PONE-D-21-08926

The screening accuracy of the Patient Health Questionnaire-2 in detecting depression among perinatal women in Italy

PLOS ONE

Dear Dr. Gigantesco,

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PONE-D-21-08926R1The screening accuracy of the Patient Health Questionnaire-2 in detecting depression among perinatal women in ItalyPLOS ONE

Dear Dr. Gigantesco,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 28 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Angela Lupattelli, PhD

Academic Editor

PLOS ONE

Reviewers' comments:

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Comments to the Author

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Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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Reviewer #1: Partly

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for inviting me to review this manuscript. It reads well, and the analyses presented are accurate. However, there is a major limitation of this study; the assessment of criterion validity of PHQ-2 must be done against a gold standard i.e. diagnostic interviews by mental health specialists.

The EPDS and PHQ-2 could be compared to establish convergent validity but not criterion validity. This is because EPDS itself is a screening instrument and that too not with a perfect sensitivity and specificity.

The authors mention that psychodiagnostic interviews have been conducted by a clinical psychologist, as part of the study. Perhaps they could revise the analyses using the interview data rather than the EPDS one. I am sorry I could not be much encouraging of the choice of EPDS as a gold standard comparator and added further to the investigators' work. However, with updated analyses, the quality of the manuscript will be significantly improved.

I look forward to reading your revised work! Thank you for your excellent work.

Best wishes,

Reviewer #2: This study looks at the validity of the PHQ-2 as a screening tool for identifying perinatal depression. It uses the EDPS as a reference standard, rather than a more robust clinical interview. This approach facilitated the involvement of a large number of women across a wide geographical area. The study finds that the PHQ-2 may be inadequate in terms of sensitivity and overall accuracy in detecting maternal depression, as defined by a positive EPDS score. This study could contribute to the existing limited evidence regarding the diagnostic utility of the PHQ-2 in perinatal depression.

This study’s findings may inform policy decisions for screening for perinatal mental illness among the maternity population. Maternal depression often goes undetected and it is important to have a way of identifying at risk women in the general maternity population. There are many relatively new specialist perinatal mental health services being developed internationally, and referrals rely on perinatal illness being effectively picked up in Primary Care and maternity settings. This paper is a useful contribution to inform the referral process for these services.

The paper is difficult to read, with the author at times using confusing, ambiguous and superfluous phrases. This often obscures the meaning. Shorter, more precise sentences throughout would make it easier to read.

Overall, I think this is an interesting paper that may warrant publication with changes to the way it is written to convey its message and context more clearly.

Specific comments according to subheading:

Title (page 1)

1. Fine – although it could be more bold for impact, for instance the title could question the validity of using the PHQ-2 as a screening tool in perinatal depression

Abstract (page 2)

2. Last line confusing. The PHQ-2 performance suggested that it has insufficient sensitivity and discriminatory power, and may be inadequate as a screening tool for maternal depression.

Introduction (page 3)

3. Paragraph 1 - Remove ‘indeed, among other things’. Perinatal depression is associated with a range of adverse outcomes (neonatal outcomes, substance and alcohol abuse, poor attendance at antenatal care, bonding, family, long-term emotional and cognitive outcomes for the child).

4. Paragraph 2 - The clinical management of perinatal depression is evidence-based and includes pharmacological and psychological approaches. The treatments mentioned here in brackets are not internationally recognised - are they names of group/psychological therapies for women? Given that this paper has international interest I would make sure treatment interventions are described.

5. Paragraph 4 - Consider referencing the literature about the Whooley questions which questions the utility and accuracy of ultra-rapid screening tools (mentioned briefly in the conclusion). The NICE guidelines in 2007 were made in the absence of validation studies in the perinatal population. There is limited evidence for the use of the Whooley questions as a screening tool for maternal depression, only having been validated in small perinatal populations with a wide range of sensitivities found.

Methods (page 4)

6. More detail to allow replicability.

Results (page 5)

7. First paragraph - Sentence does not need to be in brackets, can be part of the text. Were all the questionnaires completed in full? What happened to partially completed questionnaires?

8. First paragraph - Could calculate the statistical significant of associations, using (?) non-parametric testing. Then statements could be made regarding positive associations eg – such as ‘amongst pregnant women, screening positive for depression on the EPDS was associated with secondary or university level education’. This is interesting because women from lower educational/socioeconomic groups are less likely to access perinatal mental health care, perhaps women from those groups less likely to disclose MH difficulties in screening questionnaires. Perhaps outside the scope of this paper.

9. Second and third paragraph – confusingly worded.

Discussion (page 6)

10. Develop explanation for the recommended scoring cut off for PHQ2. Gjerdingen et al used a cut off of 2 and yielded higher sensitivity. Bennet et al used dichotomous scoring system (closer to the Whooley Questions) and yielded higher sensitivity.

11. Original PHQ2 validation study – Perhaps some exploration of the difference in sensitivities, why did they get a sensitivity of 82%, study design? Sample size?

12. In last paragraph, use of the word ‘sensitively’ referring to questioning style not helpful in a discussion about statistical sensitivity.

13. Maternity and primary care services require simple, quick screening tools to know who to refer. This paper calls in to question the appropriateness of the PHQ2, which aligns with the literature raising questions about the validity of the Whooley questions. The findings in this paper may impact on service provision and making decisions about which screening tools to use. It suggests that more comprehensive tools may be needed as a first line with potential cost/implementation implications.

Conclusion (page 8)

14. Shorter, more clearly written conclusion required. Introducing new topics that could have been brought in earlier in the paper.

Tables (page 14)

15. Table 2 - ‘At least probable minor depression’ - this is a confusing name for the category. Consider ‘screened positive for depression’ or ‘EDPS positive for depression’. Something clearer to be used consistently throughout the paper.

16. Table 2 – Prevalence is usually expressed as a proportion

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Reviewer #1: Yes: Dr. Ahmed Waqas

Reviewer #2: No

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The limited screening accuracy of the Patient Health Questionnaire-2 in detecting depression among perinatal women in Italy

PONE-D-21-08926R2

Dear Dr. Gigantesco,

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Kind regards,

Angela Lupattelli, PhD

Academic Editor

PLOS ONE