Correlations between BDI and CES-D in a sample of adolescent mothers.

Wilcox, Holly ; Field, Tiffany ; Prodromidis, Margarita 等

Depression is common among adolescents, affecting between 7% and 33% depending on its definition, assessment, and severity (Petersen, Compas, Brooks-Gunn, Stemmler, Ey, & Grant, 1993). Radloff (1991) found a dramatic increase in depression between the ages of 13 and 15, leveling off at approximately 17-18. Childbirth seems to increase the risk of depression, with Colletta (1983) reporting a rate of 59% for mothers aged 15 to 19.

Early pregnancy is also common. In a study on postpartum depression, age was made a covariate because of the disproportionate number of adolescents in the random sample of depressed mothers (Field, Healy, Goldstein, Perry, Bendell, Schanberg, Zimmerman, & Kuhn, 1988).

Identifying depression in adolescent mothers is crucial for their own well-being as well as that of their infants. Teenage mothers are noted to have less realistic developmental expectations and less desirable child-rearing practices (Field, Widmayer, Stringer, & Iganoff, 1980). Moreover, infants of adolescent mothers are more likely to have cognitive, emotional, and physical problems (Field et al., 1980). However, an understanding of adolescent depression has been hampered by a lack of well-established techniques for identifying this population (Roberts, Lewinsohn, & Seeley, 1991).

Two of the most commonly used instruments for detecting depression among adolescents are the Beck Depression Inventory (BDI) and the Center for Epidemiologic Studies Depression Scale (CES-D). The Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) has been used in over 200 studies on psychiatrically diagnosed patients (Piotrowski, Sherry, & Keller, 1985) and normal populations (Steer, Beck, & Garrison, 1986). The BDI has also been widely used to detect depression in normal adolescent samples (Barrera & Garrison-Jones, 1988; Gibbs, 1985; Kaplan, Hong, & Weinhold, 1984; Teri, 1982), in psychiatrically hospitalized adolescents (Strober, Green, & Carlson, 1981), and adolescent mothers (Colletta, 1983; Field et al., 1980; Steer, Scholl, & Beck, 1990).

The Center for Epidemiologic Studies Depression Scale was developed as part of a National Institute of Mental Health study to measure depressive symptoms among adults (Radloff, 1977). The CES-D has been used less frequently with adolescents than has the BDI. However, it has been validated with adolescents (Radloff, 1991) and adolescent mothers (Colletta, 1983; McKenry, Browne, Kotch, & Symons, 1990).

A correlation of .70 between the CES-D and the BDI has been reported for a sample of high school students (Roberts et al., 1991), indicating that they are comparable but different. Thus, the CES-D and BDI may be measuring different facets of depression. For example, the BDI has been shown to differentiate nondepressed, moderately depressed, and severely depressed individuals (Beck et al., 1961; Beck, 1967), concentrating more on somatic symptoms than does the CES-D (Campbell & Cohn, 1991). The CES-D primarily focuses on cognitive and affective symptomatology, with an emphasis on depressed mood (Radloff, 1977). Another difference is that the CES-D does not have an item on suicide, but does include four reverse-scored positive affect items (e.g., the degree to which one feels happy, hopeful, enjoys life, or feels good about oneself).

Nevertheless, items on the CES-D were originally taken from the BDI and other validated measures (Weissman, Scholomskas, Pottenger, Prusoff, & Locke, 1977), making at least some of the elements comparable. A number of studies have used the BDI and CES-D interchangeably to define depressed experimental groups, considering them to be equally useful screening instruments with good psychometric properties (Kendall, Hollon, Beck, Hammen, & Ingram, 1987; Radloft & Locke, 1986; Radloff & Teri, 1986). A study by Gotlib and Cane (1989), which compared eight widely used self-report measures of depression using DSM-III criteria, concluded that the BDI and CESD should be the scales of choice. The present study investigated the correlation between the BDI and CES-D in a sample of adolescent mothers, as well as which scale they preferred.

Self-report measures of depression often have a high rate of "false positives," identifying adolescents as depressed who do not meet the criteria for a clinical diagnosis. The validity of self-report measures has therefore been questioned. This study also analyzed how well the BDI and CES-D correlated with a clinical measure of depression, the Diagnostic Interview Schedule for Children (DISC).

METHOD

Sample

Adolescents (N = 155) were recruited from the maternity unit of a large, urban, university hospital. They were primarily unmarried, low-socioeconomic-status African American and Hispanic mothers between the ages of 13 and 21, with approximately a tenth-grade education (see Table 1). The only statistically significant difference between the depressed and nondepressed mothers was age: the depressed mothers were younger than the nondepressed mothers (p [less than] .02).

Measures

Beck Depression Inventory. The revised BDI (Beck, Rush, Shaw, & Emery, 1979) is a 21-item self-report inventory used to assess the severity of depressive symptoms. The items tap cognitive, behavioral, affective, and somatic symptoms (Teri, 1982). For each item, respondents select among four responses ranging from 0 to 3 (symptom is not present to symptom is severe). The total BDI score is the sum of all items, and ranges from 0 to 63.

Research with adolescents indicates adequate internal consistency (.80 to .90) and test-retest reliability (Strober et al., 1981; Teri, 1982). Adequate validity also has been found for its use with adolescents (Lempers, Clarke-Lempers, & Simon, 1989). Split-half reliabilities in the .90s and correlations with several clinical ratings of depression have also been reported (Steer et al., 1986). The BDI is appropriate for adolescents as young as age 13 (Steer & Beck, 1988). Since it requires a fifth-grade reading level (Flesch, 1948), it can be easily understood by the average high school student (Teri, 1982).

Table 1

Demographic Data: Means, Standard Deviations (in Parentheses), and
Percentages

 Depressed Nondepressed

Age 17.9 (1.9) 18.7 (1.7)

Education Level 10.2 (1.6) 10.8 (1.3)

Race

Caucasian 10% 6%

African American 36% 24%

Hispanic 12% 12%

Marital Status

Married 8% 5%

Single 50% 37%

Center for Epidemiologic Studies Depression Scale. The CES-D (Radloft, 1977) is a 20-item self-report scale designed to measure depressive symptoms in the general population. The items include depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, loss of energy, and sleep and appetite disturbances (Radloft & Teri, 1986), which are divided among Depressed Affect, Happy, Somatic, and Interpersonal subscales (Radloff, 1977). Items on the Happy subscale are reversed to reflect "unhappy" scores. Respondents rate the frequency (over the past week) of 20 symptoms (ranging from rarely or none of the time to most or all of the time). A total score is calculated by summing all items, and ranges from 0 to 60. Acceptable reliability and validity have been found across a wide variety of demographic characteristics, including age, education, geographic area, and racial, ethnic, and language groups (Radloff, 1977, 1991; Radloff & Locke, 1986; Radloff & Terri, 1986).

Diagnostic Interview Schedule for Children. The National Institute of Mental Health DISC (Costello, Edelbrock, Dulcan, & Kalas, 1984) was used to make DSM-III Axis I diagnoses. The DISC is a standardized diagnostic interview used in epidemiological studies of child and adolescent psychopathology. It yields a score in 27 hierarchically ordered symptom areas (e.g., attention deficit, conduct disorder, over-anxiety) and can be administered verbatim by lay interviewers.

The DISC addresses specific symptoms, as well as their chronology, duration, and associated impairments. It has a step structure that minimizes interviewing time for adolescents and children with few symptoms. Responses are coded 0, 1, and 2 (corresponding to no, somewhat or sometimes, and yes). Reliability and validity have been found to be as good as, or better than, other structured diagnostic interviews (Costello, Edelbrock, & Costello, 1985). For this study, only the Affective Disorder Module was used to assess major depression and dysthymia. The DISC scoring program was used to compute raw scores.

Procedure

All measures were read aloud to the adolescent mothers by a research associate. The order of measures was counterbalanced across subjects. After the assessments were completed, the adolescent mothers were asked whether they preferred the BDI or the CES-D.

Criteria for inclusion included (1) being between 13 and 21 years of age and (2) obtaining a BDI score from 3 to 9 or 13 or higher. The adolescent mothers were assigned to the nondepressed group if their BDI scores were from 3 to 9 (n = 56) or the depressed group if their scores were 13 or above (n = 99). Adolescents with scores of 0, 1, and 2 were dropped from the study because research has shown that these mothers may be denying depression (Field, Morrow, Healy, Foster, Adelstein, & Goldstein, 1991). Adolescents with scores of 10, 11, and 12 were considered borderline and therefore excluded.

Scores of 16 or above on the CES-D indicate depression (Radloff, 1991). Adolescent mothers who had a "nondepressed" BDI score but a CES-D score of 16 or above were assigned to the depressed group. Those who were suicidal were excluded from the study, and the appropriate referrals were made.

RESULTS

Relationship Between the BDI and CES-D

The adequacy of the BDI and CES-D as screening instruments for adolescent depression was determined by the degree to which they agreed with each other (see Table 2). Results indicated that the BDI and CES-D were highly correlated (r = .58, p [less than] .01). In addition, there were significant correlations between the BDI and the subscales of the CES-D; the highest correlation was for the Depressed Affect subscale (r = .54, p [less than] .01), followed by the Interpersonal subscale (r = .44, p [less than] .01).

[TABULAR DATA FOR TABLE 2 OMITTED]

Preference for the BDI or CES-D

Seventy-five percent of the adolescent mothers preferred the CES-D to the BDI. They indicated that the CES-D was easier to understand and quicker to complete.

Relationship Between the CES-D/BDI and the DISC

According to the DISC, 33 subjects were clinically diagnosed as having an affective disorder (major depression, n = 18; dysthymia, n = 15). Both the BDI and CES-D were correlated with the Major Depression and Dysthymia subscales of the DISC. The BDI had a higher correlation with Major Depression (r = .53, p [less than] .01), while the CESD had a higher correlation with Dysthymia (r = .41, p [less than] .01). Most subscales of the CES-D were correlated with the Dysthymia and Major Depression subscales of the DISC (see Table 2).

DISCUSSION

The majority of adolescent mothers preferred the CES-D to the BDI. Most indicated that the CES-D was quick and simple, while several mentioned that the BDI was "depressing."

The BDI and CES-D were highly correlated, indicating that they are comparable but not identical. The BDI was more correlated with the Major Depression subscale of the DISC, while the CES-D had a stronger relationship with Dysthymia.

The relationship between the BDI and DISC Major Depression is perhaps not surprising, since they measure similar characteristics. That is, BDI items assess cognitive, behavioral, affective, and somatic symptoms, and episodes of major depression are characterized by such symptoms (Nelson & Charney, 1981). Dysthymia, on the other hand, is characterized by lower severity and chronic course (Akiskal & Weise, 1992). It is also distinguished from major depression by a lack of sharp difference between the clinical condition and the usual self. In short, the BDI focuses more on intensity of symptoms, while the CES-D focuses on duration (Zich, Attkisson, & Greenfield, 1990).

The majority of adolescent mothers were depressed according to their BDI and CES-D scores, yet many did not qualify for this diagnosis according to the DISC. In order to obtain a clinical diagnosis of depression, symptoms had to have been experienced "most of the time" during the past six months, which was not usually the case.

Postpartum mothers experience many physical and psychological changes that are similar to depressive symptoms, such as sleep and eating disturbances and lack of motivation (Campbell & Cohn, 1991). Their self-report scores may be elevated as a result of discomfort due to childbirth or current level of distress, whereas a more rigorous clinical interview might reveal symptoms of insufficient duration for a diagnosis of depression. Perhaps the high scores in the present study reflected the stress and anxiety accompanying adolescent pregnancy and childbirth.

A large proportion of adolescents are depressed, and teenage pregnancy heightens depression levels (Colletta, 1983). Thus, adequate screening measures are needed to detect depressive tendencies in this population. Further studies are warranted, because depressive mood, even if not at a clinical level, has consequences for later psychological adjustment (Kandel & Davies, 1986; Rutter, Graham, Chadwick, & Yule, 1976) and can have serious repercussions for the infant (Field et al., 1980).

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This research was supported by a grant (DA06900) to Tiffany Field from the National Institute on Drug Abuse. The authors thank the adolescent mothers who participated in the study, the staff of Jackson Memorial Hospital, and Sonya Abrams, Stephanie Taylor, and Ziarat Hossain for their assistance with data entry and analysis.

Holly Wilcox, M. S., Margarita Prodromidis, Ph.D., and Frank Scafidi, Ph.D., Touch Research Institute, University of Miami School of Medicine.