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Alex Mitchell Leicester Royal Infirmary Elena Baker-Glenn University of Nottingham Paul Symonds Leicester Royal Infirmary Chris Coggan Leicester General Hospital June 2008 June 2008 Clinical Significance of DSM-IV Major, Minor and Sub-Syndromal Depression in Cancer: Preliminary Report of Chemotherapy Attendees

IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

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This is an academic presentation from June 2008, IPOS (Psycho-oncology) Conference, Madrid re subtypes of depression. It is primarily intended for clinicians and researchers working in this field.

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Page 1: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

Alex Mitchell Leicester Royal Infirmary

Elena Baker-Glenn University of NottinghamPaul Symonds Leicester Royal InfirmaryChris Coggan Leicester General Hospital

June 2008June 2008

Clinical Significance of DSM-IV Major, Minor and Sub-Syndromal Depression in Cancer:

Preliminary Report of Chemotherapy Attendees

Page 2: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

[A] About Depression subtypes

Page 3: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

Study DescriptionStudy Description

AuthorsBaker-Glenn, Symonds, Grainger, Mitchell

Demographic Results129 patients were seen at baseline, and 86 were re-interviewed at

1 month. 215 assessments were made.

InstrumentsPHQHADSDTHelp

Page 4: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

Depression

13%

20%

57%

48%

38%

18%

Anxiety

Distress/Adjustment Disorder

Depression

13%

20%

57%

48%

38%

18%

Anxiety

Distress/Adjustment Disorder

Pooled Analysis of 38 studies

Setting: mostly oncology

Instruments: mixedPoint prevalence n=6414

Page 5: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

Depression

13%

20%

57%

48%

38%

18%

Anxiety

Distress/Adjustment Disorder

Depression

13%

20%

57%

48%

38%

18%

Anxiety

Distress/Adjustment Disorder

MajorDepression

MinorDepression

Symptoms

Page 6: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

Definitions by DSM IVDefinitions by DSM IV

Major DepressionAt least 5 of 9 of the questions concerning his mental state of

health with at least “more than half the days.” For a period of two weeks or more include Q1 or Q2

Minor depression2-4 of 9 of the questions concerning his mental state of health

with at least “more than half the days.” For a period of two weeks or more include Q1 or Q2

Subsyndromal DepressionTo meet the criteria for minor depression, patients had to have, for

at least 2 weeks, at least one symptom present for more than half the days but not fulfilling criteria for major or minor depression and with no requirement Q1 or Q2

Page 7: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

Symptom Significance in DepressionSymptom Significance in Depression

(7 or) 8 symptoms (3+4)

(5 or) 6 symptoms

4 symptoms (2+2)

2 or 3 symptoms

0 or 1 symptom

ICD10

16 - 21UnspecifiedSevere

12 - 155 symptoms (Mj)Moderate

8 -112-4 symptoms (minor)Mild

4 - 71 or 2 symptoms(or no core symptoms)

Sub-syndromal

0 - 30 symptomHealthy

HADS-D ScoreDSMIVDepression Severity

=> HADS

Page 8: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

=> Symptoms

Page 9: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]
Page 10: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

PHQ9PHQ9

Linear vs algorithmic PHQ

The mean score on the PHQ9 was 6.1

23.3% scored above 9

17.7% scored above 10

Page 11: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]
Page 12: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

a. L

ittle

inte

rest

or

plea

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oing

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gs

b. F

eelin

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wn,

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d, o

r hop

eles

s

c. T

roub

le fa

lling

or

stay

ing

asle

ep, o

rsl

eepi

ng to

o m

uch

d. F

eelin

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r hav

ing

little

ene

rgy

e. P

oor a

ppet

ite o

rov

erea

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f. Fe

elin

g ba

d ab

out

your

self…

.

g. T

roub

le c

once

ntra

ting

on th

ings

,….

h. M

ovin

g or

spe

akin

g so

slow

ly th

at o

ther

peo

ple

coul

d ha

ve n

otic

ed…

i. Th

ough

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at y

ouw

ould

be

bette

r off

dead

….Three

TwoOneZero

Page 13: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

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)

Page 14: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

Basic ResultsBasic Results

Of 215 patient assessment

11.2% had major depression alone7% had minor depression alone28.8% had sub-syndromal depression

18.0% had major or minor depression46.3% had major or minor or sub-syndromal depression.

Only 40.5% of individuals had no symptoms of depression at all.

Page 15: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

Rates of Mj Mn SSRates of Mj Mn SS

11.6

8.5

31

51.1

10.3

4.7

37.2

52.2

0

10

20

30

40

50

60

Major Depression Minor Depression Subsyndromal Any Mood Problem

Baseline1 Month

Page 16: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

[B] About Clinical Significance

Page 17: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

How To Establish Clinical SignificanceHow To Establish Clinical Significance

Correlation with HADS?

Correlation with Distress Thermometer?

Correlation with who wants help?

Prognostic significance

Disability

Page 18: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

0.830.80

0.53

0.79

0.33

0.22

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Major Depression Minor Depression Sub-Syndromal

HADS-A PositiveHADS-D Positive

Page 19: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

0.79

0.60

0.48

0.42

0.270.23

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Major Depression Minor Depression Sub-Syndromal

DT PositiveHelp Positive

Page 20: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

Of those Distressed (3v4 on the DT)Of those Distressed (3v4 on the DT)

Only 19 (of 74) had major depression (26%)

Only 9 (of 74) had minor depression (12%)

35 (of 74) had SS depression (48%)

11 had major, minor or SS depression (15%)

Page 21: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

Major Depression26%

Minor Depression12%

Subsyndromal Depression

47%

None of above15%

DistressedPatients

Page 22: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

OutcomeOutcome0.27

0.09

0.18

0.18

0.27

Major DepressionMinor DepressionSub-SyndromalRemissionLost

Prognosis

Page 23: IPOS08 - Clinical Significance of DSMIV Major, Minor & Subsyndromal Depression [June2008]

SummarySummary

Major depression is not common after cancer (in comparison to other types of depression)

Major depression corresponds poorly with the distress concept

Mj + Mn + SS depression => 85% of distressed patients

Future studies using DSMIV definitions should use minor and possibly SS depression