Screening for anxiety and depression: reassessing the utility of the Zung scales. A self-rating depression scale. Dunstan and Scott [6] identified that many researchers were mistakenly applying this 50 point cut-off to raw scores rather than index scores. ​(Fig.1;1; [11]). As a library, NLM provides access to scientific literature. The site is secure. sharing sensitive information, make sure you’re on a federal Epub 2014 Sep 23. This question could not be answered by two previous systematic reviews6,7 because of the small number of primary studies available at the time. A structured interview guide for the questionnaire is available. Federal government websites often end in .gov or .mil. For a scale which is designed such that higher scores are more indicative of a positive diagnosis these points are calculated as follows: looking first within the non-clinical sample, the Mean Score + 2 Standard Deviations (SD) represents 95% specificity; similarly, within the clinical sample, the Mean Score – 2 SD represents 95% sensitivity. Utilising these two samples, the Mean ± 2SD method sets the lower value for the cut-off point (derived from the Negative Community Sample) at 40.4 and the upper value (from the Positive Clinical Sample) at 57.1. Finally, for studies that used a translated version of PHQ-9, we examined whether the translation had been validated according to recognized standards.14,15,16. 1950;3(1):32–5. Sharma B, Jain R. Right choice of a method for determination of cut-off values: a statistical tool for a diagnostic test. Reviewing these results, it is clear that mathematical methods suggest that the cut-off score of 40 for the SDS should not only be increased but increased beyond the score of 44 suggested by Dunstan et al. Epub 2012 Jan 9. Springer Nature. Carroll BJ, Fielding JM, Blashki TG. The original 1960 version contained 17 items (HDRS-17), but four other questions not added to the total score were used to provide additional clinical information. The Self-rating Depression Scale (SDS) developed by Zung [4, 5] is a norm-referenced measure, used to screen adults for the potential presence of depressive disorders. Crucially unlike the Dunstan et al. The ROC curve that results from this combination of the Positive Clinical and Negative Community samples is shown in Fig. However, Zung [16] also reports specificity measures of 52 and 56% for under 19 year-olds and those aged 65 and over. Study selection was perfomed by one author, and this might have introduced bias. Diagnostic and statistical manual of mental disorders. We also examined whether withdrawals or drop-outs were explained or accounted for. CAS  Based on this study, an even larger adjustment is required. Leeflang MMG, Moons KGM, Reitsma JB, Zwinderman AH. Note: PHQ-9 = Patient…, MeSH Article  When we summarized individual studies within receiver operating characteristic curve space for a cut-off score of 10, we found that most studies gathered within an informative top left corner (Appendix 3, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.110829/-/DC1). Similarly, research by Dunstan, Scott, and Todd [10] suggested that an index score of 55 (raw score 44) might be more appropriate for use in an Australian context. Qualtrics survey panel members meeting the sample criteria were invited to complete an online survey taking approximately 10 min. We performed a meta-analysis of the available literature using recently developed bivariate meta-analysis methods.8,9,10 We included all cross-sectional validation studies of PHQ-9 as a screening tool for major depressive disorder that met our inclusion criteria. government site. Although all professed to be receiving treatment, in an unspecified number of cases that treatment (which could be either pharmaceutical or psychotherapeutic in nature) can be expected to have induced a sufficient reduction in symptoms as to render a positive diagnosis no longer appropriate. study [10], whose findings were somewhat compromised by the nature of the samples used, the samples used here were representative of the adult population. Again, reactions to these figures may differ according to the context in which the test is being applied [22]. PMC We included studies that defined major depressive disorder according to standard classification systems such as the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental Disorders (DSM). Diagnostic performance did not vary according to the percentage of women (p = 0.39), study setting (primary care and community settings v. hospital; p = 0.73), prevalence of depression (p = 0.70), sample size (p = 1.00) or mean age (p = 0.28). Funding for the study was provided by a Staff Research Incentive Grant from the School of Behavioural, Cognitive and Social Sciences at the University of New England. We found that there were no significant differences in pooled sensitivity and specificity for cut-off scores between 8 and 11. National Library of Medicine Inclusion in an NLM database does not imply endorsement of, or agreement with, We considered the chosen cut-off score for reporting to be acceptable if it was tested as best trade-off. Zung WWK. Negeri ZF, Levis B, Sun Y, He C, Krishnan A, Wu Y, Bhandari PM, Neupane D, Brehaut E, Benedetti A, Thombs BD; Depression Screening Data (DEPRESSD) PHQ Group. Despite widespread usage, issues exist concerning the recommended cut-off score for a positive diagnosis. We identified the studies that were outside of the 95% confidence ellipse by visually inspecting the summary receiver operating characteristic curve plots. Again, reactions to these figures may differ according to the context in which the test is being applied [22]. To explore these matters further, sensitivity and specificity figures for alternative cut-off points were examined in positive clinical and negative community samples respectively. Zusammenfassung. Debra Dunstan Ph.D., M. Psych. Spitzer RL, Kroenke K, Williams JBW. Kong X, Wu Y, Wang X, Sun Y, Chen K, Li Q, Li J. Heliyon. One ROC curve method is to set the cut-off point as the value at which the distance from this perfect point is minimal [14]. However, questions have been raised regarding both the appropriateness and the correct application of cut-off scores. The brief Patient Health Questionnaire (PHQ-9) is commonly used to screen for depression with 10 often recommended as the cut-off score. Careers, Unable to load your collection due to an error. While it should be acknowledged that the use of the above methods can lead to inflated estimates of sensitivity and specificity, particularly where smaller samples are involved [11, 15], they provide valuable context for assessing the merits of alternative cut-off candidates. These points can be considered to provide the limits for the choice of a cut-off point. Our study has several limitations. Cut-Off-Werte dienen in Screening-Tests einer ökonomischen Identifikation von Erkrankungen bzw. The ROC curve (blue line) for a perfectly discriminating test. In a research context, where false positives and negatives are equally undesirable, it is ironic to note that those researchers who mistakenly applied the incorrect cut-off score of 50 would seem likely to have achieved greater accuracy in their classifications. HHS Vulnerability Disclosure, Help 2. Background: The .gov means it’s official. BMC Psychiatry. The cut-off is selected as the point with the highest Youden Index. Biochem Medica. However, questions have been raised regarding both the appropriateness and the correct application of cut-off scores. Part of The fact that different studies contributed to the calculations of different cut-off scores might be a possible explanation for this unexpected trend. Amongst this age group, sensitivity and specificity measures for the cut-off selected are both 88%. The latter provide each individual with a score which reflects the extent they report experiencing difficulties associated with the condition. However, even here, the figures suggest some increase from the current cut-off would be advisable so as to limit the number of false positives. Here the cut-off score represents the Mean + 1.2 SD for the ‘normal’ sample and the Mean – 1.2 SD for the clinical sample. To explore these matters further, sensitivity and specificity figures for alternative cut-off points were examined in positive clinical and negative community samples respectively. Knight RG, Waal-Manning HJ, Spears GF. The PHQ-9 is a popular tool for detecting depression in many settings. Litt., B.Sc., Grad. Note: PHQ-9 = Patient Health Questionnaire. Additionally, the community sample excluded individuals who qualified for the clinical sample or who were receiving treatment from a mental health professional for an anxiety disorder. Compared with diagnoses made by mental health professionals, the sensitivity of the PHQ in relation to depressive disorders is 61% and the specificity 94% [2]. We used random-effects bivariate meta-analysis at cutoff points between 7 and 15 to produce summary receiver operating characteristic curves. PubMed Central  In a two-gate design, the disease status is already known. Tran TD, Tran T, Fisher J. Validation of the depression anxiety stress scales (DASS) 21 as a screening instrument for depression and anxiety in a rural community-based cohort of northern Vietnamese women. Number of PHQ depressive disorder diagnoses by sample. Given a prevalance for depressive disorders of this ilk, then it is possible to estimate the numbers of false positives and false negatives that would occur using the alternative cut-offs under consideration (Table 7). Approximate numbers of false positives and false negatives per 100 cases to be expected using SDS cut-offs of 40 and 50. The Self-rating Depression Scale (SDS) developed by Zung [4, 5] is a norm-referenced measure, used to screen adults for the potential presence of depressive disorders. 2013;13:24. Reported correlations with other depression scales include .41 with the Hamilton Rating Scale [20], .54 with the Depression Adjective Checklist, and .68 with the Beck Depression Inventory [19]. The criteria for selecting this point are not specified but Zung quotes both means and standard deviations obtained for ‘normal’ and clinical populations and also provides measures of sensitivity and specificity. Zung’s [16] first mention of a cut-off score for the SDS comes in his paper entitled “How normal is depression”. 1999;282:1737–44. We used random-effects bivariate meta-analysis at cutoff points between 7 and 15 to produce summary receiver operating characteristic curves. The area under the curve equals .92 (95% Confidence Interval: .89, .96). NS has given final approval of the version to be published. Debra Dunstan Ph.D., M. Psych. 8600 Rockville Pike (Clinical), M. For the clinical sample, t(142.2) = 8.65, p < .001; for the community sample, t(208) = 9.75, p < .001. Psychometrics. The Youden Index for any potential cut-off score is defined as the sum of the sensitivity and specificity (expressed as probabilities) of the scale at that point minus 1. If the cut-off value chosen is to maximise the benefit that occurs from testing, these are all factors that need to be taken into consideration [22]. Based on our findings, we recommend the use of an SDS raw score of 50 as the cut-off point for clinical significance. 1995;33:335–43. 17:329; 2017] had suggested that the current recommended cut-off is lower than ideal, at least in those countries. [12], Although Hamilton's original scale had 17 items, other versions included up to 29 items (HRSD-29). A Bayesian meta-analysis, Systematic reviews: CRD’s guidance for undertaking reviews in health care, Translation and cultural adaptation of health questionnaires, Back-translation for cross-cultural research, Assessing anxiety and depression on an international level [abstract PMC72], Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews, Properties of the summary receiver operating characteristic (SROC) curve for diagnostic test data. While it should be acknowledged that the use of the above methods can lead to inflated estimates of sensitivity and specificity, particularly where smaller samples are involved [11, 15], they provide valuable context for assessing the merits of alternative cut-off candidates. (Clinical), B. Psych. 8600 Rockville Pike A cut-off score of 11 had the best trade-off between sensitivity and specificity. Australian Bureau of Statistics. Studies in primary care and hospital settings were equally heterogeneous (primary care I2 = 84.7%; hospital I2 = 84.2%). J Clin Microbiol. Evaluation of the psychometric properties of the Chinese version of the resilience scale in Wenchuan earthquake survivors. Four of the studies included in our analysis used designs in which only patients who scored below a certain cut-off on the PHQ-923,27,28 or who showed the core symptoms or at least two symptoms on the PHQ-932 underwent testing using the gold-standard test. We searched Embase, MEDLINE and PsycINFO from 1999 to August 2010 for studies that reported the diagnostic accuracy of PHQ-9 to diagnose major depressive disorders. The brief Patient Health Questionnaire (PHQ-9) is commonly used to screen for depression with 10 often recommended as the cut-off score. Tanaka-Matsumi J, Kameoka VA. Reliabilities and concurrent validities of popular self-report measures of depression, anxiety, and social desirability. The area under the curve equals .92 (95% Confidence Interval: .89, .96). Bookshelf Cluster Analysis on the Mental Health States in a Community Sample of Young Women During Pre-Pregnancy, Pregnancy, or the Postpartum Period. Given the structure of the questionnaire and its intended use as a screening tool, the optimal cutoff score may differ depending on the setting, See related commentary by Kroenke at www.cmaj.ca/lookup/doi/10.1503/cmaj.112004. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. The ROC curve that results from this combination of the Positive Clinical and Negative Community samples is shown in Fig. Understanding diagnostic tests 3: receiver operating characteristic curves. Wang, Cai, and Xu [7] suggested that an index score of 53 (raw score 42) was more appropriate for use with Chinese populations and this suggestion has since been adopted in a number of Chinese studies e.g., [8, 9]. Although all professed to be receiving treatment, in an unspecified number of cases that treatment (which could be either pharmaceutical or psychotherapeutic in nature) can be expected to have induced a sufficient reduction in symptoms as to render a positive diagnosis no longer appropriate. It should be noted that all the DSM-IV criteria on which the PHQ is based remain unchanged in the current edition of the manual, DSM-5 [, Depression screening, Zung self-rating depression scale (SDS), Cut-off score. In addition to the collection of demographic and biographical information the survey involved completion of the following scales: The Zung SDS consists of 20 self-report items that were identified in factor analytic studies of the syndrome of depression [4]. The pooled specificity results ranged from 0.73 (95% confidence interval [CI] 0.63–0.82) for a cut-off score of 7 to 0.96 (95% CI 0.94–0.97) for a cut-off score of 15. The pooled specificity results ranged from 0.73 (95% confidence interval [CI] 0.63-0.82) for a cut-off score of 7 to 0.96 (95% CI 0.94-0.97) for a cut-off score of 15. Bethesda, MD 20894, Web Policies A significant finding is that the reported blind application of a diagnostic gold standard was the only predictive source of heterogeneity. Eleven studies provided details about the diagnostic properties of the questionnaire at more than one cut-off score (including 10), four studies reported a cut-off score of 10, and three studies reported cut-off scores other than 10. Diagnostic and statistical manual of mental disorders. CAS  The point at which the two normal curves cross is 47.6. eCollection 2023 May. Although no other a priori sources of heterogeneity apart from blinding were able to explain the substantial between-study variation, we recommend that the proposed potential sources of heterogeneity (e.g., single-gated study design, training of the rater of the reference test, blinding of the assessor to the result of the reference test, and the use of validated translations of the index and reference tests) should be included if further primary studies are performed. However, if this balance is considered to be of overriding importance, a further alternative is to set the cut-off to correspond to the point where the curve intersects the line representing the points where sensitivity and specificity are equal (Fig. The Hamilton Depression Scale and the Numerical Description of the Symptoms of Depression. [10] is .604. Table 2 details the mean SDS scores for these four sub-samples. Research by Dunstan and Scott [BMC Psychiatry.
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