External validation of a shortened screening tool using individual participant data meta-analysis: A case study of the Patient Health Questionnaire-Dep-4
Shortened versions of self-reported questionnaires may be used to reduce respondent burden. When shortened screening tools are used, it is desirable to maintain equivalent diagnostic accuracy to full-length forms. This manuscript presents a case study that illustrates how external data and individual participant data meta-analysis can be used to assess the equivalence in diagnostic accuracy between a shortened and full-length form. This case study compares the Patient Health Questionnaire-9 (PHQ-9) and a 4-item shortened version (PHQ-Dep-4) that was previously developed using optimal test assembly methods. Using a large database of 75 primary studies (34,698 participants, 3,392 major depression cases), we evaluated whether the PHQ-Dep-4 cutoff of ≥ 4 maintained equivalent diagnostic accuracy to a PHQ-9 cutoff of ≥ 10. Using this external validation dataset, a PHQ-Dep-4 cutoff of ≥ 4 maximized the sum of sensitivity and specificity, with a sensitivity of 0.88 (95% CI 0.81, 0.93), 0.68 (95% CI 0.56, 0.78), and 0.80 (95% CI 0.73, 0.85) for the semi-structured, fully structured, and MINI reference standard categories, respectively, and a specificity of 0.79 (95% CI 0.74, 0.83), 0.85 (95% CI 0.78, 0.90), and 0.83 (95% CI 0.80, 0.86) for the semi-structured, fully structured, and MINI reference standard categories, respectively. While equivalence with a PHQ-9 cutoff of ≥ 10 was not established, we found the sensitivity of the PHQ-Dep-4 to be non-inferior to that of the PHQ-9, and the specificity of the PHQ-Dep-4 to be marginally smaller than the PHQ-9.
Harel, D; Levis, B; Sun, Y; Fischer, F; Ioannidis, JPA; Cuijpers, P; Patten, SB; Ziegelstein, RC; Markham, S; Benedetti, A; Thombs, BD; He, C; Wu, Y; Krishnan, A; Mani Bhandari, P; Neupane, D; Negeri, Z; Imran, M; Rice, DB; Riehm, KE; Azar, M; Levis, AW; Boruff, J; Gilbody, S; Kloda, LA; Amtmann, D; Ayalon, L; Baradaran, HR; Beraldi, A; Bernstein, CN; Bhana, A; Imma Buji, R; Chagas, MH; C. N. Chan, J; Fong Chan, L; Chibanda, D; Conway, A; Daray, FM; de Man-van Ginkel, JM; Diez-Quevedo, C; Field, S; R. W. Fisher, J; Fung, D; Garman, EC; Flisher, AJ; Gelaye, B; Gholizadeh, L; Gibson, LJ; Green, EP; Hall, BJ; Hantsoo, L; Haroz, EE; Härter, M; Hegerl, U; Hides, L; Hobfoll, SE; Honikman, S; Hudson, M; Hyphantis, T; Inagaki, M; Jin Jeon, H; Jetté, N; Khamseh, ME; Köhler, S; Kohrt, BA; Kwan, Y; Lamers, F; Asunción Lara, M; Levin-Aspenson, HF; Liu, SI; Lotrakul, M; Loureiro, SR; Löwe, B; Luitel, NP; Lund, C; Ann Marrie, R; Marx, BP; Mohd Sidik, S; Munhoz, TN; Muramatsu, K; E. M. Nakku, J; Navarrete, L; Osório, FL; Persoons, P; Picardi, A; Pugh, SL; Quinn, TJ; Rancans, E; Rathod, SD; Reuter, K; Rowe, HJ; Santos, IS; Schram, MT; Shaaban, J; Shinn, EH; Spangenberg, L; Stafford, L; Sung, SC; Suzuki, K; Lin Lynnette Tan, P
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