J Cancer Surviv (2015) 9:107–114 DOI 10.1007/s11764-014-0394-y
Development and preliminary validation of a short form of the Beck Depression Inventory for Youth (BDI-Y) in a sample of adolescent cancer survivors Jaime E. Blackmon & Cori Liptak & Christopher J. Recklitis
Received: 7 May 2014 / Accepted: 5 August 2014 / Published online: 28 August 2014 # Springer Science+Business Media New York 2014
Abstract Purpose The aim of this study was to analyze adolescent cancer survivors’ responses to the Beck Depression Inventory for Youth (BDI-Y) to determine if a short form of the measure could be developed that would accurately identify survivors with clinically significant levels of depressive symptoms. Methods Two hundred two adolescent survivors (mean age= 15.39 years, SD=1.93) completed the BDI-Y at a single time point and were divided into two groups: a derivation sample (n=105) and a replication sample (n=97). Based on correlations with the total BDI-Y score in the derivation sample, items were selected for inclusion in three potential short forms, with 6, 8, and 11 items, respectively. These short forms were then evaluated against the full BDI-Y scale first in the derivation sample and subsequently in the replication sample (n=97). Results Each of the three short forms had high correlations with the total BDI-Y scale (r>0.95), good internal consistency (α>0.80), and good overall discrimination compared to a standard BDI-Y cutoff score (AUC>0.90). The eight-item short form demonstrated notable consistency across the derivation and replication samples, with high sensitivity and specificity using a cutoff score of ≥5, making it a promising tool for clinical screening. Conclusions Abbreviated versions of the BDI-Y can accurately detect depression in adolescent cancer survivors. J. E. Blackmon : C. J. Recklitis (*) Perini Family Survivors’ Center, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA e-mail:
[email protected] C. Liptak : C. J. Recklitis Harvard Medical School, Boston, MA 02215, USA C. Liptak Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA
Implications for cancer survivors An eight-item short form demonstrates strong psychometric properties and potential for use as a screening measure in this population, while the 6- and 11-item short forms may be suited to other applications. Keywords Beck Depression Inventory for Youth . Cancer . Survivorship . Adolescents . Depression Childhood cancer is a major stressful life event for the family and the individual child [1–3]. Coping with intensive treatments as well as the major disruptions of normal life can be extremely challenging, and many children experience disruptions in mood or behavior at some point during their treatment [4–8]. Fortunately, the majority of children will cope well with these challenges and go on to make a positive adjustment as adults [9, 10]. Research from the Childhood Cancer Survivor Study (CCSS), for example, has indicated that most survivors do not have significant impairment in physical or mental health [11, 12]. At the same time, however, research from the CCSS and other studies indicates that as a group, longterm survivors of childhood cancers are at increased risk for psychological distress, both during adolescence [10, 13, 14] and during later life [12, 15, 16]. For example, compared to their siblings, adolescent survivors were 1.5 times more likely to have symptoms of depression/anxiety and 1.7 times more likely to have antisocial behaviors [10]. Childhood cancer survivors are at risk for a variety of medical late effects (e.g., second cancers; problems with growth and development; and cardiac, endocrine, and pulmonary disease) [9, 11] and are closely monitored by medical providers after completion of their treatment. Because of their increased risk of psychological late effects, treatment guidelines for childhood cancer survivors include recommendations for psychological screening as part of their post-treatment care [17] and other researchers have suggested that clinicians
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working with children with chronic illnesses should screen for symptoms of psychological distress [18]. Unfortunately, research in this area is limited and practice guidelines offer limited guidance about how this psychological screening should be conducted. Practitioners and researchers working with childhood cancer survivors have employed a variety of interview, proxy, and self-report methods for assessing their psychological adaptation [19, 20], but many of these approaches are not appropriate or streamlined enough for use in a medical setting. The majority of self-report rating scales commonly used in pediatric psycho-oncology [21] has between 20 and 66 items for even a single-symptom dimension, making them quite lengthy, for young survivors. For assessing psychological symptoms in survivors of adult cancers, by contrast, clinical screening programs and research studies have benefitted from several brief scales (=0.90 and specificity>=0.75)
Specificity 0.85 0.91 0.97 1 1 1 1
Specificity 0.76 0.80 0.86 0.92 0.94 0.98 1
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given to how each form may be suited to different research or clinical purposes. To obtain a measure of depression estimating the BDI-Y total score, the six-item short form might be preferred over the other options tested here, as it is highly correlated with the original BDI-Y and it is also the most parsimonious form we evaluated. However, between our derivation and replication samples, this short form was less consistent in terms of identifying a cutoff score that consistently discriminated between survivors with and without significant depression on the original BDI-Y. Until this six-item scale can be validated as a case finding measure in a new sample, we would not recommend it as a screening measure for depression. For clinical screening purposes, we suggest considering the eight-item short form with a cutoff score of ≥5. This short form also correlates highly with the BDI-Y and maintains good internal consistency in both the derivation and replication samples. The eight-item short form proves more consistent between samples and, with only eight items, is still substantially shorter than the full 20-item measure. Having great parsimony and high screening accuracy, this short form shows the most promise for screening AYA cancer survivors. In situations where clinicians and/or researchers have the opportunity to use more items and brevity is less of an issue, the 11-item short form may prove more consistent in other samples and provide alternatives for research as many cutoff scores in both the derivation and replication samples meet our criteria. While the results support the hypothesis that abbreviated versions of the BDI-Y can be successfully developed for the adolescent cancer survivor population, there are limitations to our findings that should be considered. Although we did divide our sample into derivation and replication groups to minimize overestimation of the association of the short forms with the original BDI-Y, this strategy cannot completely assuage this concern. Our correlations between short forms and the BDI-Y may be overestimated because analyses were performed based on scores from one single administration of the measure. A new study using separate administrations of the full BYI-D and the short forms, allowing participants’ responses to the items to vary independently over the different forms, is currently underway at our center and should address this concern. Additionally, it should be noted that analyses reported here reflect only on the association between the BDIY short forms and the original BDI-Y. The BDI-Y has been validated as a measure of depression in youth generally [23], but results from our study do not add to this body of evidence or reflect on the validity of the BDI-Y. A future study using a “gold standard” psychiatric interview as the criterion measure of depression would be useful in further supporting the BDI-Y as a measure of depression in adolescent cancer survivors, as
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well as in validating the proposed cutoff scores for the short form measures presented here. In particular, although the depression criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [44] have not changed dramatically, it would be helpful to know the concordance of these short forms with the DSM-5. Of note, our sample included a large proportion of brain tumor survivors. Brain tumor survivors are known to be at relatively high risk for psychological late effects [28, 45], so their inclusion here supports the applicability of the short forms for this high-risk group. At the same time, future studies using new samples of adolescent survivors with different diagnoses, from different institutions, and of more representative ethnicities will be needed in order to investigate the generalizability of the findings to childhood cancer survivors more broadly. Despite these limitations, the findings have important implications for assessing depression in adolescent cancer survivors. As previously noted, though depression is only one aspect of psychosocial functioning that may be affected in these survivors, it is known to be prevalent [10, 12] and may be quite amenable to treatment if identified [27, 46, 47]. Guidelines for clinical care of childhood cancer survivors recommend evaluation for depression [17], but there is currently little or no data to guide clinicians in selecting best measures for screening for depression in this population. While parent report can be used for externalizing symptoms like school problems or oppositional behavior problems that are readily apparent to an outside observer, the internal nature of depression makes it critical to evaluate it with a self-report measure [48–50]. The BDI-Y is a wellregarded measure of adolescent depression, and brief forms that can reliably substitute for the BDI-Y will allow the measure to be used in a wider range of clinical and research settings. Unlike a completely new depression measure for youth, brief forms of the BDI-Y can benefit from previous experience with the original BDI-Y, allowing its use to be informed by all the existing BDI-Y research and clinical experience. Our previous experience with the BDI-Y [28] has shown that it is useful in capturing the experience of depressive symptoms in adolescent cancer survivors. By promoting more widespread and consistent screening for depression as part of routine care of childhood cancer survivors, we hope that brief versions of the BDI-Y can help insure that affected youth are identified and referred for necessary treatment.
Conflict of interest Jaime E. Blackmon, Cori Liptak, and Christopher J. Recklitis declare that they have no conflict of interest. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed
J Cancer Surviv (2015) 9:107–114 consent was obtained from all patients for being included in the study. No animal studies were carried out by the authors of this article.
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