Depressive Symptoms in People with and without

Alcohol Abuse: Factor Structure and Measurement

Invariance of the Beck Depression Inventory (BDI-II)
Across Groups
Cecilie Skule
1
*, Pal Ulleberg
2
, Hilde Dallavara Lending
1
, Torkil Berge
1
, Jens Egeland
2,3
, Tim Brennen
2
,
Nils Inge Landr
2
1Community Mental Health Center Vinderen, Diakonhjemmet Hospital, Oslo, Norway, 2Department of Psychology, University of Oslo, Oslo, Norway, 3Vestfold Mental
Health Care Trust, Tnsberg, Norway
Abstract
This study explored differences in the factor structure of depressive symptoms in patients with and without alcohol abuse,
and differences in the severity of depressive symptoms between the two groups. In a sample of 358 patients without
alcohol problems and 167 patients with comorbid alcohol problems, confirmatory factor analysis revealed that the same
factor structures, Beck et al.s two-factor Somatic Affective-Cognitive (SA-C) model, and Buckley et al.s three-factor
Cognitive-Affective- Somatic (C-A-S) model, demonstrated the best fit to the data in both groups. The SA-C model was
preferred due to its more parsimonious nature. Evidence for strict measurement invariance across the two groups for the
SA-C model was found. MIMIC (multiple-indicator-multiple-cause) modeling showed that the level of depressive symptoms
was found to be highest on both factors in the group with comorbid alcohol problems. The magnitude of the differences in
latent mean scores suggested a moderate difference in the level of depressive symptoms between the two groups. It is
argued that patients with comorbid depression and alcohol abuse should be offered parallel and adequate treatment for
both conditions.
Citation: Skule C, Ulleberg P, Dallavara Lending H, Berge T, Egeland J, et al. (2014) Depressive Symptoms in People with and without Alcohol Abuse: Factor
Structure and Measurement Invariance of the Beck Depression Inventory (BDI-II) Across Groups. PLoS ONE 9(2): e88321. doi:10.1371/journal.pone.0088321
Editor: Brett Thombs, McGill University, Canada
Received August 13, 2013; Accepted January 11, 2014; Published February 12, 2014
Copyright: 2014 Skule et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The research was funded by the Regional Competence Centre for Double Diagnoses, South Eastern Norway, and the research fund in the Community
Mental Health Center, Vinderen, Diakonhjemmet Hospital, Oslo. The funders had no role in study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: [email protected]
Introduction
The co-occurrence of mood symptoms and the abuse of alcohol
and other drugs is common [1,2,3]. Patients with comorbid major
depression and substance abuse tend to be more severely
depressed than those without the combined condition [4]. Among
medical inpatients, more severe depressive symptoms are associ-
ated with unhealthy drinking [5].
Self-report instruments, such as the Beck Depression Inventory-
II (BDI-II), are often used in clinical practice and research.
However, research on the BDI-II and other self-report instruments
in patients with comorbid depression and substance use disorders
is scarce [6]. Studies have investigated the factor structure of the
BDI-II [8,9]. A three-factor model consisting of a cognitive,
affective and somatic factor seems to usually give the best fit
[10,11,12], but there are exceptions [7,9]. It has been claimed that
the factor structure of BDI-II scores differ among various clinical
populations [13]. If the BDI-II measure fails to operate in the same
manner across groups (i.e. there is a lack of measurement
invariance of the construct), the between-group differences in the
mean scores of the BDI-II may be misleading. However, no
previous study has compared the severity of depressive symptoms
and the factor structure of depressive symptoms between a clinical
sample of depressed participants with and without comorbid
alcohol abuse.
It is often assumed that the clinical implications of depressive
symptoms in patients with substance abuse are different than those
in depressed patients without substance abuse. This study
examines the factor structure of the BDI-II in a large clinical
sample of people seeking treatment for depression. Some of the
participants have concurrent problems of alcohol abuse, therefore
allowing a comparison of the two samples.
In this study we have two research aims: to identify differences
in the factor structure of depressive symptoms in patients with and
without alcohol abuse, and to identify differences in the severity of
depressive symptoms between the two groups.
Subjects and Methods
Participants
Participants were recruited from the attendees of cognitive-
behavioral courses of treatment for depression either via individual
consultations or in groups. In the preconsultation or during
information meetings held by group leaders/therapists conducted
PLOS ONE | www.plosone.org 1 February 2014 | Volume 9 | Issue 2 | e88321
before treatment start, the participants were informed about the
study and asked if they would like to participate in this research
project. They were informed that participation was voluntary and
were informed that they could leave the project at any time, and if
they decided not to participate in the project, it would not have
any consequences for the treatment they were offered. Participa-
tion in the project was not paid for. Exclusion criteria for taking
part in the treatment program were psychotic or acute suicidal
symptoms. The participants were from the same health region in
the south and east part of Norway. Most of the participants were
recruited from community mental health centers. A small group
was recruited from a substance abuse clinic. In total 525 patients
provided written informed consent, and all participants were
considered to possess competent consent. The project was
approved by Regional Committees for Medical and Health
Research Ethics in the South East Health Region in Norway.
The research was funded by the Regional Competence Centre for
Double Diagnoses, South Eastern Norway and the research fund
in the Community Mental Health Center, Vinderen, Diakonh-
jemmet Hospital, Oslo. The funders had no role in study design,
data collection and analysis, decision to publish, or preparation of
the manuscript.
Instruments
The Beck Depression Inventory - Second Edition (BDI-II) [7] is one of
the most commonly used self-report instruments for estimating the
severity of depression. The total score indicates whether the
individual presents a mild, moderate or major depression. The
BDI-II consists of 21 items, each of which is scored on a scale from
0 to 3. The maximum score is 63. The recommended cutoff for
minimal depression is 13, whereas a score of 1419 indicates mild,
2028 moderate and 2963 serious depression.
The Alcohol Use Disorders Identification Test (AUDIT) [14] consists
of ten items and can be self-administered by the patient. Each item
is scored on a 4-point scale. The total ranges from 040, and a
score larger than 7 indicates an alcohol problem. Based on
research the following categories have been identified for the total
score: 07 low risk, 815 moderate risk and 1619 major risk.
Procedure
A total of 525 patients provided informed consent. In addition
to the BDI-II and substance abuse screening using the AUDIT,
participants answered questions on their demographics and their
history of depression. The patients completed the screening before
the cognitive-behavioral course of treatment for depression started.
Statistical Analyses
Confirmatory factor analyses based upon maximum likelihood
estimation were applied to test the fit of the various models to the
data of both samples (descriptive statistics and intercorrelations
among the 21 items is presented separately for each sample in
Appendix A and B). All models were estimated using the statistical
software Mplus 6.1 [15]. Because the data were expected to have a
non-normal distribution, the models were estimated using
maximum likelihood estimation and tested with the Satorra-
Bentler scaled chi-square [16]. The fit of the models was evaluated
using several x2 goodness-of fit-statistics; the comparative fit index
(CFI), the root mean square error of approximation (RMSEA) and
the standardized root mean squared residual (SRMR). As a
general rule, a CFI above .95, and a RMSEA/SRMR below .06
indicates a very good fit between the model and the data, whereas
a RMSEA below .08, SRMR below .09 and a CFI above .90 is
conventionally regarded as a reasonable fit [17,18]. The fit of the
various factor structures were estimated separately for each
sample.
Measurement invariance across groups of the best-fitting factor
structures was tested in several models, using Multigroup
Confirmatory Factor Analysis. The procedure involved examining
changes in model fit measures after imposing increasingly
restrictive conditions of invariance [19]. The first model tested
whether the same items are associated with the same factor in both
groups. This is commonly referred to as configural invariance. The
second model involved examining the invariance of the factor
loadings, meaning that the loadings are the equal in both groups.
The equality of covariance between residuals was also included in
this model. The third model tested for invariance at the intercept
level of the items. This level of invariance (together with
measurement invariance established in the previous models) is
required to compare differences in the latent mean scores between
groups. The fourth model involved invariance of the item
residuals, signifying that all group differences on the items are
due to group differences on the level of the common factors. This
model is, however, regarded as representing a very stringent
criterion, and is rarely fulfilled in practice [20,21]. Two additional
models were also estimated; model 5 tested for invariance in factor
variances and model 6 for invariance in the covariance between
factors across groups.
Traditionally, evidence supporting measurement invariance has
been based on non-significant differences in the chi-square value
(Dx2) relative to the change in the degrees of freedom (Ddf)
between nested models. If the Dx2 is significant for the more
restrictive model, it can be assumed that that the two models are
not equivalent (i.e. non-invariant) across groups. However, the
Dx2 value is highly sensitive to the sample size, and based on
simulation studies, researchers [20,21] have recommended alter-
native criteria for evaluating measurement invariance across
groups. According to Chen [21], the following cutoff values have
been suggested to indicate non-invariance in large samples
(N.300): a change of $2.01 in CFI, supplemented by a change
of $.015 in RMSEA or a change of $.030 in SRMR.
Differences in the severity of depressive symptoms between the
groups with and without comorbid alcohol problems was
examined using MIMIC (multiple-indicator-multiple-cause) mod-
eling. MIMIC modeling is comparable to a multivariate regression
model in which latent variables (e.g. latent scores on factors of
depression) are caused by independent variables. The main
independent variable in this case the grouping variable separating
between those with and without comorbid alcohol problems.
Possible systematic differences between the two groups on other
variables potentially related to depression scores (e.g. gender, age)
may also be included in such an analysis as independent variables
and thereby serve as covariates.
Results
Descriptive Statistics
Table 1 shows descriptive statistics for both samples. There were
no significant differences in age and educational level between the
two samples. There were significantly more men among the
participants with a comorbid alcohol problem, and they were less
likely to be married or have a registered partner compared to the
sample without comorbid alcohol problems. The level of
depression (as measured by the total BDI-II score) was 3.5 points
higher in the sample with comorbid alcohol problems.
Depressive Symptoms with or without Alcohol Abuse
PLOS ONE | www.plosone.org 2 February 2014 | Volume 9 | Issue 2 | e88321
Model Testing
The alternative models presented in Figure 1 were separately
estimated for each sample using confirmatory factor analysis.
Table 2 shows that all models had good or acceptable RMSEA/
SRMR values in both samples. In the sample without comorbid
alcohol problems, the CFI for the one-factor model and the Beck
et al.s [7] CA-S model was below the conventional limits for
acceptable fit (..90). In the sample with concurrent alcohol
problems, only the model proposed by Ward [9] had a CFI value
above the threshold for acceptable fit.
The model formulated by Ward [9] was therefore the only one
able to fulfill all the criteria for good or acceptable fit in both
samples. However, a closer inspection of the factor loadings in
Wards model revealed the cognitive factor had several non-
significant loadings in both samples. The proposed error
covariance between Item 7 and Item 8 in the sample with
concurrent alcohol problems was also nonsignificant. Further-
more, the residual variance was negative for item 20 and had to be
constrained to zero to allow the model to converge. This feature
suggested that Wards [9] model was problematic due to
inadequate factor loadings, and was therefore abandoned from
further analyses. This justify studying the modification indices of
the alternative models more closely. In all alternative models, the
modification indices indicated that a rather large reduction in SB-
chi square value could be obtained by allowing two pairs of
correlated residuals: the first between Item 5 (guilty feelings) and
Item 8 (self-criticalness): and the second between Item 15 (loss of
energy) and item 20 (tiredness or fatigue). Both modifications were
regarded as theoretically meaningful, because the items semanti-
cally overlapped and both pair of items clustered on the same
factor in all models. No further modifications were found
necessary.
Table 2 shows that the fit indices for all models improved after
the modifications were implemented. In the sample without
concurrent alcohol problems, all models demonstrated an
acceptable or good fit to the data. In particular, Beck et al.s
[7] SA-C model and Buckley et al.s [10] C-A-S model were
regarded as better-fitting than the CA-S and one-factor model
due to the difference in CFI-value (..01) between these models.
Although a Satorra-Bentler scaled chi-square difference test
demonstrated that the Buckley et al. [10] model fitted signifi-
cantly better to the data than the Beck et al. [7] SA-C model (SB
x
2
diff
(2) =13.2, p,.01), this difference was regarded as trivial due
to the small differences in model fit measures between the two
models.
In the sample with comorbid alcohol problems, Beck et al.s [7]
SA-C model and Buckley et al.s [10] C-A-S model also
demonstrated the best fit to the data compared to the two other
modified models (e.g. DCFI$.01). However, only the RMSEA
and SRMR suggested adequate fit to the data for the two models,
whereas the GFI and CFI were close to, but did not reach the
threshold for acceptable values. Buckley et al.s [10] model was
significantly better fitting than Beck et al.s [7] SA-C (SB x
2
diff
(2) =10.3, p,.01) in this sample also. However, the comparison of
the other model fit indices suggested that the difference between
the two models was small (e.g. DCFI,.01).
Based on the small difference in model fit indices between the
two models, Beck et al.s [7] SA-C model was chosen as the
preferred one due to its more parsimonious nature, i.e.
represented by two factors instead of three factors as in the C-
A-S model [10].
Measurement Invariance across Samples
Beck et al. [7] SA-C model was tested for measurement
invariance across the two samples. As shown in Table 3, the
change in fit indices fell well below the recommended cutoff values
(DRMSEA$.015, DCFI$2.01 and DSRMR$.030) at all six
steps for testing invariance. Therefore, the results demonstrated
support for measurement invariance across groups for the SA-C
model. The same procedure for testing measurement invariance
Table 1. Patient demographics, AUDIT-score, and BDI-II-score.
Without comorbid
alcohol problem
(n=358)
With comorbid alcohol
problem (n=167) t or x
2
-value
Age (M, SD) 42.2 (11.3) 41.8 (13.0) 0.37
% Men 29.5 50.3
% Women 70.5 49.7 22.09***
Highest educational level attained
% Lower secondary 7.4 6.1
% Upper secondary/vocational 11.6 9.8
% Upper secondary/academic 13.3 20.2
% Tertiary 67.7 63.8 4.57
Marital status
% Single 29.1 39.0
% Married/reg. partner 57.1 37.2
% Divorced 12.4 23.2
% Widow/widower 1.4 0.6 20.9***
AUDIT-score (M, SD) 3.2 (2.0) 14.5 (5.8) 232.0***
Total BDI-II-score (M, SD) 23.1 (11.1) 26.6 (10.1) 23.40***
***p,.001.
doi:10.1371/journal.pone.0088321.t001
Depressive Symptoms with or without Alcohol Abuse
PLOS ONE | www.plosone.org 3 February 2014 | Volume 9 | Issue 2 | e88321
Depressive Symptoms with or without Alcohol Abuse
PLOS ONE | www.plosone.org 4 February 2014 | Volume 9 | Issue 2 | e88321
was also applied for the C-A-S model [10], and this gave the same
conclusion as for the SA-C model, i.e. support for measurement
invariance across groups.
Table 4 shows the standardized factor loadings, factor
correlations and error term correlations for the SA-C Beck model
[7]. All parameters presented in Table 4 are significant at the 5%
level.
Differences in Level of Depression Between the Samples
To test whether the level of depression on the Somatic-Affective
and the Cognitive factor was different in the two samples, MIMIC
modeling was applied using group (without vs. with comorbid
alcohol problems) as the independent variable, and gender and
marital status as covariates (due to significant differences between
groups on these two variables). The results of the analysis showed
that the latent mean score was significantly higher on both the
Somatic-Affective (0.185 (0.053), p,.001) and the Cognitive factor
(0.175 (0.044), p,.001) for patients with comorbid alcohol
problems compared to those without alcohol problems. These
differences indicate that although the factor structure is very
similar in the two samples, the level of depression varies.
In order to examine the magnitude of the difference in latent
mean scores, differences between groups in terms of standard
deviation on the latent variables was estimated by setting the
variance in each factor equal to 1. The results showed that the
relative differences between groups were of about the same size on
both factors, i.e. 0. 418 and 0.348 standard deviation on the
Cognitive factor and Somatic-Affective factor, respectively.
According to the criteria suggested by Cohen [22], this represents
a moderate effect size.
Discussion
The results showed that the same models (i.e. Beck et al.s [7]
SA-C model and Buckley et al.s [10] C-A-S model), gave the best
fit to the data in both groups. The similarity in the factor structure
of the BDI-II was further supported by the finding of measurement
invariance across groups for both models. Although there are
exceptions [see 13], this finding corroborates other studies
examining samples of various drug abuse populations [10,11,12].
The two proposed factor structures are identical with regard to
the Cognitive factor. The difference between the two models is
that the Somatic-Affective factor in Beck et al.s model is split into
two factors in Buckley et al.s [10] model: one Somatic factor and
one Affective factor. Based on the small difference in model fit
indices between the two models, one might argue that Beck et al.s
[7] SA-C model should be the preferred model due to its more
parsimonious nature.
Patients with comorbid alcohol problems reported on average a
higher degree of depressive symptoms on both the Somatic-
Affective and the Cognitive factor. A higher score on depressive
symptoms among patients with comorbid alcohol abuse has also
described by Ostacher [4]. The magnitude of the difference in
depressive symptoms on the two factors between the two groups
was found to be of equal size, suggesting that alcohol abuse has an
overall effect upon depressive symptoms. Others have claimed that
the somatic factor in depression is closely related to abstinence and
the intoxication of alcohol or other substances in patients with
Figure 1. Factor structure of the different models tested.
doi:10.1371/journal.pone.0088321.g001
Table 2. Confirmatory factor analysis fit indices for five
different factor models. Separately for the samples with and
without comorbid alcohol problems.
SB x
2
df RMSEA SRMR CFI
Without comorbid alcohol
problem (n=358)
Model 1: One factor model 557.6 189 .074 .056 .867
Modified model
b
396.4 187 .056 .049 .919
Model 2: Beck et al. [7] SA-C 431.1 188 .060 .048 .936
Modified model
b
312.0 186 .043 .042 .950
Model 3: Beck et al. [7] CA-S 464.1 188 .064 .054 .893
Modified model
b
360.7 186 .051 .046 .932
Model 4: Buckley et al. [10] C-A-S 399.4 186 .057 .047 .917
Modified model
b
299.1 184 .042 .040 .955
Model 5: Ward [9] G-C-S
a
306.7 174 .046 .041 .949
With comorbid alcohol
problem (n=167)
Model 1: One factor model 363.5 189 .074 .069 .836
Modified model
b
331.7 187 .068 .067 .864
Model 2: Beck et al. [7] SA-C 335.1 188 .068 .069 .862
Modified model
b
311.1 186 .063 .067 .882
Model 3: Beck et al [7] CA-S 339.1 188 .069 .070 .858
Modified model
b
325.5 186 .067 .067 .869
Model 4: Buckley et al [10] C-A-S 316.7 186 .065 .067 .877
Modified model
b
301.0 184 .062 .066 .890
Model 5: Ward [9] G-C-S
a, c
261.9 175 .055 .061 .918
SB x
2
=Satorra-Bentler corrected x
2
; df =degrees of freedom; RMSEA=root
mean square of approximation; SRMR =Standardized root mean square;
CFI =comparative fit index.
a
Correlated residuals allowed for Items 412 and 78,
b
Correlated residuals allowed for Items 58 and 1520.
c
Residual variance of item 20 constrained to zero.
doi:10.1371/journal.pone.0088321.t002
Table 3. Tests for measurement invariance across the sample
without alcohol problems and the sample with comorbid
alcohol problems for the SA-C model.
SB x2 Df RMSEA SRMR CFI
Beck et al. [7] SA-C:
Model 1: Configural model 623.2 372 .051 .050 .932
Model 2a: Factor loadings invariant 659.8 391 .051 .062 .927
Model 2b: Residual cov. Invariant 664.1 393 .051 .066 .926
Model 3: Item intercepts invariant 694.4 412 .051 .064 .923
Model 4: Item residual variance
invariant
726.4 433 .051 .064 .920
Model 5: Factor variance invariant 729.8 435 .051 .072 .920
Model 6: Factor covariance invariant 731.0 436 .051 .071 .920
SB x
2
=Satorra-Bentler corrected x
2
; df =degrees of freedom; RMSEA=root
mean square of approximation;
SRMR =Standardized root mean square; CFI =comparative fit index.
doi:10.1371/journal.pone.0088321.t003
Depressive Symptoms with or without Alcohol Abuse
PLOS ONE | www.plosone.org 5 February 2014 | Volume 9 | Issue 2 | e88321
comorbid substance abuse [11]. On this basis, if is expected that
the difference in level of depression between the two groups should
primarily be found on the Somatic factor. This claim was not
confirmed in our study [see also 12].
The results from the current study support the view that major
depression and substance-induced depression differ mainly in the
level of depressive symptoms, rather than in the structure of the
symptoms [12]. However, it is difficult to determine the direction
of causality between depressive symptoms and alcohol abuse. Our
study indicates that depression-like symptoms in patients with
alcohol problems are not merely transient, alcohol-induced effects.
Patients with comorbid depression and alcohol abuse should be
offered parallel and adequate treatment for both conditions.
There are some limitations in our study. The participants did
not undergo a clinical interview to verify that their symptoms
assessed with BDI-II indicated a formal diagnosis of depression.
Despite these diagnostic limitations, we improved our understand-
ing regarding the type and strength of symptoms in a sample of
patients with depressive symptomatology. This study cannot
illuminate the complex ways in which depressive symptoms and
alcohol problems continue to interact over time. The strength is
the size of the sample, which consists of two groups of depressed
subjects with and without comorbid alcohol abuse.
Conclusion
Although there were differences in the symptom load, the basic
factor structure is similar in patients with depressive symptoms
with and without unhealthy alcohol use. This finding may
strengthen the arguments for giving both of these problems
clinical attention during treatment.
Supporting Information
Table S1 Beck Depression Inventory-II. Means, standard
deviations and inter-item correlations for patients without alcohol
problems (n =358).
(DOC)
Table S2 Beck Depression Inventory-II. Means, standard
deviations and inter-item correlations for patients with comorbid
alcohol problems (n =158).
(DOC)
Author Contributions
Conceived and designed the experiments: CS PU HD TB JE TB NIL.
Performed the experiments: CS PU HD TB JE TB NIL. Analyzed the
data: CS PU HD TB JE TB NIL. Contributed reagents/materials/analysis
tools: CS PU HD TB JE TB NIL. Wrote the paper: CS PU HD TB JE TB
NIL.
References
1. Davis L, Uezato A, Newell JM, Frazier E (2008) Major depression and comorbid
substance disorders. Curr Opin Psychiatry 21: 1418.
2. Hesse M (2004) Achieving abstinence by treating depression in the presence of
substance-use disorders. Addict Behav 29: 11371141.
3. Kessler RC, Nelson CB, McGonagle KA, Edlund MJ, Fank RG, et al. (1996)
The epidemiology of co-occurring addictive and mental disorders: implications
for prevention and service utilization. Am J Orthopsychiatry 66: 1731.
4. Ostacher MJ (2007) Comorbid alcohol and substance abuse dependence in
depression: impact on the outcome of antidepressant treatment. Psychiatr Clin
North Am 30: 6976.
5. Palfai TP, Cheng DB, Samet JH, Kramer KL, Roberts MS, et al. (2007)
Depressive symptoms and subsequent alcohol use and problems. A prospective
study of medical inpatients with unhealthy alcohol use. J Stud Alcohol Drugs 68:
673680.
6. Dum M, Pickren J, Sobell IC, Sobell MB (2008) Comparing the BDI-II and the
PHQ-9 with outpatient substance abusers. Addict Behav 33: 381387.
7. Beck AT, Steer RA, Brown GK (1996) Beck Depression Inventory - Second
Edition. U.S.A; Haarcourt Assessment Inc.
8. Vanheule S, Desmet M, Groenvynck H, Rosseel Y, Fontaine J (2008) The factor
structure of the Beck Depression Inventory-II: a evaluation. Assessment 15: 177
187.
9. Ward CL (2006) Comparison of factor structure models for the Beck Depression
Inventory-II. Psychol Assess 18: 8188.
10. Buckley TC, Jefferson PD, Heggie JA (2001) A psychometric evaluation of BDI-
II in treatment seeking substance abusers. J Subst Abuse 20: 197204.
11. Johnson ME, Neal DB, Brems C, Fisher DG (2006) Depression as measured by
the Beck depression inventoryII among injecting drug users. Assessment 66:
1731.
12. Seignourel PJ, Green C, Schmitz JM (2008) Factor structure and the diagnostic
efficiency of the BDI-II in treatment-seeking substance users. Drug Alcohol
Depend 93: 271278.
13. Quilty LC, Zhang AK, Bagby MR (2010) The latent symptoms structure of the
Beck Depression Inventory-II in outpatients with major depression. Psychol
Assess 22: 603608.
14. Babor TF, Higgins-Biddle JC, Saunders JB, Monterio MG (2001) The Alcohol
Use Disorders Identification Test: Guidelines for use in primary care. 2nd
Table 4. Multigroup confirmatory factor analysis with robust
maximum likelihood estimation. Standardized factor loadings,
factor correlation and error correlations for the modified SA-C
model [7].
Standardized loadnings/
correlations
Cognitive
1 Sadness .659
2 Pessimism .607
3 Past Failure .691
5 Guilty Feelings .587
6 Punishment Feelings .462
7 Self-Dislike .679
8 Self-Criticalness .663
9 Suicidal Thoughts or Wishes .530
14 Worthlessness .732
Somatic-affective
11 Agitation .403
15 Loss of Energy .661
16 Changes in Sleeping Pattern .394
17 Irritability .418
18 Changes in Appetite .511
19 Concentration Difficulty .707
20 Tiredness or Fatigue .616
21 Loss of Interest in Sex .481
4 Loss of Pleasure .718
10 Crying .528
12 Loss of Interest .706
13 Indecisiveness .686
Correlation CSA .859
Correlation e5e8 .340
Correlation e15e20 .449
All loadings/correlations are significant at the .001 level.
doi:10.1371/journal.pone.0088321.t004
Depressive Symptoms with or without Alcohol Abuse
PLOS ONE | www.plosone.org 6 February 2014 | Volume 9 | Issue 2 | e88321
edition. Geneva; World Health Organization, Department of Mental Health
and Substance Dependence.
15. Muthen LK, Muthen BO (2010) Mplus Users Guide. Sixth Edition. Los
Angeles, CA: Muthen & Muthen.
16. Satorra A, Bentler PM (2001) A scaled difference chi-square test statistics for
moment structure analysis. Psychometrica 66: 507514.
17. Hu L, Bentler PM (1999) Cutoff criteria for fit indexes in covariance structure
analysis: conventional criteria versus new alternatives. Structural Equation
Modeling 6: 155.
18. Loehlin JC (1998) Latent variable models: an introduction to factor, path, and
structural analyses. 3rd Edition. London: Lawrence Erlbaum Associates.
19. Byrne BM (2012) Structural equation modeling with Mplus, Basic Concepts,
Applications, and Programming. New York, NJ; Routledge.
20. Cheung GW, Rensvold RB (2002) Evaluating goodness-of-fit indexes for testing
measurement invariance. Structural Equation Modeling, 9, 233255.
21. Chen FF (2007) Sensitivity of goddness of fit indexes to lack of measurement
invariance. Structural Equation Modeling, 14, 464504.
22. Cohen J (1988) Statistical power analysis for the behavioural sciences. 2 ed, New
York: Academic Press.
Depressive Symptoms with or without Alcohol Abuse
PLOS ONE | www.plosone.org 7 February 2014 | Volume 9 | Issue 2 | e88321