Alex Mitchell www.psycho-oncology.info

Department of Cancer & Molecular Medicine, Leicester Royal Infirmary

Department of Liaison Psychiatry, Leicester General Hospital

Portugal 2010Portugal 2010

IX Congresso Portugues de Psico-Oncologia

How do investigations inform clinical practice?

IX Congresso Portugues de Psico-Oncologia

How do investigations inform clinical practice?

T1. BackgroundT1. Background

Survivorship

Treatment rates

10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases

0

10

20

30

40

50

60

70

80

90

100

Melanom

aBrea

st (fe

male)

Urinary

bladde

r

Prostat

e

Colon

All site

s

Rectum

Non-H

odgkin

lymph

oma

Ovary

Leuk

emiaLu

ng and

bron

chus

Pancre

as

1975-19771984-19861996-2004Change

5 Year Survival in US Cancers

Suicidal ThoughtsSuicidal ThoughtsStudied 554 (411 BW 143 BSA).

We measured suicidal thoughts :

not at all 0; several days 1; more than half the days 2; nearlyevery day 3. We report here, the proportion of people with any suicidal thoughts (non zero scores).

All = 8%Of major or minor depression. 22% had suicidal thoughtsOf major depression 36% had suicidal thoughts (45% BW)Of those with distress 18.0%

% Receiving Any treatment for Depression% Receiving Any treatment for Depression

10.9 11.3

8.18.8

4.3

5.6

10.9

13.8

6.8

17.9

3.4

5.5

15.4

7.2

0

2

4

6

8

10

12

14

16

18

20

High Inc

omeBelg

ium

France

German

y

Israe

l

Italy

Japa

nNeth

erlan

dsNew

Zeala

nd

Spain USALow

Inco

me

ChinaColom

biaSouth

Afri

caUkra

ine

Wang P et al (2007) Lancet 2007; 370: 841–50

n=84,850 face-to-face interviews

% Receiving Any treatment for Mental Health% Receiving Any treatment for Mental Health

7.2

34.6

5.7 6.3 6.4

11.7

19.1

14

8.9

3.9 3.25.7

32.7

5 57.7

11

16.1

6.5 6.2

2.3 1.8

0

5

10

15

20

25

30

35

40

All P

atie

nts

Men

tal I

ll Hea

lth

No

Men

tal I

ll He

alth

No

chro

nic m

edic

al co

nditi

ons

1 ch

roni

c m

edica

l con

ditio

n2

chro

nic

med

ical c

ondi

tions

3 ch

roni

c m

edica

l con

ditio

ns

18-4

4 ye

ars

45-6

4 ye

ars

65-7

4 ye

ars

75+

Cancer n=4878

No Cancer n=90,737

Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590

Q. Why Low Treatment Rates?Q. Why Low Treatment Rates?

Clinicians?

Patients?

94.2%

37.4%

8 yrs N= 9282 NCS‐R

n=226Comment: Frequency of cancer specialists enquiry about depression/distress from Mitchell et al (2008)

Comment: Slide illustrates diagnostic accuracy according to score on DT

11.815.4

30.4 28.9

41.9 42.9 40.7

57.1

82.4

66.771.4

15.8

25.0

26.124.4

19.4 19.0

33.3

21.4

11.8

22.2 14.3

72.4

59.6

43.546.7

38.7 38.1

25.921.4

5.911.1

14.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Zero One Two Three Four Five Six Seven Eight Nine Ten

Judgement = Non-distressedJudgement = UnclearJudgement = Distressed

0

0.05

0.1

0.15

0.2

0.25

0.3

Eight

Nine Ten

Eleven

Twelv

eTh

irtee

nFo

urtee

n

Fiftee

nSixt

een

Seven

teen

Eighteen

Ninetee

n

Twen

tyTw

enty-

one

Proportion MissedProportion Recognized

HADS-D

Testing Clinicians: A Meta-AnalysisTesting Clinicians: A Meta-Analysis

All cancer professionalsSE =39.5% and SP =77.3%.

OncologistsSE =38.1% and SP = 78.6%; a fraction correct of 65.4%.

By comparison nursesSE = 73% and SP = 55.4%; FC = of 60.0%.

When attempting to detect anxiety oncologists managedSE = 35.7%, SP = 89.0%, FC 81.3%.

Presented at IPOS2009

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Post

-test

Pro

babi

lity

Ave Confidence+

Ave Confidence-

Baseline Probability

Above Ave Confidence+

Above Ave Confidence-

High Confidence+

High Confidence-

Low confidence = more cautious, fewer false positives, more false negatives

High confidence = less cautious, more false positives, low false negatives

p180

462 (42%)Meetable Needs

1093 (100%)Population

388 (84%)Aware of Need

172 (44%)Requested Help

80 (47%)Needs Met

462 needs

17.3%

322 DSMIV

25%

Can tools (investigations) help?Can tools (investigations) help?

Q. How Common is the Problem?Q. How Common is the Problem?

Depression

Distress

Anxiety

Requires depressed mood for most of the day, for most days (by subjective account or observation) for at least 2 years

The symptoms cause clinically significant distress OR impairment in social, occupational, or other important areas of functioning.

Requires persistently low mood two (or more) of the following six symptoms:

(1) poor appetite or overeating (2) Insomnia or hypersomnia(3) low energy or fatigue (4) low self-esteem (5) poor concentration or difficulty

making decisions (6) feelings of hopelessness

DSM-IV Dysthymic disorder

Acute: if the disturbance lasts less than 6 months Chronic: if the disturbance lasts for 6 months

These symptoms cause marked distress that is in excess of what would be expected from exposure to the stressor OR significant impairment in social or occupational (academic) functioning

Requires the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months.

DSM-IV Adjustment disorder

2 weeksThese symptoms cause clinically important distress OR impair work, social or personal functioning.

Requires two to four out of nine symptoms with at least at least one from the first two (depressed mood and loss of interest).

DSM-IV Minor Depressive Disorder

2 weeksThese symptoms cause clinically important distress OR impair work, social or personal functioning.

Requires five or more out of nine symptoms with at least at least one from the first two (depressed mood and loss of interest).

DSM-IV Major Depressive Disorder

2 weeks unless symptoms are unusually severe or of rapid onset).

At least some difficulty in continuing with ordinary work and social activities

Requires two of the first three symptoms (depressed mood, loss of interest in everyday activities, reduction in energy) plus at least two of the remaining seven symptoms (minimum of four symptoms)

ICD-10 Depressive Episode

DurationClinical SignificanceSymptoms

Depression

13%

20%

57%

48%

38%

18%

Anxiety

Adjustment Disorder

N=11N=4

N=10

Comment: Slide illustrates meta-analytic rates of mood disorder

Prevalence of depression in Palliative settings

20 studies involving 2655 individuals

16.9% (95% CI = 13.2% to 21.0%)

13.0% (95% CI = 11.6% to 14.5%) for MDD

p572

Proportion meta-analysis plot [random effects]

0.0 0.2 0.4 0.6

combined 0.17 (0.13, 0.21)

Maguire et al (1999) 0.05 (0.01, 0.14)

Akechi et al (2004) 0.07 (0.04, 0.11)

Kadan-Lottich et al (2005) 0.07 (0.04, 0.11)

Love et al (2004) 0.07 (0.04, 0.11)

Wilson et al (2004) 0.12 (0.05, 0.22)

Chochinov et al (1997) 0.12 (0.08, 0.18)

Wilson et al (2007) 0.13 (0.10, 0.17)

Kelly et al (2004) 0.14 (0.06, 0.26)

Chochinov et al (1994) 0.17 (0.11, 0.24)

Le Fevre et al (1999) 0.18 (0.10, 0.28)

Breitbart et al (2000) 0.18 (0.11, 0.28)

Meyer et al (2003) 0.20 (0.10, 0.35)

Minagawa et al (1996) 0.20 (0.11, 0.34)

Lloyd-Williams et al (2001) 0.22 (0.14, 0.31)

Hopwood et al (1991) 0.25 (0.16, 0.36)

Desai et al (1999) [late] 0.25 (0.10, 0.47)

Payne et al (2007) 0.26 (0.19, 0.33)

Lloyd-Williams et al (2003) 0.27 (0.17, 0.39)

Jen et al (2006) 0.27 (0.19, 0.36)

Lloyd-Williams et al (2007) 0.30 (0.24, 0.36)

proportion (95% confidence interval)

Prevalence of depression in Oncology settings

57 studies involving 9195 individuals across 12 countries.

The prevalence of depression was 17.3% (95% CI = 13.8% to 21.2%),

13.0% (95% CI = 11.6% to 14.5%) for MDD

p572

Proportion meta-analysis plot [random effects]

0.0 0.3 0.6 0.9

combined 0.1730 (0.1375, 0.2116)

Colon et al (1991) 0.0100 (0.0003, 0.0545)

Massie and Holland (1987) 0.0147 (0.0063, 0.0287)

Hardman et al (1989) 0.0317 (0.0087, 0.0793)

Derogatis et al (1983) 0.0372 (0.0162, 0.0720)

Lansky et al (1985) 0.0455 (0.0291, 0.0676)

Mehnert et al (2007) 0.0472 (0.0175, 0.1000)

Katz et al (2004) 0.0500 (0.0104, 0.1392)

Singer et al (2008) 0.0519 (0.0300, 0.0830)

Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)

Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)

Lee et al (1992) 0.0660 (0.0356, 0.1102)

Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)

Grassi et al (2009) 0.0826 (0.0385, 0.1510)

Grassi et al (1993) 0.0828 (0.0448, 0.1374)

Walker et al (2007) 0.0831 (0.0568, 0.1165)

Kawase et al (2006) 0.0851 (0.0553, 0.1240)

Coyne et al (2004) 0.0885 (0.0433, 0.1567)

Alexander et al (2010) 0.0900 (0.0542, 0.1385)

Love et al (2002) 0.0957 (0.0650, 0.1346)

Ozalp et al (2008) 0.0971 (0.0576, 0.1510)

Morasso et al (2001) 0.0985 (0.0535, 0.1625)

Costantini et al (1999) 0.0985 (0.0535, 0.1625)

Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)

Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)

Morasso et al (1996) 0.1121 (0.0593, 0.1877)

Prieto et al (2002) 0.1227 (0.0825, 0.1735)

Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)

Payne et al (1999) 0.1290 (0.0363, 0.2983)

Kugaya et al (1998) 0.1328 (0.0793, 0.2041)

Alexander et al (1993) 0.1333 (0.0594, 0.2459)

Gandubert et al (2009) 0.1597 (0.1040, 0.2300)

Razavi et al (1990) 0.1667 (0.1189, 0.2241)

Akizuki et al (2005) 0.1797 (0.1376, 0.2283)

Leopold et al (1998) 0.1887 (0.0944, 0.3197)

Devlen et al (1987) 0.1889 (0.1141, 0.2851)

Berard et al (1998) 0.1900 (0.1184, 0.2807)

Joffe et al (1986) 0.1905 (0.0545, 0.4191)

Berard et al (1998) 0.2100 (0.1349, 0.3029)

Maunsell et al (1992) 0.2146 (0.1605, 0.2772)

Grandi et al (1987) 0.2222 (0.0641, 0.4764)

Evans et al (1986) 0.2289 (0.1438, 0.3342)

Spiegel et al (1984) 0.2292 (0.1495, 0.3261)

Golden et al (1991) 0.2308 (0.1353, 0.3519)

Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)

Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)

Kathol et al (1990) 0.2961 (0.2248, 0.3754)

Green et al (1998) 0.3125 (0.2417, 0.3904)

Jenkins et al (1991) 0.3182 (0.1386, 0.5487)

Burgess et al (2005) 0.3317 (0.2672, 0.4012)

Hall et al (1999) 0.3722 (0.3139, 0.4333)

Morton et al (1984) 0.3958 (0.2577, 0.5473)

Baile et al (1992) 0.4000 (0.2570, 0.5567)

Passik et al (2001) 0.4167 (0.2907, 0.5512)

Bukberg et al (1984) 0.4194 (0.2951, 0.5515)

Massie et al (1979) 0.4850 (0.4303, 0.5401)

Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)

Levine et al (1978) 0.5600 (0.4572, 0.6592)

Plumb & Holland (1981) 0.7750 (0.6679, 0.8609)

proportion (95% confidence interval)

Distress Thermometer

Distress Thermometer – Pooled Table

ScoreRansom 2006

Tuinman2008

Mitchell 2009

Lord 2010

Hoffman 2004

Gessler2009

Clover 2009

Jacobsen 2005 Sum

Proportion

Zero 68 38 61 123 14 27 65 71 467 18.4%

One 72 31 42 68 5 26 39 46 329 12.9%

Two 77 22 35 44 5 18 30 54 285 11.2%

Three 65 37 42 46 8 23 45 46 312 12.3%

Four 51 29 29 30 8 7 21 31 206 8.1%

Five 41 46 62 40 11 13 41 48 302 11.9%

Six 38 32 23 28 2 16 26 31 196 7.7%

Seven 36 21 23 38 2 15 32 16 183 7.2%

Eight 18 12 18 29 6 9 19 15 126 5.0%

Nine 16 5 8 14 3 3 13 9 71 2.8%

Ten 9 4 7 20 4 0 9 13 66 2.6%

Sum 491 277 350 480 68 157 340 380 2543

Proportion 19.3% 10.9% 13.8% 18.9% 2.7% 6.2% 13.4% 14.9%

Proportion

18 .4 %

12 .9 %

11.2 %12 .3 %

8 .1%

11.9 %

5.0 %

2 .8 % 2 .6 %

7.7% 7.2 %

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Zero One Two Three Four Five Six Seven Eight Nine Ten

Insignificant SevereModerateMildMinimal

p124

50%

ET - Table of Cut-PointsET - Table of Cut-Points

Distress Thermometer

Anxiety thermometer

Depression Thermometer

Anger Thermometer

Help Thermometer Cut-point

Insignificant 39.0 25.6 50.1 55.7 54.3 0,1

Minimal 20.1 22.5 18.3 13.6 15.4 2,3

Mild 16.9 16.5 12.2 10.5 12.2 4,5

Moderate 12.0 14.5 9.8 6.6 6.6 6,7

Severe 11.9 20.8 9.5 13.6 11.2 8,9,10

p130

8%

DT37%

DepT23%

AngT18%

AnxT47%

4%

7%

1%

1%

9%

3%

0%

2%

4%

15%

3%

2%

Nil41%

Non-Nil59%

DT

AnxT AngT

DepT

Q. Investigations => ScreeningQ. Investigations => Screening

What is available?

Observation

Interview

Visual

Self-Report

DepressionScreening

DISCS

VA-SES

ET/DT

HAMD-D17

PhysicalGeneral

Signs ofDS

6

CDSS#10

MADRAS10

Trained

ConfidentSkilledClinician

Alone

YALE

SMILEY

Comment: This is a reminder of the structure of the HADS scale, this version adapter for cancer.

Inadequate Data(n=11)

No data (n= 250)

No reference standard(n= 293)

Accuracy or Validity Analyses(n= 210)

HADS Validity Analyses(n=50)

HADS in CancerInitial Search (n= 768)

ScaleTypes

Sample Size (cases)

HADS-T(n=26)

HADS-D(n=14)

HADS-A(n=10)

Less than 30(n=22)

More than 100(n=8)

30 to 100(n=20)

Review articles (n= 16)

Depression(n=22)

Any Mental Ill Health(n=24)

Anxiety(n=4)

OutcomeMeasure

No interview standard(n=149)

Validity of HADS vs depression (DSMIV)Validity of HADS vs depression (DSMIV)

SE 71.6% (68.3)

SP 82.6% (85.7)

Prev 13%

PPV 38%

NPV 95%

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Post

-test

Pro

babi

lity

HADS+

HADS-

Baseline Probability

HADS7v8+

HADS7v8-

Depression_HADS-d (7v8)

Q. Why only depression / anxiety?Q. Why only depression / anxiety?

?

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

DistressThermometer

AnxietyThermometer

DepressionThermometer

AngerThermometer

TenNineEightSevenSixFiveFourThreeTwoOneZero

Comment: Slide illustrates scores on ET tool

DT DepTVsHADS-A

AnxT AngT

AUC:DT=0.82DepT=0.84AnxT=0.87AngT=0.685

6. How Valid Are the Tools6. How Valid Are the Tools

DT vs HADS-T Validity (n=660)DT vs HADS-T Validity (n=660)

SE SP AUC CUT

DT – 71.9% 78.4% 0.814 cut point >=4

AnxT – 75.7% 73.4% 0.821 cut point >=5

DepT – 77.6% 82.2% 0.855 cut point >=3

AngT – 77.5% 77.6% 0.823 cut point >=2

HelpT - 69.1% 80.8% 0.809 cut point >=3

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Pos

t-tes

t Pro

babi

lity

Baseline Probability

HADSd+

HADSd-

HADS-T+

HADS-T-

HADS-A+

HASD-A-

Depression_HADS

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Post

-test

Pro

babi

lity

1Q+1Q-Baseline ProbabilityDT+DT-2Q+2Q-HADSd+HADSd-HADS-T+HADS-T-BDI+BDI-EPDS+EPDS-HADS-A+HASD-A-

Depression_all

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Post

-test

Pro

babi

lity

DT+ [N=4]DT+ [N=4]Baseline Probability1Q+ [N=4]1Q- [N=4]2Q+2Q-DT/IT+DT/IT-HADST+ [N=13]HADST+ [N=13]PDI+PDI-

Mitchell AJ. Short Screening Tools for Cancer Related Distress A Review and Diagnostic Validity Meta-analysis JNCI (2010) in press

Distress

Validity of DT vs depression (DSMIV)Validity of DT vs depression (DSMIV)

SE 80%

SP 60%

PPV 32%

NPV 93%

DT vs DSMIV DepressionDT vs DSMIV Depression

SE SP PPV NPV

DTma 80.9% 60.2% 32.8% 92.9%

DTLeicesterBW 82.4% 68.6% 28.0% 98.3%

DTLeicesterBSA 100% 59.6% 26.8% 100%

BSA = British South Asian BW= British White

Q. Problem with somatic symptoms?Q. Problem with somatic symptoms?

Approaches to Somatic Symptoms of Depression

InclusiveUses all of the symptoms of depression, regardless of whether they may or may not be secondary

to a physical illness. This approach is used in the Schedule for Affective Disorders and Schizophrenia (SADS) and the Research Diagnostic Criteria.

ExclusiveEliminates somatic symptoms but without substitution. There is concern that this might lower

sensitivity. with an increased likelihood of missed cases (false negatives)‏

EtiologicAssesses the origin of each symptom and only counts a symptom of depression if it is clearly not

the result of the physical illness. This is proposed by the Structured Clinical Interview for DSM and Diagnostic Interview Schedule (DIS), as well as the DSM-III-R/IV).

SubstitutiveAssumes somatic symptoms are a contaminant and replaces these additional cognitive symptoms.

However it is not clear what specific symptoms should be substituted

Medically Unwell Alone

Primary Depression Alone

Secondary Depression

Comment: Slide illustrates concept of phenomenology of depressions in medical disease

FatigueAnorexiaInsomnia

Concentration

Study: Coyne Thombs MitchellN= 4500; Pooled database study; All comparative studies

Physical illness+comorbid depressionVsPhysical illness aloneVsPrimary depression alone

Co-morbid Depression vs Primary Depression

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Agitatio

n (Com

orbid)

Agitatio

n (Prim

ary)

Anxiety

(Com

orbid)

Anxiety

(Prim

ary)

Appetite

(Comorb

id)

Appetite

(Prim

ary)

Concen

tratio

n (Comorb

id)

Concen

tratio

n (Prim

ary)

Fatigu

e (Comorb

id)

Fatigu

e (Prim

ary)

Guilt (

Comorbid)

Guilt (

Primar

y)

Hopeles

snes

s (Comorb

id)

Hopeles

snes

s (Prim

ary)

Insomnia

(Comor

bid)

Insomnia

(Prim

ary)

Loss In

teres

t (Comorb

id)

Loss In

teres

t (Prim

ary)

Low Mood (C

omorbid)

Low Mood (P

rimary

)

Retard

ation (

Comorbid)

Retard

ation (

Primary)

Suicide (

Comorbid)

Suicide (

Primar

y)

Weight L

oss (C

omorbid)

Weight L

oss (P

rimary

)

*

*

*

*

*

**

*

*

Comorbid Depression

Primary Depression

n=4069 vs 4982Comment: Slide illustrates similar symptoms profile in comorbid vsprimary depression

Co-morbid Depression vs Medical Illness Alone

n= 4069 vs 1217

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Anxiety

(Com

orbid)

Anxiety

(Med

ical)

Concen

tratio

n (Comorb

id)

Concen

tratio

n (Med

ical)

Fatigu

e (Comorb

id)Fati

gue (

Medica

l)

Hopeles

snes

s (Comorb

id)

Hopeles

snes

s (Med

ical)

Insomnia

(any t

ype)

(Comorb

id)

Insomnia

(any t

ype)

(Med

ical)

Loss In

teres

t (Comorb

id)

Loss In

teres

t (Med

ical)

Low Mood (C

omorbid)

Low Mood (M

edical)

Retard

ation (

Comorbid)

Retard

ation (

Medica

l)

Suicide (

Comorbid)

Suicide (

Medica

l)

Weight L

oss (C

omorbid)

Weight L

oss (M

edical)

Worthles

snes

s (Comor

bid)

Worthles

snes

s (Med

ical)

Medical Illness Alone

Comorbid Depression

**

*

*

*

*

*

*

*

Comment: Slide illustrates distinct symptoms profile in comorbid depression vs medical illness alone

Medically Unwell Alone

Primary Depression Alone

Secondary Depression

Comment: Slide illustrates concept of phenomenology of depressions in medical disease

FatigueAnorexiaInsomnia

Concentration

Medically Unwell

Primary Depression

Secondary Depression

Comment: Slide illustrates actual phenomenology of depressions in medical disease

Weight loss

AgitationRetardation

Q. How to Choose A Cut-OffQ. How to Choose A Cut-Off

British Journal of Cancer (2007) 96, 868 – 874

Distress Thermometer

Distress Thermometer – PooledProportion

18 .4 %

12 .9 %

11.2 %12 .3 %

8 .1%

11.9 %

5.0 %

2 .8 % 2 .6 %

7.7% 7.2 %

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Zero One Two Three Four Five Six Seven Eight Nine Ten

Insignificant SevereModerateMildMinimal

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50%

PHQ9 Linear distribution

0

5

10

15

20

25

30

35

Zero One Two

Three

Four

Five Six

Seven

Eight

Nine

TenElev

enTwelveThir

teen

Fourte

enFifte

enSixt

een

Sevente

enEigh

teen

PHQ9 (Major Depression)PHQ9 (Minor Depression)PHQ9 (Non-Depressed)

Baker-Glen, Mitchell et al (2008)

SampleSample

We analysed data collected from Leicester Cancer Centre from 2008-2010 involving 531 people approached by a research nurse and two therapeutic radiographers.

We examined distress using the DT and daily function using the question:

“How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?”

“Not difficult at all =0; Somewhat Difficult =1; Very Difficult =2; and Extremely Difficult =3”

Dysfunction in 531 cancer patientsDysfunction in 531 cancer patients

55.7%

34.3%

7.3%

2.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Unimpaired Mild Moderate Severe

Unimpaired by DT ScoreUnimpaired by DT Score

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

1 2 3 4 5 6 7 8 9 10 11

18%

DepT23%

Distress69%

Dysfunction76%

0.3%

3% 2%

26%28% 22%

Of the 293 Non-Nil

DysfunctionDistress

DepT

DT distribution by ImpairmentDT distribution by Impairment

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

0 1 2 3 4 5 6 7 8 9 10

Extreme and incapacitating

Very Severe and very disabling

Moderately Severe and disabling

Moderate and quite disabling

Moderate and somewhat disabling

Mild-Moderate and slight disabling

Mild but not particularly disabling

Very mild and not disabling

Minimal but bearable

Minimal and not problematic

None at all

T4. Screening in Cancer: ImplementationT4. Screening in Cancer: Implementation

Clinician Opinion

Patient Opinion

1,2 or 3 Simple QQ24%

Clinical Skills Alone20%

ICD10/DSMIV24%

Short QQ24%

Long QQ8%

Algorithm26%

Short QQ23%

ICD10/DSMIV0%

Clinical Skills Alone17%

1,2 or 3 Simple QQ34%

Cancer StaffIdeal Method (n=226)

Psychiatrists

Effective?

Comment: “Ideal” method of eliciting symptoms of distress/depression according to clinician

Comment: Slide illustrates actual gain in meta-analysis of screening implementation in primary care

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Post

-test

Pro

babi

lity

Clinical+Clinical-Baseline ProbabilityScreen+Screen-

Comment: Slide illustrates Bayesian curve comparison from RCT studies of clinician with and without screening

This illustrates ACTUAL gain from screening in Study from Christensen

800 Patients Approached

100 Not Willing (13%) 700 Patients Willing (87%)

500 Staff Willing (71%)TAU

402 Data Collected (80%)Screen Data

Leicester: UptakeLeicester: Uptake T177 t680

Pre-Post Screen - DistressPre-Post Screen - Distress

Before After

Sensitivity of 49.7%

Specificity of 79.3%

PPV was 67.3%

NPV was 64.1%

Pre-Post Screen - DistressPre-Post Screen - Distress

Before After

Sensitivity of 49.7% 55.8% =>+5%

Specificity of 79.3% 79.8% =>+1%

PPV was 67.3% 70.9% =>+4%

NPV was 64.1% 67.2% =>+3%

There was a non-significant trend for improve detection sensitivity (Chi² = 1.12 P = 0.29).

Qualitative AspectsQualitative Aspects

DISTRESS

43% of CNS reported the tool helped them talk with the patient about psychosocial issues esp in those with distress

28% said it helped inform their clinical judgement

DEPRESSION

38% of occasions reported useful in improving communication.

28.6% useful for informing clinical judgement

Next StepNext Step269 Nurse-patient

interactions

Helped 65 (24%) Not Helped 204 (76%)

Unmet Needs 150 (55.8%)

Referred 23 (8.6%) Declined Helped 20 (7.4%)

No Unmet Needs 34 (12.6%)

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2x2 Clinician Help Table : ACTUAL HELP2x2 Clinician Help Table : ACTUAL HELP

Clinician thinks:Unmet Needs

Clinician thinks no Unmet Needs

Patient Says:Help Wanted (60)

Helped 21/35 (60%)

Helped 11/23(48%)

Patient Distressed

Helped 65/102(63%)

Helped 31/62(50%)

Patient Not distressed orHelp Not Wanted

Helped 8/35(23%)

Helped 20/117(17%)

b. Intervention and helpb. Intervention and helpPREDICTORS

1. patient desire for help

2. number of unmet needs

3. clinicians confidence

4. patient reported anger

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RCT using DT Carlson et al 2010RCT using DT Carlson et al 2010

Screening for Distress in lung and breast cancer outpatients: A randomized controlled trial Linda Carlson Tom Baker Cancer Centre, University of Calgary

1) Minimal Screening: the Distress Thermometer (DT) [n=365]

2) Full Screening: DT, Problem Checklist, Psychological Screen for Cancer (PSSCAN) [n=391] a personalized report

3) Triage: Full screening plus optional personalized phone triage [378]

FURTHER READING:

Screening for Depression in Clinical Practice An Evidence-Based guide

ISBN 0195380193 Paperback, 416 pagesNov 2009Price: £39.99