Differential Item Functioning in a Spanish Translation

of the Beck Depression Inventory

Francisca Azocar and Patricia Aren

University of California, San Francisco
San Francisco General Hospital

Jeanne Miranda
Georgetown University

Ricardo F. Muoz
University of California, San Francisco
San Francisco General Hospital

Brief and culturally compatible measures of depression are necessary, yet

most depression scales are translated without regard for cultural biases. In
this study, 292 medical outpatients completed an English or a Spanish-
translated and back-translated version of the Beck Depression Inventory
(BDI). The BDI items were analyzed for bias between Spanish and English-
speaking patients to determine the equivalence of the scale. A Differential
Item Function (DIF) using a Mantel Haenszel Approach for Ordered Response
Categories was used to analyze how likely subjects in the two ethnic
groups were to endorse each response category. The results suggest that
regardless of level of depression, Latinos are more likely to endorse items
reflecting tearfulness and punishment, and less likely to endorse inability
to work. Cultural interpretations and recommendations for use of the BDI
are discussed. 2001 John Wiley & Sons, Inc. J Clin Psychol 57: 355
365, 2001.

Keywords: cross-cultural psychology; Latino mental health; depression; dif-

ferential item functioning

An earlier version of this paper was presented at the Interamerican Congress of Psychology. This study was
funded in part by NIMH Grant MH37992, PI: Ricardo F. Muoz.
Correspondence concerning this article should be addressed to: Francisca Azocar, Ph.D., now at United Behav-
ioral Health, 425 Market St., 27th Floor, San Francisco, CA 941052426.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 57(3), 355365 (2001)

2001 John Wiley & Sons, Inc.
356 Journal of Clinical Psychology, March 2001

Depression in the Latino community is a common and serious problem. Many Latinos see
their primary-care physicians when seeking help for emotional problems. Consequently,
brief and easy measures of depression are necessary. Most common depression scales are
simply translated, without regard for possible cultural biases that may be introduced.
Although the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh,
1961) has been widely used, no published research has examined potential cultural biases
in any Spanish translation used with Latinos in the United States. The purpose of this
study is to determine whether a translated version of the BDI is an equivalent measure of
depression in Spanish-speaking Latino medical patients, by comparing the performance
of BDI items in Spanish-speaking Latinos and English-speaking U.S. nationals.

Background

It is expected that by the year 2020 there will be more than 52 million Latinos in the
United States, making Latinos the largest minority group in the nation (U.S. Bureau of
Census, 1990). The prevalence of depressive symptoms in the Latino community is quite
high. For example in Los Angeles County, prevalence rates exceeded 27% in Latinos,
compared with 15.6% in White non-Latinos (Frerichs, Aneshensel, & Clark, 1981). Over-
all, the prevalence of major depression among medical outpatients varies from 5.8% to
10.0% (Hoeper, Nycz, Cleary, Regier, & Goldberg, 1979; Schulberg, Saul, & McClel-
land, 1985; Jones, Badger, Ficken, Leeper, & Anderson, 1987; Von Korff et al., 1987).
However, Muoz and Ying (1993, pp.111112) found lifetime prevalence rates of 14.2%
for English-speaking and 25.5% for Spanish-speaking primary-care patients at a public
hospital, and a current (six-month) prevalence rate of 11.8% for English-speaking and
21.8% for Spanish-speaking patients.
Depression is often expressed somatically, and symptoms of depression such as inabil-
ity to sleep, irritability, tiredness, lack of energy, and appetite or weight change may
easily be confused with medical illnesses. In addition, visiting a mental-health specialist
is viewed by many Latinos as potentially stigmatizing, leading them to seek mental-
health care from a primary-care physician rather than from the mental-health sector.
Depression often goes unrecognized and untreated. Schulberg et al. (1985) found that
primary-care physicians fail to recognize 75% of cases regardless of ethnicity, yet depres-
sion in Latino patients may be even less likely to be detected due to language barriers. To
facilitate the recognition of depression, it is important to develop and validate screeners
that can accurately assess depression in Latino patients. In an era of managed care quick
pencil-and-paper screeners that are time- and cost-efficient, this can facilitate the early
detection and treatment of depressive symptomatology.
Commonly used depression scales in both English and Spanish within primary-care
settings include the Center for Epidemiological Studies Depression scale (CES-D; Radloff,
1977); the BDI (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961); and the Medical
Outcomes Study depression scale (Burnam, Wells, Leake, & Landsverke, 1988). More re-
cently the Prime-MD (Primary Care Evaluation of Mental Disorders; Spitzer et al, 1995)
was developed for physicians to screen for mental disorders in primary care. In addition to
mood disorders, the Prime-MD assesses anxiety, eating, alcohol, and somatoform disor-
ders. Although all these scales currently have official Spanish translations, little is known
about their validity or reliability with Spanish-speaking populations within the United States.
The number of studies investigating Spanish-translated screening scales increased
during the 1980s. However, most psychometric studies focused on the CES-D and yielded
inconsistent findings (Frerichs, Aneshensel, & Clark, 1981; Guarnaccia, Angel, & Lowe-
 Item Bias in a Spanish Translation of the BDI 357

Worobey, 1989; Roberts, Vernon, & Rhodes, 1989; Roberts, Rhodes, & Vernon, 1990;
Golding, Aneshensel, & Hough, 1991; Stroup-Benham, Lawrence, & Trevillo, 1992).
Studies have found no differences between ethnic groups in the predictive value or dimen-
sionality of Spanish-translated scales like the CES-D (Frerichs et al., 1981; Roberts,
Vernon, & Rhodes, 1989; Roberts, Rhodes, & Vernon, 1990). However, other studies
have found group differences when examining the scales at an item level, with Latinos
reporting positive emotional states less often than Anglos (Golding, Aneshensel, & Hough,
1991). These findings suggest that differential item endorsement by different ethnic groups
may exist.
Most studies using Latino samples have assumed that methodologies and assessment
tools can be used cross-culturally. However, this practice disregards possible changes in
psychometric properties due to translation bias and it ignores the impact that culture may
have on the meaning of scale items. Studies have shown that the internal structure of an
instrument may change as a function of translation (Marn & VanOss Marn, 1991). In
addition, measures may show high internal consistency when used in Spanish (e.g., alpha
coefficients), yet have little construct validity (Deyo, 1984). It is possible that these
problems arise because scale items are not tapping culture-specific manifestations of
depression. For example, Kay and Portillo (1989) developed a depression symptom scale
in Spanish based on common words used by Mexican American women to describe
dysphoria. They found little correspondence between their emic scale (i.e., culture-
specific) and the BDI and the CES-D scale.
Given the potential problems in translating English normed scales into Spanish, it is
very surprising that few studies assess and correct for potential cultural biases and sys-
tematic errors. According to Velasquez (1992), between 1949 and 1992 only 65 psycho-
metric studies using Latino clinical samples and 38 studies using nonclinical Latino samples
were published. Eighty-five percent of these studies involved the MMPI and none exam-
ined the validity and reliability of commonly used diagnostic tools. Researchers have
found both acculturation and language differences in response to the MMPI (Whitworth,
1988; Montgomery & Orozco, 1983; Padilla, Olmedo, & Loya, 1982). Yet shorter assess-
ment tools such as the BDI are more commonly used in treatment outcome research, and
in community mental-health settings, as measures of distress or symptom severity. A
recent literature search in Psych-Info revealed five citations of studies on the reliability
and validity of Spanish translations of the BDI between 1976 and the present (Conde-
Lopez & Chamorro, 1976; Ramos-Brieva, 1986; Torres-Castillo, Hernandez-Malpica, &
Ortega-Soto, 1991). However, these studies were conducted in Spain, and their general-
izability to Spanish-speaking populations in the U.S. is unknown, given the cultural and
language differences. The only study examining the BDI in Latinos within the U.S. used
an elderly sample (Gatewood-Colwell, Kaczmarek, & Ames, 1989).

Beck Depression Inventory

The BDI is a frequently used self-report measure for assessing severity of depression.
The scale consists of 21 self-valuative items, each with three symptom-choices reflecting
a respondents experience over the course of a week. Scores above 16 suggest moderate
depression, with scores above 24 suggesting severe depression. Although the BDI has
proved applicable across a variety of cultures, testing has been primarily limited to Euro-
pean countries such as Switzerland, France, Finland, Czechoslovakia, Germany, and Spain
(for a review see Shaw, Vallis, & McCabe, 1985). Studies using the BDI in Latino sam-
ples in the U.S. have shown that it has adequate internal consistency. Bernal, Bonilla,
358 Journal of Clinical Psychology, March 2001

and Santiago (1995) examined the internal consistency and construct validity of the same
Spanish-translated version of the BDI used in the present study. Using a clinical sample
from an outpatient clinic at the University of Puerto Rico, the authors report an alpha
coefficient of .89. A principal-components analysis with varimax rotation revealed a sim-
ilar factor structure in three of the four factors reported by Beck, Steer, and Garbin
(1988). Yet to date, no published reports on the cultural validity and applicability of any
Spanish-translated versions of the BDI for the general population in the U.S. have been
published.
Given the high prevalence of depression and the increased need for services, as well
as the need for methodologically sound research on Latinos, it is imperative that screen-
ing and diagnostic instruments for depression be examined. The purpose of this study is
to examine whether a Spanish-translated version of the BDI is an equivalent measure of
depression in Spanish- and English-speaking medical patients. More specifically, we
examined item bias by comparing item functioning in Spanish-speaking Latinos and
English-speaking U.S. nationals.

Methods
Subjects

Study subjects were originally recruited for participation in the Depression Prevention
Research Project (DPRP; for details see Muoz & Ying, 1993). Participants were medical
patients seen at the outpatient general medical clinics at both the University of California,
San Francisco and at San Francisco General Hospital. Exclusion criteria were (1) current
mental health treatment, (2) illiteracy, (3) terminal illness, and (4) psychosis. Two hun-
dred and ninety-two subjects who completed the BDI as part of the screening for the
DPRP were included for this study. Fifty-five participants were literate only in Spanish;
the remaining 237 were English-speaking. Within the English-speaking sample, only
11.3% were Latino and within the Spanish-speaking sample 98% were Latinos. Among
the Latinos 28% were from Nicaragua, 23% from Mexico, 15 % from EL Salvador, 13%
were born in the United States, and the rest came from various other Latin American
countries. Participants had an age range of 18 to 69. Approximately 70% were low-
income, earning less than 10,000 dollars a year. No differences between the Spanish- and
English-speaking groups were detected in demographic characteristics, except for num-
ber of years in the U.S. (see Table 1). Approximately 19% met criteria for lifetime major
depression and 15% met criteria for current major depression.

Procedure

All participants were interviewed first in the medical clinics and then invited back for a
more lengthy interview. On the first visit, interviewers obtained general demographic
information and administered a screening instrument. On the second visit, interviewers
administered the Diagnostic Interview Survey (Robins, Helzer, Croughan, & Ratcliff,
1981) and the Beck Depression Inventory. At the third visit, interviewers administered a
series of paper-and-pencil questionnaires including a biculturality scale developed by the
research team which assessed language, cultural activities, and contact. At the time of this
study, there was no official Spanish translation of the BDI available. All measures used in
the DPRP study (including the BDI) were translated by the DPRP research team of mental-
health professionals and students using Brislins (1976) method. The instruments were
first translated into Spanish, and then independently translated back into English by a
 Item Bias in a Spanish Translation of the BDI 359

Table 1
Participant Characteristics by Language Group

Characteristics English Spanish

n 237 55
Age
M 50.84 49.21
SD 12.21 12.24
Gender
% Men 46.9 33.3
% Women 53.1 66.7
Ethnicity
% White 44.4 0.0
% African American 28.0 3.4
% Latino 11.3 98.0
% Asian 10.3 0.0
% Other 6.3 0.0
Education
M 12.22 11.00
SD 3.42 4.47
Annual Income
M 9,970 7,600
SD 11,050 5,540
Years in the USA
M 45.15 23.18*
SD 17.72 11.46

*p , .01.

group blind to the original English version. The original and the back-translated versions
were then compared and any differences were discussed and reconciled.

Statistical Procedures

We conducted item analyses of the BDI to determine Differential Item Functioning, or

DIF, using the Mantel-Haenszel Approach for Ordered Response Categories (Mantel,
1963). According to Dorans and Schmitt (1991), DIF is the unexpected difference in
response to a test item between two populations, once the attribute the test is measuring
is controlled for. The Mantel-Haenszel procedure uses the constant odds ratio model to
yield easily interpretable results. The procedure is as follows: The sample is divided into
two groups, a reference group (the group the test was originally developed for) and the
focal group (the group anticipated to respond differently to the test). In this case, the
reference group is the English-speaking sample and the focal group is the Spanish-
speaking sample. Language then is the independent variable. The sample is further strat-
ified into depressed versus not depressed, as determined by the BDI score. Therefore, the
BDI depression score is the stratifying variable, which is meant to control for the varying
degree to which patients in each ethnic group are seen as depressed by the BDI. Strat-
ifying in this way controls for the potential influence level of depression would have on
responses to the BDI items. Finally, each item is analyzed to determine how likely sub-
jects in the two groups are to endorse a response category for each item. Therefore, the
response to the item is considered the dependent variable.
360 Journal of Clinical Psychology, March 2001

While a Mantel-Haenszel test usually results in an odds ratio, in this analysis, we

employed an extended standardization procedure using the z statistic as recommended by
Dorans and Schmitt (1990). Extended standardization provides us with an average DIF
value for each item. For each item, this is a distribution of constructed-item scores for
both the English-speaking sample and Spanish-speaking sample. The expected item-level
scores at each strata is computed using frequencies to create a weighted average score.
These scores are then compared between the English-speaking and Spanish-speaking
groups, creating a z score. The z score provides information about the magnitude of
difference between groups in their response to the item. The results are interpreted by size
of the z score and direction of the score. If the item has a z score that is significantly large
and is positive, then the focal group is more likely to endorse a higher score on this item.
If the z score is significantly large and negative, then the focal group is less likely to
endorse a larger category on this item. We then used the Bonferroni control for multiple
comparisons to determine significance.

Results
Preliminary Analyses
In this sample, the BDI had two factors: an affective factor and a somatic factor. Using a
principal-components analysis with varimax rotation, the two factors were replicated in
the two language subsamples. The coefficient alpha for the entire scale was .97, with the
affective and somatic subscales showing coefficients of .97 and .93, respectively. These
findings show high levels of internal consistency and are congruent with previous research.
There was no significant difference in the mean BDI-scale score between the English-
speaking group, 14.87 (SD 5 10.13), and the Spanish-speaking group, 14.60 (SD 5
11.10).

Differential Item Functions

The results from this study revealed that four BDI items were biased for the Spanish-
speaking sample. The items reflecting punishment (Item 6), with a z 5 2.86, p , .003;
tearfulness (Item 10), with a z 5 2.07, p , .05; and appearance (Item 14), with a z 5 2.16,
p , .01, were more likely to be endorsed by Spanish speakers regardless of their level of
depression. On the other hand, the Spanish speakers were less likely to say they could not
work (Item 15), z 5 22.34, p , .01, regardless of level of depression. Table 2 shows all
the BDI items with their respective z-scores between language groups and significance
level.

Discussion
Although the BDI is an adequate measure of depression in the Spanish-speaking popu-
lation, four items were biased in this translated version of the BDI. One could speculate
that the bias is a function of the translation itself, or that the particular behaviors, atti-
tudes, or beliefs thought to be specific to depression are actually culturally specific regard-
less of depressive symptomatology. Therefore, such items may not be associated with
level of depression. Item functioning will be discussed in the context of Latino culture.

Cultural Interpretation of Biased Items

Item 6, I feel Im being punished. Whether depressed or not, Latinos were more
likely to endorse feeling punished. Most Latinos are strongly influenced by Catholicism.
 Item Bias in a Spanish Translation of the BDI 361

Table 2
Differential Item Functions for the BDI Items by Group

Items M SD Z-Score p

1. . . . I am so sad. . . .
English .54 .76
1.32 ns
Spanish .75 .93
2. . . . I feel the future is hopeless. . . .
English .65 .85
1.55 ns
Spanish .85 1.16
3. . . . I feel I am a complete failure. . . .
English .68 .89
.40 ns
Spanish .81 1.01
4. . . . I am bored with everything. . . .
English .92 .80
.37 ns
Spanish .96 1.01
5. . . . I feel guilty all of the time.
English .47 .70
.96 ns
Spanish .56 .78
6. . . . I feel Im being punished.
English .52 .99
2.86 .003
Spanish .94 1.14
7. . . . I hate myself.
English .59 .71
21.48 ns
Spanish .46 .64
8. . . . I blame myself for everything. . . .
English .71 .83
.58 ns
Spanish .75 .86
9. . . . I would kill myself. . . .
English .23 .48
.88 ns
Spanish .10 .36
10. . . . I used to be able to cry. . . .
English .67 1.07
2.07 .05
Spanish .87 1.10
11. . . . I dont get irritated at all. . . .
English 1.05 .93
.74 ns
Spanish 1.17 1.04
12. . . . I have lost all of my interest. . . .
English .59 .78
1.76 ns
Spanish .83 .96
13. . . . I cant make decisions. . . .
English .75 .91
1.72 ns
Spanish 1.00 1.10
14. . . . I believe that I look ugly.
English .69 .87
2.16 .01
Spanish .88 1.10
15. . . . I cant do any work at all.
English 1.02 .88
22.34 .01
Spanish .77 .78
16. . . . I wake up several hours earlier. . . .
English 1.13 .96
2.24 ns
Spanish 1.13 .95
17. . . . I am too tired to do anything.
English 1.13 .79
21.56 ns
Spanish .98 .85
18. . . . I have no appetite at all anymore.
English .48 .74
2.51 ns
Spanish .44 .64
19. . . . I have lost more than 15 pounds.
English .63 1.00
21.72 ns
Spanish .35 .74
20. . . . I am so worried about my physical problems. . . .
English .85 .84
22.80 ns
Spanish .85 .64
21. . . . I have lost interest in sex completely.
English 1.03 1.08
21.39 ns
Spanish .81 1.10
362 Journal of Clinical Psychology, March 2001

Beliefs such as God will punish you for all your sins, We are born in sin, We must
repent or God will punish us are commonly held among Latinos and serve as explana-
tions about things that are occurring in their lives (Cuellar & Roberts, 1984). During
situations of crises or stress, regardless of levels of depression, Latinos may believe that
negative events occur because they are being punished by God for something they did or
that it is simply fate. The notion of fatalism or el destino is the belief that things happen
because of fate and one has little or no control over the situation (Garza, 1977).

Item 10, I feel like crying. Latinos were likely to report more crying than Anglos,
regardless of level of depression. This finding could be interpreted as Latinos being more
likely to express sadness than Anglos. Given high levels of stress, especially in immi-
grant Latinos who have left behind family and friends, an expected and culturally appro-
priate response would be to have pena and cry when feeling sad, melancholic, or in crisis
(Cuellar & Roberts, 1984). In fact, Latino culture has practices and symbolisms that
portray crying as an acceptable behavior reflecting suffering. For example in past tradi-
tional funerals, criers called lloronas would be hired to weep at wakes and funerals.
Mexican mythology has the story of the La Llorona or weeping woman who can be heard
crying at night near the edge of the river where she killed her children. Endorsement of
suffering is a highly regarded Catholic virtue and even believed to be beneficial (Acosta,
1984). Therefore, whether depressed or not, Latinos may allow themselves to cry more
than Anglos.

Item 14, I believe I look ugly. In this item it may be unclear whether the bias is
introduced by the translation itself, or whether it is a cultural bias. I believe has a
stronger connotation than its literal translation Yo creo, because creo denotes some hes-
itation by the person endorsing the item. On the other hand, since Latinos are not part of
the White, blond, blue-eyed prototype represented in the media, they may feel unattrac-
tive, and therefore endorse this item whether or not they are depressed. In addition, it is
culturally appropriate for Latinos to consider themselves physically unattractive as they
get older, since with aging, beauty is believed to come from within. Intrinsic to the notion
of familismo older people, particularly grandmothers, are expected to take on the role of
guiding the family in child rearing and in spiritual and moral issues. The needs of the
family are above and beyond the needs of the individual (Ramos-McKay, Comas-Diaz, &
Rivera, 1988). Feeling that one looks ugly could be expected in a Latino sample where
the mean age is about 50 and the role of grandparent is expected within the family. This
may reflect a real contrast with the more individually based American cultural norm,
which stresses aging gracefully and delaying looking older as much as possible.

Item 15, I cant do any work at all. Latinos are less likely to say that they cannot
work, regardless of their level of depression. Low-wage employment, under-education,
and discrimination are factors that contribute to the poverty rate of Latinos. However,
Latinos have a solid work ethic, and in fact Latino men show higher labor-force partici-
pation than non-Latino men (78% versus 74% in 1991) (cf. Aguirre-Molina & Molina,
1994). Latinos in the U.S. are likely to take several menial jobs paying very low wages
and without benefits to support themselves and often the families they have left behind in
their country of origin. Particularly in the case of undocumented Latinos who are ineli-
gible for benefits, work is their only means of subsistence. Most are paid hourly wages,
so that missed hours of work may result in a drastic decrease of income. Therefore,
regardless of their depressive symptoms, Latinos are unlikely to endorse being unable to
work.
 Item Bias in a Spanish Translation of the BDI 363

Summary. As these results show, four items of this translated version of the BDI are
biased, with Latinos being equally likely to endorse (or not endorse) these items regard-
less of their level of depression. This would mean that if a Latino patient is not depressed,
yet endorses Items 6, 10, and 14, the BDI score could be as much as nine points higher
than a nondepressed Anglo patient. Biased items artificially increase or, as with Item 15,
decrease the total score of the scale. Thus, Latino samples with depression levels equal to
English-speaking samples would have mean scores up to six points greater. Care is needed
to discard or modify items that denote certain culturally specific behaviors, attitudes, or
beliefs as symptomatic of depression, or norms for clinical cutoff scores need to be
examined. When translating measures, the cultural sensitivity and appropriateness of the
scale should be considered. Care is also needed in the translation of items reflecting a
depressed mood to avoid introducing bias due to semantic differences. Yet, DIF analyses
are not usually conducted with translated versions of diagnostic or symptomatic measures.
By comparing an English-speaking group to a Spanish-speaking group, this study
examined the equivalence of items for patients who were depressed versus nondepressed
in these two language groups. Although the inclusion of a Latino bilingual group would
have allowed us to compare language differences within one ethnic group, bilingual
fluency was not assessed in this study; rather patients chose which language they pre-
ferred to be interviewed in, based on their comfort level with either language. In addition,
Dorans & Schmidt (1991) maintain that the reference group used in a DIF analysis should
be the group the scale was normed for, namely an English-speaking group. Although
biculturality was measured, we were unable to examine its effect given that the sample
that returned for the third interview was too small (n 5 45). In addition, the acculturation
measure was not administered to the White English-speaking sample, making it impos-
sible to examine the effect of acculturation on DIF. Future studies examining the DIF
between English- and Spanish-speaking samples should include both a Latino English-
speaking sample and monolingual Spanish- and English-speaking samples. This would
allow an examination of the differential effects of language and ethnicity.
The BDI is an adequate measure of depressive symptomatology which could effec-
tively be used with Latino patients for clinical and research purposes. It is an easy paper-
and-pencil self-report questionnaire which can be scored immediately and can serve to
alert physicians of potential suicidality and other symptomatology. However, caution
should be used when using screening instruments like the BDI within primary-care set-
tings. Scales measuring symptomatology tend to have low specificity leading to greater
false positives. Therefore, screening instruments should be used to alert physicians that
further clinical evaluation is necessary, but not to determine diagnoses.
As mentioned previously, there was no official Spanish translation when the DPRP
study was conducted. Since then, Beck (1993) released a Spanish-translated version of
the BDI which is similar to our translation. Although there are only minor differences
between both translations, two of the biased items have a semantically different meaning.
In Becks Spanish translation of Item 6, all four statements have . . . punished for life
added, which is not in the English BDI. Also, the last statement of Item 14 from Becks
Spanish BDI translates back into English as I feel I am ugly rather than I feel I look
ugly. Given that these two items have semantic meanings in English that are different
from those in Spanish, and that this study suggests that four of the items in the BDI are
culturally biased when translated into Spanish, psychometric studies that include DIF
analyses need to be conducted with Becks Spanish translation to ensure its cultural
sensitivity and appropriateness. Further research is needed to validate the BDI. This can
be accomplished by rewriting confusing items and discarding biased items. New clinical
norms need to be set for the Latino Spanish-speaking population.
364 Journal of Clinical Psychology, March 2001

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