Beck Depression Inventory vs. Hamilton Depression Scale Beck

The revised Beck Depression Inventory (BDI-II), published in 1996 was authored by Aaron Beck, Robert A. Steer, and Gregory K. Brown. Similar to its predecessor, it consists of 21multiple choice questions that assist in determining the severity of depression. Each item consists of four statements arranged in order to ascertain the severity of a certain symptom of depression. BDI-II conforms to the DSM-IV criteria for depression. Clients who are presented with the BDI-II are asked to answer each question based upon the way they have felt for the past two weeks in order to accurately conform to the DSM-IV criteria. The BDI-II is intended for adolescents and adults and should not be administered to those under the age of thirteen.

Scoring

The BDI-II consists of twenty one questions, all of which correspond to a particular symptom of depression. Each item consists of a four point scale ranging from 0-3. Items 16 and 18 consist of seven items which are used to indicate an increase or decrease in both sleep patterns and appetite. A total score of 0-13 is considered minimal range, 14- 19 is considered mild, 20-28 is considered moderate, while 20-63 is considered to be severe (Beck, Steer and Brown, 1961). The BDI-II may be scored by hand or by using a software program such as Q Local, where the scores may be recorded and monitored by the clinician. The test may be administered frequently, as it is intended to monitor symptoms that have occurred within a two week range.

Reliability

Beck’s Depression Inventory II has been used for many years with great success. Its reliability is still questioned by some. Sprinkle, Lurie, Insko, Atkinson, Jones, Logan and Bassada (2002) state that “Although the BDI-II manual (Beck, Steer, & Brown, 1996) and various other reports (e.g., Dozois et al., 1998, and Steer, Kumar, Ranieri, & Beck, 1998) have offered substantial evidence for the instrument’s commendable “split-half” internal consistency (with reported coefficient alphas of .91 and slightly higher), there are only two published reports to date on the instrument’s test- retest reliability (par.6). Sprinkle et al., (2002) further report “Beck, Steer, and Brown (1996) reported on 26 outpatients (no diagnostic information is offered) who were administered the BDI-II at the times of their first and second therapy sessions (approximately one week apart), producing a test-retest correlation of .93” (par 6).

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Validity

Validity of the BDI-II appears to be favorable. A study conducted by Storch, Roberti and Roth (2002) examined the psychometric properties of the BDI-II. 414 students from two separate universities participated in the study. Their results “supported BDI-II two-factor structure measuring cognitive-affective and somatic depressive symptoms” (par.1). They concluded that the validity of the BDI-II was supported by favorable results “with self-report measures of depression and anxiety” (par.1). The results of this study duplicate past research of a college sample which supported the reliability and validity of the BDI-II.

Arnau, Meager, Norris, and Bramson (2001) also conducted a psychometric evaluation of the BDI-II using primary care patients. The study consisted of 340 primary care patients (7 of which were eliminated due to incomplete responses). 68.8% of the participants were female and the age group tested ranged from ages 18-54(M = 36.5, SD = 10.1, Arnau et al., 2001). The average score from the participants was 8.4 (SD = 9.7). They reported that “scores of 14 or higher, suggesting at least a mild level of depression (Beck et al., 1996 as cited in Arnau et al., 2001) were observed in 23.2% of the sample” (p.3). Arnau et al., (2001) also found an alpha coefficient of .94, which they considered to be excellent internal consistency. They concluded that the BDI-II “yielded strong evidence for the factorial validity of the BDI-II in a primary care setting” (p.6). They found that the BDI-II could easily be implemented into the primary care setting without disrupting patient flow.

BDI-II Reviews

Arbisi and Farmer, reviewers of BDI-II indicate that the BDI-II is easy to administer and requires approximately five to ten minutes to complete. Arbisi states concern however, that “there are no validity indicators contained on the BDI or the BDI-II and the ease of administration of a self-report lends itself to the deliberate tailoring of self-report and distortion of the results” (Beck, Steeler & Brown, 1961 par. 5).

Arbisi and Farmer concur that the manual BDI-II was well written and provides a multitude of supportive information regarding “norms, factor structure, and notably, nonparametric item-option characteristic curves for each item” (Beck, Steer & Brown, 1961 par. 4). They contend that the BDI-II “has improved upon the original by updating the items to reflect contemporary diagnostic criteria for depression and utilizing state-of-the-art psychometric techniques to improve the discriminative properties of the instrument” (Beck, Steer & Brown, 1961 par. 10). Although the reviewers have noted their concern regarding the lack of room for diversity, Arbisi and Farmer appear to approve of its use as a depression assessment tool.

Hamilton Depression Scale

The Hamilton Depression Scale (abbreviated as HDS, HAMD or HAD) is used to measure the severity of symptoms of depression. For many years it was considered to be the “gold standard”. It was developed by Max Hamilton in the late 1950s and was used to evaluate the performance of the first antidepressants. It was released in 1960. Upon its release, Hamilton acknowledged that it had “room for improvement” (p. 56). He revised the HDS in 1967. The HDS consists of 21 multiple choice questions. The first 17 questions determine the severity of the depression symptoms, while the additional four questions address the areas of paranoia and obsession and their relation to depression .The HDS can be administered to both children and adults. It is considered to be easy to read and interpret; it is recommended that the HDS be administered only by a licensed professional.

Scoring

The HDS was intended to be administered by an experienced clinician by conducting a clinical interview.  Scoring and administrating the scale may be considered cumbersome as Hamilton did not provide structured guidelines for this purpose. “No standardized probe questions were provided to elicit information from patients and no behaviorally specific guidelines were developed for determining each item’s rating” (Health Care Technology Systems, 2010). Seventeen items are rated on a 5-point (0-4) or a 3-point (0-2) scale. Overall scores of 0-6 are considered normal. Scores from 7-17 are indicative of mild depression. Scores from 18-24 represent moderate depression. Scores that are greater than 24 are representative of severe depression.

Reliability

Bagby, Ryder, Schuller, and Marshall (2004) state that “Clinician-rated instruments should demonstrate three types of reliability: 1) internal reliability, 2) retest reliability, and 3) interrater reliability” (par.4). They contend that the internal reliability of the HDS estimates ranged from “0.46 to 0.97, and 10 studies reported estimates 0.70″ (par.5). They further contend that the majority of items contained in the HDS indicate sufficient reliability .Per their testing, the following items were met in each sample:” (Guilt, middle insomnia, psychic anxiety, somatic anxiety, gastrointestinal, 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, hypochondriasis)” (par.6). A potential problem was suggested with loss of insight, as it had the greatest number of variables. Interrater reliability was considered to be poor. Cicchetti and Prusoff (1983, as cited in Reynolds and Kobak, 1995) state “in a study of interrater reliability of a 22-item version of the HDRS found low levels of reliability for individual items, with 14 of the 22 items demonstrating intraclass correlation coefficients of less than .40” (par. 4).

Retest Reliability

Scores for the retest reliability of the HDS ranged from 0.81 to 0.98. Williams (1998 at cited in Bagby et al., 2004) “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” (par.8). Doing so increased the retest reliability to 0.54 in spite of the fact that only four items met the necessary criteria for reliability; i.e.: “depressed mood, early insomnia, psychic anxiety, and loss of libido” (par.8).

Validity

The Hamilton Depression Scale is comprised of 1) Content, 2) Convergent, 3) Discriminant, 4 Factorial, and 5) Predicative Validity. Content validity is determined by “examining scale items to determine correspondence with known features of a syndrome” (Bagby et al., 2004 par. 9). Convergent validity is sufficient when a scale indicates Pearson’s r values of a minimum of 0.50 in conjunction with measures of the same syndrome. Discriminant validity is determined by indicating that groups that differ in diagnostic status may be separated through the use of the scale. “Predictive validity of symptom severity measures such as the Hamilton depression scale is determined by a statistically significant (p<0.05) capacity to predict change with treatment" Bagby et al., 2004 par. 9). Factorial validity may be established by using factor analysis or principal-component analysis to indicate that a positive example can be found in several samples.

HDS Reviews

Bernard Carroll wrote a letter to the editor of the American Journal of Psychiatry in December, 2005 entitled: “Why the Hamilton Depression Scale Endures.” He offers three reasons why the HDS remains the gold standard. First of all, he contends that Hamilton’s HDS “focused on patient’s burden of illness” (par.1). He suggests that this is the reason why the HDS contains examples of anxiety that are present in depressive episodes, but are not part of the diagnosis for depression. He further contends that Hamilton intended the use of this scale for client’s that are well known by the clinician. In this light, the HDS displays a range “from mild to extreme illness” (par. 1).

Second, Carroll contends that the demand for a revised scale based upon modern criteria of major depression is not realistic. Carroll believes that “Current definitions of major depression, instantiated in DSM-IV, for instance, are deliberately atheoretical nominalist conventions that lack unifying constructs, predictive validity, and explanatory power” (par.2). He believes that this is the reason why those who are diagnosed with DSM-IV criteria for major depression are so contrasting. He adds: “In the future, we might add biomarkers or endophenotypes to clinical symptoms in assessing depression, but that day is not here” (par.2).

Third, Carroll does not believe that the HDS has been outmatched in performance. He does not believe that the HDS is insensitive to changes in the severity of depression symptoms. When compared to the Montgomery-Asberg Depression Rating Scale, he believes that the Hamilton Depression Scale is superior in its “sensitivity to change and in detecting early change with treatment while having the advantage of far more comprehensive symptom coverage” (par.3).

Carroll concludes his letter by stating” The endurance of the Hamilton depression scale is remarkable, considering how many unauthorized, nonvalidated, mutant versions now circulate (Hamilton’s original 17 items have expanded to 28 at my last count). This is not progress, however, because the text versions and procedural use in many contemporary treatment trials are corrupted” (par 4).

Paul C Burnett, a reviewer of the HDS contends that the manual is “extensive and comprehensive” (par.2). The instructions for administering the test are clear and contain examples of the scoring process. All of the symptoms contained in the test are described and provide examples to be used in the interviewing process. He believes that the symptoms contained in the test conform to the criteria listed in the DSM-IV.

The manual, which contains a sample of 202 depressed patients, is comprised of 76% inpatients, 24% outpatients, and 69% female (par.3). The manual contends that the demographics are fair, despite the fact that no data is provided to support this. He contends that the manual did not include data to support the procedure that was utilized to select this demographic.

Burnett states that “Internal consistency estimates were found to be .79 and .81 for the clinical and self-report forms respectively, indicating moderate reliability” (par. 4). Other studies suggest that the internal consistency range from .45 to .95, which is stated in the manual as “consistent with the results from the verification sample” (par.4). Burnett does not consider a range of .45 to .81 as acceptable internal consistency.

Burnett concludes that the HDS consists of a well written and concise manual, which clearly describes the administration and scoring process. He finds that the two scales have “moderate internal consistency, sound concurrent validity, and relatively consistent and stable factor structures” (par. 7). His only complaint is that the verification sample is minimal and does not sufficiently describe the manner in which it was selected.

The Stronger Assessment Tool

Both Aaron Beck and Max Hamilton have created an assessment tool to determine the severity of the symptoms of depression. While Hamilton’s Depression Scale was considered to be the gold standard, and may be administered to both children and adults, one would have to conclude that Beck’s Depression Inventory-II is the stronger of the two assessments. It appears that the BDI-II can be administered with ease and does not require an interviewing process. The BDI-II has been revised to monitor the severity of symptoms of depression for the last two weeks, while Hamilton’s HDS does not state such strict guidelines. It also appears as though the BDI-II contains a stronger internal consistency with an alpha coefficient of .95 as opposed to the HDS internal coefficiency of .79 and .81.

Another reason for this conclusion was the original intention of use of the scales. Hamilton’s HDS was developed to evaluate the performance of the first generation of antidepressants, while Beck’s Depression Inventory was developed to determine the nature of the severity of symptoms of depression without the use of medication. Beck’s BDI-II appears to have surpassed the HDS as reviewers have considered this assessment tool as “utilizing state-of-the-art psychometric techniques to improve the discriminative properties of the instrument” (Beck, Steer & Brown, 1961 par. 10). It appears as though Beck’s BDI-II is the preferred choice among today’s clinicians.