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

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.