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Methods to improve the efficiency of screening for multiple mental disorders
Phil Batterham Centre for Mental Health Research
The Australian National University
Hierarchical screening
2
General psychological distress
Internalizing disorders
Depression Anxiety
Social phobia Generalized
anxiety Panic disorder
Externalizing disorders
Alcohol abuse Substance abuse Adult ADHD
Hierarchical screening
3
Psychological distress (e.g. K6)
Depression (PHQ-9)
GAD (GAD-7)
Social phobia (SOPHS-5)
Panic disorder
(PHQPAN-5)
Finish 4 disorders, 26 items
Hierarchical screening
4
First-phase screening approaches 1. No hierarchy (control)
2. K6 score
3. Psychological distress decision tree
4. Disorder-specific decision tree
5. Gating items
Method 1: No hierarchy (control)
5 5
Depression (PHQ-9)
GAD (GAD-7)
Social phobia (SOPHS-5)
Panic disorder (PHQ-Panic-5)
Method 2: K6 hierarchy
6 6
K6 score
<5
STOP
≥5
Full screen
Depression (PHQ-9)
GAD (GAD-7)
Social phobia (SOPHS-5)
Panic disorder (PHQ-Panic-5)
Method 3: Distress decision tree
7 7
• Choose distress items that best discriminate absence of disorder
• Subgroups least likely to have disorder escape further screening
• Chi-Square Automatic Interaction Detection (treedisc macro in SAS)
Method 3: Distress decision tree
8 8
Chi-Square Automatic Interaction Detection (CHAID) • Divides the sample into subsamples with
different risks of outcome
• Diagram with leaves and branches
• Categorical items
• Branching based on item that best differentiates on the basis of the outcome
• Smallest p-value from a chi-square statistic
Method 3: Distress decision tree
9 9
Chi-Square Automatic Interaction Detection (CHAID) • Splitting stops when:
– There is a small number of observations in a leaf (20 observations)
– No split would result in a significant 2 value (=.2)
– A specified level of branching is reached (6 levels)
Method 3: Distress decision tree
10 10
K7 (depressed)
MWBS9 (close to others)
K18 (tense/shaky)
FULL SCREEN
0 1 3,4
K18 (tense/shaky)
2
K11 (good mood)
K11 (good mood)
K18 (tense/shaky)
MWBS11 (decisive)
K8 (restless)
FULL SCREEN
FULL SCREEN
STOP (n=23)
STOP (n=95)
FULL SCREEN
STOP (n=14)
FULL SCREEN
K2 (nervous)
FULL SCREEN
K19 (angry)
FULL SCREEN
FULL SCREEN
STOP (n=37)
0,1
2,3,4 2,3,4 0,1
0
3,4 0,1,2
0-2 3,4
4 0-3 0 1-4
0,1 2,3,4
0 1-4
MWBS2 (useful)
FULL SCREEN
1-4
2,3,4
0,1
K1 (so sad...)
STOP (n=11)
K3 (restless)
FULL SCREEN
STOP (n=10)
0 1 2,3,4
2,3,4 0,1
Method 4: Disorder decision tree
11 11
PHQ-2 (down/
depressed)
SOCPH-4 (suffered social
occasions)
SOCPH-5 (social fear disruption)
PHQPAN-1 (anxiety attack)
PHQPAN-1 (anxiety attack)
GAD7-1 (nervous/ anxious)
GAD7-1 (nervous/ anxious)
PHQ-1 (little
interest)
FULL SCREEN
FULL SCREEN
FULL SCREEN
STOP (n=425)
FULL SCREEN
STOP (n=52)
FULL SCREEN
GAD7-3 (worrying)
FULL SCREEN
FULL SCREEN
0 1 2,3
1,2 3,4,5
1
2,3
Yes No
No 3,4
4
Yes
0,1 2,3
0,1 2,3
0,1
3,4
FULL SCREEN
FULL SCREEN
PHQ-1 (little
interest)
FULL SCREEN
2
PHQPAN-1 (anxiety attack)
STOP (n=189)
FULL SCREEN
No Yes
0,1 2,3
0,1
Method 5: Gating items
12 12
PHQ-9 Items 1 & 2
PHQ-9 Items 3-9
GAD-7 Item 1
GAD-7 Items 2-7
PHQ-panic Item 1
PHQ-panic Items 2-5
SOPHS Item 1
SOPHS Items 2-5
END
PHQ1 ≥ 2 or PHQ2 ≥ 2 PHQ1<2 and PHQ2<2
GAD1 > 2 GAD1 < 2
PHQ-pan1 = “No” PHQ-pan1 = “Yes”
SOPHS1 ≤ 2 SOPHS1 > 2
Testing the hierarchies
• Efficiency
– Mean number of items presented
• Precision – Sensitivity relative to control
13
Validation samples
• Two community-based samples
• N1 = 1360; N2 = 668
• Recruited through Facebook ads
• Australia-wide, 18+
14
Sample 1 (N=1360)
15
0% 10% 20% 30% 40%
18-24
25-29
30-39
40-49
50-59
60 and over
Refused
M
F
O/R
0%
10%
20%
30%
40%
50%
60%
Metropolitan Regional Rural Remote Refused
Sample 2 (N=668)
16
0% 10% 20% 30% 40%
18-24
25-29
30-30
40-49
50-59
60 and over
Refused
M
F
O/R
0%
10%
20%
30%
40%
50%
60%
Metropolitan Regional Rural Remote Refused
Samples: Psychopathology
17
MDD 34%
GAD 26%
PD 22%
SP 7%
MDD 25%
GAD 20%
PD 14%
SP 16%
None: 63% None: 53%
N = 1360 N = 668
(Not to scale)
Results: Efficiency gains
18
22.0 21.8
18.4
14.6
11.8
0
5
10
15
20
25
No hierarchy K6 hierarchy Psychologicaldistress items
Disorder-baseditems
Gating items
Me
an it
em
s p
rese
nte
d
1% 16% 34% 46%
Results: Projected efficiency gains
19
22.0
18.2
16.2
13.3
10.1
0
5
10
15
20
25
No hierarchy K6 hierarchy Psychologicaldistress items
Disorder-baseditems
Gating items
Me
an it
em
s p
rese
nte
d
17% 26% 40% 54%
Results: Summary
20
95.7%
99.7% 99.9% 100.0%
90%
92%
94%
96%
98%
100%
No hierarchy K6 hierarchy Psychologicaldistress items
Disorder-baseditems
Gating items
Sen
siti
vity
Results: Summary
• Two-phase hierarchical screening was efficient and precise
• Using gating items had most efficiency gain (up to 54%)
• Using decision trees also had large efficiency gains (up to 40%)
• K6 did not improve screening efficiency
21
Considerations
• The K6/K10 were designed to “rule in” not “rule out”
• Hierarchical screening works better for:
– Low rates of psychopathology
– Longer screening scales (60% fewer items)
• Tested with other disorders/outcomes
– PTSD, adult ADHD, alcohol abuse, suicidality
22
Considerations
• Purpose of screening
• Brevity vs. need for data
• Ease of implementation vs. efficiency
– Gating only works for scales with gated scoring criteria
– Pencil and paper vs. computer-based
23
Future research: Adaptive screening
• Fully adaptive measures
– Each response determines next item presented
• PROMIS measures
– IRT-calibrated item banks
– PROMIS-depression 5-item adaptive screener more precise than 20-item CES-D
24
Future research: Adaptive screening
25
From: Pilkonis PA, et al. Item Banks for Measuring Emotional Distress From the Patient-Reported Outcomes Measurement Information System (PROMIS®): Depression, Anxiety, and Anger. Assessment 2011 18: 263-283
Future research: Adaptive screening
26
From: Pilkonis PA, et al. Item Banks for Measuring Emotional Distress From the Patient-Reported Outcomes Measurement Information System (PROMIS®): Depression, Anxiety, and Anger. Assessment 2011 18: 263-283
Future research: Adaptive screening
27
From: Choi SW et al. Efficiency of static and computer adaptive short forms compared to full-length measures of depressive symptoms. Qual Life Res, 2010, 19: 125-136.
Future research: Adaptive screening
• Assess severity level, not clinical criteria
→ Test against DSM criteria using decision tree approach
• Validated in US
→ Validate internationally
• Limited array of mental health problems
→ Develop item banks for other disorders
28
Future research: Adaptive screening
29
Psychological distress
Psychosis Internalising
Depression Generalised
anxiety
Panic / agoraphobia
Social phobia
PTSD OCD
Externalising
Alcohol use/abuse
Substance use/abuse
Adult ADHD Anger
Suicidality
Future research: Adaptive screening
30
Emergency referral
Referral to MH professional
Referral to phone service
Referral to primary care
Low intensity online CBT
Psychoeducation
Watchful waiting
Item bank
Adaptive screening tools: •Anxiety •Depression •Suicidality, etc
Assessment: •Resources •Context •Preferences
Care decision
Ongoing monitoring
VIRTUAL CLINIC
STEPPED CARE SERVICE
Conclusions
• Hierarchical screening for multiple disorders can result in large efficiency gains without sacrificing accuracy
• Disorder-specific items more useful than general distress items
• Much promise in adaptive screening
31
Conclusions
• May be applied to – Virtual clinics
– Primary care screening
– Research
– School-based screening
– Other service contexts
32
33
Collaborators
Prof Helen Christensen Black Dog Institute, The University of New South Wales, Sydney Australia
Dr Alison Calear Centre for Mental Health Research, The Australian National University, Canberra Australia
Dr Matthew Sunderland and Dr Natacha Carragher National Drug and Alcohol Research Centre, The University of New South Wales, Sydney Australia
Prof Andrew Mackinnon Orygen Youth Health Research Centre, The University of Melbourne, Melbourne Australia
34
Acknowledgements
The College of Medicine, Biology and Environment, The Australian National University
Australasian Society for Psychiatric Research
National Health and Medical Research Council (Australia)