Use of Scoring
The BDI II is scored by summing the ratings for the 21 items. Each item is rated on a 4 point scale ranging from 0 â 3. If an examinee has made multiple endorsements for an item, the alternative with the highest rating is used. The maximum total score is 63.
Special attention must be paid to the correct scoring of the Changes in Sleeping Pattern and Changes in Appetite items. Each of these items contains seven options rated, in order, as 0, 1a, 1b, 2a, 2b, 3a, 3b, to differentiate between increases and decreases in behaviour or motivation. If a higher rated option is chosen by the respondent, the presence of an increase or decrease in either symptom should be clinically noted for diagnostic purposes.
Interpretation of Scores
Cut scores for the BDI II should be based on the clinical considerations for which the instrument is being administered. The following procedures were employed for the purpose of developing a set of cut scores for the assessment of the severity of depression among patients with major depressive disorder.
For the purpose of developing a screening instrument for major depression for clinical purposes, sensitivity of the test was considered to be more important than specificity. That is, the clinician would want to adopt a relatively lower threshold for detecting depression in order to decrease the probability of any false negatives. Therefore, the cut score guidelines below are suggested for total scores of patients diagnosed with major depression.
| Total Scores | Range |
| 0 – 13 | minimal |
| 14 – 19 | mild |
| 20 – 28 | moderate |
| 29 – 63 | severe |
