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for the measurement of depression; its scales B. Administration of the Inventory.-The in-
ventory was administered by a trained interviewer
are based on the old psychiatric nomen- ( a clinical psychologist or a sociologist) who read
clature; and factor analytic studies reveal aloud each statement in the category and asked
that the Depression Scale contains a num- the ~ a t i e n tto select the statement that seemed
ber of heterogeneous factors only one of to fit him the best at the present time. In order
which is consistent with the clinical concept
the patient, the items were presented in such a
-
that the instrument reflect the current status of -
of depre~sion.~ Jasper's Depression-Elation way as to elicit the patient's attitude at the time
test O was derived from a study of normal of the interview. The patient also had a copy
college students, and his report does not of the inventory so that he could read each
refer to any studies with a psychiatric statement to himself as the interviewer read each
population. statement aloud. On the basis of the
response, the interviewer circled the number ad-
Method jacent to the appropriate statement.
In addition to administering the Depression In-
A. Constrnction~ofthc Innwttory.-The itetns in ventory, the interviewer collected relevant back-
this inventory were primarily clinically derived. ground data, administered a short intelligence test,
In the course of the psychoanalytic psychotherapy and elicited dreams and other ideational material
of depressed patients, the senior author made sys- relevant to the psychoanalytic hypotheses being
tematic observations and records of the character- investigated. These additional procedures were all
istic attitudes and symptoms of depressed patients. administered after the Depression Inventory.
H e selected a group of these attitudes and sytnptoms C. Description of Paticnt Population.-The pa.
that appeared to be specific for these depressed ticnts were drawn from the routine admissions to
patients and which were consistent with the de- the psychiatric outpatient department of a univer-
scriptions of depression contained in the psychi- sity ltospital (Hospital of the University of
atric literature." On the basis of this procedure, Pcr~nsylvania) and to the psychiatric outpatient
he constructed an inventory composed of 21 cate- dcp:~rtn~cntand psychiatric inpatient service of a
gories of symptoms and attitudes. Each category metropolitan 11ospit:d (Philadelphia General Hos-
tlescrihcs a specific behavioral manifestation of pital). The outpatients were seen either on the
tleprcssion and consists o f a graded series of 4 s a n ~ c thy of thcir first visit to the outpatient
to 5 sclf-evaluative statements. The statements dep:~rtn~cntor a specific appointment was madc
arc ranked to reflcct the rangc of severity of the for thrln to con~cI~acka few days later for thc
sytnptocn from neutral to tnaxin~al scverity. Nu- cotnplcte work-up. Hospitalized patients were all
n~cricalvalues from 0-3 are assigned each statc- sccn the day following their admission to the
nicnt to indicate the clcgrcc of severity. In tnntly hospital, i.e., during thcir first full day in the
cntcgorics, 2 alternative stntctncnts are presented hospital. The demographic features of the popu-
a t ;I give11 level antl arc assigned the same weight; lation arc listed in Tablc 1. It will be noted
thcse cquiv;~lcnt statctncnts are Iabcled a and b that thcrc are 2 patient san~ples,onc the original
(for csamplc, 21, 21,) to indicatc that thcy are group (226 paticnts) , thc other the replication
a t tltc satnc Icvcl. The itetns were chosen on the graul) (183 patients). The original sample (Study
basis o i thcir relationship to tlic overt behavioral I ) was taken over a 7-month period starting in
tnat~ifest:~tions of drpression and do not reflect any June, 1959, the sccond (Study 11) over a 5-month
period. Thc completion of the first study coin-
theory rcparding the etiology or the underlying
cided with the introduction of some new pro-
~~sycl~ological processes in depression. jcctive tests not relevant to this report.
Thc syn~ptoni-attitudecategories are as follows: l'he most salient aspects of this table are the
a. Mood k. Irritability predominance o f white patients over Negro Pa'
b. Pessimism 1. Social \\'ithdrawal ticnts, the age concentration between 15 and 4.1,
c. Scnse of Failure m. Indecisiveuess antl the high frequency of patients in the k ~ c r
d. Lack of Satis- n. Body Image socioeconomic groups ( I V and V). The socid
faction o. Work Inhibition position was derived from Hollit~~shead's Two
e. Guilty Feeling p. Sleep Disturbance Factor Index of Social Position,' which uses the
f. Scnse of Punish- q. Fatigability factors of education and occupation in the class
ment r. Loss of Appetite level determination.
g. Sclf-Hate s. Weight Loss The distribution of diagnoses was similar for
h. Self Accusations t. Somatic Pre- Studies I and 11. Patients with organic bratn
i. Self Punitive occupation damage and mental deficiency were autornaticall~
\Vishes u. Loss of Libido excluded from the study. The among
j. Crying Spells the major diagnostic categories were psychotic . i)
Beck et
disorder 41%,, psychoneurotic disorder 4376, per-
sonality disorder 16%. The distributions among
the subgroups were in order of frequency as fol-
lows :
Per Cent
Schizophrenic reaction 28.2
Psychoneurotic depressive reaction 25.3
Anxiety reaction 15.5
Involutional reaction 5.5
Psychotic depressive reaction 4.7
Personality trait disturbance 4.5
Sociopathic personality 4.5
Psychophysiological disorder 3.4
Manic-depressive, depressed 1.8
Personality pattern disturbance 1.8
All other diagnoses 4.8
100.0
D. Estcrnal 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, tlie psychiatrist saw the patient first; in
the rcmnintler, the Depression Inventor). wns atl-
ministered first.
Four esperienced psychiatrists participated in
the diagnostic stody.* They may be charactcrized
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 rc-
garding tlie criteria for each of the nosological
entities and focused special attention on thc various
types of depression. In every case, the Diagnostic
and Statistical Manr~alof Mcntal Disorders of the
American Psychiatric Association ' 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
* I n the initial group of 226 patients, some of
the diagnostic evaluations were made by a "non-
standard diagnostician," that is, a psychiatrist other
than the 4 regular psychiatrists. In all, 40 patients
were seen by these psychiatrists.
ARCHIVES OF GENERAL P S Y C H I A T R ~
a practical testing ground for the application of T o establish the degree of agreement, the
the agreed-on instructions and principles and al- psychiatrists interviewed 100 patients and made in-
]owed further discussion of interview techniques, dependent judgments of the diagnosis and the Depth
the logic of diagnosis, and the pinpointing of of Depression. All 4 diagnosticians participated
specific diagnoses. in the double assessment and were randomly paired
Since the main focus of the research was to be with one another so that each of the patients
on depression, the diagnosticians also established seen by 2 diagnosticians. The procedure was to
have one psychiatrist interview the patient and
specific indices to be used in making a clinical
then after a resting period of a few minutes, the
estimation of the Depth of Depression. These
indices represented the pooled experience of the other psychiatrist would interview the patient.
4 clinicians and were arrived a t independently After the second interview was conplete, the
of the Depression Inventory. For each of the clinicians generally would meet and discuss the
cases seen concurrently to ascertain the reasons
specified signs and symptoms the psychiatrists
made a rating on a Cpoint scale of none, mild, for disagreement (if any).
moderate, and severe. The purpose of specifying
these indices was to facilitate uniformity among Results
the psychiatrists; however, in making the over-all A. Reliability of Psychiatrists' Ratings.-
rating of the Depth of Depression, they made a
global judgment and were not bound by the rat- The agreement among the psychiatrists re-
ings in each index.$ They also concentrated on garding the major diagnostic categories of
the intensity of depression at the time of the psychotic disorder, psychoneurotic disorder,
interview; hence, the past history was not as im- and personality disorder was 73% in the
portant as the mental status examin~t' Ion.
100 cases that were seen by 2 psychiatrists.$
The indices of depression which were devised
and used by the psychiatrists were as follows : This level of agreement, while higher than
I. Apperance 11. Thought Content that reported in many investigations, was
Facies Reported Mood considered too low for the purposes of our
Gait Helplessness study.
Posturc Pessimism The degree of agreement, however, in the
Crying 1:celings of In- rating of "Depth of Depression" was much
Speech adequacy and
higher. Using the Cpoint scale (none, mild,
Volume Inferiority
KW Sonlatic pre- moderate, and severe) to designate the in-
Speed occupation tensity of depression, the diagnosticians
Amount Conscious guilt showed the following degree of agreement:
Suicidal content Complete agreement 56%
111. Vegetative Signs 1 V. Psycl~osocial One degree of disparity 41%
Sleep Perf ortilance Two degrees of disparity 2%
Appetite Indecisiveness Three degrees of disparity 1%
Constipation Loss of drive This indicates that there was agreement
Loss of interest within one degree on the Cpoint scale in
Fatigability 97% of the cases.
T11e diagnosticians also ratcd the patient on the E. Reliability of Depression Inventory.-
degree of agitation and overt anxiety and filled
out a check list to indicate the presence of other Two methods for evaluating the internal
specific psychiatric and psychosomatic symptoms consistency of the instrument were used.
and disturbances in concentration, memory, recall, First, the protocols of 200 consecutive cases
judgment, and reality testing. H e also made a rat- were analyzed. The score for each of the
ing of the severity of the present illness on a 21 categories was compared with the total
4-point scale.
score on the Depression Inventory for each
+ A number of problems arose in assessing the individual. With the use of the ~ r u s k a l -
relative degree of depression of patients with con- Ilrallis Non-Parametric Analysis of Vari-
trasting clinical pictures. For example, would a
patient who is regressed and will not eat be rated $ A detailed description of the reliability studies
as more depressed than a patient who is not re- \\ill be reported in a separate article? The types
gressed but has made a genuine suicidal attempt? of disagreement regarding the nosological cate-
Such problems involved complex clinical judgments gories and the reasons for disagreement are being
and will be the subject of a later report. systematically investigated in another study.
*Ice by Ranks," it was found that all of Depression was made by one of the
ategories showed a significant relationship psychiatrists. The interval between the 2
o the total score for the inventory.§ Sig- tests varied from 2 to 6 weeks. It was found
,ificance was beyond the 0.001 level for all that changes in the score on the inventory
ategories except category S (Weight-loss tended to parallel changes in the clinical
ategory), which was significant at the 0.01 Depth of Depression, thus indicating a con-
evel. sistent relationship of the instrument to the
The second evaluation of internal con- patient's clinical state. (These findings are
istency was the determination of the split- discussed more fully in the section on valida-
ialf reliability. Ninety-seven cases in the tion studies.)
irst sample were selected for this analysis. An indirect measure of inter-rater relia-
The Pearson r between the odd and even bility was achieved as follows : Each of the
ategories was computed and yielded a re- scores obtained by each of the 3 interviewers
iability coefficient of 0.86; with a Spear- was plotted against the clinical ratings. A
nan-Brown correction, this coefficient rose very high degree of consistency among the
o 0.93.' interviewers was observed for the mean
Certain traditional methods of assessing scores respectively obtained at each level of
h: stability and consistency of inventories depression. Curves of the distribution of
ind questionnaires, such as the test-retest the Depression Inventory scores plotted
nethod and the inter-rater reliability method, against the Depth of Depression were
yere not appropriate for the appraisal of notably similar, again indicating a high de-
he Depression Inventory for the following gree of correspondence among those who
seasons: If the inventory were readmin- administered the inventory.
steretl after a short period of time, the C. Validation of the Depression Inven-
:orrelation between the 2 sets of scores could tory.-The means and standard deviations
)e spuriously inflated because of a memory for each of the Depth of Depression cate-
lactor. If a long interval was provided, gories are presented in Table 2. It can be
he consistency would be lowered because seen from inspection that the differences
)f the fluctuations in the intensity of de- among the means are as expected; that is,
~ressionthat occur in psychiatric patients. with each increment in the magnitude of
The same factors precluded the successive depression, there is a progressively higher
idministration of the test by different in- mean score. The Kruskal-Wallis One-way
.erviewers. Analysis of Variance by Ranks was used
Two indirect methods of estimating the to evaluate the statistical significance of these
rtalility of the instrument were available. differences; for both the original group
The first was a variation of the test-retest (Study I ) and the replication group
methotl. The inventory was administered to (Study 11), the p-value of these cliffer-
a group of 38 patients at two different ences is <0.001.
times. At the time of each administration
Since the Iiruskal-IVallis test evaluates
of the test, a clinical estimate of the Depth
-$This procedure is designed to assess whether the over-all association between the scores
on the Depression Inventory and the Depth
Mriation in response to a particular category is of Depression ratings, the Mann-Whitney
associated with variation in total score on the
inventory. For each category, the distribution of U test l4 was used to appraise the power of
total inventory scores for individuals selecting a the Depression Inventory to discriminate
Particular alternative response was determined. between specific Depth of Depression cate-
The Iiruskal-Wallis test was then used to assess gories. It was found that all differences
hhether the ranks of the distribution of total scores between adjacent categories (none, mild,
increased significantly as a function of the differ-
ences in severity of depression indicated by these moderate, and severe) in both studies were
alternative responses. significant at <0.0004 with the exception of
TABLE3.-Correlation Between D e ~ r e s s i ~ ~
Inventory Scores and Clinicians' Ratings
of Depth of Depresston
f l y
. .
Correlation Standard
n Coefficient Error P
Study1 226 0.65 0.068 <0.01
Study I1 183 0.67 0.06'd <0.01
Depth or Depresston
Decreased Increc-d
Depression Decreased 26 2
Inventory
Score Increased a 2
568
liability and validity. The high correlation primary diagnosis of depression only 50%
coefficient on the split-half item analysis of the time.2 This problem was solved by
and the significant relationship between the having the diagnosticians make judgments
individual category scores and the total of the intensity of depression. When this
scores indicate the instrument is highly re- was done, a high degree of consistency was
liable. The highly significant relationship found among the psychiatrists' ratings.
between the scores on the inventory and While this classification disregarded the
the clinical ratings of Depth of Depression primary diagnosis, it did employ the same
and the power to reflect clinical changes in diagnostic signs and symptoms that are gen-
the Depth of Depression attest to the validity erally considered characteristic of primary
of this instrument. depression. The change from the usual diag-
When the question arises of assessing nostic procedure was to treat depression as a
some diagnostically relevant behaviors as, personality dimension and not sin~plyas a
for example, are presented by states of de- discrete nosdogical entity. It was found,
pression, the clinician is quite naturally moreover, that this particular cluster of
disposed to rely upon clinical observation symptoms occurred in association with al-
and tends to mistrust personality inventories. most every other nosological category. In
This objection to so-called "objective" in- fact, in only about 26% of the cases was
struments is formally expressed by H o r q 8 depression found to be completely absent.
who, in commenting on the "relative ste- While the psychiatrists showed a close
rility" of personality inventories in predict- agreement on the estimate of the Depth of
ing behavior, challenges the assumption that Depression, one can still raise questions as
the items in an inventory convey the same to whether they were actually assessing de-
or similar meaning to everyone who takes pression, or whether it might have been some
the test. H e argues that "a personality self- other personality variable. While there is
rating questionnaire is in the nature of a no reason to assume that clinical evaluation
projective test: each item serves as an am- is the ultimate criterion, as long as one is
biguous stimulus whose interpretation is dealing with a clinical phenomenon we will
affected by the subject's needs, wishes, fears, have to rely on expert judgment as our
etc." This approach, in his opinion, re- criterion until other measures are developed.
moves from consideration the efficacy of a The ability of the inventory to approxi-
self-rating inventory as an accurate self- mate clinical judgments of intensity of de-
evaluation. However, the adequacy of any pression offers a number of advantages in
test as an accurate index of what it is sup- its use for research purposes. First, it meets
posed to measure is essentially an empirical the problem of the variability of clinical
question and cannot be resolved by fiat. judgment of nosological entities and provides
Thus, in the case of the Depression In- a standardized, consistent measure that is
ventory, it was possible to obtain self- not sensitive to the theoretical orientation or
evaluations from the patient that were idiosyncrasies of the individual who ad-
consistent with the total behavior of the pa- ministers it. Second, since the inventory can
tient as observed by the clinician. be administered by an interviewer who is
A formidable problem in evaluating the easily trained in its use, it is far more
validity of an inventory centers around the economical than a clinical psychiatric in-
adequacy of the external criterion. In view terview. Third, since the inventory provides
of the well known variability of psychiatric a numerical score, it facilitates comparison
diagnoses, it is necessary to have some other with other quantitative data. Finally, since
consistent standard against which the in- the inventory reflects changes in the Depth
ventory score can be judged. I n our study, of Depression over time, it provides an ob-
-for example, there was concurrence on the jective measure for judging improvement
569