Response to the Comments on "Indian Medical Students with Depression, Anxiety, and Suicidal behavior: Why Do They Not Seek Treatment?"

We thank the authors for their meticulous appraisal and critique of our article. We would like to clarify the relevant points raised.

The appropriateness of using a cutoff of 15 on Patient Health Questionnaire-9 (PHQ-9) for determining the presence of depression and the wisdom of classifying the participants scoring 10–14 as normal has been questioned. We acknowledge that Kroenke et al. originally reported that a PHQ-9 score ≥10 had a sensitivity of 88% and a specificity of 88% for major depression. In the same report, they also clarified that a score of ≥15 usually indicated major depression and that a score of 10–14 represented a spectrum of patients. Later, a meta-analysis that summarized the psychometric properties of the PHQ-9 across different cutoff scores reported that the pooled specificity was 0.96 for a cutoff score of 15, and it was suggested that the optimal cutoff score can be different based on the purpose and setting. In our study, since PHQ-9 was used as a standalone instrument to determine the presence of depression, a relatively stricter cutoff of 15 was chosen to achieve greater specificity of the diagnosis. This, however, does not belittle the symptoms of the students who scored between 10 and 14 on PHQ-9, and it is indeed important to address their emotional difficulties.

Despite ensuring anonymity and assuring confidentiality, a nonparticipation rate of 26.5% was observed in our study. No faculty psychiatrist or psychologist was physically present at the time of data collection, due to ethical concerns that their presence may be regarded as a coercive strategy to enhance student participation in the study. The data was collected by the first author, who is a medical student in the same institute.

At the time of conducting the study, there was no official policy on student mental health in our institute. Hence, the usual ethical principles, including confidentiality, were employed in dealing with student mental health issues. An official policy on student mental health may dispel students’ misgivings, thereby facilitating the utilization of mental health services.