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Primary study data and study level data extracted from primary reports were combined. For HADS-D cut-off thresholds of 5-15, a bivariate random effects meta-analysis was used to estimate pooled sensitivity and specificity, separately, in studies that used semi-structured diagnostic interviews (eg, Structured Clinical Interview for<jats:italic>Diagnostic and Statistical Manual of Mental Disorders<\/jats:italic>), fully structured interviews (eg, Composite International Diagnostic Interview), and the Mini International Neuropsychiatric Interview. One stage meta-regression was used to examine whether accuracy was associated with reference standard categories and the characteristics of participants. Sensitivity analyses were done to assess whether including published results from studies that did not provide raw data influenced the results.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Individual participant data were obtained from 101 of 168 eligible studies (60%; 25\u2009574 participants (72% of eligible participants), 2549 with major depression). Combined sensitivity and specificity was maximised at a cut-off value of seven or higher for semi-structured interviews, fully structured interviews, and the Mini International Neuropsychiatric Interview. Among studies with a semi-structured interview (57 studies, 10\u2009664 participants, 1048 with major depression), sensitivity and specificity were 0.82 (95% confidence interval 0.76 to 0.87) and 0.78 (0.74 to 0.81) for a cut-off value of seven or higher, 0.74 (0.68 to 0.79) and 0.84 (0.81 to 0.87) for a cut-off value of eight or higher, and 0.44 (0.38 to 0.51) and 0.95 (0.93 to 0.96) for a cut-off value of 11 or higher. Accuracy was similar across reference standards and subgroups and when published results from studies that did not contribute data were included.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>When screening for major depression, a HADS-D cut-off value of seven or higher maximised combined sensitivity and specificity. A cut-off value of eight or higher generated similar combined sensitivity and specificity but was less sensitive and more specific. To identify medically ill patients with depression with the HADS-D, lower cut-off values could be used to avoid false negatives and higher cut-off values to reduce false positives and identify people with higher symptom levels.<\/jats:p><\/jats:sec><jats:sec><jats:title>Trial registration<\/jats:title><jats:p>PROSPERO CRD42015016761.<\/jats:p><\/jats:sec>","DOI":"10.1136\/bmj.n972","type":"journal-article","created":{"date-parts":[[2021,5,10]],"date-time":"2021-05-10T14:25:33Z","timestamp":1620656733000},"page":"n972","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":214,"title":["Accuracy of the Hospital Anxiety and Depression Scale Depression subscale (HADS-D) to screen for major depression: systematic review and individual participant data meta-analysis"],"prefix":"10.1136","author":[{"given":"Yin","family":"Wu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brooke","family":"Levis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ying","family":"Sun","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chen","family":"He","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ankur","family":"Krishnan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dipika","family":"Neupane","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Parash Mani","family":"Bhandari","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zelalem","family":"Negeri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Benedetti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5644-8432","authenticated-orcid":false,"given":"Brett D","family":"Thombs","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2021,5,10]]},"reference":[{"key":"2021051011250583000_373.may10_1.n972.1","doi-asserted-by":"publisher","DOI":"10.1016\/S0006-3223(03)00587-0"},{"key":"2021051011250583000_373.may10_1.n972.2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1525-1497.2005.00269.x"},{"key":"2021051011250583000_373.may10_1.n972.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.biopsych.2005.05.001"},{"key":"2021051011250583000_373.may10_1.n972.4","doi-asserted-by":"publisher","DOI":"10.1093\/rheumatology\/40.12.1327"},{"key":"2021051011250583000_373.may10_1.n972.5","doi-asserted-by":"publisher","DOI":"10.1111\/j.1464-5491.2006.01943.x"},{"key":"2021051011250583000_373.may10_1.n972.6","doi-asserted-by":"publisher","DOI":"10.1016\/j.genhosppsych.2007.10.008"},{"key":"2021051011250583000_373.may10_1.n972.7","unstructured":"National Institute for Clinical Excellence . 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