High Beck Depression Inventory 21 scores in adolescents without depression are associated with negative self-image and immature defense style

Highlights

• Adolescents with high BDI-21 scores but no depression have negative self-image.

• Adolescents without depression but high BDI scores rely on immature defense styles.

• High BDI scores without depression associated with parents’ psychiatric problems.

• Other psychiatric diagnoses than depression may contribute to high BDI scores.

• High BDI scores call for assessing an adolescent's wellbeing and need for support.

Abstract

Beck Depression Inventory (BDI) is widely used in assessing adolescents’ psychological wellbeing, but occasionally the result diverges from diagnostics. Our aim was to identify factors associated with discrepancies between BDI scores and diagnostic assessment in adolescent psychiatric patients and general population.

The study comprised 206 inpatients (13–17 years old) and 203 age and gender matched non-referred adolescents. Study subjects filled self-reports on depression symptoms (BDI-21), alcohol use (AUDIT), defense styles (DSQ-40) and self-image (OSIQ-R), and on background information and adverse life events. Diagnostics was based on K-SADS-PL interview, and/or clinical interview and clinical records when available.

We compared subjects who scored in BDI-21 either 0–15 points or 16–63 points firstly among subjects without current unipolar depression (n = 284), secondly among those with unipolar depression (n = 105). High BDI-21 scores in subjects without depression diagnosis (n = 48) were associated with female sex, adverse life events, parents’ psychiatric problems, higher comorbidity, higher AUDIT scores, worse self-image and more immature defense styles. Low BDI-21 scores among subjects with depression diagnosis (n = 23) were associated with male sex, more positive self-image and less immature defense style.

In conclusion, high BDI-21 scores in the absence of depression may reflect a broad range of challenges in an adolescent's psychological development.

Introduction

Major depressive disorder (MDD) is one of the most common psychiatric disorders in adolescence with a cumulative prevalence of up to 20% (Avenevoli et al., 2015). It often leads to a decrease in cognitive and social functioning and increases the risk for suicidality. Furthermore, depressive symptoms that do not reach the diagnostic threshold of MDD (prevalence 5–29%) also cause significant impairment (Carrellas et al., 2017). Several screening and diagnostic tools for depression have therefore been developed (Brooks and Kutcher, 2001, Stockings et al., 2015). In clinical practice, self-reported depressive symptoms and clinical diagnostics occasionally diverge raising the question what could explain this discrepancy. To our knowledge, this issue has not been studied in adolescents.

Research data on the risk factors for depression point to factors worth considering also in subthreshold depression. The three most important risk factors for depression in adolescents are female sex, a family history of depression and exposure to psychosocial stress (Thapar et al., 2012). The intergenerational transmission of depressive symptoms arises from a mix of hereditary and environmental factors (Mason et al., 2017, Weissman et al., 2006). Various psychosocial stress factors can induce depression in adolescents (St Clair et al., 2015; Rice et al., 2017), and susceptibility appears to be higher in females than males (St Clair et al., 2015). Depressive symptoms in adolescents are also associated with psychological factors, in particular negative self-image (Fine et al., 1993, Erkolahti et al., 2003) and immature styles (Chan, 1997, Muris et al., 2003, Ruuttu et al., 2006).

For identifying depressive symptoms, one of the most widely used structured self-reports is Beck Depression Inventory (BDI)− 21 (Beck et al., 1961). This 21-item depression scale has been validated for adolescents (Stockings et al., 2015). BDI-21 does not, however, directly screen the DSM depression criteria and stresses cognitive symptoms. For diagnostics in adolescents the gold standard is the semi-structured clinical interview called The Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL) (Ambrosini, 2000, Kaufman et al., 1997). Studies that compare the results of BDI and clinical diagnostics usually aim at defining the psychometrics of BDI (Kumar et al., 2002, Osman et al., 2008, Dolle et al., 2012). Our aim, in contrast, is to investigate what psychological and background factors explain why the self-report and the diagnostic appraisal may diverge. We compare the BDI-21 scores and psychiatric diagnostics among both psychiatric inpatients and control subjects from general population. Our premise is to consider the clinicians’ assessments as the gold standard for psychiatric diagnostics, while acknowledging that the diagnostics in adolescent psychiatry entails uncertainties (Lauth et al., 2010, Youngstrom et al., 2011). Drawing on research on the risk factors for depression, our hypothesis is that divergence between the absence of unipolar depression diagnosis and high BDI-21 scores is associated with immature defense styles and negative self-image.