Assessing depression symptoms in those with insomnia: An examination of the beck depression inventory second edition (BDI-II)

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Abstract

Background

Due to concerns about overlapping symptomatology between medical conditions and depression, the validity of the beck depression inventory (BDI-II) has been assessed in various medical populations. Although major depressive disorder (MDD) and primary insomnia (PI) share some daytime symptoms, the BDI-II has not been evaluated for use with insomnia patients.

Method

Participants (N = 140) were screened for the presence of insomnia using the Duke structured clinical interview for sleep disorders (DSISD), and evaluated for diagnosis of MDD using the structured clinical interview for DSM-IV-TR (SCID). Participants’ mean BDI-II item responses were compared across two groups [insomnia with or without MDD) using multivariate analysis of variance (MANOVA), and the accuracy rates of suggested clinical cutoffs for the BDI-II were evaluated using a receiver operating characteristic (ROC) curve analysis.

Results

The insomnia with depression group had significantly higher scores on several items; however, the groups did not differ on insomnia, fatigue, concentration problems, irritability, libido, increased appetite, and thoughts relating to suicide, self-criticism and punishment items. The ROC curve analysis revealed moderate accuracy for the BDI-II’s identification of depression in those with insomnia. The suggested BDI cutoff of ⩾17 had 81% sensitivity and 79% specificity. Use of the mild cutoff for depression (⩾14) had high sensitivity (91%) but poor specificity (66%).

Conclusion

Several items on the BDI-II might reflect sleep disturbance symptoms rather than depression per se. The recommended BDI-II cutoffs in this population have some support but a lower cutoff could result in an overclassification of depression in insomnia patients, a documented problem in the clinical literature. Understanding which items discriminate insomnia patients without depression may help address this nosological issue.

Introduction

MDD and PI share daytime symptoms (e.g., concentration difficulties, reduced sleep, and fatigue) (Moul et al., 2002), and insomnia is a highly prevalent complaint in those with MDD (Kupfer et al., 1982). Approximately 60% of adults meeting criteria for MDD complain of insomnia, and between 10% and 20% of adults endorsing current insomnia display evidence of MDD (Ohayon, 2007). Furthermore, self-report measures employed to assess depression include symptoms that are essential features of PI. For example, The BDI-II (Beck et al., 1996), includes the following symptoms that overlap with the Research Diagnostic Criteria (RDC) for insomnia (Edinger et al., 2004): insomnia, mood disturbance, irritability, fatigue, impaired concentration, and motivation/anergia. These symptoms have been reported in clinical studies of insomnia patients, and thus, informed development of RDC for insomnia.

Due to concerns about overlapping symptomatology between medical conditions and depression, the validity of the BDI and the BDI-II has been assessed in various medical populations. The BDI-II has been assessed in: chronic pain patients (Poole et al., 2006); Hepatitis C patients (Golden et al., 2007); adults post-acute coronary events (Di Benedetto et al., 2006); African American primary care patients (Dutton et al., 2004); traumatic brain injury patients (Rowland et al., 2005); low income African American medical patients (Grothe et al., 2005); medical outpatients (Viljoen et al., 2003); stroke patients (Aben et al., 2002); and in primary care medical patients (Arnau et al., 2001). The findings of these studies generally support the use of the BDI-II in these populations. However, Golden et al. (2007) found the BDI-II does not correspond well to a clinical diagnosis of MDD in Hepatitis C patients. The Cardiac Depression Scale was found to be more sensitive to the more subtle manifestation of depression than was the BDI-II in patients who are post-acute coronary syndrome (Di Benedetto et al., 2006), and Poole et al. (2006) suggest scoring the BDI-II using a two-factor approach in chronic pain patients. In summary, the empirical literature available thus far suggests support for the use of the BDI-II with most but not all medical populations.

As noted above, the assessment of depression in insomnia patients is similarly confounded by overlapping symptomatology across depressive and insomnia syndromes. As a result, it is difficult to ascertain whether elevated total scores or elevated responses on individual items of commonly used depression inventories reflect insomnia, depression with sleep symptoms, or comorbid insomnia and MDD. The purpose of this study was to assess the accuracy of the BDI-II, one of the most commonly used depression measures, in detecting MDD in patients known to meet diagnostic criteria for insomnia. To date, the BDI has not been evaluated for use with insomnia patients.

Section snippets

Participants

Participants were a mixture of clinic-referred patients who presented as outpatients seeking insomnia treatment or as research volunteers for ongoing insomnia treatment trials at two academic medical centers (Duke University Medical Center, Durham, NC and Rush Medical Center, Chicago, IL). Each site has an active insomnia clinic that services outpatients per calendar year as well as active NIH and/or industry sponsored insomnia research programs. The clinical patients at these sites include a

Results

The internal consistency estimate (i.e., Cronbach’s alpha) for the depressed and nondepressed groups were .888 and .817, respectively. Cronbach’s alpha was calculated using all 21 items.

Discussion

The purpose of this study was to examine the properties of the BDI-II in a group characterized by significant symptom overlap with depression (i.e., insomnia patients). As expected, those with insomnia and depression had higher scores on the summed score of the BDI-II than those with insomnia alone. It is of note however that the insomnia group with no depression had scores in the “mild” symptom range for the BDI-II, rather than the no-symptom range (i.e., scores below 14). The accuracy

Role of funding source

The funding sources for the data presented in this manuscript had no involvement in study design, collection, analysis and interpretation of data, writing of this manuscript, or the decision to submit it for publication.

Contributors

Jack Edinger, Colleen Carney and Andy Krystal designed and implemented the two studies from which data were collected for use in this study. Dr. Carney conducted the statistical analyses, prepared the first draft of the manuscript, and revised sections and conducted analyses for the second draft. Dr. Ulmer worked on the first draft, and revised sections and conducted analyses for the second draft. Dr. Edinger provided final edits of the first and second drafts, and wrote much of the Discussion

Conflict of interest statement

None of the authors have any financial, personal or other relationships with any entities who might inappropriately influence, or be perceived to have influenced the research presented in this manuscript.

Acknowledgements

This research was supported by a Pickwick Fellowship Award (Dr. Carney) from the National Sleep Foundation and by the National Institute of Mental Health Grant No. R01, MH067057 (Dr. Edinger).

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