Pain 99 (2002) 289298 www.elsevier.

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A conrmatory factor analysis of the Beck Depression Inventory in chronic pain

Stephen Morley a,*, Amanda C. de C. Williams b, Stephanie Black b
a

Academic Unit of Psychiatry and Behavioural Sciences, School of Medicine, University of Leeds, Leeds, LS2 9 JT, UK b INPUT, St Thomass Hospital, University of London, London, SE1 7EH UK Received 11 December 2001; accepted 26 April 2002

Abstract The Beck Depression Inventory (BDI) is widely used to assess depression in chronic pain despite doubts about its structure and therefore its interpretation. This study used a large sample of 1947 patients entering chronic pain management to establish the structure of the BDI. The sample was randomly divided to conduct separate exploratory (EFA) and conrmatory factor analyses (CFA). EFA produced many satisfactory two-factor solutions. The series of CFA generated showed reasonable t for ten of those solutions. All included a rst factor identied as negative view of the self (items: failure, guilt, self-blame, self-dislike, punishment and body image change), and a second factor identied as somatic and physical function (items: work difculty, loss of appetite, loss of libido, fatigability, insomnia and somatic preoccupation). The remaining items (suicidal ideation, social withdrawal, dissatisfaction, sadness, pessimism, crying, indecisiveness, weight loss, irritability) loaded infrequently or not at all in the CFA solutions. They did not form a coherent factor but comprised items associated with negative affect. When compared with published data from samples of depressed patients drawn from mental health settings the mean item scores for items reecting the negative view of the self were consistently statistically lower that that observed in samples; there was no consistent difference between the samples on the items reecting somatic and physical function; but the mean scores for the remaining affect items were signicantly greater in the mental health samples. This version of depression is strikingly different from the psychiatric model of depression (e.g. DSM-IV or ICD-10), which is primarily dened by affective disturbance, and secondarily supported by cognitive and somatic symptoms. The nding is consistent with a reconsideration of what constitutes depression in the presence of chronic pain. It also has important clinical implications: it may provide a way to distinguish depressed patients with typical cognitive biases, who require specic treatment for depression alongside pain management. q 2002 International Association for the Study of Pain. Published by Elsevier Science B.V. All rights reserved.
Keywords: Beck Depression Inventory; Chronic pain; Conrmatory factor analysis; Depression

1. Introduction Issues of adequate measurement and underlying models of co-morbid pain and depression (or depressed mood) have taxed research in pain for at least two decades. An integration of empirical data from a range of primary care and community studies supports the mechanisms of psychological distress amplifying pain, compromising adaptation to pain, and acting as a stressor to cause or worsen distress (von Korff and Simon, 1996). Pincus and Williams (1999) provide an overview of several models of depression and chronic pain paying due attention to contemporary cognitivemotivational models of depression. The three most discussed, Becks cognitive schema model, Seligmans
* Corresponding author. Tel.: 144-113-343-2733; fax: 144-113-2433719. E-mail address: s.j.morley@leeds.ac.uk (S. Morley).

helplessness model and Abramsons hopelessness model see Hammen (1997) for an overview of these models all consider the individuals construction of the self, and hypothesize a ltering processing mechanism, where information congruent with the self construct will get preferential self processing (Pincus and Williams, 1999 p. 213). Recent work using experimental tasks to investigate cognitive bias in chronic pain patients has led Pincus and Morley (2001) to conclude that pain patients with raised scores on questionnaire measures of depression typically do not display the cognitive biases shown by depressed patients, in that they are not characterised by self depreciation (negative view of the self) typical of depression occurring in a mental health context. Pincus and Williams (1999) argue that there is a need for a new model to describe the interaction between depression and chronic pain. They recognise that this is likely to proceed with a series of

0304-3959/02/$20.00 q 2002 International Association for the Study of Pain. Published by Elsevier Science B.V. All rights reserved. PII: S 0304-395 9(02)00137-9

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studies examining different aspects of depression in chronic pain, including the study of individual symptoms and the development of measurement. The study reported in this article is with regard to this aspect and concerns the analysis of a large data set of chronic pain patients response to the symptoms of depression as represented in the Beck Depression Inventory (BDI). The BDI is a widely used measure for severity of depression, despite the original authors, who worked with normal and psychiatric populations, warning that With respect to medical problems, the somatic complaints measured by the BDI must be carefully weighed before concluding that a medical patient is indeed depressed (Steer et al., 1985). The inclusion of somatic items in the BDI risks ination of the total score by somatic complaints unrelated to mood, rendering it unsatisfactory as an outcome variable and for clinical use. Various factor structures have been proposed in medical populations (Schwab et al., 1967; Plumb and Holland, 1977; Clark et al., 1983; Cavanaugh et al., 1983; Campbell et al., 1984; Emmons et al., 1987; Karanci, 1988; Judd et al., 1989; Johnson et al., 1996, Soderman and Lisspers, 1997) and in chronic pain populations (Peck et al., 1989; Sullivan and DEon, 1990; Williams and Richardson, 1993; Chibnall and Tait, 1994, Schuster and Smith, 1994; Gurland et al., 1988; Geisser et al., 1997). A large exploratory factor analysis of responses of chronic pain patients (Williams and Richardson, 1993) suggested little shared variance between most of the somatic items and the remainder of the cognitive and affective content. Two modelling studies have further explored these phenomena. Novy et al. (1995) tted a psychiatric model, previously conrmed on a sample of depressed alcoholic patients, to 247 chronic pain patients and found slightly better t of a single second order construct of depression than an inter-correlated model of a single factor with three sub factors. Both structures accounted for over 90% of variance and both were better than the baseline model of three independent factors. However, the baseline model tested by Novy et al. is of questionable applicability in chronic pain, given that it was established on a subpopulation of psychiatric patients and that it could not be conrmed in a more homogeneous psychiatric sample by other investigators (Startup et al., 1992). A second model et al., 1995) used the responses of 306 ling study (De Gagne chronic pain patients and combined the BDI total score with subscale total from other measures of pain, activity and social support. The obtained solution comprised four factors in which the BDI total score loaded with life control and affective distress (subscales of the Multidimensional Pain Inventory: Kerns et al., 1985) on a distress factor. As our data set did not include these additional scales the De Gagne et al. study did not provide us with a testable model. In this study we report the analysis of BDI items from a large sample of patients referred to a pain management programme. Our strategy was to conduct a series of exploratory factor analyses on a randomly selected half of the

sample and then to use conrmatory factor analysis on the remaining sample to check the models emerging from the exploratory factor analyses. Our prior expectations, based on our reading of the literature were that: (1) items representing somatic aspects of depression would not load with the cognitive/affective items on a common factor, but would form a separate factor; (2) items representing negative self appraisal would emerge as a separate factor, and that the mean score on these items would be lower than those reported in depressed samples drawn from psychiatric (mental health) populations; (3) that there would not be a single rst order factor such as that found by Novy et al. (1995). 2. Methods 2.1. Participants Archival data from chronic pain patients entering a multidisciplinary pain management programme between 1989 and mid-1998 was used. The programme routinely collects demographic, clinical and psychological data using standardised assessments. The rehabilitative treatment programme aims to restore optimal physical function, range and level of activity, improve mood, and reduce the use of drugs and other health care, and to equip the individual with more helpful understanding of, and beliefs about, pain and its implications: cognitive methods for resolving anxious and depressed styles and content of thinking are included. For this study, all the records for all patients assessed for the programme between its inception and 1998 were obtained. The BDI item scores and basic clinical and demographic data were extracted. A total population of 2041 patients included a sample of 1947 with adequate data sets virtually complete BDI of which 1225 (62.8%) were women. The majority of the sample were white/Caucasian (91.2%) with 4.6% Afro-Caribbean, and 2.4% Asian. With respect to social economic status and employment 25.2% were classied as unskilled, 50% as skilled/manual and 24.8% as professional/managerial; 9.1% were employed and a further 8.1% were in employment but restricted by their pain; 35% were unemployed and the majority of these patients attributed this to their pain; 24.1% were on pensionable sick pay. Of the remaining patients 14.6% were retired, 7.9% homemakers and 1.2% students. The primary sites of pain for the group as a whole were: low back (55%), lower limb (10.6%), shoulder and upper limb (10.5%), head and neck (9.7%), chest and thorax (4%), pelvis (3.6%), abdomen (3.3%) and perineum, rectum and genital area (2.5%). The mean time since pain onset was 117.5 months (SD, 109.3; range 3648; median, 79 months). 2.2. Measure The programme uses the original 21-item BDI (Beck et al., 1961). There is a considerable literature on the BDI and

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its reliability and validity in mental health contexts is established, it is sensitive to treatment changes and has been used as a primary outcome measure in many randomised controlled trials of treatments for depression and cognitive behavioural treatment for chronic pain (Flor et al., 1992; Morley et al., 1999). The 21 items cover the major features of depression as observed in psychiatric settings. Table 1 shows the item content identied by letter and its abbreviated description. Each item consists of four statements presented in an ordered sequence to reect increasing intensity of experience. Each item is scored on a 03 scale with 0 indicating absence of the symptom and 3 the most intense statement. Clinically made psychiatric diagnoses are not routinely made in the pain management programme and this data is therefore not available for concurrent analysis. 2.3. Analyses The sample of 1947 was randomly split using the algorithm available in SPSS to produce two samples, one for exploratory factor analysis (EFA; n 973) and one for conrmatory factor analysis (CFA; n 974). As a check a set of statistical comparisons between the samples on their demographic, clinical characteristics and mean item scores for the BDI was conducted; there were no statistical differences between the samples. The rst sample (n 973) was subjected to several different methods of EFA, including principal axis factoring (PAF) and maximum likelihood extraction (MLE), using the suite of programmes available SPSS and in EQS (Bentler,
Table 1 BDI items: letter code, short identier and items Short identier A B C D E F G H I J K L M N O P Q R S T U Sadness Pessimism Sense of failure Dissatisfaction Guilt Punishment Self-dislike Self-accusations Suicidal ideas Crying Irritability Social withdrawal Indecisiveness Body image change Work difculty Insomnia Fatigability Loss of appetite Weight loss Somatic preoccupation Loss of libido Item extremes

1995). Our strategy for the EFA was to be data-guided and we therefore placed few restraints on the methods of analysis, attempting orthogonal and oblique rotation of factors for each method. The purpose of this strategy was to seek convergence across the methods. In initial analyses a cutoff value of 0.4 was set for factor loadings. Later analyses on improved models used a lower cut-off of 0.3 to check for cross-loadings. A criterion for factor stability of at least three high-loading items on a factor with near-zero loadings on other factors was deemed desirable for an acceptable solution. These criteria were established following consultation with texts on multivariate analysis e.g. Tabachnick and Fidell (1996), and consultation with an acknowledged reskog, personal communication). In authority (K.G. Jo pursuit of establishing consistent solutions that met the criteria the EFA were re-run with the increasing constraint of reducing the number of factors to be extracted. The second sample was used to test models using CFA. A nal set of analyses were conducted in which the item scores from the current sample used in the CFA were compared with published data for the BDI from two large samples drawn from mental health settings. The comparisons were made with t-tests and calculation of effect sizes. 3. Results 3.1. Exploratory factor analyses While four factor solutions were produced by free extraction methods they failed to meet the predetermined criteria (see example in Appendix A), or in the case of PAF failed to

I do not feel sad/I am so sad or unhappy that I cannot stand it. I am not particularly pessimistic or discouraged about the future/I feel that the future is hopeless and that things cannot improve. I do not feel like a failure/I feel I am a complete failure as a person (parent, husband, wife). I am not particularly dissatised/I am dissatised with everything. I do not feel particularly guilty/I feel as though I am very bad or worthless. I do not feel I am being punished/I feel I deserve to be punished, I want to be punished. I do not feel disappointed in myself/I hate myself. I do not feel I am any worse than anybody else/I blame myself for everything bad that happens. I do not have any thoughts of harming myself/I would kill myself if I could. I do not cry any more than usual/I used to be able to cry but now I can not cry at all even though I want to. I am no more irritable now than I ever am/I do not get irritated at all at the things that used to irritate me. I have not lost interest in other people/I have lost all my interest in other people and do not care about them. I make decisions about as well as ever/I can not make decisions at all any more. I do not feel I look worse than I used to/I feel that I am ugly or repulsive looking. I can work about as well as before/I cannot do any work at all. I can sleep as well as usual/I wake up early every day and cannot get more than 5 h sleep. I do not get any more than usual/I get too tired to do anything. My appetite is no worse than usual/I have no appetite at all any more. I have not lost much weight, if any, lately/I have lost more than 15 pounds (7 kg). I am no more concerned about my health than usual/I am completely absorbed in what I feel. I have not noticed any recent changes in my interest in sex/I have lost interest in sex completely.

292 Table 2 Statistics used to evaluate CFAs Index Method of estimation

S. Morley et al. / Pain 99 (2002) 289298

Good t indicated by Non-signicant ratio of x 2: df #3 .0.95 $0.95 $0.95 $0.95 ,0.05 and CIs

x NFI
NNFI CFI RCFI RMSEA

Difference between estimate and sample Normed t index (BentlerBonett) compares x 2 value of model to x 2 value of independence model (variables uncorrelated) Non-normed t index is similar to NFI but incorporates degrees of freedom Comparative t index (CFI) (Bentler) compares t of model with alternative models Robust CFI (SatorraBentler) Root mean square error of approximation measures discrepancy per degree of freedom

converge within a reasonable number of iterations. A threefactor solution was attempted for each of the methods. Orthogonal methods contained many cross-loadings and the factors were not well distinguished. Oblique methods produced more distinct factors but with few items in the second and third factors with sufciently high loadings. The process was repeated for two factor solutions. These produced generally more robust solutions with little evidence of cross-loadings and factors with a sufcient number of items. These models were then submitted to conrmatory factor analysis. 3.2. Conrmatory factor analyses CFA was conducted using the EQS programme (Bentler, 1995). The data were treated as if continuous, following the model analysis of the BDI by Byrne (1994). A corrected SatorraBentler x 2 was used to allow for non-normality, and robust standard errors for parameter estimates and robust goodness-of-t indices. Each factor was tested for goodness-of-t before the model as a whole was tested. The criterion for goodness-of-t was set at 0.95, and RMSEA , 0.05. The statistics used to evaluate the CFA models are shown in Table 2. As a result of the initial CFA four of the models met the evaluation criteria. These, along with their test statistics, are shown as models 14 in Table 3. Table 4 offers a graphical representation of these data in which the consistency with which the items load on the two factors across the ten

models evaluated can be readily seen. Models 1, 2 and 3 were subjected to further investigation by consecutive sequential modication of the factors in which items were entered or deleted using the loadings and their 95% condence interval (CI) from the relevant EFA as a guide. Thus items with a high loading but a CI greater than 0.1 were deleted, and where available items with a lower loading and a smaller CI were added. The evaluative statistics for the model t for these modications are also shown in Table 3 where the modications are identied by lower case letters. Factor 1 consistently included items that reect negative evaluation of the self. The items failure, guilt, punishment, self dislike, self blame, appear in all the models; body image change also loads signicantly in more than half the models whereas suicidal ideation loads in only three models. The items loading on factor 2 were predominantly concerned with somatic and physical function but as can be seen from Table 4 there is less consistency in the frequency with which they load. Nevertheless six items loaded in more than half of the tested models (work difculty, loss of appetite, loss of libido, fatigability, insomnia and somatic preoccupation). The remaining items either loaded infrequently or not at all on either of the two factors (suicidal ideation, social withdrawal, dissatisfaction, sadness, pessimism, crying, indecisiveness, weight loss, and irritability). 3.3. Comparison with mental health data We selected model 2, a variation of the solution derived

Table 3 Summary statistics for the conrmatory factor analysis solutions for the 4 models tested and their variants a Model number method 1 MLE/VAR 1a 2 MLE/OBL 2a 2b 2c 3 EQS/PAF 3a 3b 4 PAF/OBL
a

x2
76.51 57.72 138.97 112.23 91.38 62.22 36.12 182.89 140.36 132.91

Degrees of freedom 34 26 64 53 43 34 26 76 64 53

S B x 2 66.10 47.96 119.64 97.29 77.15 51.24 31.69 156.87 117.61 113.20

NFI 0.959 0.968 0.943 0.950 0.958 0.969 0.977 0.935 0.949 0.944

NNFI 0.969 0.975 0.961 0.966 0.970 0.981 0.991 0.953 0.965 0.957

CFI 0.977 0.982 0.968 0.973 0.977 0.986 0.993 0.961 0.971 0.966

RCFI 0.979 0.985 0.972 0.976 0.980 0.987 0.996 0.963 0.974 0.968

RMSEA 0.036 0.036 0.035 0.034 0.035 0.030 0.020 0.039 0.036 0.040

90% CI RMSEA 0.026 0.023 0.027 0.026 0.025 0.018 0.000 0.031 0.028 0.032 0.047 0.049 0.043 0.043 0.044 0.041 0.035 0.046 0.044 0.049

The denition of the column is given in Table 2. MLE, maximum liklihood extraction; VAR, varimax; OBL, oblique; EQS, EQS program; PAF, principal axis factoring.

Table 4 Graphical representation of CFA solutions for each two factor model a
Factor 1 Model C Failure E Guilt F Punishment G Selfdislike H Self blame N Change in body image W W W W W W W W W 3 I Suicidal ideas Factor 2 O Work difculty W W W W W W W W W W 10 R Loss U Loss of appe- of libido tite Q 1Fatigability P Insomnia T Somatic preoccupation L Social withdrawal D Dissatisfaction Not loading A Sadness B Pessimism J Crying S Indecisiveness S Weight loss K Irritability

S. Morley et al. / Pain 99 (2002) 289298

1. MLE VAR 1a 2. MLE OBL 2a 2b 2c 3. EQS PAF 3a 3b 4. PAF OBL Total frequency
a

W W W W W W W W W W 10

W W W W W W W W W W 10

W W W W W W W W W W 10

W W W W W W W W W W 10

W W W W W W W W W W 10

W 7

W W W W W W W W W W 10

W W W W W W W W W 9

W W W W W W W W 7 W W W W W W W W W

W W W 6

W W

W W

An item loading on the factor in indicated by W. The model reported in detail is shown in bold. The nal row indicates the frequency with which each item loaded across the 10 models.

293

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from the initial maximum likelihood oblique solution for further exploration. This model includes the six items that load most consistently on factor 1 and the six items that load in more than half of the solutions for factor 2. It therefore appears to capture the broadest consistent features of the CFAs. Table 5 shows the items statistics for the CFA sample organized in accordance with model 2a. A graphical representation of the distribution of the total BDI score for this data set is shown in Fig. 1 in which the recommended cut scores for levels of depression according to convention are superimposed. The mean total score for the sample was 17.58 (SD, 8.66; 95% CI: 17.03, 18.13) and the distribution of the sample was slightly positively skewed with a median score of 16, range 053, inter-quartile range 1123. The conventional cut points for mild, moderate and severe depression in a psychiatric setting are: ,10, minimal depression; 1019, mild depression; 2029, moderate depression; .30, severe depression (Beck et al., 1988). Applying these to cut points to the present sample allocated 17.8, 45.6, 26.6 and 10% of cases to the four categories. An alternative cut point of 21 for major depression in a chronic pain population, derived by Geisser et al. (1997) which classied 28.5% of the current sample as depressed. We compared (t-test) the mean items scores of the CFA sample (n 964) with those provided for a sample of patients with major depressive disorder (MDD) from the manual for the BDI (n 248). We made a second set of comparisons with a data set from a sample drawn from a
Table 5 Item statistics for the sample used in the conrmatory factor analysis (n 974) Factor and items Mean SD

mental health setting in the UK and used in a previous factor analysis (Startup et al., 1992). This sample comprised 309 individuals referred for treatment in the Second Shefeld Psychotherapy trial of psychological treatments for depression. The complete sample included 139 who met DSM-III criteria for major depressive episode. The sample therefore represents the range of persons referred to a mental health setting with problems of mood regulation and is a more heterogeneous sample than that reported in the BDI manual. It is not known if either of these samples included patients with concurrent chronic pain. Fig. 2 shows a plot of the item means for each data set. In the rst comparison (MDD diagnosed patients) a consistent pattern emerged: for items reecting negative view of the self, with the exception of body image change, the mean scores for the chronic pain group were signicantly lower than the mean scores of the MDD sample. The t values ranged from 4.88 to 23.94 (effect sizes from 0.35 to 1.70). In contrast there was no overall consistent difference between the groups on items representing the somatic and physical function. There were no differences for work difculty, fatigability, and loss of libido, but the chronic pain group showed elevated item scores on somatic preoccupation and insomnia, while the MDD group reported greater appetite loss. However, the associated effect sizes for these comparisons were markedly lower than for the comparisons for the rst factor (0.010.31). The remaining seven items not tted by the present factor

Percentage endorsing scale point 0 1 2 3

Number missing

Self denigration C Sense of failure E Guilt F Punishment G Self-dislike H Self-accusations N Body image change Physical function L Social withdrawal O Work difculty P Insomnia Q Fatigability R Loss of appetite T Somatic preoccupation U Loss of libido Affect A Sadness B Pessimism D Dissatisfaction I Suicidal ideas J Crying K Irritability M Indecisiveness S Weight loss

0.77 0.71 0.41 0.44 0.78 0.73 0.49 1.50 1.73 1.32 0.61 0.85 1.24 0.96 1.00 0.93 0.49 0.82 0.96 0.80 0.32

0.95 0.94 0.73 0.66 0.81 0.87 0.63 0.71 1.10 0.71 0.80 0.81 1.12 0.90 0.89 0.62 0.72 0.88 0.56 0.83 0.73

53.7 59.0 73.1 64.1 42.5 53.5 57.3 4.1 12.3 8.2 55.7 38.4 33.6 36.4 33.4 21.1 63.5 39.4 15.8 44.3 80.4

21.7 15.1 13.8 30.1 40.6 22.1 37.0 53.2 36.5 58.3 31.8 42.0 28.2 37.2 38.1 69.9 25.7 48.5 74.6 32.8 11.6

18.7 22.2 12.3 4.0 13.4 22.3 4.8 34.3 17.5 27.1 8.5 16.2 18.8 19.4 22.1 7.6 9.4 2.3 7.8 21.1 4.2

5.9 3.7 0.8 1.8 3.4 2.0 0.0 8.3 33.8 6.4 4.0 3.3 17.4 6.4 5.8 2.7 1.5 9.8 1.9 1.8 3.9

10 13 14 11 14 12 10 10 12 10 13 13 16 10 9 9 12 12 10 12 17

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Fig. 1. Cumulative frequency distribution of the BDI total score for the CFA sample.

solutions but which largely reect affective state were all endorsed with signicantly greater magnitude by the MDD sample (range of t values 3.3413.6; effect sizes 0.230.87). The second comparison (Shefeld, UK sample) was consistent with the pattern observed in the USA sample of MDD patients: The Shefeld sample scored consistently higher on items reecting a negative view of the self with the exception that there was no difference with respect to suicidal ideation (effect size 0.04). The t values ranged from 4.56 to 12.68 (effect sizes from 0.240.39). Once again there was no difference between the samples with respect to body image change. With regard to the second factor there were no differences between the samples for fatigability and concern about health; the Shefeld sample reported signicantly lower scores for work difculty, loss of appetite, loss of libido, and insomnia, but greater social withdrawal and dissatisfaction. The effect sizes for the signicant differences range between 0.14 and 0.35. With the exception of weight loss and irritability the remaining items not tted by the present factor solutions (predominantly affect related) were all endorsed with signicantly greater magnitude by the Shefeld sample (range of t values 3.414.43; effect sizes 0.200.27).

The exploratory analysis revealed two factors that were reasonably consistently conrmed in the conrmatory stage. As expected, a factor emerged relating to somatic items, here called physical and somatic function, on which most patients scored at least moderately. We also identied a factor relating to a negative view of the self, on which most patients scored relatively low. Unexpectedly, the remaining items formed no coherent factor, but appeared to have a common content relating to affect, and were relatively frequently endorsed by the majority of patients. It is worthwhile comparing our factor solution with those of Novy et al. (1995) and Startup et al. (1992) described above (it is not possible to compare ours with that of De et al. (1995) since theirs included many items from Gagne another questionnaire). The rst factor in the Novy et al., study incorporated items AJ, and items L and N (see Table 1), that is, most of the negative self-view items in our rst factor plus most of the affective items which remained outside our two factors. The second and third factors in the Novy et al., study were (respectively) performance difculty, (indecisiveness, work inhibition, somatic preoccupation, and libido), and physiological manifestations, (irritability, insomnia, fatigability, loss of appetite, and weight loss). Thus the items that fell into our second factor,

4. Discussion In this study we derived and then conrmed the factor structure of the BDI in chronic pain using a large patient sample whose size makes it very unlikely that the factor solution capitalised on chance. Given the convergence of multiple solutions which met statistical criteria on two factors, we would conclude that there is a relatively robust structure to the BDI responses of chronic pain patients which can cast further light on the phenomena of depressed mood and major depressive disorder in chronic pain, and which has important clinical implications.

Fig. 2. Item means for the chronic pain, UK (Startup et al., 1992) and USA (BDI manual) samples.

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somatic and physical function, in the Novy et al., study were shared between two factors, each with an affect item incorporated, however, these factors were correlated. Certain differences, considered below, between our populations may have a bearing on these ndings. In the Startup et al. study of mental health patients, the second self-denigration factor (identical to model 3-Tables 3 and 4) contained the same items as our rst factor but without body image change, while their third vegetative factor (suicidal ideas, insomnia, loss of appetite, and weight loss) only partly overlapped with our second factor irrespective in any of the solutions shown in Tables 3 and 4. However, their solution had a major mood/motivation factor, which we did not nd. Interestingly, they commented that while the mood/ motivation disturbance was central to depression, the selfdenigration dimension might vary independently, but since few depression scales sample it adequately and in terms of Becks original cognitive formulation it is just one of several distortions, this remains speculative. This factor structure means that despite the relatively high total BDI scores in the sample, which in a unidimensional model would suggest that around 40% are moderately or severely depressed, the content of their scores shows relatively little of the self-denigratory component which characterises clinical depression: the median score on this six-item factor was 3 (with 21.9% scoring zero, 28.9% scoring 6 or more and 2.8% scoring 12 or more). Furthermore, the failure to identify a single factor characterised as a cognitive/affective component suggests that despite relatively high endorsement of the eight affective items (22.2% scored 8 or more, a mean of 1 per item; 0.1% scored 16 or more, but only 3.2% scored zero in total), they do not in combination form a single depressive component. We note that the most frequently endorsed item among these are irritability and dissatisfaction, which may reect aspects of emotional experience independent of depression and related rather to living with chronic pain. Price (1999) found frustration to be the emotion most frequently endorsed/offered by patients with chronic pain. Our tentative conclusion is that the BDI cannot measure depression in chronic pain patients, but instead may be a useful tool for considering components of cognitive, affective and behavioural distress that vary considerably within the population. This is not to suggest that the BDI should be abandoned, because it has excellent clinical content and extensive data on its use is available, but that the item endorsement pattern requires careful consideration as it may reveal more than any total or subscale score. Neither are we suggesting that the term depression should be abandoned in the context of chronic pain, but rather that further analysis of the components of depressive symptomatology and their interrelationship with chronic pain should be pursued (Pincus and Williams, 1999; Pincus and Morley, 2001). Further work needs to be done to establish the utility of the current factor solution and its temporal stability. It

requires replication on other chronic pain populations, using conrmatory factor analytic methods. It is unclear whether differences between our population and that sampled by Novy et al. can account for differences in our solutions: their patients were primarily suffering from bromyalgia (75%); 16% had sympathetically maintained pain, and the remainder head and visceral pain, whereas the majority of our population had mainly musculoskeletal pain; there were also substantially fewer black patients in our sample, which was of predominantly Caucasian origin. However, ethnic and diagnostic differences, within chronic pain, tend not to distinguish patients in psychological terms, and do not emerge from analyses of individual differences in patients as predictors or mood (Turk, 1996; Morris 2001). 1 We also note that a direct comparison of BDI scores and established clinical diagnosis of depression was not available in our sample and conversely in the comparison samples we used information about concurrent chronic pain was not available. The extent to which comparisons were contaminated is unknown but we suspect the incidence of co-morbidity is quite small given the sources of referral in each setting. In the current study multiple solutions which met statistical criteria converged on two factors: a negative view of the self, on which most patients scored relatively low; and functional/physical disturbance, on which most patients scored at least moderately. It can therefore be concluded that there is a relatively robust structure to the BDI responses of chronic pain patients which can cast further light on the phenomena of depressed mood and major depressive disorder in chronic pain, and which has clinical implications. The nding is consistent with a model proposed by Pincus and Morley (2001) derived from experimental data that revealed that depressed pain patients do not exhibit the cognitive biases shown by depressed patients without chronic pain. These data and the current psychometric analyses contribute to a reconsideration of what constitutes depression in the presence of chronic pain (Williams, 1998, Pincus and Williams, 1999). Most patients with chronic pain, although distressed by pain and by the impact of pain on their lives (factor 2), do not take a particularly negative view of themselves (factor 1) which colours interpretation of their daily experience. Clinically, the solution may offer a means to distinguish depressed patients with typical cognitive biases particularly in their view of themselves (factor 1), from non-depressed patients: depressed patients require specic treatment aimed at resolving their depression. Novy et al. (1995) recommended the single factor hierarchical model for its parsimony in measuring
1 Although we had a large sample we did not run separate sub-analyses on cultural sub-groups. There was a relatively small sample of non-Caucasian patients (about 80) and data on the birthplace and duration of residence in the UK was not available. It is therefore unknown the extent to which racial origin in this sample corresponds to cultural variation.

S. Morley et al. / Pain 99 (2002) 289298 Table A1 Pattern matrix for the MLE 2 factor oblique solution Short identier A B C D E F G H I J K L M N O P Q R S T U Sadness Pessimism Sense of failure Dissatisfaction Guilt Punishment Self-dislike Self-accusations Suicidal ideas Crying Irritability Social withdrawal Indecisiveness Body image change Work difculty Insomnia Fatigability Loss of appetite Weight loss Somatic preoccupation Loss of libido Factor 1 0.378 0.351 0.723 0.306 0.626 0.443 0.762 0.603 0.405 0.287 0.070 0.183 0.368 0.385 20.047 20.066 0.105 20.037 20.012 0.120 0.006 Factor 2 0.365 0.369 20.059 0.402 20.008 20.046 20.082 20.055 0.231 0.249 0.284 0.432 0.358 0.132 0.492 0.312 0.403 0.481 0.200 0.414 0.401

297

disparate symptoms under a single term (Persons, 1986; Costello, 1993; van Praag, 1993). These criticisms are consistent with those of the entire DSM system as an unsatisfactory way to further understanding of psychological disorder (Follette, 1996). Certainly, more careful study of patients cognitive content and processes, and of their behaviour, in relation to depressed and non-depressed mood in chronic pain is likely to bear considerably greater dividends (Pincus and Morley, 2001) than use of the BDI to classify patients according to inappropriate psychiatric yardsticks. Acknowledgements This work was carried out with a grant (SPGS 588) from South Thames Region NHS Executive Research and Development Small Project Grant Scheme, which paid the salary of the third author. We thank Dr Mike Startup for giving us access to his data set. Appendix A The pattern matrices for MLE 2 factor oblique solution and four factor principal axis factoring oblique solution are shown in Tables A1 and A2 References
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a common core of depressive symptomatology which can be fractioned into more primary constituents (p. 269), but if depression is a different phenomenon in chronic pain than in its absence, then parsimony at a statistical level is not a sufcient criterion for accepting the solution. There is a strand of thinking within mainstream depression research which recommends that symptoms are studied separately to understand better their natural history, cognitive and emotional covariates, and treatment responses, and that their interrelationships are examined, rather than combining
Table A2 Pattern matrix for four factor principal axis factoring oblique solution Short identier A B C D E F G H I J K L M N O P Q R S T U Sadness Pessimism Sense of failure Dissatisfaction Guilt Punishment Self-dislike Self-accusations Suicidal ideas Crying Irritability Social withdrawal Indecisiveness Body image change Work difculty Insomnia Fatigability Loss of appetite Weight loss Somatic preoccupation Loss of libido Factor 1 0.68 0.71 0.18 0.46 0.05 0.2 0.07 20.13 0.36 0.35 0.04 0.33 0.27 0.02 0.12 20.03 0.04 0.00 00.00 0.37 0.16 Factor 2 20.03 0.02 20.02 0.00 0.04 0.03 20.07 0.03 0.09 0.13 0.02 0.10 0.09 0.01 20.04 0.12 20.02 0.71 0.40 20.02 0.18 Factor 3 0.04 0.00 0.57 0.11 0.58 0.34 0.69 0.68 0.22 0.13 0.113 20.08 0.28 0.39 20.04 0.00 0.14 20.03 0.01 20.01 0.00 Factor 4 0.02 20.02 20.07 0.15 0.00 0.00 0.03 0.03 0.00 20.03 0.25 0.17 0.16 0.16 0.52 0.28 0.48 0.15 20.06 0.23 0.19

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