A bifactor model of the Beck Depression Inventory and its association with medical prognosis after myocardial infarction

Ricardo de Miranda Azevedo*, Annelieke M Roest, Robert M Carney, Johan Denollet, Kenneth E Freedland, Sherry L Grace, Seyed H Hosseini, Deirdre A Lane, Kapil Parakh, Louise Pilote, Peter de Jonge

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

16 Citations (Web of Science)


OBJECTIVES: Evidence suggests that depression is associated with adverse outcomes in patients with myocardial infarction (MI). Some of the symptoms of depression may also be symptoms of somatic illness and these may confound the association between depression and prognosis. We investigated whether depression following MI is associated with medical prognosis independent of these somatic symptoms.

METHOD: The database of an individual patient data meta-analysis was used. Endpoints were all-cause mortality and cardiovascular events. Nine studies were included. Bifactor factor analysis included 13,100 participants and 7,595 participants were included in survival models. Dimensions were generated from the Beck Depression Inventory using factor analyses. The prognostic association was assessed using mixed-effects Cox regression analysis.

RESULTS: A bifactor model, consisting of a general factor and 2 general depression-free subgroup factors (a somatic/affective and a cognitive/affective), provided the best fit. There was a significant association between the general depression factor and all-cause mortality (hazard ratio [HR] = 1.25; 95% confidence interval [CI] [1.17, 1.34], p < .001) and cardiovascular events (HR = 1.18; 95% CI [1.13, 1.23], p < .001). After adjustment for demographics, measures of cardiac disease severity, and health-related variables, the association between the general depression factor and all-cause mortality (HR = 1.14; 95% CI [1.04, 1.25], p = .003) and cardiovascular events (HR = 1.16; 95% CI [1.10, 1.23], p = .014) attenuated. Additionally, the general depression-free somatic/affective factor was significantly associated with the endpoints, while the general depression-free cognitive/affective was not.

CONCLUSIONS: A general depression factor is associated with adverse medical prognosis following MI independent of somatic/affective symptoms that may be partly attributable to somatic illness. (PsycINFO Database Record

Original languageEnglish
Pages (from-to)614-24
Number of pages11
JournalHealth Psychology
Issue number6
Publication statusPublished - Jun 2016
Externally publishedYes


  • Aged
  • Depression/diagnosis
  • Factor Analysis, Statistical
  • Female
  • Humans
  • Internationality
  • Male
  • Middle Aged
  • Myocardial Infarction/diagnosis
  • Prognosis
  • Proportional Hazards Models
  • Psychiatric Status Rating Scales

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