of depression most point 25 so that this is this is a massive debate but it's important to recognize that this. So-called mental health or psychiatric Bible the D.S.M. 5 now. We take it as it is. As factual. But it's really a compilation of expert opinion. Does not or has not. To this point in time. Provided a scientific basis. And so. Their liability to important to remember. OK so. It. Could cost you. So that's that's that constitutes a very good excellent in fact awful Don't use this one though if you should if you decide to if you decide to use if you're if you one of your clients problems is depression and you want to use the victim Persian inventory that's fine but please find your own. Nation studies phone just use this one because part of this. Exercise that you know of one is choose to do research yourself you'll find plenty of other. Research articles on the V.D.I. OK that's it for now. So.