Minimal clinically important difference on the Beck Depression Inventory--II according to the patient's perspective

Abstract

Background: The Beck Depression Inventory, 2nd edition (BDI-II) is widely used in research on depression. However, the minimal clinically important difference (MCID) is unknown. MCID can be estimated in several ways. Here we take a patient-centred approach, anchoring the change on the BDI-II to the patient's global report of improvement.

Method: We used data collected (n = 1039) from three randomized controlled trials for the management of depression. Improvement on a 'global rating of change' question was compared with changes in BDI-II scores using general linear modelling to explore baseline dependency, assessing whether MCID is best measured in absolute terms (i.e. difference) or as percent reduction in scores from baseline (i.e. ratio), and receiver operator characteristics (ROC) to estimate MCID according to the optimal threshold above which individuals report feeling 'better'.

Results: Improvement in BDI-II scores associated with reporting feeling 'better' depended on initial depression severity, and statistical modelling indicated that MCID is best measured on a ratio scale as a percentage reduction of score. We estimated a MCID of a 17.5% reduction in scores from baseline from ROC analyses. The corresponding estimate for individuals with longer duration depression who had not responded to antidepressants was higher at 32%.

Conclusions: MCID on the BDI-II is dependent on baseline severity, is best measured on a ratio scale, and the MCID for treatment-resistant depression is larger than that for more typical depression. This has important implications for clinical trials and practice.

Keywords: 2nd edition (BDI-II); Beck Depression Inventory; depression; minimal clinically important difference; outcome assessment; primary care.

Fig. 1.

Change in Beck Depression Inventory, 2nd edition (BDI-II) scores by baseline BDI-II score on (a) difference scale or (b) ratio scale, stratified by global rating from generalized linear model analyses pooled across all studies. In terms of absolute difference (a) improvement associated with feeling better increases with increasing baseline severity indicating a baseline dependency. There is less baseline dependency when measuring change in terms of percent reduction from baseline [i.e. ratio scale (b)]. In absolute terms, for every ten-point increase in baseline severity, the mean improvement associated with feeling better increased by 4.8 points [interaction term −0.48, 95% confidence interval (CI) −0.85 to −0.09]. The model fit on the absolute scale improved following addition of the interaction with baseline [Akaike's Information Criterion (AIC) reduced from 6649.48 to 6595.81]. Modelling change on the ratio scale (i.e. percent reduction from baseline) further improved the model fit (AIC 6469.01). Adding the interaction into the ratio model improved the model fit (AIC 6371.06), but the interaction with baseline was not supported by the test for interaction (interaction coefficient −0.21, 95% CI −0.65 to 0.23), and the simpler ratio without interaction is more parsimonious.