Skip to main content Accessibility help

Confirmatory factor analysis of the Beck Depression Inventory–II in patients with advanced cancer: A theory-driven approach

  • Kristen G. Tobias (a1), Jonathan Lehrfeld (a1), Barry Rosenfeld (a1), Hayley Pessin (a2) and William Breitbart (a2)...



The diagnosis and treatment of depression are complicated by the presence of a serious medical illness, such as cancer. The role of inflammation in the pathophysiology of depression remains unknown; however, the symptom cluster of sickness behavior is more clearly related to inflammation. Symptom clusters may provide the specificity needed to improve treatment outcomes. The purpose of this study is to use confirmatory factor analysis to examine the construct of sickness behavior in patients with advanced cancer using the Beck Depression Inventory–II (BDI–II).


Patients (N = 167) were recruited from chemotherapy clinics and the Department of Psychiatry at Memorial Sloan Kettering Cancer Center. Symptoms were a priori delineated using the factor labels sickness behavior and negative affectivity (two-factor model), and affective, cognitive, and sickness behavior (three-factor model). These data were also fit for a more traditional model using affective, cognitive, and somatic factors.


The mean total BDI–II score was 14.74 (SD = 8.52; range = 1–46). Fit statistics for all models were good, but the novel three-factor model with sickness behavior provided the best fit: χ2(186) = 273.624; p < 0.001; root-mean-square error of approximation = 0.053; comparative fit index = 0.949.

Significance of results:

Both the two- and three-factor models provide support for the unique construct of sickness behavior in patients with advanced cancer. High factor correlations with the BDI–II and other measures of distress were observed, which raises questions about theoretically distinct, but related, constructs.


Corresponding author

Address correspondence and reprint requests to: Kristen G. Tobias, Fordham University, 441 East Fordham Road, Bronx, New York 10458. E-mail:


Hide All
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Publishing.
Arnau, R.C., Meagher, M.W., Norris, M.P., et al. (2001). Psychometric evaluation of the Beck Depression Inventory–II with primary care medical patients. Health Psychology, 20(2), 112119.
Beck, A.T., Weissman, A., Lester, D., et al. (1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42(6), 861865.
Beck, A.T., Steer, R.A. & Brown, G.K. (1996). Manual for the Beck Depression Inventory–II. San Antonio, TX: The Psychological Corporation.
Bjelland, I., Dahl, A.A., Haug, T.T., et al. (2002). The validity of the Hospital Anxiety and Depression Scale: An updated literature review. Journal of Psychosomatic Research, 52(2), 6977.
Brothers, B.M., Yang, H.C., Strunk, D.R., et al. (2011). Cancer patients with major depressive disorder: Testing a biobehavioral/cognitive behavior intervention. Journal of Consulting and Clinical Psychology, 79(2), 253260.
Brouwer, D., Meijer, R.R. & Zevalkink, J. (2013). On the factor structure of the Beck Depression Inventory–II: G is the key. Psychological Assessment, 25(1), 136145.
Buckley, T.C., Parker, J.D. & Heggie, J. (2001). A psychometric evaluation of the BDI–II in treatment-seeking substance abusers. Journal of Substance Abuse Treatment, 20(3), 197204.
Charlton., B.G. (2000). The malaise theory of depression: Major depressive disorder is sickness behavior and antidepressants are analgesic. Medical Hypotheses, 54(1), 126130.
Dantzer, R. & Kelley, K.W. (2007). Twenty years of research on cytokine-induced sickness behavior. Brain, Behavior, and Immunity, 21(2), 153160.
Frankl, V.E. (1969). The Will to Meaning: Foundations and Applications of Logotherapy. New York: World Publishing Company.
Hall, B.J., Hood, M.M., Nackers, L.M., et al. (2013). Confirmatory factor analysis of the Beck Depression Inventory–II in bariatric surgery candidates. Psychological Assessment, 25(1), 294299.
Harris, C.A. & D'Eon, J.L. (2008). Psychometric properties of the Beck Depression Inventory–Second Edition (BDI–II) in individuals with chronic pain. Pain, 137(3), 609622.
Hart, B.L. (1988). Biological basis of the behavior of sick animals. Neuroscience and Biobehavioral Reviews, 12(2), 123137.
Hopko, D.R., Armento, M.E., Robertson, S.M., et al. (2011). Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: Randomized trial. Journal of Consulting and Clinical Psychology, 79(6), 834849.
Huang, C. & Chen, J.H. (2015). Meta-analysis of the factor structures of the Beck Depression Inventory–II. Assessment, 22(4), 459472.
Krebber, A.M., Buffart, L.M., Kleijn, G., et al. (2014). Prevalence of depression in cancer patients: A meta-analysis of diagnostic interviews and self-report instruments. Psycho-Oncology, 23(2), 121130.
Lie, H.C., Hjermstad, M.J., Fayers, P., et al. (2015). Depression in advanced cancer: Assessment challenges and associations with disease load. Journal of Affective Disorders, 173, 176184.
McDaniel, J.S., Musselman, D.L., Porter, M.R., et al. (1995). Depression in patients with cancer: Diagnosis, biology, and treatment. Archives of General Psychiatry, 52(2), 8999.
Miaskowski, C., Dodd, M. & Lee, K. (2004). Symptom clusters: The new frontier in symptom management research. Journal of the National Cancer Institute. Monographs, no. 32, 1721.
Mystakidou, K., Parpa, E., Tsilika, E., et al. (2008). The experience of hopelessness in a population of Greek cancer patients receiving palliative care. The International Journal of Social Psychiatry, 54(3), 262271.
Nissim, R., Gagliese, L. & Rodin, G. (2009). The desire for hastened death in individuals with advanced cancer: A longitudinal qualitative study. Social Science & Medicine, 69(2), 165171.
Pinquart, M. & Duberstein, P.R. (2010). Depression and cancer mortality: A meta-analysis. Psychological Medicine, 40(11), 17971810.
Raison, C.L. & Miller, A.H. (2003). Depression in cancer: New developments regarding diagnosis and treatment. Biological Psychiatry, 54(3), 283294.
Rosenfeld, B., Breitbart, W., Stein, K., et al. (1999). Measuring desire for death among patients with HIV/AIDS: The schedule of attitudes toward hastened death. The American Journal of Psychiatry, 156(1), 94100.
Rosenfeld, B., Breitbart, W., Galietta, M., et al. (2000). The schedule of attitudes toward hastened death: Measuring desire for death in terminally ill cancer patients. Cancer, 88(12), 28682875.
Segal, D.L., Coolidge, F.L., Cahill, B.S., et al. (2008). Psychometric properties of the Beck Depression Inventory II (BDI–II) among community-dwelling older adults. Behavior Modification, 32(1), 320.
Shattuck, E.C. & Muehlenbein, M.P. (2016). Towards an integrative picture of human sickness behavior. Brain, Behavior, and Immunity, 57, 255262.
Spitzer, R.L., Kroenke, K. & Williams, J.B. (1999). Validation and utility of a self-report version of PRIME–MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. The Journal of the American Medical Association , 282(18), 17371744.
Steer, R.A., Ball, R., Ranieri, W.F., et al. (1999). Dimensions of the Beck Depression Inventory–II in clinically depressed outpatients. Journal of Clinical Psychology, 55(1), 117128.
Vodermaier, A., Linden, W. & Siu, C. (2009). Screening for emotional distress in cancer patients: A systematic review of assessment instruments. Journal of the National Cancer Institute, 101(21), 14641488.
Zigmond, A.S. & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67(6), 361370.



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed