Depressive disorders are still underrecognized in medical settings despite major associated disability and costs. The use of short screening questionnaires may improve the recognition of depression in different medical settings.1 The depression module of the Patient Health Questionnaire (PHQ-9) has become increasingly popular in research and practice over the past decade.2 In its initial validation study, a score of 10 or higher had a sensitivity of 88% and a specificity of 88% for detecting major depressive disorders. Thus, a score of 10 has been recommended as the cut-off score for diagnosing this condition. In a recent review of the PHQ-9, Kroenke and colleagues argued against inflexible adherence to a single cut-off score.2 A recent analysis of the management of depression in general practice in the United Kingdom showed that the accuracy of predicting major depressive disorder could be improved by using 12 as the cut-off score. 4 Given the widespread use of PHQ-9 in screening for depression and that certain cut-off scores are being recommended as part of national strategies to screen for depression (based on initial validation studies, which might not be generalizable), 4,5 we attempted to determine whether the cut-off of 10 is optimum for screening for depression. This question could not be answered by two previous systematic reviews 6,7 because of the small number of primary studies available at the time. We also aimed to provide greater clarity about the proper use of PHQ-9 given the many settings in which it is used. MethodsWe performed a meta-analysis of the available literature using recently developed bivariate meta-analysis methods. 8,9,10 We included all crosssectional validation studies of PHQ-9 as a screening tool for major depressive disorder that met our inclusion criteria. is commonly used to screen for depression with 10 often recommended as the cut-off score. We summarized the psychometric properties of the PHQ-9 across a range of studies and cut-off scores to select the optimal cut-off for detecting depression.

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