Comparison of SIS - I and BDI- II for assessing Depression in Recurrent Breast Cancer Patients

Anindita Mukherjee, Koustav Mazumder & Susmita Ghoshal

        The study intended to examine the depression scores and diagnosed levels of depression as obtained from Somatic Inkblot Series-I (SIS-I) and Beck Depression Inventory-II (BDI-II), and to high-light the special contribution, if any, of SIS-I in assessing depression among recurrent breast cancer patients. Thirty participants in the age range of 30-60 years were administered the BD- II and SIS-I. Results indicated that, there was a positive correlation between the depression scores as obtained from SIS-I and from BDI-II. Level of depression measured by BDI -I and SIS-I did not agree completely in terms of diagnostic levels. Presence of inner depression and excessive anxiety regarding the persons’ own body and physical symptoms of breast cancer were prominently observed from the content analysis of Somatic Inkblot series-I. The study indicates the need for using both self-report inventory (BDI-II) and projective techniques (SIS-I) as supplementary to each other and revealed the nature of discrepancy between them in diagnosing the level of depression.

Comparison of SIS- I and BDI-II for assessing depression in recurrent breast cancer patients:

        Breast cancer patients receiving chemotherapy for their recurrent disease often report the presence of depression (Mukherjee et.al, 2018). Depression can be measured by both projective and subjective techniques. The present study purported to examine if depression in recurrent breast cancer patients may be assessed equally adequately with self-report inventory and projective techniques. Somatic Inkblot series-I (Cassel, 1980, Dubey et al. 2019) has been used as the projective measure of depression and the Beck Depression Inventory-II (Beck, 1996) has been used as subjective report inventory. The controversy between the relative effectiveness of subjective report versus projective tests in case of psychological phenomena has a long history (Anastasi & Urbina, 1997). While both are amenable to some forms of subjectivity, the inventories to biased self-perception of the participant, and the projective tests to biased interpretation and theoretical preference of the examiner, there have been claims and counter claims for proving the appropriateness of either. In general, inventories rely for check on their measures of statistical reliability and validity, and projective tests on their ability to predict and discriminate (Dubey, et al, 2019).

Objectives: The objectives of the present study are:

1. To determine the relation between the depression scores as obtained from SIS-I and from BDI-II among recurrent breast cancer patients,
2. To determine the relation between the level of depression as diagnosed from SIS-I and from BDI -II among recurrent breast cancer patients,
3. To highlight the special contribution, if any, of SIS in assessing depression among recurrent breast cancer patients.

Method:

Hypotheses:

1. There is a positive relation between the depression scores as obtained from SIS-I and from BDI-II among recurrent breast cancer patients.

• The persons diagnosed as having a certain level of depression from BDI-II would be similarly diagnosed by SIS-I also.

Participants:

In the present study, the technique of purposive sampling has been used. Participants were 30 recurrent breast cancer patients belonging to low and medium socio-economic status, aging between 30 years to 60 years. Data were collected from Chandigarh.

Measures used:

The following tools have been used in the study:

• Brief information schedule for demographic information
• Beck Depression Inventory-II.
• SIS-I.

Procedure of data collection:

        Data for the present study has been collected by a trained Clinical Psychologist under individual administration condition. At first consent was taken from each participant. The tools were administered in a predetermined sequence. Approximately, 50 minutes were required for completing the whole protocol for each person.

        Scoring for BDI-II was done following the manual in terms of ‘no depression’, ‘mild depression’, moderate depression’, and ‘severe depression’. Scoring for SIS I was done following Application of Somatic Inkblot Series-I - New Scoring System (Cassell & Dubey, 2002). It yielded both scores for depression and levels of depression in terms of ‘no or minimal depression’, ‘mild depression’, ‘moderate depression’ and ‘severe depression’. Following the manual, a four-point scale has been used to score the level depression. Score 0 indicates level of ‘No Depression’ for no depressive content in responses; Score 1 means presence of mild depressive content in the face of humans or animals and denoted as ‘Mild Depression’; Score 2 that is level of ‘Moderate Depression’ is associated with the expression with a strong negative affect; Score 3 for depressed affect is associated with pathological anatomical response and denoted as the level of ‘Severe Depression’. The responses could also be analysed qualitatively.

Results:

        Initially the sample was divided in two age groups (30-45years or the younger group, and 45-60 years or the older group), and in two income groups (earning below Rs. 10000.00 per month that is low-income group, and above Rs. 10000.00 up to Rs. 25000.00 per month that is middle income group). Since age and income may contribute to depression, initially ‘independent samples t-tests’ were conducted to determine if there were significant differences in terms of these two variables in depression scores as assessed by BDI-II and SIS-I.

Table 1: Means, SDs, and t values indicating difference in age on scores of depressions assessed by BDI- II and SIS-I for 30 participants.

Table 1 revealed that there was no significant difference between the two age groups on scores of depressions assessed by BDI-II and SIS-I for the 30 participants.

Table 2: Means, SDs, and t-values indicating difference in income level on scores of depressions assessed by BDI-II and SIS-I for 30 participants

Table 2 revealed that there was no significant difference between the income groups on scores of depressions assessed by BDI-II and SIS-I for the 30 participants.

Since there was no significant difference between the two age groups and two income groups all 30 patients were treated together for subsequent calculations.

        To determine the relation between the depression scores as obtained from SIS-I and from BDI-II, Pearson’s Product Moment Correlation Coefficients were computed between the two sets of depression scores. The ‘r’ value was .639 (p< .000), indicating that there was considerable overlap between the two concepts. However, the ‘r’ value was not so large as to suggest that the two instruments assessed almost the same construct. Thus hypothesis 1 was accepted.

        To compare the levels of depression (no depression or minimal, mild, moderate, severe) as diagnosed from SIS-I and from BDI-II, the levels of depression (none or minimal depression, mild, moderate, and severe depression) were calculated for all participants according to the manuals. Apparently, it was observed that with BDI-II, there were 3 people with minimal depression, 18 with mild and 9 with moderate depression. None was diagnosed as having severe level of depression with BDI-II. With SIS-I, there were 10 people with no depression, 3 with mild depression, 12 with moderate depression, and 5 with severe depression. Thus, BDI-II did not diagnose severe depression for any, while SIS-I did. SIS-I also diagnosed a smaller number of people with no depression in comparison to BDI-II.

        Subsequently in BDI-II, the minimal and mild depressed groups were clubbed to represent lower depression and moderate group was treated as with higher depression. With SIS-I, the minimal and mild depressed groups were clubbed to represent lower depression and moderate and severe groups were treated as with higher depression. Cross tabulation revealed that while the two instruments agreed solely on lower depression, they disagreed on higher depression, SIS-I diagnose greater number of persons as considerably depressed (Table 3). Kappa was calculated to determine if the difference was significant. The Kappa value was found to be .494 with associated significance level of .002, indicating that the two instruments did not agree in terms of diagnostic levels. Thus, the Hypothesis 2 was rejected.

Table 3: Frequency of participants falling in low / high categories according to BDI-II and SIS-I

        Table 3 reveals that BDI-II and SIS-I agreed for those having minimal or mild depression, that is they identified equally well a substantial portion of those with no or little risk equally well. There were also 9 persons whom both scales considered as falling in the high depression category. But there were 8 persons whom the BDI-II considered as falling in lower category, but SIS-I categorized as falling in higher (moderate or severe) category.

Discussion:

        From the results(tables)it has been found that level of depression assessed by BDI-II and SIS-I did not agree completely in terms of diagnostic levels. While there was considerable overlap between the two scores, and some agreement between the levels of depression defined by the two measures, there were 8 individuals out of 30, that is 26.66% of the sample, who were diagnosed as belonging to high level of depression by SIS-I, but not by BDI-II. Such finding may imply that both instruments are partly valid in diagnosing level of depression in breast cancer patients. Before accounting for the discrepancies, it would be interesting to compare the findings with global rate of depression in general as well as breast cancer population.

        Table 3 reveals that BDI-II considers that out of 30 breast cancer patients, 21 (70%) had mild or no depression, and 9 (30 %) had high depression. It is also important to indicate that all these 9 individuals had moderate, and not severe depression. On the other hand, SIS-I reveals that 17 out of 30 (56.66%) patients had moderate or severe level of depression and 13 (43.33%) had minimal or mild depression. Reference to worldwide epidemiology of depression, mostly assessed by self-report inventories or clinician rating, tells us that the figures indicating rate of depression in the population varies widely, making any conclusion difficult (Grover, Dutt & Avasthi, 2010). Global lifetime prevalence rate has been estimated around 12.1% by a large-scale study (Andrade et al., 2003). In a study, conducted in South India, has reported the prevalence of 15.1 percent(Poongothai, et al. 2009). Both the instruments used in the present study reports higher prevalence of depression, which is expected because of their diseased condition. Indeed, several studies abroad and in the Indian subcontinent have also revealed a high degree of depression in breast cancer patients (Mannan, et.al., 2016, and Mukherjee et.al., 2018). Therefore, the comparisons do not provide us much assistance to account for the discrepancy between the two instruments.

Conclusion:

        The result of this study should be considered carefully as studies of this kind demand longitudinal method across months; but the present study did not fulfil this demand. It is also important to state that this is an exploratory study with a smaller sample. For future research, it would be better if we try to replicate the present results with a larger sample. Still, the study indicates the need for using both self-report and projective tests as supplementary to each other and shows the nature of discrepancy that may crop up and may be used to qualify data.

It also remains for future analysis to demonstrate whether and how the patients who responded differently to BDI-II and SIS-I differ in their personality and demographical structure from those who did not, that is those who had less need to erect defences against their inner depressive disposition.

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