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A revised Spanish version of the Beck Depression Inventory: Psychometric properties with a Puerto Rican sample of college students

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A revised Spanish version of the Beck Depression Inventory: Psychometric properties with a Puerto Rican sample of college students
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  A Revised Spanish Version of the Beck DepressionInventory: Psychometric Properties with a Puerto RicanSample of College Students  Janet Bonilla University of Puerto Rico-Mayagüez  Guillermo Bernal and Axel Santos University of Puerto Rico-Río Piedras  Douglas Santos University of Puerto Rico-Mayagüez The Beck Depression Inventory (BDI) is a widely used self-report measurefor depression. This study has two objectives: (a) to revise, develop, andadapt a Spanish language BDI (BDI-S) that takes the criteria for the diag-nosis of major depression according to the DSM-IV into consideration; and(b) to evaluate the psychometric properties (internal reliability and con-struct validity) of the revised version of the BDI (BDI-S). A sample of 351undergraduate students at the University of Puerto Rico participated inthis study. The participants who agreed to participate in the study andsigned the consent form completed self-report measures related to depres-sion (BDI-S, CES-D, and LCSd-7), dysfunctional cognition (DAS-A and IBT),stressful life events (LES), and social support (CAS). The coefficient ofinternal consistency obtained for the 22 BDI-S items was .88. The corre-lation coefficients between the BDI-S and instruments that measured otherconstructs (not depression) were lower than the correlation coefficientsbetween instruments that measured the same constructs. Factor analysis This research was supported by the Institutional Funds for Research Program (FIPI) from the Dean of GraduateStudies and Research of the University of Puerto Rico-Río Piedras (UPR-RP) and by funds of ATLANTEAProjects from the Presidency of the University of Puerto Rico. This research also was supported by the CUSEPat the UPR-RP. We are grateful to the following research assistants: Nelson Varas, Lymaries Padilla, MildredMaldonado, Eduardo Lugo, Arelis Rodríguez, Tania Maysonet, Sheilla Rodríguez, Lionel Martínez, ElixmahirDávila, Vannessa Arce, Gerardo Soto-Mayor, Yvette Portell, and Glorimar Miranda.Correspondence concerning this article should be addressed to: Janet Bonilla, Department of Social Sciences,UPR-Mayagüez, P.O. Box 9266, Mayagüez, Puerto Rico, 00681–9266; e-mail: janet_bonilla@yahoo.com. JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 60(1), 119–130 (2004) © 2004 Wiley Periodicals, Inc.Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10195  revealed that the factor loading for the BDI-S was congruent with dimen-sions of depression reported in the literature. These results generally sup-porttheinternalconsistencyandtheconstructvalidityoftheBDI-S. ©2003Wiley Periodicals, Inc. J Clin Psychol 60: 119–130, 2004. An epidemiological study conducted in Puerto Rico found that mood disorders evaluatedaccording to the Diagnostic Interview Schedule (DIS) constitute the fourth most preva-lent psychiatric disorder among 16- to 64-year-olds (Canino, Bird, et al., 1987). Amongthis population, 7.9% have presented some type of mood disorder at some point in theirlives and 2.9% during the last six months. The prevalence of major depression in thispopulation is specifically 4.6%. Canino, Rubio-Stipec, et al. (1997) reported higher lev-els of depressive symptomatology and mood disorders in women than in men (2:1 to 3:1)and in Hispanics as well as in Anglo-Saxons.The prevalence rate of depression in Puerto Rico supports the need to develop, orrevise, and adapt instruments in Spanish to measure this mental health condition. Fur-thermore, depression is one of the most frequent reasons reported by Puerto Ricans forseeking psychological services (Rosselló & Bernal, 1996).The 21-item version of the Beck Depression Inventory (BDI) is widely used in clin-ical and research contexts. It is a sensitive measure for depressive symptoms and issimple to administer and code (Beck, 1967; Beck, Weissman, Lester, & Trexler, 1974).However, although it is a sensitive instrument to measure different levels of depression,it was not developed to establish clinical diagnosis (Beck et al., 1974).The reliability and validity of the BDI has been fully documented in NorthAmericanand European contexts (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; Bernal, Bon-illa, & Santiago, 1995; Vázquez & Sanz, 1991). The internal (  . 86–.93) and temporal( r   .82) reliability of the BDI for English-speaking populations is considered very good(Beck et al., 1974; Nietzel, Russell, Hemming, & Greter, 1987). In European and Spanish-speaking populations, Sanz and Vázquez (1993) reported an internal reliability of .93(split-half method).Concurrent validity of the BDI has been supported in studies that compared the totalscore of the instrument with scores obtained from global scales for psychiatric symptom-atology (Beck & Beamesderfer, 1974; Beck et al., 1961). Beck and Beamesderfer (1974)reported that in nine studies conducted in the United States and Europe, the correlationbetween the BDI and other instruments used to measure depression that were adminis-tered concurrently (e.g., Hamilton Rating Scale) fluctuated between .61 and .73. In Spain,Conde-López, Chamorro, and Useros-Serrano (1976) studied the concurrent validity of the BDI with the Global Rating Scale in clinical and community samples. They reporteda correlation coefficient, between both instruments, of .72 for the clinical sample and .76for the community sample.The construct validity of the BDI also has been evaluated using factor analysis. Themost consistent factors reported include the following two areas of depression:  somatic (items on insomnia and weight and appetite loss) and  self-esteem  (items on feelings of failure, guilt, and self-punishment).Ahigh internal reliability for the BDI was obtained (  .89) in a study conducted byBernal, Bonilla, and Santiago (1995) with a sample of 300 outpatients at the UniversityPsychological Services and Research Center (CUSEP) in Puerto Rico. Furthermore, the 120  Journal of Clinical Psychology, January 2004  construct validity of the instrument was supported using factor analysis. The factorsidentified in the study were consistent with the conceptualization of depression and withfactors that have been identified in other studies (Beck & Beamesderfer, 1974). Fourfactors were identified:  negative attitudes or sadness  (e.g., items on feelings of failure,self-deception, guiltiness, crying, and ideas of suicide);  cognitive-behavior   (e.g., itemson dissatisfaction, irritability, loss of interest in social activities, and fatigue);  biological (e.g., items on insomnia, loss of appetite, lost of interest in sex); and  somatic  (e.g., itemsabout physical problems).The literature reviewed suggests that reliability and validity of the BDI is supportedin different cultural contexts as well as in different samples (e.g., clinical and communitypopulations). The study presented here has two objectives: (a) to develop, or revise, andadapt a Spanish language BDI (BDI-S) that takes diagnostic criteria for mayor depressionaccording to the Diagnostic and Statistical Manual of Mental Disorders, fourth ed. (DSM-IV; American Psychiatric Association, 1994) into consideration; and (b) to evaluate thepsychometric properties (internal reliability and construct validity) of the revised versionof the BDI (BDI-S). The working hypotheses were the following: (a) The BDI-S willyield a high internal reliability coefficient, (b) the BDI-S will yield high correlationcoefficients with other instruments that measure depressive symptomatology, and (c6)the BDI-S will yield a factorial structure consistent with the factors previously identifiedin the conceptualization of depression.Method Participants A total of 351 undergraduate students from the University of Puerto Rico, with a meanage of 21.65 ( SD  4.03) years, participated in this study.Approximately 7 of 10 partici-pants (69.02%) in the sample were women. A high percentage of participants were fromurban areas (74.4%,  n  261), single (68%,  n  238), and without children (79.9%,  n  280). The majority of participants were from Río Piedras (57.9%,  n  201) and May-agüez (31.7%,  n  110) campuses, followed by Bayamón (8.6%,  n  30) and MedicalSciences (1.7%,  n  6) campuses. Participants’educational level varied between one andseven years of undergraduate studies (mean  3.34 years; DT  1.3 years). Sixty-onepercent ( n  213) of the participants lived with their parents while attending college, andothers lived with relatives (4.5%,  n  16), sexual partners (4.5%,  n  16), or alone (3.9%, n  14). The remaining 26.2% ( n  92) of the sample did not respond to the question.Half of the participants were employed while studying (51%,  n  170). Most participantswere from the faculty of Social Sciences (44.9%), followed by Business Administration(17%), Natural Sciences (16.1%), Engineering (15.1%), Humanities (4.4%), Public Com-munication (2%), and Architecture (.5%).  Instruments Arevised Spanish-language version (BDI-S) of the 21-item BDI was used in conjunctionwith self-report measures for the following variables: depressive symptomatology, cog-nitive dysfunctions, stressful life events, and social support. The instruments used in thisstudy are described next.  BDI-S.  This instrument contains three sections. All items in the three sections areanswered within a 14-day time frame; the srcinal BDI used a time frame of 7 days. This  BDI-S in Puerto Rico  121  time frame adapts the BDI-S to the temporal criteria for major depression in the DSM-IV.The first section of the BDI-S contains 22 groups of sentences used to evaluate depres-sive symptomatology (see Table 1). Item 22 was added to measure the respondent’s psy-chomotor activity. In addition, the bidirectionality of these depressive symptoms specifiedin the DSM-IV were collected by items in this section. Examples of bidirectionality arepresented in Table 1 (e.g., weight loss or weight gain). The total score of the BDI-Sfluctuates from 0 to 66. The authors developed the second and third sections of theBDI-S. The second section included 12 sentences to evaluate functional impairment inareassuchasinterpersonalrelationships,occupationalcontext,andotherimportantaspects.The third section has three questions regarding the use of drugs or other substances (e.g.,medication or alcohol), the presence of a medical condition that can affect the state of mood of an individual, and the loss of a relative during the last two months. Center Epidemiology Scale for Depression (CES-D).  The CES-D is a short self-report scale widely used in epidemiological studies specifically designed to measuresymptoms of depression.The CES-D consists of a 3-point Likert scale, which includes 20items to measure the frequency and magnitude of depression symptoms. The score of theCES-D can fluctuate from 0 to 60, with a cutoff score of 16 (equivalent to six depressivesymptoms). The temporal and internal consistency of the CES-D, as well as its concur-rent and construct validity, has been well documented (Masten, Caldwell-Colbert,Alcala,& Mijares, 1986; Roberts, 1980; Vera et al., 1991). Table 1  DSM-IV Symptom Categories and BDI-S Items That Measure Major Depression DSM-IV Symptom CategoriesItemNumberDescription of BDI-S Item1. Depressed mood most of the day (feel sad or empty). 1 Mood (sadness)10 Mood (sadness)2. Markedly diminished interest or pleasure in all or almostall activities, most of the day.12 Diminished interest3. Significant weight loss when not dieting or weight gain; 18 Appetiteor decrease or increase in appetite nearly every day. 19 Weight4. Insomnia or hypersomnia early every day; psychomotor 15 Loss of energyagitation or retardation nearly every day; fatigue or loss 16 Sleepof energy nearly every day. 17 Lost of energy22 Psychomotor Activity5. Feelings of worthlessness or excessive or inappropriate 3 Worthlessnessguilt nearly every day; diminished ability to think or 5 Guiltconcentration, or indecisiveness, nearly every day. 7 Worthlessness8 Guilt13 Indecisiveness20 Worry6. Recurrent thought of death, recurrent suicide ideationwithout a specific plan, or suicidal attempts or specificplans for committing suicide.9 Suicide The major depressive disorder diagnostic requires the presence of at least five symptoms for 14 days. 122  Journal of Clinical Psychology, January 2004  Symptom Check List (SCL/LCS-36).  The SCL / LCS-36 was developed by McNeil,Greenfield, Attkinson, and Binder (1989) using as reference the LCS-90 developed byDerogatis, Lipman, and Covi (Derogatis & Cleary, 1977). The LCS-36 is a self-reportmeasure consisting of 36 items designed to examine psychiatric symptomatology. Itemsare answered using a 5-point Likert scale to indicate the presence and magnitude of symptoms (e.g., how much dislike or distress?).Ahigh internal reliability for the LCS-36(  .94) was reported by Bernal, Bonilla, and Santiago (1995) with a clinical sample of 300 outpatients in Puerto Rico. They also reported a factorial structure for LCS-36 con-sistent with those reported by Hoffman and Overall (1978), Lipman, Covi, and Shapiro(1979), and McNeil et al. (1989).In this study, seven items of the LCS-36, designed to evaluate symptoms of depres-sion, were used as a brief scale of depression (LCSd-7).The following items were includedin this brief scale: self-esteem, guiltiness, loss of interest, sadness, loneliness, psycho-motor retardation, and hopelessness. Version A of the Dysfunctional Attitudes Scale (DAS-A).  The DAS-A was used toevaluate dysfunctional attitudes associated with depression. This scale consists of 40items that are answered using a 7-point Likert scale. The score of the DAS-A can fluc-tuate from 0 to 280, with a cutoff score of 120 (For students, the cutoff score used is 140.)In studies conducted with several populations (e.g., clinical and community groups), theinternal reliability of the DAS-Ahas ranged from .79 to .92 and temporal reliability from.71 to .84.The construct validity of the DAS-Ahas been evaluated using several methods,and the results confirm its validity (Beck, Brown, Steer, &Weissman, 1991; Cane, Olinger,Gotlib, & Kuiper, 1986; Sanz & Vázquez, 1993; Weissman, 1979).  Irrational Belief Inventory (IBT).  The IBT also was used to evaluate dysfunctionalattitudes associated with depression. The IBT consists of 100 items in which high scoresare associated with a high presence and magnitude of dysfunctional cognitions. Previousstudies have found internal reliability of the IBTthat fluctuate between .66 and .80 (Jones,1969). The construct validity of the IBT has been evaluated through its relationship withmeasures of depressive symptomatology (Jones, 1969). Jones (1969) reported an associ-ation score of .53 between the IBT and the BDI.  Life Event Schedule (LES).  The LES is a self-report scale developed by Sarason,Johnson, and Siegel (1978) that consists of 57 items. Participants are asked to identifywhat events (i.e., marriage) they have experienced and the period of time that has elapsedsince they experienced this event (i.e., from 0 to 6 months ago or from 7 months to 1 yearago).Also, respondents evaluate the impact of the event using a Likert scale ranging from1 to 3 to indicate a positive experience and  1 to  3 to reflect a negative experience. Azero indicated that this particular event had no impact on the individual’s life during itsoccurrence. Social Support Questionnaire (Cuestionario de Apoyo Social; CAS—its name inSpanish).  The CAS was developed by Bernal, Maldonado, and Bonilla (1998). Severalinstruments such as the Inventory of Socially Supportive Behaviors (ISSB) and the Ari-zona Social Support Interview Schedule (ASSIS) were used as references to develop theCAS. The CAS consists of 12 questions and includes the following dimensions of socialsupport: type, need, sufficiency, and satisfaction with social support.Apreliminary studyreported an internal reliability of .68 for the CAS (Bernal et al., 1998). Furthermore,through factor analysis two dimensions of social support were identified: (a) type and  BDI-S in Puerto Rico  123
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