A comparison of psychometric properties between internet and paper versions of two depression instruments (BDI-II and MADRS-S) administered to clinic patients
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BACKGROUND: Self-report measures can guide clinical decisions and are useful when evaluating treatment outcomes. However, many clinicians do not use self-report measures systematically in their clinical practice. Internet-based questionnaires could facilitate administration, but the psychometric properties of the online version of an instrument should be explored before implementation. The recommendation from the International Test Commission is to test the psychometric properties of each questionnaire separately. OBJECTIVE: Our objective was to compare the psychometric properties of paper-and-pencil versions and Internet versions of two questionnaires measuring depressive symptoms. METHODS: The 87 participating patients were recruited from primary care and psychiatric care within the public health care system in Sweden. Participants completed the Beck Depression Inventory (BDI-II) and the Montgomery-Åsberg Depression Rating Scale-Self-rated (MADRS-S), both on paper and on the Internet. The order was randomized to control for order effects. Symptom severity in the sample ranged from mild to severe depressive symptoms. RESULTS: Psychometric properties of the two administration formats were mostly equivalent. The internal consistency was similar for the Internet and paper versions, and significant correlations were found between the formats for both MADRS-S (r = .84) and the BDI-II (r = .89). Differences between paper and Internet total scores were not statistically significant for either questionnaire nor for the MADRS-S question dealing with suicidality (item 9) when analyzed separately. The score on the BDI-II question about suicidality (item 9) was significantly lower when administered via the Internet compared with the paper score, but the difference was small (effect size, Cohen's [d] = 0.14). There were significant main effects for order of administration on both questionnaires and significant interaction effects between format and order. This should not, however, pose a problem in clinical use as long as the administration format is not changed when repeated measurements are made. CONCLUSIONS: The MADRS-S can be transferred to online use without affecting the psychometric properties in a clinically meaningful way. The full BDI-II also seems to retain its properties when transferred; however, the item measuring suicidality in the Internet version needs further investigation since it was associated with a lower score in this study. The use of online questionnaires offers clinicians a more practical way of measuring depressive symptoms and has the potential to save resources.
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The Montgomery-Åsberg depression scale has demonstrated satisfactory internal consistency in both paper-and-pencil and Internet formats.
“The MADRSS has demonstrated satisfactory internal consistency in both paper-and-pencil and Internet formats. 29,30”
From Internet-based treatment for provoked vulvodynia: Factors associated with treatment outcomes (2025) · cites this paper as [30]
The Montgomery Åsberg Depression Rating Scale self-assessment (MADRS-S) has good reliability and has been validated as an internet-based measure.
“The instrument has good reliability (Montgomery and Asberg, 1979) and has been validated as an internet-based measure (Holländare et al., 2010; Thorndike et al., 2009).”
From Learning how to recover from stress: Results from an internet-based randomized controlled pilot trial (2023) · cites this paper as Holländare et al., 2010
Online questionnaires produce similar results as the classical pen-and-paper format.
“A number of studies have shown that online questionnaires produce similar results as the classical pen-and-paper format (Hollandare et al., 2010).”
From Can We Boost Treatment Adherence to an Online Transdiagnostic Intervention by Adding Self-Enhancement Strategies? Results From a Randomized Controlled Non-inferiority Trial (2021) · cites this paper as Hollandare et al., 2010
A high correlation has been found between administration of MADRS-S via the internet and using paper-and-pencil assessments.
“A high correlation has been found between administration of the survey via the internet and using paper and pencil assessments (Hollandare et al., 2010).”
From Internet-based treatment for vulvodynia (EMBLA) – Study protocol for a randomised controlled study (2021) · cites this paper as Hollandare et al., 2010
The MADRS-S has adequate psychometric properties administered via both paper-and-pencil assessment and the internet.
“The MADRS-S has adequate psychometric properties administered via both paper-and-pencil assessment and the internet [23].”
MADRS-S is a valid and reliable tool when administered over the internet.
“MADRS-S has been found to be a valid and reliable tool when administered over the internet [27].”
From An Internet-Based Cognitive Behavioral Therapy Program Adapted to Patients With Cardiovascular Disease and Depression: Randomized Controlled Trial (2019) · cites this paper as [27]
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- Authors
- Holländare, F., Andersson, G., & Engström, I.
- Affiliations
- Örebro University (SE)
- Linköping University (SE)
- Corresponding author
- Holländare, Fredrik
- Venue
- Journal of Medical Internet Research
- Publisher
- JMIR Publications Inc.
- Published
- 2010-12-19
- Volume
- 12
- Issue
- 5
- Pages
- e49
- ISSN
- 1438-8871 (ISSN-L)
- PMC
- PMC3057311
- OpenAlex
- W2029775242
- Cited by
- 179
- References
- 23
- Citations by year
- 2026: 5 · 2025: 5 · 2024: 4 · 2023: 9 · 2022: 9 · 2021: 20 · 2020: 9 · 2019: 9 · 2018: 8 · 2017: 11 · 2016: 9 · 2015: 18 · 2014: 17 · 2013: 23 · 2012: 11
- FWCI
- 19.14
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Journal of Medical Internet Research (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Sociology and Political Science › Survey Methodology and Nonresponse
- Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
- Keywords
- internet-based questionnaire, paper-and-pencil administration, psychometric properties, Beck Depression Inventory-II, depressive symptoms, suicidality, order effects, self-report measures, depression assessment
- MeSH terms
- Adult, Depression, Diagnosis, Computer-Assisted, Female, Humans, Male, Middle Aged, Psychiatric Status Rating Scales, Psychiatry, Psychometrics, Surveys and Questionnaires, Retrospective Studies, Sensitivity and Specificity, Severity of Illness Index, Sweden, Reproducibility of Results, Internet
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