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External validation of a shortened screening tool using individual participant data meta-analysis: A case study of the Patient Health Questionnaire-Dep-4

Harel D 1 , Levis B 2 , Sun Y 3 , Fischer F 4 , Ioannidis JPA 5 , Cuijpers P 6 Show all authors , Patten SB 7 , Ziegelstein RC 8 , Markham S 9 , Benedetti A 10 , Thombs BD 11 , DEPRESsion Screening Data DEPRESSD PHQ Collaboration

Affiliations 

  • 1 Department of Applied Statistics, Social Science, and Humanities, New York University, United States; Center for the Promotion of Research at the Intersection of Information, Society, and Methodology, New York University, United States. Electronic address: daphna.harel@nyu.edu
  • 2 Centre for Prognosis Research, School of Medicine, Keele University, Staffordshire, United Kingdom
  • 3 Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
  • 4 Department of Psychosomatic Medicine, Center for Internal Medicine and Dermatology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
  • 5 Department of Medicine, Stanford University, Stanford, CA, USA; Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA; Department of Biomedical Data Science, Stanford University, Stanford, CA, USA; Department of Statistics, Stanford University, Stanford, CA, USA
  • 6 Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, the Netherlands
  • 7 Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  • 8 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
  • 9 Department of Biostatistics and Health Informatics, King's College London, London, UK
  • 10 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada; Department of Medicine, McGill University, Montréal, Québec, Canada; Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montréal, Québec, Canada
  • 11 Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada; Department of Medicine, McGill University, Montréal, Québec, Canada; Department of Psychiatry, McGill University, Montréal, Québec, Canada; Department of Psychology, McGill University, Montréal, Québec, Canada; Department of Educational and Counselling Psychology, McGill University, Montréal, Québec, Canada; Biomedical Ethics Unit, McGill University, Montréal, Québec, Canada
Methods, 2022 Aug;204:300-311.
PMID: 34780986 DOI: 10.1016/j.ymeth.2021.11.005

Abstract

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.

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