Use of the 21-item Depression Anxiety Stress Scale to assess depression in adolescents

To the Editor, Khanna et al.[1] used the 21-item Depression Anxiety Stress Scale (DASS-21) to assess depression and factors associated therewith among adolescents. We have several concerns about the appropriateness of their methods. First, the DASS-21 was not designed to be used as a screening instrument, let alone as a diagnostic screen for depression; an examination of the items in the DASS-21 will immediately allow the reader to understand why this is so. Furthermore, Khanna et al.[1] did not specify what DASS-21 cutoff was used to presume the presence of depression, nor did they provide any information about the sensitivity, specificity, and other psychometric characteristics pertinent to this cutoff. Therefore, their claim that they studied the prevalence of depression is untenable. Second, Khanna et al.[1] asserted that the DASS-21 has been validated among adolescents in India. They cited the study by Singh et al.[2] in support. However, all that Singh et al.[2] did was to forward and back translate the DASS-21 between English and Hindi and examine the factor structure of the instrument. Singh et al.[2] did not examine the concurrent validity of the DASS-21 nor did they validate the use of the DASS-21 as either a screening or diagnostic instrument, as used by Khanna et al.[1] Finally, school-going adolescents are exposed to day-to-day fluctuations in levels of stress in family, peer group, and academic, emotional, and other domains at a time when personality is developing and coping skills are yet to mature. In consequence, there could be corresponding day-to-day fluctuations in DASS-21 scores, making this instrument of low value for the identification of a formal diagnosis of depression in this population. In summary, we believe that the DASS-21 was inappropriately used in this study and so the findings of the study should be viewed with caution. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.