1 Reviewer Comments:

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4 Reviewer 1 comments
5 A point that needs some explanation by the researchers relates to a few statements they have
6 made in response to the reviewer comments. For example, they have stated: “The reviewer
7 suggested the sensitivity and specificity need to be based only on the ROC curve for the scale
8 used. Which is inappropriate, when the gold standard diagnosis is available. Keeping the
9 desirability of the reviewer, now we have provided sensitivity and specificity by both the
10 methods”. Forgetting about the “desirability of the reviewer”, the statements are still difficult
11 to comprehend. It appeared to me that the researchers are saying that when diagnosis by a
12 doctor is used as a gold standard, one can find out sensitivity and specificity of a new
13 diagnostic tool without resorting to ROC curve analysis. If this interpretation of the
14 statements by the researchers are correct, it implies that the researchers have missed the main
15 issue, viz., how the ‘new cut-off values’ reported in table were found out. Probably the
16 confusion originates from the fact that once a specific cut off value is fixed, one may find out
17 the sensitivity and specificity relating to that cut-off value by resorting to a cross-tabulation.
18 For example, one may find out the sensitivity and specificity of cut-off values reported in
19 table 3 through a cross-tabulation of total sample based on the gold-standard and the known
20 cut-off value of the new diagnostic tools (identified by previous researchers, obviously
21 through ROC curve analysis, or in some special cases based on some other criteria).
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23 Response: We thank the reviewer for understanding our view on the analysis. We have been
24 emphasizing that if a gold standard is available, it is used to determine the cut-offs of a new
25 scale or a existing scale. As desired, to avoid confusion, we have given cut-offs determined
26 by both methods and explained this in the analysis section.
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28 It is common knowledge that optimal cut-off values of a diagnostic tool is determined on the
29 basis of a trade-off between sensitivity and specificity. The researchers have claimed that
30 they have provided ‘sensitivity and specificity by both the methods’, without explaining
31 which are the two methods. But, as mentioned above, here the question is about finding out
32 the optimal cut-off value, the sensitivity and specificity of which can be found out through
33 cross-tabulation or directly from the output of the ROC curve analysis. Unless otherwise
34 stated, one may assume that the cut-off values shown in table 5 and table 6 are found using
35 ROC curve analysis. In this situation, the statement that the researchers have used two
36 different methods to find out sensitivity and specificity and that ‘The only point of contention
37 is which method to use’ fails to make any sense to me.
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39 Response: We have clarified this issue in the methodology section, result section and also
40 indicated the same in the headings of the table 5 and 6.
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42 In the section on special comments, the researchers have stated: “we feel that evaluating the
43 psychometric properties against the gold standard is the most appropriate method”. This
44 implied that the researchers may have used the gold standard in some special way (i.e., other
45 than through ROC curve analysis, not known to many people), to find out the optimal cut-off
46 value to be applied to a new measure. In such a case, the researchers may give some more
47 information regarding this method, which may prove useful for many.
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49 Response: We have given the desired information in the statistical analysis method.
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51 Reviewer 2 comments
52 1. When GDS cut-off is raised from 13 to 26, there seems to be no further increase in
53 specificity. What that seems to suggest is that the variability in scores in the sample is
54 not optimal; for instance, most of them may have had scores in a limited range and
55 hence, increasing the cut-off offers no additional benefit in terms of increasing
56 specificity. This (limited variability in scores in the sample) may be mentioned by the
57 authors in the limitations section so that the reader is informed about it.
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59 Response: In the present study, the GDS cut-offs used have varied from 13 to 20,
60 rather than 26. In the present study, when a cutoff of 20 for GDS-30 was used, only
61 29.6% had depression and other scored less than 20, which suggests that there is a
62 wide variation in the GDS-30 total score. Hence, we feel that there is no need to
63 conclude that there is a limited variability in the GDS-30 score.
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65 Reviewer 3 comments
66 The changes are adequate
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68 Response: We thank the reviewer for accepting the revisions to be satisfactory.
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