Many studies have reported that symptoms of depression
subsequent adverse cardiovascular outcomes.1,2Questions have
been raised, however, about the validity of assessing symptoms
of depression with self-report questionnaires in the context of
acute or chronic medical illness.2–5Symptoms that commonly
occur following an AMI, including fatigue or loss of energy,
changes in sleep patterns and changes in appetite, may be
misinterpreted by healthcare providers, researchers or patients as
mood-related. The Beck Depression Inventory (BDI) and its
revised version, the BDI–II, are the most commonly used self-
report depressive symptom measures in post-AMI depression
research.6–8Continuous scores on the BDI and BDI–II, as well
as scores above a cut-off level, have been found to predict poor
cardiovascular outcomes.1,2The authors of one systematic review
of the association between post-AMI depression and mortality,
however, argued that 50–75% of medical patients endorse some
of the somatic items on the BDI and that patients with cardio-
vascular disease may score close to 10 points on the BDI (the
standard cut-off for identifying possible depression) on somatic
symptoms alone.2Owing to the practical difficulty of determining
whether non-specific somatic symptoms such as fatigue and
appetite change are the result of depression or medical illness,
alternative self-report measures such as the Hospital Anxiety
and Depression Scale (HADS),9which exclude somatic symptoms,
have been developed. The argument for using alternative measures
that do not include somatic symptoms, however, is not based on
empirical evidence from studies showing that assessment methods
that include somatic symptoms, such as the BDI or BDI–II, are
confounded by the presence of a medical illness.10
We investigated whether self-report of depressive symptom
severity is confounded by the presence of an acute medical
condition by examining BDI–II responses in three different
groups: cardiac patients, psychiatric out-patients and under-
graduate students. The objective of this study was to compare
scores from post-AMI patients with those of the other two groups
on items of the BDI–II that reflect somatic concerns common
both following AMI and in depression, after matching on
cognitive/affective symptom scores. Essentially, this was an
empirical test of the hypothesis that scores on depression
symptom measures that include somatic symptoms, such as the
BDI and BDI–II, are exaggerated among medically ill patients
owing to the misattribution of somatic symptoms to depression.
The post-AMI cohort consisted of patients who were treated for
acute myocardial infarction at one of five tertiary care hospitals
or one of five community hospitals in Que ´bec, Canada, between
December 1996 and November 1998. Patients were eligible for
enrolment in the study if they were admitted through the
emergency department and not transferred from another hospital,
survived at least 24h after admission, read and understood French
or English, and were medically capable of giving informed consent.
Research nurses approached eligible patients for informed consent
and enrolment within 2–3 days of admission to hospital.
Participants completed self-administered questionnaires that
Somatic symptom overlap in Beck Depression
Inventory–II scores following myocardial infarction
Brett D. Thombs, Roy C. Ziegelstein, Louise Pilote, David J. A. Dozois, Aaron T. Beck, Keith S. Dobson,
Samantha Fuss, Peter de Jonge, Sherry L. Grace, Donne E. Stewart, Johan Ormel and Susan E. Abbey
Depression measures that include somatic symptoms may
inflate severity estimates among medically ill patients,
including those with cardiovascular disease.
To evaluate whether people receiving in-patient treatment
following acute myocardial infarction (AMI) had higher
somatic symptom scores on the Beck Depression Inventory–II
(BDI–II) than a non-medically ill control group matched on
Somatic scores on the BDI–II were compared between 209
patients admitted to hospital following an AMI and 209
psychiatry out-patients matched on gender, age and
cognitive/affective scores, and between 366 post-AMI
patients and 366 undergraduate students matched on gender
and cognitive/affective scores.
Somatic symptoms accounted for 44.1% of total BDI–II score
for the 209 post-AMI and psychiatry out-patient groups,
52.7% for the 366 post-AMI patients and 46.4% for the
students. Post-AMI patients had somatic scores on average
1.1 points higher than the students (P50.001). Across
groups, somatic scores accounted for approximately 70% of
low total scores (BDI–II 54) v. approximately 35% in patients
with total BDI–II scores of 12 or more.
Our findings contradict assertions that self-report depressive
symptom measures inflate severity scores in post-AMI
patients. However, the preponderance of somatic symptoms
at low score levels across groups suggests that BDI–II
scores may include a small amount of somatic symptom
variance not necessarily related to depression in post-AMI
and non-medically ill respondents.
Declaration of interest
The British Journal of Psychiatry (2010)
197, 61–66. doi: 10.1192/bjp.bp.109.076596
included the BDI–II in English or French at the time of enrolment,
and 477 patients completed all BDI–II items. This study was
ancillary to a prospective cohort study of quality of life after
AMI,11which received ethical approval from the Montre ´al General
Hospital ethics review board.
Psychiatry out-patient comparison sample
The psychiatry out-patient sample consisted of adults (518 years
old) seeking treatment for mental health problems at an out-
patient psychiatric clinic in New Jersey, USA. These participants
completed the BDI–II as part of a standardised intake assessment
prior to being interviewed and diagnosed by experienced
psychiatrists with a clinical interview using DSM–IV criteria.12
The sample was drawn from participants in four studies that
investigated the use of the BDI–II in people receiving psychiatric
out-patient treatment.13–16Data collection was conducted with
the approval of the institutional review board of the University
of Medicine and Dentistry of New Jersey, School of Osteopathic
Medicine. Patient data used in this study were drawn from
participants matched as closely as possible in terms of age, gender
and race/ethnicity (White or Black and minority ethnicity) to the
477 patients in the post-AMI cohort.17If more than one
individual from the psychiatry out-patient group was found to
match with a post-AMI patient, a computer-generated random
number selected the participant to be included. When there was
no exact match, the closest possible match was sought by selecting
the psychiatric out-patient nearest in age. Following initial
matching, the BDI–II scores in the psychiatry out-patient group
(n=477) were substantially higher than in the post-AMI group
(n=477); a subset of the initially matched patients was therefore
extracted based on exact matches on BDI–II cognitive/affective
symptom scores. To do this, for each possible cognitive/affective
score, all post-AMI or psychiatry patients were included from
the group with fewer patients with that score. Then, the same
number of patients from the other group with that score was
included, selected using computer-generated random numbers.
For example, if 10 people from the psychiatry out-patients group
and 15 people from the post-AMI group had a cognitive/affective
score of 6, all 10 from the first group were selected along with 10 of
the 15 patients in the post-AMI group, based on random number
Student comparison sample
The undergraduate student sample consisted of 996 psychology
students from the University of Calgary who completed all items
on the BDI–II.18Students were approached during class time and
asked to participate in the study. Informed consent was provided,
and data collection was approved by the institutional review board
at the University of Calgary. Undergraduate students were
matched with patients in the post-AMI group for both gender
and cognitive/affective symptom total scores, since a much greater
proportion of the student sample was female (66.9%) compared
with the post-AMI group (17.4%). For females and males
separately, at each cognitive/affective symptom score level, all
post-AMI or psychiatry patients were included from the smaller
group, and matches from the other group were based on
computer-generated random numbers.
Symptoms of depression were assessed using the 21-item BDI–II.7
Items consist of four statements scored 0–3, with higher scores
instructed to describe the way they have been feeling during the
past 2 weeks. There is extensive evidence of the validity and
reliability of the BDI–II in both psychiatric and non-psychiatric
populations.19,20Studies have reported several different factor
structures for the BDI–II.21,22In our study, in order to test
whether somatic symptoms might be overreported by the post-
AMI in-patients, a total score was computed for BDI–II items that
potentially overlap with somatic symptoms common after an
AMI. Based on a review of existing factor models and item
content, scores on BDI–II items 15–21 (loss of energy, sleep
problems, irritability, appetite problems, concentration, fatigue,
loss of interest in sex) were summed to calculate somatic symptom
scores. Items 1–14 (sadness, pessimism, past failure, loss of
pleasure, guilty feelings, punishment feelings, self-dislike, self-
criticalness, suicidal ideation, crying, agitation, loss of interest,
Differences between the three study cohorts were assessed on
categorical variables using chi-squared tests and on continuous
variables with two-tailed t-tests. No adjustment was made for
multiple comparisons since the statistical tests were done for
illustrative purposes rather than hypothesis testing. To test
whether somatic scores on the BDI–II differed between the groups
overall and at different levels of cognitive/affective scores, we used
two-tailed t-tests. In addition, we reported the effect size statistic
Hedges’s g, which represents a standardised difference between
two means.23In a post hoc analysis, score distributions on each of
the seven somatic items for the study groups were compared using
the Mann–Whitney U-test. Hochberg’s sequential method was used
to maintain a family-wise type I error rate of a50.05 for item
comparisons between the post-AMI and psychiatry out-patient
groups and between the post-AMI group and the students.
Prior to matching, the mean BDI–II scores were 9.2 (s.d.=7.9) for
the 477 post-AMI patients, 22.6 (s.d.=12.2) for the 477 psychiatry
out-patients and 9.1 (s.d.=7.6) for the 996 college students. The
percentage with very low scores on the BDI–II (total score 0–3)
was 24.1% (n=115) among post-AMI patients, 3.8% among
psychiatry out-patients (n=18) and 25.2% (n=251) among the
students. Among the two patient groups there were 209 exact
matches based on cognitive/affective scores. Of the student group,
366 were successfully matched with post-AMI patients. The
post-AMI patients were on average 3.4 years older than the
psychiatry out-patient comparison group (P=0.006), but gender
and ethnicity were similar owing to the matching protocol
(Table 1). In the psychiatry out-patients matched group, primary
DSM–IV Axis I diagnoses included major depressive disorder
(n=81; 38.8%), dysthymia (n=10; 4.8%), depression not otherwise
specified (n=9; 4.3%), alcohol dependence (n=3; 1.4%), anxiety
disorders (n=52; 24.9%) and adjustment disorders (n=54;
25.8%). Compared with the post-AMI patients, the matched
students were on average 39.5 years younger (P50.001). The
number of women in the post-AMI and student groups were the
same owing to the matching protocol, and ethnicity was similar.
Clinical characteristics of the matched post-AMI patients are
provided in online Table DS1.
Cognitive/affective and somatic symptoms
Post-AMI patients v. psychiatry out-patients
Overall, somatic scores accounted for 44.1% of the total BDI–II
scores for both the 209 post-AMI patients and the 209 matched
psychiatry out-patients, with no difference between the groups.
Thombs et al
Depression scores following myocardial infarction
However, there was variation across the range of cognitive/
affective scores. The post-AMI group had relatively higher somatic
symptom scores at lower levels of cognitive/affective symptoms,
whereas those in the psychiatry out-patient group reported
relatively higher somatic scores at higher levels of cognitive/
affective symptoms (Table 2). None of these differences was
statistically significant, however, and, as shown by the Hedges’s g
effect size statistic, the differences were generally small based on
Cohen’s operational definitions (small 0.2, medium 0.5, large
0.8).24The only item with a statistically significant difference
between the two patient groups was item 19 (concentration), for
which participants in the psychiatric out-patient group scored
higher than those in the post-AMI group (mean score 0.86 v.
0.67). Item comparisons are shown in online Table DS2.
In both groups, somatic symptoms accounted for the highest
proportion of total BDI–II scores among patients with low
Post-AMI patients v. students
Table 3 shows cognitive/affective and somatic scores for the
post-AMI patient group and the student group. Overall, somatic
symptom scores accounted for 52.7% of the total BDI–II score for
the 366 post-AMI patients compared with 46.4% in the matched
student sample. Post-AMI patients scored on average 1.1 points
higher on somatic scores than the students matched on cognitive/
affective scores (P50.001), and this was generally consistent across
the range of cognitive/affective scores, with the exception of the
8–11 range where there was no difference between the groups. The
higher somatic scores among post-AMI patients were due to signif-
icantly higher scores on items 15 (loss of energy), 20 (tiredness or
fatigue) and 21 (loss of interest in sex), as shown in online Table
DS2. The proportion of total scores accounted for by somatic items
in the student cohort across the range of cognitive/affective scores
was similar to the pattern in the two patient groups.
Clinical lore, which has been echoed in the research literature,2–5
suggests that assessment of depression symptoms with self-report
tools that include somatic symptoms (such as the BDI or BDI–II)
may inflate symptom severity scores substantially among patients
with acute or chronic medical disease, including post-AMI
patients.5,25,26The results of this study showed that post-AMI
patients did not have higher somatic symptom scores than
psychiatry out-patients matched on age, gender and cognitive/
affective scores, and reported, on average, somatic symptom scores
only one point higher than undergraduate students matched on
gender and cognitive/affective scores. Furthermore, the large
proportion of post-AMI patients who scored below 4 on the
BDI–II appears to be inconsistent with previous speculation of
substantial upward bias of BDI and BDI–II scores in post-AMI
patients compared with people who are not medically ill.5,25,26
Given the degree of physical burden associated with an acute
coronary event, it may seem surprising that post-AMI patients
did not have substantially higher somatic symptom scores than
psychiatry out-patients or college students after matching for
cognitive/affective symptom scores. One explanation for this
finding may relate to the overt nature of symptom assessment,
which has been shown to influence responses to self-report
questionnaires.27,28Indeed, it is well established that the content
of items presented early in a questionnaire or survey may
influence responses on subsequent items.29,30Respondents to
self-report questionnaires use the same tacit assumptions that
guide everyday conversation and attempt to make their input
relevant to the ongoing conversation or, in the case of
questionnaires, to the purposes of the research.30The seven
BDI–II items with potential somatic overlap between depression
and an AMI are found near the end of the 21-item questionnaire
(items 15–21) and follow items on self-dislike, sadness, guilt and
suicidal ideation, among other questions likely to be recognised
by patients as related to depression. Thus, responses to the
somatic items may be perceived implicitly as queries about
depression rather than literally as questions about physical health
status. Given this, post-AMI in-patients who are tired or not
eating well, for instance, may still not endorse these somatic
symptoms on the BDI–II, since they recognise this as a ‘depression
questionnaire’. Some of these patients may either attribute these
symptoms to their acute cardiac event and the hospitalisation
Demographic characteristics of the matched samples
Age, years: mean (s.d.)58.9 (12.2) 55.5 (12.9)0.006 60.4 (12.6)20.9 (4.1)
Female, n (%)39 (18.7)35 (16.7) 0.60882 (22.4)82 (22.4)1.000
White, n (%) 196 (93.8)201 (96.2) 0.263348 (95.1) 345 (94.3)0.622
AMI, acute myocardial infarction.
Comparison of cognitive and somatic scores for the myocardial infarction and psychiatric out-patient groups
Post-AMI patient group Psychiatric out-patient groupSomatic score comparison
of total score
of total score
AMI, acute myocardial infarction.
Thombs et al
itself or refrain from endorsing these symptoms so that they do
not appear depressed.
To the best of our knowledge, no previous study has reported
the degree to which patients with relatively low scores on the
BDI–II report predominantly somatic symptoms compared with
patients with higher overall score levels. It is possible that patients
with lower-grade symptoms might experience their distress more
somatically, although this has not been documented and would
appear to contradict current understanding of depression.20It
would appear more likely that BDI–II scores reflect some degree
of common somatic experiences, such as fatigue, that many people
report regardless of their medical status, and that the relative effect
of this on overall BDI–II scores is more prominent among
respondents with very low cognitive/affective scores. This
interpretation is consistent with previous reports using factor
analytic methods that found that 6–10% of the explained variance
in BDI–II scores is due to variance from somatic symptoms that is
orthogonal or unrelated to a general depression factor in samples
of post-AMI patients, substance-dependent men and psychiatry
out-patients.17,21,31It is also consistent with evidence from 2481
patients enrolled in the Enhancing Recovery in Coronary Heart
Disease Patients (ENRICHD) trial that both somatic and cognitive
symptoms of depression on the BDI were associated with medical
comorbidity,32but that the association of somatic symptoms with
medical comorbidity was much more robust than for cognitive
symptoms. Similarly, a number of studies have found that
somatic symptoms of depression as measured by the BDI are
more robustly related to cardiac prognosis than cognitive
One limitation of this study is that the three cohorts were not
drawn from the same setting. An additional limitation is that
information on medical comorbidities was not available for the
psychiatry out-patient or student groups. One might expect
in particular that some of the participants in the psychiatry out-
patient group, given the mean age of the analysed sample, would
have some medical comorbidity. This would be less of an issue in
the student sample. Thus, the general consistency of the main
finding, that post-AMI patients do not report substantially more
somatic symptoms than either psychiatry out-patients or college
students, provides confidence in the results.
It may be tempting, based on the results of this study, to
conclude that depressive symptoms among post-AMI patients
are not influenced by the general somatic profile of acutely ill
patients or that depressive symptoms in medically ill patients
are no different from the symptoms of depression in non-
medically ill populations. Such conclusions are beyond the scope
of this study, which only established that the proportion of
somatic symptoms reported by post-AMI patients does not exceed
that reported by psychiatry out-patients or undergraduate
students. The nature, quality and causal pathways of post-AMI
depression were not addressed in this study. Indeed, a number
of biological mechanisms linking depression and cardiovascular
disease havebeen identified,
activation, reduced heart rate variability, heightened inflammatory
response and endothelial dysfunction.36With these factors in
mind, it is likely that key aspects of depression may differ in
patients with cardiovascular disease compared with non-medically
ill patients, even though results from our study suggest that
depression may be experienced – or at least reported – similarly.
Likewise, it is important that the results of this study should
not be used to infer the degree to which the BDI–II would be
useful as a screening tool for major depressive disorder. The study
addressed the degree to which continuous scores on the BDI–II,
reflecting depression symptom severity, may be influenced by bias
owing to somatic symptom overlap following an AMI. It did not
address the degree to which the BDI–II accurately identifies cases
of major depressive disorder, which is an altogether different
question. Indeed, a recent systematic review demonstrated
potential pitfalls in using the BDI, BDI–II and other self-report
questionnaires as screening tools for major depressive disorder
in cardiovascular care settings.37
Future research is needed to improve our understanding of
how patients make sense of, and respond to, self-report
questionnaires such as the BDI and BDI–II. For instance, a study
that randomly assigned post-AMI or other medically ill patients to
receive either the standard BDI–II questionnaire or a version of
the BDI–II in which somatic symptom items were administered
prior to the cognitive/affective items would provide valuable
information about how patients respond to somatic symptom
items embedded in self-report measures of depressive symptoms.
Such a study would ideally include a qualitative component that
would enable patients to explain factors that they considered in
formulating item responses. There is increasing interest in the
nature of depression following an AMI,25,26,33–35and a better
understanding of the nature of self-report symptom scores would
inform this research.
In summary, the results of this study challenge clinical lore
suggesting that the assessment of depressive symptom severity
with standard self-report instruments, such as the BDI or
BDI–II, will be substantially biased in medically ill patients
misattribution of somatic symptoms from medical conditions
to depression. This study found that post-AMI patients did
not have higher somatic symptom scores than psychiatry out-
patients whowere matched
Compared with undergraduate students, somatic symptom scores
for post-AMI patients were only approximately one point
higher. Across groups,however,
somatic symptoms at low score levels suggests that BDI–II
scores may include a small amount of somatic symptom variance
ill patientsowing tothe
on cognitive/affective scores.
Comparison of cognitive and somatic scores for the myocardial infarction and college student groups
Post-AMI patientsStudents Somatic score comparison
of total score
of total score
AMI, acute myocardial infarction.
Depression scores following myocardial infarction
not necessarily related to depression in medically ill and
non-medically ill respondents.
Brett D. Thombs, PhD, Departments of Psychiatry; Epidemiology, Biostatistics and
Occupational Health; and Medicine, McGill University, Montre ´al, and Department of
Psychiatry and Center for Clinical Epidemiology and Community Studies, Jewish
General Hospital, Montre ´al, Que ´bec, Canada; Roy C. Ziegelstein, MD, Department of
Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA;
Louise Pilote, MD, MPH, PhD, Division of Clinical Epidemiology, Research Institute of
McGill University Health Center, Montre ´al, and Division of Internal Medicine, Research
Institute of McGill University Health Center, Montre ´al, Que ´bec; David J. A. Dozois,
PhD, Department of Psychology, University of Western Ontario, London, Ontario,
Canada; Aaron T. Beck, MD, Department of Psychiatry, University of Pennsylvania,
New Jersey, Pennsylvania, USA; Keith S. Dobson, PhD, Department of Psychology,
University of Calgary, Alberta; Samantha Fuss, BA, Department of Psychology, York
University, Toronto, Ontario, Canada; Peter de Jonge, PhD, Interdisciplinary Centre
for Psychiatric Epidemiology, Departments of Psychiatry and Internal Medicine,
University Medical Centre Groningen, University of Groningen, and Centre of Research
on Psychology in Somatic Diseases, Department of Medical Psychology, Tilburg
University, Tilburg, The Netherlands; Sherry L. Grace, PhD, School of Kinesiology and
Health Science, York University, Toronto, and Women’s Health Program, University
Health Network, Toronto; Donne E. Stewart, MD, Women’s Health Program,
University Health Network, Toronto, and Faculty of Medicine, University of Toronto,
Ontario, Canada; Johan Ormel, PhD, Interdisciplinary Centre for Psychiatric
Epidemiology, Departments of Psychiatry and Internal Medicine, University Medical
Centre Groningen, University of Groningen, The Netherlands; Susan E. Abbey, MD,
Women’s Health Program, University Health Network, Toronto, and Faculty of
Medicine, University of Toronto, Ontario, Canada
Correspondence: Dr Brett D. Thombs, Jewish General Hospital,
4333 Cote Ste Catherine Road, Montre ´ al Que ´bec H3T 1E4, Canada. Email:
First received 14 Dec 2009, final revision 1 Mar 2010, accepted 31 Mar 2010
B.D.T. is supported by a New Investigator Award from the Canadian Institutes of Health
Research (CIHR) and an E´tablissement de Jeunes Chercheurs award from the Fonds de
la Recherche en Sante ´ Que ´bec. R.C.Z. is supported by grants from the National Institutes
of Health (R21NS048593), the National Center For Complementary and Alternative Medicine
(R24AT004641) and the Miller Family Scholar Program of the Johns Hopkins Center for
Innovative Medicine. The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Center For Complementary and
Alternative Medicine or the National Institutes of Health. The Depression and Myocardial
Infarction (DepreMI) study was funded by a grant from the Netherlands Organisation for
Scientific Research to Ormel (Zon MW, Grant no. 904-57-100). P.d.J. is supported by a Vidi
grant from the Dutch Medical Research Council (016-086-397). The Toronto cohort study
was conducted with funds from the Heart and Stroke Foundation of Ontario and the
Samuel Lunenfeld Foundation of Toronto, Ontario, awarded to D.E.S., S.E.A. and S.L.G. is
supported by a New Investigator Award from the CIHR. Collection of data for the Que ´bec
cohort was supported by a grant from the Fonds de la Recherche en Sante ´ de Que ´bec
(961305-104) awarded to L.P., who is a research scholar funded by the CIHR and a William
Dawson Professor of Medicine at McGill University. S.F. is a CIHR Strategic Training Fellow
in Pain: Molecules to Community and is supported by a Canada Graduate Scholarship –
Masters Award from the CIHR.
The authors are grateful to Dr Robert A. Steer for allowing us to use data from the
psychiatry out-patient sample.
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If Homelessness Were Genetic
If homelessness were genetic,
Institutes would be constructed
With tall white walls,
And ‘driven’ people (with thick glasses)
If homelessness were genetic
Bright young things
Would draft manifestos
‘To crack the problem’,
Girls with braces on their teeth
Would stoop to kiss
Boys with dandruff
At Unit discos
While dancing (slowly)
To ‘Careless Whisper’.
Meanwhile, upstairs, in the offices
Secretaries in long white coats
And horn-rimmed spectacles,
Would cross their legs
And take dictation:
‘Miss Brown, a memo please,
To the eminent Professor Levchenko,
‘‘Many thanks indeed
For all those sachets you sent to me,
Of homeless toddlers’ teeth.’’ ’
If homelessness were genetic
Rats from broken homes
Would sleep in cardboard shoeboxes
Evading violent fathers,
Who broke their bones,
While small white mice
With cocaine habits
Would huddle in fear,
Sleeping in doorways,
Receiving calibrated kicks from gangs of passers-by
(A ‘geneenvironment interaction’).
If homelessness were genetic
Then the limping man, with swollen feet,
And the voices crying out within his brain
Would not traipse
Between surgery and casualty
Being turned away
For being roofless
Because, of course,
Homelessness would be genetic
The British Journal of Psychiatry (2010)
197, 66. doi: 10.1192/bjp.197.1.66