Академический Документы
Профессиональный Документы
Культура Документы
An
for
The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been
pointed out by a number of authors.
Pasamanick12 in a recent article viewed
the low interclinician agreement on diagnosis
as an indictment of the present state of
psychiatry and called for "the development
of objective, measurable and verifiable
criteria of classification based not on personal or parochial considerations, but on
behavioral and other objectively measurable
manifestations."
Attempts by other investigators to subject
clinical observations and judgments to objective measurement have resulted in a
wide variety of psychiatric rating scales.4,15
These have been well summarized in a review article by Lorr11 on "Rating Scales
and Check Lists for the Evaluation of
Psychopathology." In the area of psychological testing, a variety of paper-andpencil tests have been devised for the purpose
of measuring specific personality traits; for
example, the Depression-Elation Test, devised by Jasper9 in 1930.
This report describes the development
of an instrument designed to measure the
behavioral manifestations of depression. In
the planning of the research design of a
project aimed at testing certain psychoanalytic formulations of depression, the necessity
for establishing an appropriate system for
identifying depression was recognized. Because of the reports on the low degree of
Inventory
Measuring
Depression
A. T. BECK, M.D.
C. H. WARD, M.D.
M. MENDELSON, M.D.
J. MOCK, M.D.
AND
J. ERBAUGH, M.D.
PHILADELPHIA
nesota
for
562
population.
Method
A. Construction of the Inventory.The items in
this inventory were primarily clinically derived.
In the course of the psychoanalytic psychotherapy
of depressed patients, the senior author made sys
tematic observations and records of the character
istic attitudes and symptoms of depressed patients.
He selected a group of these attitudes and symptoms
that appeared to be specific for these depressed
patients and which were consistent with the de
scriptions of depression contained in the psychi
atric literature.10 On the basis of this procedure,
he constructed an inventory composed of 21 cate
gories of symptoms and attitudes. Each category
describes a specific behavioral manifestation of
depression and consists of a graded series of 4
to 5 self-evaluative statements. The statements
are ranked to reflect the range of severity of the
symptom from neutral to maximal severity. Nu
merical values from 0-3 are assigned each state
ment to indicate the degree of severity. In many
categories, 2 alternative statements are presented
at a given level and are assigned the same weight ;
these equivalent statements are labeled a and b
(for example, 2a, 2b) to indicate that they are
at the same level. The items were chosen on the
basis of their relationship to the overt behavioral
manifestations of depression and do not reflect any
Guilty Feeling
f. Sense of Punishg.
1. Social Withdrawal
Indecisiveness
m.
n.
Body Image
Work Inhibition
p. Sleep Disturbance
o.
ment
r.
Self-Hate
s.
Fatigability
Appetite
Weight Loss
t.
Somatic Pre-
u.
Loss of Libido
h. Self Accusations
i. Self Punitive
Wishes
q.
Loss of
occupation
j. Crying Spells
54-
DEPTH OF DEPRESSION
563
Schizophrenic reaction
Psychoneurotic depressive reaction
Anxiety reaction
Involutional reaction
00
t-i
2
^
S
F5
2S
CO
-i
28.2
25.3
15.5
5.5
4.7
4.5
4.5
3.4
1.8
1.8
4.8
100.0
D. External Criterion.The patient was seen
either directly before or after the administration
of the Depression Inventory by an experienced
psychiatrist who interviewed him and rated him
on a 4-point scale for the Depth of Depression.
The psychiatrist also rendered a psychiatric diag
nosis and filled out a comprehensive form de
signed for the study. In approximately half the
cases, the psychiatrist saw the patient first ; in
the remainder, the Depression Inventory was ad
ministered first.
Four experienced psychiatrists participated in
the diagnostic study.* They may be characterized
as a group as follows :
approximately 12 years
experience in psychiatry, holding responsible
teaching and training positions, certified by the
American Board of Psychiatry, interested in re
search, and analytically oriented.
The psychiatrists had several preliminary meet
ings during which they reached a consensus re
garding the criteria for each of the nosological
entities and focused special attention on the various
types of depression. In every case, the Diagnostic
and Statistical Manual of Mental Disorders of the
American Psychiatric Association1 was used, but
it was found that considerable amplification of the
diagnostic descriptions was necessary. After they
had reached complete agreement on the criteria
to be used in making their clinical
judgments, the
psychiatrists composed a detailed instruction man
ual to serve as a guide in their diagnostic eval
uations.
The psychiatrists then participated in a series
of interviews, during which two of them jointly
interviewed a patient while the other two ob
served through a one-way screen. This served as
the
Beck et al.
55
564
specific diagnoses.
To establish the
degree
of agreement,
the
Speed
III.
Vegetative Signs
Sleep
Appetite
Constipation
tensity
occupation
Amount
Conscious guilt
Suicidal content
IV. Psychosocial
Performance
Indecisiveness
Loss of drive
Loss of interest
Complete
agreement
Fatigability
The
of
showed the
Vol. 4,
June,
1961
DEPTH OF DEPRESSION
565
by Ranks,14 it was found that all of Depression was made by one of the
categories showed a significant relationship psychiatrists. The interval between the 2
to the total score for the inventory. Sig
tests varied from 2 to 6 weeks. It was found
nificance was beyond the 0.001 level for all that changes in the score on the inventory
categories except category S (Weight-loss tended to parallel changes in the clinical
category), which was significant at the 0.01 Depth of Depression, thus indicating a con
level.
sistent relationship of the instrument to the
The second evaluation of internal con patient's clinical state. (These findings are
sistency was the determination of the split- discussed more fully in the section on valida
half reliability. Ninety-seven cases in the tion studies.)
first sample were selected for this analysis.
An indirect measure of inter-rater relia
ance
The Pearson
categories
liability coefficient
was
man-Brown
to 0.93.5
Certain traditional methods of assessing
the stability and consistency of inventories
and questionnaires, such as the test-retest
method and the inter-rater reliability method,
were not appropriate for the appraisal of
the Depression Inventory for the following
reasons: If the inventory were readministered after a short period of time, the
correlation between the 2 sets of scores could
be spuriously inflated because of a memory
factor. If a long interval was provided,
the consistency would be lowered because
of the fluctuations in the intensity of de
pression that occur in psychiatric patients.
The same factors precluded the successive
administration of the test by different in
terviewers.
Two indirect methods of estimating the
stability of the instrument were available.
The first was a variation of the test-retest
method. The inventory was administered to
a group of 38 patients at two different
times. At the time of each administration
of the test, a clinical estimate of the Depth
\s=s\This procedure is designed to assess whether
variation in response to a particular category is
associated with variation in total score on the
inventory. For each category, the distribution of
total inventory scores for individuals selecting a
particular alternative response was determined.
The Kruskal-Wallis test was then used to assess
whether the ranks of the distribution of total scores
increased significantly as a function of the differences in severity of depression indicated by these
alternative responses.
Beck et al.
interviewers
was
mean
tory.-The
means
score.
The Kruskal-Wallis
Analysis
One-way
57
566
Depression
Inventory Scores and Clinicians' Ratings
of Depth of Depression
ft
Correlation
Coefficient *
o"
Study I
Study II
226
0.65
183
0.67
Standard
Error
0.068
0.059
<0.01
<0.01
Nw
*
ta
o t
00 M
t--s
00
te;
o s
ri
-s-s-i
S? ^
f-
o w
t~
C3
If
-e
K s
o.g
2 "5
z;
es
S!
t> 00
00
w m
os
M 00
rt' =>'
='
>> 1
aw
SS
mCQ
to
<
-"-
r.
<o
,2
Pearson biserial
a
2
a
o
58
Vol. 4,
June, 1961
DEPTH OF DEPRESSION
567
those 2
"S
a
S I
>
.
ai
d
"
o
o
'
S
?
S s "
0
a
oS
te.
Depression
correctly predicted.
was
Comment
<
The
Ss
g
to
II
CO
Table
2
CQ M
OD
g S&
"a
Depth of Depression
Eh
255
Beck et al.
Decreased
Increased
Depression
Inventory
Decreased
26
Score
Increased
59
568
liability
primary diagnosis
of
569
DEPTH OF DEPRESSION
REFERENCES
diagnostic categories. A re
gressed schizophrenic, for example, might
among standard
Summary
The present study describes an inventory
which has been developed to provide a
quantitative assessment of the intensity of
depression. This instrument was admin
istered by an interviewer to a random sample
of 226 clinic and hospitalized psychiatric
patients. For purposes of replication, a
second sample of 183 cases was subjected
to the same procedure. Independent clinical
ratings of the Depth of Depression were
made by experienced psychiatrists.
Studies of the internal consistency and
stability of the instrument indicate a high
degree of reliability. Comparisons between
the scores on the inventory and the clinical
judgments by the diagnosticians indicate a
high degree of validity.
The inventory was able to discriminate
effectively among groups of patients with
varying degrees of depression. It also was
able to reflect changes in the intensity of
depression after an interval of time. In
view of these attributes of reliability and
validity, this instrument is presented as a
useful tool for research study of depression,
and as a step in the direction of placing
psychiatric diagnosis on a quantitative basis.
The authors wish to express their appreciation
to their consultants, Seymour Feshbach, Ph.D. and
Marvin Hurvich, Ph.D.
Department of Psychiatry, Research Labora
tories, Hospital of the University of Pennsylvania,
3400 Spruce St., Philadelphia 4.
Beck et al.
(Jan.) 1950.
9. Jasper, H. H.: A Measurement of Depression-
Measure of Extra-
Appendix
Depression Inventory
A
(Mood)
570
2b I
am so
sad
or
painful
I am so sad
stand it
unhappy that
or
unhappy
it is very
that I can't
(Pessimism)
la
2a
particularly pessimistic or
discouraged about the future
I feel discouraged about the future
I feel I have nothing to look forward
am
not
ever
get
over
troubles
I feel that the future is hopeless and
that things cannot improve
C (Sense of Failure)
0 I do not feel like a failure
1 I feel I have failed more than the
average person
2a I feel I have accomplished very little
that is worthwhile or that means any
goes wrong
2b I feel I have many bad faults
I
thing
J (Crying Spells)
0
1
2
3
Punishment)
may happen to me
I feel I am being punished
am
no
more
irritated
now
2
3
than I used to
I feel irritated all the time
I don't get irritated at all at the
that used to irritate me
than I
will be
punished
3
62
get annoyed
or
irritated
more
easily
things
(Social Withdrawal)
0
1
punished
3a I feel I deserve to be
3b I want to be punished
2
or
ever am
I
I
I
I
(Irritability)
0
worthless
(Sense
(Self-punitive Wishes)
I don't have any thoughts of harming
myself
1 I have thoughts of harming myself but
2b As I look back
of
weaknesses or mistakes
2a I blame myself for everything that
my
(Self Accusations)
to
(Self Hate)
0
la
lb
2
3
571
DEPTH OF DEPRESSION
Q (Fatigability)
(Indecisiveness)
out
help
more
(Body Image)
1
2
3
looking
doing something
anything
(Sleep Disturbance)
0 I can sleep as well
1
2
as usual
I wake up more tired in the morning
than I used to
I wake up 1-2 hours earlier than usual
and find it hard to get back to sleep
I wake up early every day and can't
get more than 5 hours sleep
Beck et al.
more
more
more
than 5 pounds
than 10 pounds
than 15 pounds
(Somatic Preoccupation)
(Work Inhibition)
lately
I have lost
I have lost
I have lost
U (Loss of
Libido)
2
3
to
be
63