Beck Depression Inventory 1

The Beck Depression Inventory in 28 Countries: A Meta-Analysis Dianne A. van Hemert Fons J. R. van de Vijver Ype H. Poortinga Tilburg University, the Netherlands

Corresponding author: Dianne A. van Hemert Department of Psychology Tilburg University P.O. Box 90153 5000 LE Tilburg The Netherlands Phone: +31 13 466 3005 Fax: +31 13 466 2370
Email: d.a.vanhemert@kub.nl

Beck Depression Inventory 2

Running head: THE BECK DEPRESSION INVENTORY IN 28 COUNTRIES

The Beck Depression Inventory in 28 Countries: A Meta-Analysis

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Abstract The Beck Depression Inventory (BDI) is one of the most widely used instruments to assess depression. Studies using the BDI in normal populations from 28 countries were collected. Depression showed the same correlates at individual and country level, which suggests that depression has the same meaning at the two levels. BDI scores were negatively correlated with economical and political variables and with indicators of societal equality. Splitting the sample in two subsets of more and less affluent countries resulted in significant differences on various correlations with the BDI. For example, BDI correlated significantly different with suicide rate and Hofstedes Masculinity for more and less affluent countries. Finally, after controlling for GNP, correlations with well-being, Confucian Work Dynamism and HumanHeartedness from the Chinese Value Survey, and Schwartzs Autonomy value were significant.

Keywords: Depression Beck Depression Inventory Subjective well-being Happiness Country indicators Functional equivalence

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The Beck Depression Inventory in 28 Countries: A Meta-Analysis The present study focuses on negative affect across individuals and countries. It is studied whether depression in normal populations, as measured by the Beck Depression Inventory (BDI; Beck et al., 1961), has a similar meaning at individual level and country level of analysis. This similarity is a prerequisite for interpreting BDI scores at country level. Further, hypotheses are tested about correlates of depression at country level. In 1961, Aaron Beck and his colleagues (Beck et al., 1961) published the BDI to measure the behavioral manifestations of depression. The BDI is not based on a theory but on clinical observation of symptoms displayed by depressive patients (Steer et al., 1986). These symptoms include disturbed mood (sadness, loneliness, apathy) and a negative self-concept and self-punitive wishes. Further, depressive persons can suffer from physical and vegetative symptoms such as anorexia, insomnia, and loss of libido. Depressed individuals can also experience changes in activity level: They show either retardation or agitation (Beck, 1967). The BDI consists of 21 items describing symptoms and categories reflecting overt behavioral manifestations of depression. The categories reflect both psychological and somatic symptoms. The BDI is one of the most widely used depression self-rating scales. More than 2,000 empirical studies have employed the BDI (Richter et al., 1998). Although originally developed as a measure for clinical populations, it is now also widely used as a measure of depression in non-clinical samples. This takes the form of epidemiological research and research studying the correlates of depression, like demographical and psychological variables. It should be kept in mind that there is a difference between population depression scores as a continuous variable and the prevalence of depression in a population, treating depression as a categorical

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disorder. In the first instance the extent of depression can be taken as a continuous variable with a mean level that is a characteristic of a population as a whole. In the second instance there is a proportion of individuals scoring above a threshold. According to Rose (1992), the visible part of the iceberg (prevalence) is a function of its total mass (the population average) (p. 72). BDI scores of normal individuals can be aggregated to obtain country level data. However, in order to be able to interpret such data, one has to know whether the meanings of individual-level and country-level BDI scores are equivalent. This is a question of functional equivalence (Van de Vijver & Leung, 1997). One way to examine similarity of meanings is to make use of external variables that are part of the nomological networks of depression across levels. In this method, correlations of context variables with BDI scores are compared at individual and country level. This strategy focuses on functional equivalence, as it refers to the functional context of the concept (see also Van Hemert et al., submitted). An example of different correlations at individual and country level was described by Myers and Diener (1996). Within most nations there is hardly a relationship between income and happiness; although Americans earn on average twice as much today as they did in 1957, they have not become happier. At the same time people in rich countries are generally happier than people in less prosperous countries. To conceptionalize country-level correlations, it is useful to turn to the notions of happiness and subjective well-being. Generally, three aspects of subjective wellbeing are distinguished: positive affect, lack of negative affect, and satisfaction with life (Diener, 1994; Myers & Diener, 1995). It seems reasonable to assume that depression in normal populations is inversely related to subjective well-being and happiness. Therefore, theories about cultural differences in these concepts can be at

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the basis of cross-cultural hypotheses about correlates of depression cross-culturally. A first theory, labeled livability theory by Veenhoven (1995), states that happiness is influenced by objective living conditions. These are broadly defined, ranging from education and income to equality, stability and freedom. Maslow's (1970) needgratification theory underlies this perspective (Oishi et al., 1999). The comparison theory claims that happiness is dependent on comparison with other times' or other people's conditions (Veenhoven, 1995). This theory stresses relative living conditions as contrasted to absolute living conditions. Two types of comparison can be distinguished: Social comparison involves comparison with other people and lifetime comparison involves comparison with other times in life. The folklore theory (Veenhoven, 1995) states that happiness is a reflection of the national character of a country and is unrelated to the actual quality of life in that country. In general, subjective well-being and happiness have been found to depend on absolute (objective) quality of life (Diener et al., 1993; Veenhoven, 1995), supporting the livability theory. Arrindell et al. (1997) related country scores on subjective well-being to a number of country-level characteristics. Subjective wellbeing was found to be higher in wealthy countries with a high level of civil rights. Diener et al. (1995) reported positive correlations between subjective well-being and economical and political variables, as well as variables related to equality and individualism, in 55 nations. Similar findings were reported by Veenhoven (1999), who examined happiness in 43 countries. He also found happiness to be related to educational variables, variables concerning media availability, and Schwartz's Autonomy. Inglehart (1997, 2000) found stability of democracy and to a lesser degree level of democracy to go together with well-being. Further, a strong relationship (r = . 74; p < .01) was found between subjective well-being and wealth. Inglehart added

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that above a threshold of about US$6,000 (in 1991 dollars) there was hardly a relationship. Diener and Diener (1995) reported similar findings. With respect to the comparison theory, Hagerty (2000) found that a more positively skewed national income is associated with lower happiness. As for lifetime comparison, Easterlin (1995) discusses evidence for a positive link between economical growth and the increase of happiness. However, studies by Diener et al. (1993) and Veenhoven (1995) did not find support for the idea that well-being is dependent on relative quality of life (for instance through social comparison). Some evidence has been found to support the folklore theory. In the study by Arrindell et al. (1997) the Neuroticism and Psychoticism scales from the Eysenck Personality Questionnaire (EPQ-N respectively EPQ-P) were negatively correlated with subjective well-being (r = -.41, p < .05 respectively r = -.40, p < .05). Furthermore, of the well-known dimensions of Hofstede (1980) uncertainty avoidance and power distance were negatively correlated with subjective well-being, while a high level of individualism went together with high subjective well-being. Although no significant correlation was found with masculinity for the total sample, in poorer countries masculinity and subjective well-being were positively correlated whereas in richer countries the opposite was found. Additionally, studies on depression and well-being suggest that depression might also be positively correlated with marital status (Diener et al., 2000; Mastekaasa, 1994; Myers, 1992; Myers & Diener, 1995; Veenhoven, 1983), religiosity (Myers, 1992; Myers & Diener, 1995; Van den Eeden & Braam, 1999), and employment (Myers, 1992). No studies are available that relate (continuous) depression scores to other psychological or contextual measures at country level. Yet, there are several studies

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of such relationships at the individual level. In the following discussion we review individual-level studies using context variables which will be used later on in the country-level analyses. Several authors reported a negative correlation of depression with socioeconomic status (Gibbs, 1985) and with level of education (Oliver & Burkham, 1979; Williamson, 1989), as would be predicted from livability theory. As for personality, numerous authors report a significant, positive correlation between BDI scores and EPQ-N (e.g., Heaven & Shochet, 1995; Meites et al., 1980; Tashakkori et al., 1989; Saklofske et al., 1995; Salamero et al., 1994; Ulusahin & Ulug, 1997; Williams et al., 1998). The Marlowe-Crowne Social Desirability Scale was significantly negatively correlated (r = -.36; p < .01) with the BDI scores in a study by Carr et al. (1996). This finding is in agreement with results of Tashakkori et al. (1989) who found more depressive participants to have lower scores on the Lie scale from the Eysenck Personality Questionnaire (EPQ-L), which is considered to measure social desirability or social conformity. Tanaka-Matsumi and Kameoka (1986) also found negative correlations between BDI scores and social desirability scales. Sometimes BDI scores were found to be negatively related to extraversion, as measured by EPQ-E (Carrillo et al., 1996; Ulusahin & Ulug, 1997) and positively correlated with EPQ-P (Saklofske et al., 1995; Tashakkori et al., 1989). Costa and McCrae (1980) presented a model of personality influences on subjective well-being, according to which extraversion enhances subjective well-being through positive affect, whereas neuroticism is related to negative affect, thereby negatively influencing subjective well-being or happiness. Similar findings were reported by DeNeve and Cooper (1998) in their meta-analysis of personality traits and subjective well-being.

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The present study examines two questions. The first involves the equivalence of depression in normal populations as measured by the BDI at individual and country level. Correlations with context variables at individual and country levels are compared to assess equivalence. Positive evidence with respect to this first question is conditional for the second part of the study. This second part examines the correlates of depression at country level. Based on the theories and literature discussed, the following country-level hypotheses are tested. General hypotheses:
1. Subjective

well-being and happiness are negatively related to

depression1. 2. Prevalence rates of (clinical) depression are positively related to depression. 3. Suicide rate is positively related to depression. Livability theory: 4. More affluent countries show lower depression scores. (According to the livability theory affluence pertains to economical well-being, as well as education and political stability.) Comparison theory: 5. Equality of income distribution is negatively related to depression (social comparison). 6. Economical growth is negatively related to depression (lifetime comparison). Folklore theory: 7. National character traits explain a significant portion of variance in depression.

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Demographic hypotheses: 8. The percentage of married people is negatively related to depression. 9. Religiosity is negatively related to depression. 10.Unemployment is positively related to depression. Method Data Collection PsycInfo (formerly known as PsycLit) was searched for reports, using the keywords BDI and Beck and Depression (time period covered: 1960- July 1999). Two strategies were used to find additional studies. First, several authors of obtained references were asked by letter or e-mail to provide all reports they had available on the Beck Depression Inventory. Second, by looking at references in literature already identified another part of the data set was found. Studies were included in the data set if mean scores on the BDI and sample sizes were reported. If available, the standard deviation of BDI score distribution, the internal consistency of the BDI measured by Cronbachs alpha, and the mean and standard deviation of the age distribution were recorded. There was an important restriction concerning the type of sample used; clinical samples and all other groups were excluded that were expected to produce scores deviating from a representative sample in a national population. Studies reporting ethnic diverse samples were only included if no significant differences in means were reported between the ethnicities. This restriction was needed because ethnic differences within a country were not the focus of our study. Each separate group of participants in a single report, for instance men and women or different age groups, was regarded as an independent study. Two problems arose in the data collection. The first problem concerned the different versions of the BDI. In 1979, a revised version of the BDI (copyrighted in

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1978) was published (Beck et al., 1979). Instead of asking participants to report on their feelings at the moment of administration, the revised version asks to report on the past week including today. Also, the wording of several items was changed. Although the number and global meaning of the 21 items remained the same, and high correlations between the versions were found, significant differences in means have been reported (Beck & Steer, 1984; Lightfoot & Oliver, 1985). The 1961 version generally shows lower means. Most articles did not explicitly state what version was used. To obtain this information various strategies were followed. First, if the version was specified in the list of references, either 1961 or from 1978, this was used as an indicator of the version. Nevertheless, Beck et al. (1988) acknowledge that there is no feasible way of determining which version researchers have actually employed from the descriptions presented in the majority of studies. They add that most researchers cite the 1961 reference, although some of them actually used the 1978 version. Second, when no reference was given it was assumed that other studies by the same author(s) and from the same country used the same version. In some countries, different versions have been used. In countries in which several samples were studied the ambiguous studies were eliminated, in others the year was decisive: All studies published before 1981 were regarded to concern the 1961 version, the others were considered to have used the 1978 version. A short form (Beck & Beck, 1972) was also introduced, consisting of 13 items from the original BDI. Gould (1982) and Reynolds and Gould (1981) found this short version for patients to be reliable and valid, and highly correlated with the standard from. Studies using this version were also included. Generally, it was clear when this version was used. The second problem in forming the data sets concerned translations and adaptations in non-English speaking countries. Translations were not always literal.

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Beck et al. (1988) also mentioned this problem. Some translations involved deleting or adding items or modifying the content of existing items. Thus, several studies had to be ignored in setting up the data set. In one case, the deletion only concerned one item (Tashakkori et al., 1989). Here the mean total score was adjusted by adding one-twentieth of the total score. Data Sets <Table 1> Three data sets were composed. The first data set included the studies using the 1961 version of the BDI. It consisted of 72 studies, providing data for 117 separate samples. Twenty-five countries were represented in this data set. Table 1 shows all countries in this data set with their means, standard deviations, and reliabilities. The second data set contained the studies using the 1978 version of the BDI (Table 2). Thirty-seven studies, with 56 samples from 13 countries made up this data set. Finally, 13 studies using the short version of the BDI formed the third data set (Table 3). It consisted of 33 samples and included 8 countries. <Table 2> <Table 3> Publication years ranged from 1974 to 1999 in the 1961-version data set, from 1988 to 1999 in the 1978-version data set, and from 1984 to 1997 in the shortversion data set. Medians were 1993, 1995, and 1985 for the 1961-version, 1978version and short-version data set, respectively. Many studies did not specify the number of men and women in their samples or did not report the BDI scores for both genders separately. Thus, in the 1961version data set 43% of the studies either had mixed samples or did not provide information on distribution of the sexes. It could be established for 19% of all

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participants that they were men and for 28% that they were women. For the 1978version data set the corresponding figures were 7% men and 13% women. In 71% of the studies in this data set, either the samples were mixed or no separate information on sex was mentioned. Finally, the short-version data set contained 15% men and 16% women; 36% of the samples were mixed or had an unknown gender distribution. Age ranged from 15.00 to 74.10 years in the 1961-version data set, from 15.90 to 74.04 years for the 1978-version data set and from 17.27 to 84.50 years in the short-version data set. Participants were on average 22.99 (SD = 11.21) year in the 1961-version data set, 25.42 (SD = 8.66) year in the 1978-version data set and 39.57 (SD = 21.12) year in the short-version data set. Data on age were available in 83% and 89% of the studies in the 1961-version and the 1978-version data sets respectively, and in all studies of the short-version data set. Correlations across versions were calculated by correlating the means (weighted for sample size) of all data sets at country level: r = .64 (ns) between the 1961-version and the 1978-version data sets ; r = .79 (p < .05) between the 1961version and the short-version data sets; and r = .42 (ns) between the 1978-version and the short-version data sets. Compared with the correlation of .94 between the 1961 and the 1978 version reported by Lightfoot and Oliver (1985), correlations are low. However, it should be noted that correlations were calculated at country level instead of individual level. Unfortunately the data were not suited for individual-level analyses. Analysis and Testing of Hypotheses Functional equivalence across levels was evaluated by comparing correlations between context variables and depression scores at individual and country level. As

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no data at the individual level were available, information about the nature of correlations with the BDI at individual level had to be drawn from existing literature on the subject. Country-level correlations were derived from the total data set collected for the present study. To test the hypotheses as formulated in the introduction several indicators at country level were used. General Hypotheses Subjective well-being. Dieners subjective well-being was derived from Diener et al (1995). This measure combines scores from several surveys and is available for 25 countries. Ingleharts (1997) measure of subjective well-being was derived from questions concerning happiness and satisfaction with life as a whole (23 countries). Happiness. Veenhoven (1999) reported data on happiness from the World Database of Happiness (update 1996). His measure of happiness was used for 27 countries. Prevalence rates. The World Health Organization (1999) reported 1998 data on burden of disease by cause and by WHO Region for several neuropsychiatric disorders. The disorders included unipolar major depression and bipolar affective disorder. Percentages of sufferers could be calculated for the following regions: Africa, America (subdivided in 'high income' and 'low and middle income'), Eastern Mediterranean, Europe (subdivided in 'high income' and 'low and middle income'), South-East Asia (subdivided in 'India' and 'other low and middle income'), and Western Pacific (subdivided in 'high income', 'China', and 'other low and middle income'). By assigning region scores to countries, data were available for all countries.

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Suicide rates. Death rates per 100,000 inhabitants by suicide were collected using the Demographic Yearbook 1987 (United Nations, 1990a). Data were available for 25 countries. Livability Theory Affluence. An overall score on Affluence (similar to Georgas et al., submitted) was derived from factor analyzing (for the countries involved in the present study) all variables constituting five ecosocial factors as used by Georgas and Berry (1995): Ecological factor (temperature and precipitation), Economical factor, Educational factor, Mass communication factor (number of telephones, newspapers, etc.) and Population factor (mortality and birth rates). The scores on the resulting single factor were used as a measure of Affluence. Where data on the indicators were not available for a country in the data set, they were added by using the Demographic Yearbook 1987 (United Nations, 1990a), the UNESCO Statistical Yearbook 1990 (United Nations, 1990b) and the historical weather data web site (Washington Post, n.d.). Data on Affluence were available for all 30 countries. Gross National Product. Data on the GNP per capita were obtained from the Georgas and Berry (1995) database. Political Rights and Democracy. We combined four variables concerning political rights and democracy into one dimension. Humana (1986) collected data from several United Nations instruments and constructed the Human Rights Index for rights and freedoms in 40 categories (28 countries). The indices for Political Rights and for Civil Liberties in the year 1984 to 1985 were available for 29 countries (Freedom House, n.d.). Vanhanens (1997) Index of Democratization over the year 1980 is a weighted combination of two indicators of dimensions of democracy, namely Competition (smaller parties share of the votes) and Participation

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(percentage of total population who voted in the election). This index was available for 29 countries. We factor analyzed all four variables. A one-factor solution was found with an eigenvalue 3.33, explaining 83.24% of variance. Factor scores on this Political Rights and Democracy factor were used for further analyses (27 countries). Civil rights. For 24 countries Guptas measure for observance of civil rights, as cited by Diener et al (1995), was used. The original sign was reversed so as to obtain a higher score for more observance of civil rights. Additional measures of democracy. Ingleharts (1997) measure of the level of democracy in 1990, as well as the measure for stability of democracy (expressed in number of years of continuous democracy) were available for 23 countries. Deaths from political violence. As a measure of political instability the data by Taylor and Jodice (1983) on deaths of political violence between 1948 and 1977 were used. This measure was corrected for population size, and available for all countries but one. Comparison Theory Gini index. The Gini index expresses the degree of income inequality in a society. Indices for 21 countries, ranging from 1986 to 1995, were collected from the World Development Report (World Bank, 1999). A higher value denotes more inequality. Economic growth. Average annual growth of the Gross Domestic Product (GDP) between 1980 and 1987 was retrieved from the World Development Report 1989 (World Bank, 1989) and available for 27 countries. Folklore Theory Eysenck Personality Questionnaire. Studies reporting means on the four scales of the Eysenck Personality Questionnaire (EPQ; Eysenck & Eysenck, 1975)

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were collected across 38 countries. The four scales are the EPQ-P (Psychoticism), the EPQ-E (Extraversion), the EPQ-N (Neuroticism), and the EPQ-L (Social Desirability). The data set includes 153 studies, providing data for 333 separate samples, and is described in more detail in Van Hemert et al. (submitted). Data on the EPQ scales were available for 24 countries in the BDI data set. Hofstedes measures. Data for 27 countries were available on Hofstedes (1980, 2001) work-related values Individualism, Masculinity, Power Distance, and Uncertainty Avoidance. Values from Chinese Value Survey. The Chinese Culture Connection (1987) reported factor scores of 22 countries (overlapping with 13 countries in the present data set) on four dimensions of the Chinese Value Survey. The four dimensions included Integration ('broadly integrative, socially stabilizing emphasis', but not familial bonding), Confucian Work Dynamism (hierarchical work ethic), HumanHeartedness ('gentleness, compassion', but also a 'legalistic approach'), and Moral Discipline (moral self-control and moderation ('following the middle way')). Schwartzs Values. Schwartz (1994) provided data on values in 19 countries of our sample. Factor analysis by Georgas et al. (submitted) yielded two bipolar factors, labeled Autonomy and Hierarchy. Scores on these two dimensions were used as indicators. Demographic Hypotheses Marital Status. Percentages of married females and males between 25 and 44 years old were taken from the Georgas and Berry (1995) database. Data were available for 27 countries. Religiosity. An analysis was done on a part of the 1990-1991 World Values survey (Inglehart, 1993, 1997). This study included 47,871 participants from 39

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countries. It provided data on religion, including a range of topics related to religion, like the meaning of life, religious services, the role of churches and praying. We selected six items to fit in a scale measuring religiosity. Examples of items are Do you find that you get comfort and strength from religion?, How important is God in your life?, and How often do you pray to God outside of religious services?. The six items yielded a one-factor solution in factor analysis at country level, with an eigenvalue of 5.39 (89.8% of variance explained). Cronbachs alpha was .85. Data on religion were available for 21 countries. Unemployment. The percentage of unemployment in 1987 was available for 23 countries (United Nations, 1993). Results Descriptives Means, standard deviations, and values of Cronbachs alpha for the different versions of the BDI in every country appear in Table 1, Table 2, and Table 3. Moderate levels of depression according to Beck and Steer (mean score between 17 and 29; cited by Apostolou et al., 1999) were found in Israel and Kuwait, whereas mild levels of depression (mean score between 10 and 16) were found in India, Iran, Hong Kong, Australia, Japan, and Turkey. Cronbachs alpha was higher than .80 in all countries but former West-Germany. In order to be able to calculate correlations between BDI scores and country characteristics, mean scores were aggregated at country level (weighted by sample size) and then standardized within each of the three data sets. Subsequently the three data sets were combined into one total data set. Again scores were aggregated to country level to obtain one final score per country. A boxplot of standardized BDI mean scores at country level revealed two outliers, Kuwait and Israel (Figure 1), both

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showing a z-score higher than 2.0. These countries (also) scored above the threshold of 17 for mild depression as defined by Beck and Steer (Apostolou et al., 1999). The Kuwait data were based on three samples from two studies (N = 274), which were both published after the Gulf War. Possibly the influence of post-war stress was visible in these studies (Al-Issa & Ismail, 1994; Lester & Abdel-Khalek, 1998). The Israel data (N = 574) were based on only one study in a Palestine sample (Abdallah, 1997). Particularly in this group, the political situation is likely to enhance feelings of unsafety and depression. The outliers used the 1961 version of the BDI, but different translations. Kuwait and Israel were deleted from the data set, and standardizations were carried out again in all three data sets before combining them into the total data set, that was used for further analysis. <Figure 1> Correlations at Individual and Country Level: Establishing Functional Equivalence <Table 4> To establish functional equivalence of depression at individual and country level, the relationships of BDI scores with other variables were examined at both levels. The nature of correlations at both levels with selected context variables is shown in Table 4. The individual level data were derived from studies discussed before, complemented with information from Beck et al. (1988). The country level data were derived from the total data set of the present study. Correlations with income and education showed the same pattern across levels, but suicide rate and alcohol use did not. Although the correlations with the EPQ scales showed the same pattern at individual level and country level except for EPQ-L, none of the country level correlations with EPQ scales reached significance. The small number of countries might explain the absence of significant correlations at this level. Notable

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differences between individual level and country level occur for suicide rate and alcohol use. The overall similarities seem to suggest that functional equivalence of the BDI can be assumed. Correlations with Country Level Variables: Hypothesis Testing Pearson correlations and significance levels were calculated both in the regular way and with a bootstrapping procedure. For each correlation coefficient 10,000 bootstrapped samples were drawn with replacement from the original data set. The advantage of this procedure is not having to rely on the bivariate normality of the data and applicability to small samples. General Hypotheses <Table 5> Measures of both subjective well-being and happiness showed negative correlations with depression scores (Table 5). Thus, the first hypothesis was supported. Although both depression prevalence rates correlated positively with BDI scores, only one reached significance. Thus, the second hypothesis remains open. Suicide rate was negatively related to depression, a rather unexpected finding, that contrasts with other reports (Lester, 1988, 1986). This disconfirms the third hypothesis. Livability Theory In general a higher level of Affluence was related to a lower level of depression. This finding is in agreement with prior findings on the relationship between subjective well-being and GNP per capita (e.g., Diener et al., 1993). Political variables also showed a homogeneous picture: Political Rights and Democracy, civil rights, and the stability of democracy all correlated negatively with the BDI mean score. These findings indicate that the livability theory (fourth hypothesis) was

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supported. A factor analysis of all variables testing the livability theory resulted in a one-factor solution with an eigenvalue of 7.20, explaining 79.98% of variance. The significant negative correlation between BDI score and factor scores on this Livability factor (Table 5) confirms this conclusion. Comparison Theory The correlation between the Gini index, indicating equality of income distribution, and BDI scores was not significant, contrary to expectation. Hypothesis 5 could not be confirmed. However, the correlation between economical growth and depression was significant in the bootstrap procedure: Hypothesis 6 was confirmed. In sum, social comparison does not appear to be associated with depression, but lifetime comparison does. Folklore Theory None of the EPQ scales correlated significantly with BDI score. Hofstedes measures were related both positively (Masculinity and Power Distance) and negatively (Individualism) to BDI scores, largely replicating earlier mentioned findings by Arrindell et al. (1997). The Chinese Integration value correlated negatively to BDI, and the Confucian Work Dynamism dimension showed a significant positive correlation, but only when bivariate normality was assumed. Finally, Schwartzs Autonomy factor was negatively related to BDI. This finding is in agreement with results reported by Sagiv and Schwartz (2000), who found values concerning achievement, self-direction and stimulation to be positively correlated with the affective component of subjective well-being across three cultural groups. It is difficult to conclude whether this evidence does or does not support the rather unspecific predictions of the folklore theory. Demographic Hypotheses

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None of the demographic hypotheses were confirmed. Percentages of married females and males were positively correlated with the level of depression, contradicting expectations. Correlations with religiosity and the percentage of unemployed persons were not significant. In sum, it can be concluded that wealthy, egalitarian, individualistic, and politically stable countries appear to be less depressed. These findings mainly support the livability theory. Further Exploration of Country-Level Correlations In general, country-level variables tend to be correlated with GNP. To explore which other factors are relevant, relationships between depression and country level indicators were further explored by (1) splitting the sample into more and less affluent countries and (2) calculating partial correlations controlling for GNP per capita. More affluent countries (N = 14) were defined as having a GNP per capita (data from 1987) higher than the median of the distribution (9,210 US$). Less affluent countries (N = 14), consequently, had a GNP lower than 9,210 US$. The difference between the two subsample correlations was tested for statistical significance by evaluating the difference between the z-values of the correlation coefficients of both subsamples (Hays, 1988, p. 591). For five variables a significant (p = .05) difference was found between correlations of the two subsamples. A significant difference between more and less affluent countries appeared in the correlation between suicide rate and depression. Whereas a negative significant correlation was found for affluent countries (r = -.70), a non-significant (but positive) correlation of .22 was found for less affluent countries. Also, the difference in correlations between the Gini index and depression was significant. In affluent countries income inequality was positively correlated with depression (the more unequal, the more depressive; r = .46), in less

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affluent countries the opposite was true (r = -.48). Hofstedes Masculinity score also showed different correlations (p = .05) in the two subsamples; in affluent countries a high level of masculinity went together with a high level of depression (r = .77), whereas in less affluent countries the opposite was the case (r = -.42). This finding is congruent with Arrindell et al.'s (1997) results on subjective well-being, reported before. Human-Heartedness correlated positively with BDI scores for affluent countries (r = .84), whereas in less affluent countries a negative (although nonsignificant) correlation of -.27 was found. Correlations with Moral Discipline also differed significantly for the two subsamples (p = .05). Both correlations were positive (resp. r = .12 and r = .79). A relationship between wealth and depression could not be established in either subsample, in contrast to findings on subjective well-being in poor and rich countries (Inglehart, 1997). Briefly summarized, in more affluent countries depression levels correlated positively with the Gini index, Neuroticism, Masculinity, Human-Heartedness, and the percentage of married males, while negative correlations were found with variables related to happiness, prevalence of depression, political rights, livability and with suicide. Less affluent countries only showed significant correlations of depression with the percentage of married females (positive) and Autonomy (negative). Thus, Ingleharts (1997) finding, that only for less affluent countries GNP shows a relationship with well-being, could not be replicated. Partial correlations, controlling for GNP, left only four significant correlations. Ingleharts well-being (r = -.53, p < .01), Confucian Work Dynamism (r = .64, p < .05), Human-Heartedness (r = .60, p < .05), and Schwartzs Autonomy (r = -.56, p < .05) correlated with mean BDI score. Discussion

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In the present study differences between countries in the level of depression, as measured by the Beck Depression Inventory, were investigated. Two research questions were addressed. First, the equivalence of BDI scores across different levels of analysis was examined. Patterns of correlations with context variables were compared at individual level and country level. In general, meanings of depression appeared to be reasonably similar at individual and country level. Differences occurred for suicide rate and alcohol use. Myers (1992) reported a similar inequivalence: Countries with higher levels of well-being also have higher suicide rates, while obviously individuals attempting suicide experience relatively low levels of well-being. It is not clear what the factors are behind these findings. However, both suicide and alcohol use (death by liver cirrhosis) correlated significantly with GNP per capita (resp. r = .59, p < .01, and r = .46, p < .05). This points to several possibilities. First, suicide may be more visible in richer countries. Also, suicide may be more accepted as a way to solve problems. Alcohol use may be related to GNP because alcohol is more easily available in wealthier countries. Alternatively, other ways to deal with problems are more common in poorer countries. Differences in correlations with the EPQ scales were quite small, except for the EPQ-L. Van Hemert et al. (2001) studied equivalence of the four EPQ scales at individual level and at country level, and found unsatisfactory equivalence for both the EPQ-P and the EPQ-L. Therefore, it may well be that differences in meaning of the EPQ-L at individual and country level contributed to the difference in correlations with BDI scores. Further, small sample sizes at country level may have prevented correlations from reaching significance. A negative answer to this first question would imply that the second question would be difficult to analyze. We concluded that overall the evidence was

Beck Depression Inventory 25

sufficiently positive on functional equivalence across levels to allow analysis of the second question. Second, an attempt was made to explain country differences in BDI score in terms of contextual factors. As for the concepts of depression and subjective wellbeing, BDI scores were negatively correlated with subjective well-being measures. Furthermore, prevalence rates of clinical depression were positively correlated with depression score levels. The relatively low level of correlations can be explained by considering the nature of the populations involved. As self-reported depression inventories rely on the voluntary participation of individuals, extremely depressed participants are likely to be missed in questionnaire studies of non-clinical samples. Mean depression scores were lower in affluent countries, that is countries with a high GNP, a high level of education, and a high level of information available through media. Also, countries with a low level of depression were more egalitarian, more democratic, and had more civil, human, and political rights. All these findings confirm the livability theory, explaining happiness through objective living conditions like income and education. This theory gets most support from the present results. These findings are in line with results reported by Veenhoven (1995, 1999), Diener et al. (1995), and Arrindell et al. (1997). For the comparison theory, claiming that happiness is dependent on comparison with other times' or other people's conditions, little support was found, as only economic growth was related to depression. This latter finding is not in agreement with Diener and Oishi (2000), who concluded from an examination of Veenhovens surveys that people in countries with high economic growth did not report more happiness.

Beck Depression Inventory 26

Also for the folklore theory, stating that happiness is a reflection of the national character of a country, only mixed evidence was found. Some variance could be explained by national character of a country, but mostly this was a function of GNP. Some value indices, Confucian Work Dynamism, Human-Heartedness and Schwartz's Autonomy, were related to depression when GNP was controlled for. An obvious difficulty with folklore theory is the lack of precision of the predictions that can be derived from it. Any significant correlation provides supporting evidence, even independent of sign. In general, several reasons can be named for the sometimes unclear results. First, many of the samples in the data set consisted only of students. Possibly, these samples are not representative. In poor countries students are relatively rich, in rich countries they are relatively poor (Diener et al., 1993). Apart from their extreme economic position (either relatively rich or relatively poor), student samples tend to be uniform in many other aspects. This argument was supported by Veenhoven (1995), who found the correlation between average happiness and GNP per capita to be larger in a general population than in a student population. Second, besides differences in means a shift in symptoms could take place, with more somatic and psychological symptoms scoring higher in one country than another. No raw data were available to do analyses on this point. A third reason is the presence of cultural bias. Bias can limit the validity of findings considerably (cf. Van de Vijver & Leung, 1997). For example, item bias should be taken seriously in cross-cultural administration of instruments. Byrne and Campbell (1999) illustrated this by showing that BDI item scores can vary across countries even when the factorial structure is equivalent cross-culturally. Unfortunately, the lack of raw scores at item level in the present data set did not allow for an investigation of item bias. Another source of bias

Beck Depression Inventory 27

could emerge from the composition of the sample. It is clear that western, affluent countries are overrepresented in the present study. Splitting the sample in more and less affluent countries partly controls for this, but at the same time implies a restriction of range. A third kind of bias pertains to the indicators. Some indicators like GNP and suicide rate are proxies for psychological variables with partly unknown ramifications. In summary, depression scores seemed sufficiently equivalent at the individual level and country level to allow country-level analyses with individual-level data. Cross-national differences in depression among normal samples were found to be connected to mainly economical and political variables. These connections could be best explained in terms of livability theory. At the same time, these variables did not explain all variance in depression. Psychological variables at the level of nations should be explored further to obtain a more differentiated picture of processes related to levels of depression across countries.

Beck Depression Inventory 28

Acknowledgement The authors would like to thank Jim Georgas from the University of Athens for providing the data on the Affluence indicator.

Beck Depression Inventory 29

Footnote
1

Depression refers to country-level mean scores on the BDI

Beck Depression Inventory 30

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Beck Depression Inventory 32

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Beck Depression Inventory 33

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Beck Depression Inventory 35

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Beck Depression Inventory 36

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Beck Depression Inventory 37

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Beck Depression Inventory 39

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Beck Depression Inventory 40

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Beck Depression Inventory 41

Table 1 Study Characteristics of the 1961-Version Data Set Country Australia Bulgaria Canada China Denmark Finland Germany West Greece Iceland India Iran Ireland Israel Italy Kuwait Netherlands New Zealand Nigeria Norway Spain Sweden United Kingdom USA Hong-Kong Total mean
a

Number of Resp. Samples 225 3 691 1 2140 13 100 1 217 1 285 4 42 1 37 1 187 2 490 3 405 1 359 3 574 2 445 6 274 3 359 3 844 4 180 1 100 1 1524 3 3913 5 4481 14 5456 34 2780 7 26108 117

Mean 7.57 9.14 8.85 6.68 5.00 2.59 5.30 4.89 5.77 10.71 11.35 7.32 17.75 8.16 16.59 4.62 7.64 7.30 5.92 7.34 6.18 7.25 6.75 11.44 7.98

BDIa SD 6.50 -5.84 4.18 0.40 1.17 -5.40 5.50 7.02 -6.57 10.02 6.46 9.27 4.98 7.03 7.90 5.33 7.09 6.37 5.85 6.37 8.29 6.50

Alpha --0.82 ---0.60 --0.88 0.82 0.85 0.91 --0.82 0.88 ---0.89 -0.85 0.86 0.86

All numbers are weighted by sample size

Beck Depression Inventory 42

Table 2 Study Characteristics of the 1978-Version Data Set Country Argentina Australia Brazil Canada Greece Japan Mexico Netherlands Spain Turkey United Kingdom USA Hong-Kong Total mean
a

Number of Resp. Samples 608 2 1343 3 3203 6 139 3 98 1 116 2 1012 12 10 1 2407 5 1514 4 47 1 1602 13 675 3 12774 56

Mean 8.46 9.55 8.47 7.53 8.17 10.99 7.64 1.00 6.44 13.06 4.60 8.56 10.86 8.81

BDIa SD 7.26 7.50 6.69 4.61 6.69 8.04 7.58 1.10 5.81 7.88 4.20 6.63 7.90 6.88

Alpha 0.86 0.86 0.83 -0.86 ---0.83 --0.86 0.86 0.85

All numbers are weighted by sample size

Beck Depression Inventory 43

Table 3 Study Characteristics of the Short-Version Data Set Country Australia Canada Finland France Germany West Iran Netherlands New Zealand Total mean
a

Number of Resp. Samples 1659 5 499 2 1070 4 376 3 60 1 305 1 156 1 1091 16 5216 33

Mean 3.45 7.28 2.69 2.85 3.72 8.03 2.80 2.50 3.67

BDIa SD 4.25 6.07 2.88 2.50 3.24 3.29 3.50 3.09 3.68

Alpha 0.88 -0.73 --0.83 -0.81 0.84

All numbers are weighted by sample size

Beck Depression Inventory 44

Table 4 Correlations Between BDI Score and Context Variables Within Countries and Between Countries Context variables Income (SES) Educationc Suicide Alcohol used Anxietye EPQ-P EPQ-E EPQ-N EPQ-L
a

Individual levela + + + + + -

Country levelb -.46* -.54** -.46* -.25 -.02 .29 -.05 .23 .23

Results are based on literature reviewed in the introduction section, and studies

reported by Beck et al. (1988)

b

Results are based on analyses from the present study

At country level measured by the Education factor (Georgas & Berry, 1995),

consisting of the teacher-pupil ratio in the first level, the gross enrollment in the second and the third level, and the percentage of adult illiterates
d

At country level measured by death rate through liver cirrhosis (United Nations,

1990a)
e

At country level measured by mean scores on the question How often do you feel

nervous or tense at work? (Hofstede, 1976) as cited in Lynn (1981), with reversed sign *p < .05 **p < .01

Beck Depression Inventory 45

Table 5 Correlation Coefficients and Significance Levels (Regular and After Bootstrapping) Between Standardized BDI Scores and Context Variables for More Affluenta and Less Affluent Countries

Context variables

N countries

Total sample

BDI More affluent countries (Nmax = 14) a General hypotheses

Less affluent countries (Nmax = 14) -.29 -.49 -.03 -.23 .24 .22 -.31 -.18 -.33 -.40 -.04 -.12 -.16 -.11 -.48

Subjective Well-Being Diener Inglehart Happiness (Veenhoven, 1999) Prevalence rates Unipolar major depression Bipolar affective disorder Suicide rate Affluence Gross National Product Political Rights and Democracy Civil rightsb Level of democracy Stability of democracy Death by political violence (corrected) Factor score Livability Gini Index

24 23 26 28 28 23 28 28 25 23 23 23 28 20 20

-.46* -.66** -.24 .19 .33 -.46* -.50** -.46* -.46* -.46* -.29 -.46* -.02 -.40 .17

-.42 -.74** -.59* -.52 -.50 -.70* Livability theory -.18 -.14 -.73** -.62* .15 -.28 .12 -.62* Comparison theory .46

Beck Depression Inventory 46

Economic growth Eysenck Personality Questionnaire Psychoticism (EPQ-P) Extraversion (EPQ-E) Neuroticism (EPQ-N) Social Desirability (EPQ-L) Hofstede's Measures Individualism Masculinity Power Distance Uncertainty Avoidance Chinese Values Integration Confucian Work Dynamism Human-Heartedness Moral Discipline Schwartzs Values Autonomy factor Hierarchy factor Percentage of married females Percentage of married males Religiosity (Inglehart, 1997) Percentage unemployed
a

25 23 23 23 22 26 26 26 26 13 13 13 13 18 18 25 25 21 22

.34 .29 -.05 .23 .23 -.45 .38 .50** .07 -.67* .64* .48 .40 -.62** .35 .65** .52** .29 -.12

.45 Folklore theory .33 .18 .49 -.10 -.07 .77** .40 .36 -.41 .33 .84** .12 -.36 .44 Demographic hypotheses .41 .40 .36 .07

.34 .13 -.19 -.11 -.10 -.26 -.42 .30 -.26 -.68 .76 -.27 .79 -.72* .05 .74** .43 .10 -.36

More affluent countries have a GNP (1987) higher than 9210 US$, less affluent countries have a GNP lower than 9210 US$ Original sign changed **p < .01 (conventional significance test)

*p < .05

Beck Depression Inventory 47

p < .05

p < .01 (significance in bootstrap prcedure)

Beck Depression Inventory 48

Figure Caption Figure 1. Boxplot of standardized mean BDI scores

Israel Kuwait

-1

-2

N=

30 Standardized mean BDI score