'Optimal' cutoff selection in studies of depression screening tool accuracy using the PHQ-9, EPDS, or HADS-D: A meta-research study

doi:10.1002/mpr.1956

Review

. 2023 Sep;32(3):e1956.

doi: 10.1002/mpr.1956. Epub 2022 Dec 3.

'Optimal' cutoff selection in studies of depression screening tool accuracy using the PHQ-9, EPDS, or HADS-D: A meta-research study

Eliana Brehaut¹, Dipika Neupane^{1

2}, Brooke Levis^{1

3}, Yin Wu^{1

4}, Ying Sun¹, John P A Ioannidis⁵, Sarah Markham⁶, Pim Cuijpers⁷, Scott B Patten⁸, Andrea Benedetti^{2

9

10}, Brett D Thombs^{1

2

4

9

11

12}

Affiliations

¹ Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.
² Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada.
³ Centre for Prognosis Research, School of Medicine, Keele University, Staffordshire, UK.
⁴ Department of Psychiatry, McGill University, Montréal, Québec, Canada.
⁵ Department of Medicine, Department of Epidemiology and Population Health, Department of Biomedical Data Science, Department of Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA.
⁶ Department of Biostatistics and Health Informatics, King's College London, London, UK.
⁷ Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
⁸ Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
⁹ Department of Medicine, McGill University, Montréal, Québec, Canada.
¹⁰ Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montréal, Québec, Canada.
¹¹ Department of Psychology, McGill University, Montréal, Québec, Canada.
¹² Biomedical Ethics Unit, McGill University, Montréal, Québec, Canada.

PMID: 36461893
PMCID: PMC10485315
DOI: 10.1002/mpr.1956

Review

'Optimal' cutoff selection in studies of depression screening tool accuracy using the PHQ-9, EPDS, or HADS-D: A meta-research study

Eliana Brehaut et al. Int J Methods Psychiatr Res. 2023 Sep.

. 2023 Sep;32(3):e1956.

doi: 10.1002/mpr.1956. Epub 2022 Dec 3.

Authors

Affiliations

¹ Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.
² Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada.
³ Centre for Prognosis Research, School of Medicine, Keele University, Staffordshire, UK.
⁴ Department of Psychiatry, McGill University, Montréal, Québec, Canada.
⁵ Department of Medicine, Department of Epidemiology and Population Health, Department of Biomedical Data Science, Department of Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA.
⁶ Department of Biostatistics and Health Informatics, King's College London, London, UK.
⁷ Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
⁸ Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
⁹ Department of Medicine, McGill University, Montréal, Québec, Canada.
¹⁰ Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montréal, Québec, Canada.
¹¹ Department of Psychology, McGill University, Montréal, Québec, Canada.
¹² Biomedical Ethics Unit, McGill University, Montréal, Québec, Canada.

PMID: 36461893
PMCID: PMC10485315
DOI: 10.1002/mpr.1956

Abstract

Objectives: Optimal cutoff thresholds are selected to separate 'positive' from 'negative' screening results. We evaluated how depression screening tool studies select optimal cutoffs.

Methods: We included studies from previously conducted meta-analyses of Patient Health Questionnaire-9, Edinburgh Postnatal Depression Scale, or Hospital Anxiety and Depression Scale-Depression accuracy. Outcomes included whether an optimal cutoff was selected, method used, recommendations made, and reporting guideline and protocol citation.

Results: Of 212 included studies, 172 (81%) attempted to identify an optimal cutoff, and 147 of these 172 (85%) reported one or more methods. Methods were heterogeneous with Youden's J (N = 35, 23%) most common. Only 23 of 147 (16%) studies described a rationale for their method. Rationales focused on balancing sensitivity and specificity without describing why desirable. 131 of 172 studies (76%) identified an optimal cutoff other than the standard; most did not make use recommendations (N = 56; 43%) or recommended using a non-standard cutoff (N = 53; 40%). Only 4 studies cited a reporting guideline, and 4 described a protocol with optimal cutoff selection methods, but none used the protocol method in the published study.

Conclusions: Research is needed to guide how selection of cutoffs for depression screening tools can be standardized and reflect clinical considerations.

Keywords: edinburgh postnatal depression scale; hospital anxiety and depression scale; major depression; optimal cutoff selection; patient health questionnaire-9; screening.

PubMed Disclaimer

Conflict of interest statement

All authors completed the ICJME uniform disclosure form and declared no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years. All authors declare no other relationships or activities that could appear to have influenced the submitted work.

Figures

**FIGURE 1**
Flowchart of the study selection process

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References

1. Agresti, A. , & Coull, B. (1998). Approximate is better than ‘exact’ for interval estimation of binomial proportions. The American Statistician, 52(2), 119–126. 10.2307/2685469 - DOI
1. Bhandari, P. M. , Levis, B. , Neupane, D. , Patten, S. B. , Shrier, I. , Thombs, B. D. , Benedetti, A. , Sun, Y. , He, C. , Rice, D. B. , Krishnan, A. , Wu, Y. , Azar, M. , Sanchez, T. A. , Chiovitti, M. J. , Saadat, N. , Riehm, K. E. , Imran, M. , Negeri, Z. , & Yonkers, K. A. (2021). Data‐driven methods distort optimal cutoffs and accuracy estimates of depression screening tools: A simulation study using individual participant data. Journal of Clinical Epidemiology, 137, 137–147. 10.1016/j.jclinepi.2021.03.031 - DOI - PubMed
1. Bossuyt, P. M. , Reitsma, J. B. , Bruns, D. E. , Gatsonis, C. A. , Glasziou, P. P. , Irwig, L. M. , Cohen, J. F. , Moher, D. , Rennie, D. , de Vet, H. C. W. , Kressel, H. Y. , Rifai, N. , Golub, R. M. , Altman, D. G. , Hooft, L. , & Korevaar, D. A. (2015). Stard 2015: An updated list of essential items for reporting diagnostic accuracy studies. BMJ, 351(5527), h5527. 10.1136/bmj.h5527 - DOI - PMC - PubMed
1. Bossuyt, P. M. , Reitsma, J. B. , Bruns, D. E. , Gatsonis, C. A. , Glasziou, P. P. , Irwig, L. M. , & de Vet, H. (2003). Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD initiative. BMJ, 326(7379), 41–44. 10.1136/bmj.326.7379.41 - DOI - PMC - PubMed
1. Burton, C. , Simpson, C. , & Anderson, N. (2013). Diagnosis and treatment of depression following routine screening in patients with coronary heart disease or diabetes: A database cohort study. Psychological Medicine, 43(3), 529–537. 10.1017/S0033291712001481 - DOI - PubMed

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[1] Agresti, A. , & Coull, B. (1998). Approximate is better than ‘exact’ for interval estimation of binomial proportions. The American Statistician, 52(2), 119–126. 10.2307/2685469 - DOI

[2] Agresti, A. , & Coull, B. (1998). Approximate is better than ‘exact’ for interval estimation of binomial proportions. The American Statistician, 52(2), 119–126. 10.2307/2685469 - DOI

[3] Bhandari, P. M. , Levis, B. , Neupane, D. , Patten, S. B. , Shrier, I. , Thombs, B. D. , Benedetti, A. , Sun, Y. , He, C. , Rice, D. B. , Krishnan, A. , Wu, Y. , Azar, M. , Sanchez, T. A. , Chiovitti, M. J. , Saadat, N. , Riehm, K. E. , Imran, M. , Negeri, Z. , & Yonkers, K. A. (2021). Data‐driven methods distort optimal cutoffs and accuracy estimates of depression screening tools: A simulation study using individual participant data. Journal of Clinical Epidemiology, 137, 137–147. 10.1016/j.jclinepi.2021.03.031 - DOI - PubMed

[4] Bhandari, P. M. , Levis, B. , Neupane, D. , Patten, S. B. , Shrier, I. , Thombs, B. D. , Benedetti, A. , Sun, Y. , He, C. , Rice, D. B. , Krishnan, A. , Wu, Y. , Azar, M. , Sanchez, T. A. , Chiovitti, M. J. , Saadat, N. , Riehm, K. E. , Imran, M. , Negeri, Z. , & Yonkers, K. A. (2021). Data‐driven methods distort optimal cutoffs and accuracy estimates of depression screening tools: A simulation study using individual participant data. Journal of Clinical Epidemiology, 137, 137–147. 10.1016/j.jclinepi.2021.03.031 - DOI - PubMed

[5] Bossuyt, P. M. , Reitsma, J. B. , Bruns, D. E. , Gatsonis, C. A. , Glasziou, P. P. , Irwig, L. M. , Cohen, J. F. , Moher, D. , Rennie, D. , de Vet, H. C. W. , Kressel, H. Y. , Rifai, N. , Golub, R. M. , Altman, D. G. , Hooft, L. , & Korevaar, D. A. (2015). Stard 2015: An updated list of essential items for reporting diagnostic accuracy studies. BMJ, 351(5527), h5527. 10.1136/bmj.h5527 - DOI - PMC - PubMed

[6] Bossuyt, P. M. , Reitsma, J. B. , Bruns, D. E. , Gatsonis, C. A. , Glasziou, P. P. , Irwig, L. M. , Cohen, J. F. , Moher, D. , Rennie, D. , de Vet, H. C. W. , Kressel, H. Y. , Rifai, N. , Golub, R. M. , Altman, D. G. , Hooft, L. , & Korevaar, D. A. (2015). Stard 2015: An updated list of essential items for reporting diagnostic accuracy studies. BMJ, 351(5527), h5527. 10.1136/bmj.h5527 - DOI - PMC - PubMed

[7] Bossuyt, P. M. , Reitsma, J. B. , Bruns, D. E. , Gatsonis, C. A. , Glasziou, P. P. , Irwig, L. M. , & de Vet, H. (2003). Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD initiative. BMJ, 326(7379), 41–44. 10.1136/bmj.326.7379.41 - DOI - PMC - PubMed

[8] Bossuyt, P. M. , Reitsma, J. B. , Bruns, D. E. , Gatsonis, C. A. , Glasziou, P. P. , Irwig, L. M. , & de Vet, H. (2003). Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD initiative. BMJ, 326(7379), 41–44. 10.1136/bmj.326.7379.41 - DOI - PMC - PubMed

[9] Burton, C. , Simpson, C. , & Anderson, N. (2013). Diagnosis and treatment of depression following routine screening in patients with coronary heart disease or diabetes: A database cohort study. Psychological Medicine, 43(3), 529–537. 10.1017/S0033291712001481 - DOI - PubMed

[10] Burton, C. , Simpson, C. , & Anderson, N. (2013). Diagnosis and treatment of depression following routine screening in patients with coronary heart disease or diabetes: A database cohort study. Psychological Medicine, 43(3), 529–537. 10.1017/S0033291712001481 - DOI - PubMed

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'Optimal' cutoff selection in studies of depression screening tool accuracy using the PHQ-9, EPDS, or HADS-D: A meta-research study

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'Optimal' cutoff selection in studies of depression screening tool accuracy using the PHQ-9, EPDS, or HADS-D: A meta-research study

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