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Alex Mitchell [email protected] Royal Infirmary UK
Matthew Loscalzo [email protected] of Hope, CA
Karen Clark [email protected] & Les Biller Patient and Family Resource Center
Chris Hosker [email protected] Psychiatry, Leeds
IPOS2009IPOS2009
IPOS2009 – Workshop
Screening for Distress In Cancer: A Practical & Theoretical Guide To What Really Works
IPOS2009 – Workshop
Screening for Distress In Cancer: A Practical & Theoretical Guide To What Really Works
8.30 -9.00: Coffee, welcome, outline & handoutsLed by Mitchell
9.00 to 9.10: Audience Needs and Questions [10mins]Intro Led by Hosker
9.10: PART A “The Context”Talk Led by Mitchell9.50 10mins discussionALL
10.00 Audience Task 1 & 2 [30mins]Feedback Summary from Clark, Loscalzo
10.30: PART B – “New Methods & their Implementation”
Talk Led by Loscalzo, Clark
11.00 Break [15mins]
11:15 Audience Task 3 & 4 [30mins] Feedback Summary from Hosker, Mitchell
11.45: PART C “Advanced methods”Led by Mitchell
12:15 Summary [15mins] ALL
12.30 Lunch
Part A. ContextPart A. Context
The issues - under recognition; identifying distress/adjustment; minor and subsyndromal disorders, problems with current tools
Alex Mitchell [email protected] Royal Infirmary UK
Depression
13%
20%
57%
48%
38%
18%
Anxiety
Distress/Adjustment Disorder
N=11N=4
N=10
[handout 1]
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
Major Depression26%
Minor Depression12%
Subsyndromal Depression
47%
None of above15%
DistressedPatients
Current Detection StrategiesCurrent Detection Strategies
1,2 or 3 Simple QQ15%
Clinical Skills Alone73%
ICD10/DSMIV0%
Short QQ3%
Other/Uncertain9%
Methods to Evaluate Depression
Unassisted Clinician Conventional Scales
Verbal Questions Visual-Analogue Test
PHQ2
WHO-5
Whooley/NICE
Distress Thermometer
Depression Thermometer
Ultra-Short (<5)Short (5-10) Long (10+)Untrained Trained
1,2 or 3 Simple QQ15%
Clinical Skills Alone73%
ICD10/DSMIV0%
Short QQ3%
Other/Uncertain9%
1,2 or 3 Simple QQ15%
Clinical Skills Alone73%
ICD10/DSMIV0%
Short QQ3%
Other/Uncertain9%
=> Table scales
[handout 2]
=> accuracy
[handout 3]
[handout 4]
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)
[handout 5]
Methods to Evaluate Depression
Unassisted Clinician Conventional Scales
Ultra-Short (<5)Short (5-10) Long (10+)Untrained Trained
Implementation Implementation Implementation
Acceptability? Acceptability ? Acceptability ?
Accuracy? Accuracy? Accuracy?
Willingness of Clinicians to Screen
=> acceptability
Willingness of Clinicians to Screen
=> acceptability
n=226 How=>
1,2 or 3 Simple QQ15%
Clinical Skills Alone73%
ICD10/DSMIV0%
Short QQ3%
Other/Uncertain9% Other/Uncertain
2%
Use a QQ15%
ICD10/DSMIV13%
Clinical Skills Alone55%
1,2 or 3 Simple QQ15%
Cancer StaffCurrent Method (n=226)
Psychiatrists
[handout 6]
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?
Validity=>
[handout 6]
Accuracy
=>Routine Abilities of Clinicians=> Validity of current tools
Accuracy
=>Routine Abilities of Clinicians=> Validity of current tools
Testing Clinicians vs DTTesting Clinicians vs DT114 ratings from clinical nurse specialists (CNS).
81 individuals (71%) scored above a cut-off of 3 (mild distress)
64 patients (56%) scored above a cut-off of 4 (moderate distress)
37 (32.4%) individuals scores above 5 (severe distress)
[handout 7]
ResultsResultsDT 3v4 (mild, high prevalence)
DT 4v5 (moderate, medium prevalence)
DT 5v6 (severe, low prevalence)
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
Pos
t-tes
t Pro
babi
lity
Severe Distress CNS+Severe Distress CNS-Baseline ProbabilityMild Distress CNS+Mild Distress CNS-Mod Distress CNS+Mod Distress CNS-
Testing Clinicians: A Meta-AnalysisTesting Clinicians: A Meta-AnalysisMethods12 studies reported in 7 publications. Two studies examined detection of
anxiety, 8 broadly defined depression (includes HADS-T), 3 strictly defined depression and 7 broadly defined distress.
9 studies involved medical staff and 2 studies nursing staff. Gold standard tools including GHQ60, GHQ12 HADS-T, HADS-D, Zung and SCID.
The total sample size was 4786 (median 171).
ResultsAll cancer professionals showed a mean SE of 39.5% and SP 77.3%.
Oncologists had a SE of 38.1% and SP of 78.6%; a fraction correct of 65.4%.
By comparison nurses had a SE of 73% and SP of 55.4%; FC = of 60.0%.
When attempting to detect anxiety, oncologists managed a SE of 35.7%, SP 89.0%, FC 81.3%.
Individual Lecture 2-24June 2009: 9.00am (Category Communication Skills) Sess 13 Lect 3
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
Nurse Positive
Nurse Negative
Baseline Probability
Doctor Postive
Doctor Negative
0.8520.368Nurse
0.7240.458Doctor
NPVPPV
N=10 vs N=2
HADS Validity vs Structured InterviewHADS Validity vs Structured InterviewMETHODSAgainst depression 9x studies of the HADS-D; 5x of the
HADS-T and 2x of the HADS-A were identified.
RESULTSHADS-T = HADS-D = HADS-AThe clinical utility index (UI+, UI-) was 0.214 and 0.789
for the HADS-D.
Sensitivity Specificity PPV NPV FCHADS-D 51.4% 86.9% 41.6% 90.8% 81.4% HADS-A 82.4% 81.7% 35.9% 97.4% 81.8%
HADS-T 77.7% 84.3% 44.5% 95.9% 83.4%Individual Lecture 2; 24 June 2009: 3.30pm (Category Methods and Measurements); Session 273
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-T Positive (N=5)HADS-T Negative (N=5)Baseline ProbabilityHADS-A Positive (N=2)HADS-A Negative (N=2)HADS-D Positive (N=9)HADS-D Negative (N=9)
HADS vs ClinicianHADS vs Clinician
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
Clinician Positive (Fallowfield et al, 2001)
Clinician Negative (Fallowfield et al, 2001)
Baseline Probability
HADS-D Positive (Mata-analysis)
HADS-D Negative (Meta-analysis)
Part B. New Tools & ImplementationPart B. New Tools & Implementation
Waiting room, computerized ratings, help question, implementation [30mins]
Matthew Loscalzo [email protected] of Hope, CA
Karen Clark [email protected] & Les Biller Patient and Family Resource Center
Part C. Advanced MethodsPart C. Advanced Methods
Adapting scales, custom scales, visual analogue scales, more on help, combination techniques
Alex Mitchell [email protected] Royal Infirmary UK
Should We use Special Tools?
=>Phenomenology of Comorbid Depression
Should We use Special Tools?
=>Phenomenology of Comorbid Depression
Cancer Specific ToolsCancer Specific Tools
PDIPsychological Distress Inventory
ESASEdmonton Symptom Assessment System (9VAS)
Distress Barometer
Hornheide QuestionHornheide Questionnaire, Short Form (9)
PS-ScanPsychological Screen for Cancer
MAX-PCMemorial Anxiety Scale for Prostate Cancer
QSC-R23Questionnaire on Stress in Cancer
?IESMEQMood Evaluation QQ
DT / MT / IT / ETDistress thermometer
FoP scaleFear of disease progression scale
BCFDBrief Case Find for Depression
RSCLRotterdam Symptom Checklist
AnxietyDepressionGeneric / Distress
Somatic Bias in Mood Scales [handout 2b]
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Loss
of e
nerg
yDi
min
ishe
d dr
ive
Slee
p di
stur
banc
eCo
ncen
trat
ion/
inde
cisi
onDe
pres
sed
moo
d
Anxi
ety
Dim
inis
hed
conc
entr
atio
n
Inso
mni
aDi
min
ishe
d in
tere
st/p
leas
ure
Psyc
hic
anxi
ety
Help
less
ness
Wor
thle
ssne
ssHo
pele
ssne
ssSo
mat
ic a
nxie
tyTh
ough
ts o
f dea
th
Ange
rEx
cess
ive
guilt
Psyc
hom
otor
cha
nge
Inde
cisiv
enes
sDe
crea
sed
appe
tite
Psyc
hom
otor
agi
tatio
nPs
ycho
mot
or re
tard
atio
nDe
crea
sed
wei
ght
Lack
of r
eact
ive
moo
dIn
crea
sed
appe
tite
Hype
rsom
nia
Incr
ease
d w
eigh
t
All Case ProportionDepressed ProportionNon-Depressed Proportion
n=1523
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
Depressed Mood
Diminished drive
Diminished interest/pleasure
Loss of energy
Sleep disturbance
Diminished concentration
Sensitivity
1 - Specificity
n=1523
Approaches to Somatic Symptoms of DepressionApproaches 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
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 4982
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
**
*
*
*
*
*
*
*
New Tools (Ultra-Short)
=> DT=> PHQ2=> ET=> Help QQ
New Tools (Ultra-Short)
=> DT=> PHQ2=> ET=> Help QQ
20 Instruments for Depression20 Instruments for Depression
MDI (11)Personal HQ (16)
GDS (30,15) (5)(4)(2)PHQ9 (9) (2)
DEPS (10)
Zung (20)DADS (7)
CES-D (20) (13)(10) (6)EPDS (10) (8)(6)(5)Distress Therm (1)
BSI (53)MOS-D (8)WHO-5 (5)
BDI (21) (13) (7) (2)MADRAS (10)PHQ2 (2)
HAM-D (21) (7) (6)HADS (7) (1)PHQ1
Long > 10Short > 5 < 11Ultra-short <6
[handout 4]
[handout 10]
- Please circle the number (0-10) that best describes how much distress you have been experiencing in the past week, including today.
- What phone number would you like us to contact you on if necessary?
Please tick WHICH of the following is a cause of distress:
DiarrhoeaAnger
ConstipationWorry
IndigestionSadness
EatingNervousness
Is there anything important you would like to add to the list?__________________________________________________________________________________________
Mouth soresFears
BreathingDepression
Bathing/ DressingEmotional Problems
Getting around
Hot flushesSleepDealing with children
SexualFatigueDealing with partner
Feeling swollenNauseaFamily Problems
Metallic taste in mouthPain
Tingling in hands/ feetPhysical problemsWork/School
Nose dry/ congestedTransport
Skin dry/ itchyLoss of meaning or purpose in life
Money
FeversRelating to GodHousing
Changes in UrinationLoss of faithChildcare
Physical Problems contd…Spiritual/ Religious ConcernsPractical Problems
Distress Thermometer
=> Validity
Distribution of DT ScoresRansom (2006) PO (n=491)
13.814.7
15.7
13.2
10.4
8.47.7 7.3
3.7 3.3
1.8
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7 Score 8 Score 9 Score 10
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
1 - Specificity
Sens
itivi
tyPHQ2 Two QQ
PHQ2 Interest
PHQ9
PHQ2 Depression
HADS-D DT (4v5)
DT (3v4)
HADS-T
[handout 1]
[handout 8]
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
DT
15%
DT(38%)
AngT(26%)
DepT(30%)
AnxT(65%)
8%
2%
4%
0%
10%
0%
0%
0%
2%
21%
1%
2%
ET vs DT (n=130)ET vs DT (n=130)Of 63% DT low scorers
51% recorded emotional difficulties on the new Emotion Thermometers (ET) tool
Out of those with any emotional complication
93.3% would be recognised using the AnxT alonevs 54.4% who would be recognised using the DT alone.
[handout 9]
DT DepTVsHADS-A
AnxT AngT
AUC:DT=0.82DepT=0.84AnxT=0.87AngT=0.685
DT DepTVsHADS-D
AnxT AngT
AUC:DT=0.67DepT=0.75AnxT=0.62AngT=0.69
What Have We Learned?What Have We Learned?
Overview of mood complication of cancer
Current Detection Strategies
Routine Abilities of Cancer Clinicians
Willingness of Clinicians to Screen
Validity of the Current Methods
Phenomenology of Comorbid Depression
Scope for new tools (DT & ET)
Future of Screening
Not just depression
Too long
Low rule-in
Modest
HADS-D poor
Include somatic
Potentially useful
Help?
Advanced Methods
=> Algorithms=> Combinations=> Cost-benefits
Advanced Methods
=> Algorithms=> Combinations=> Cost-benefits
Cancer Population
CNS Assessment
Possible case
Depression
Screen #1+ve
n = 200 No Depression
Sp 55%
Se 70%
n = 800
N = 1000
TP = 140
FP = 360Probable Non-Case TN =440
FN = 60
PPV 28% NPV 88%
Screen #1-ve
YieldTP = 140
TN = 440
FN = 60
FP = 360
NPV 88%
PPV 28%
Sp 55%
Se 70%
Cancer Population
CNS Assessment
Possible case
Depression
Screen #1+ve
n = 200 No Depression
Sp 55%
Se 70%
n = 800
N = 1000
TP = 140
FP = 360Probable Non-Case TN =440
FN = 60
PPV 28%
Oncologist Assessment Sp 80%
Sp 40%
NPV 88%
Probable Depression TP = 56
FP = 72Probable Non-Case TN =288
FN = 84
PPV 44% NPV 77%
Screen #1-ve
Screen #2+ve
Screen #2+ve
Cumulative YieldTP = 56
TN = 728
FN = 144
FP = 72
NPV 83%
PPV 44%
Sp 91%
Se 28%
[handout 11]
Credits & Acknowledgments
Elena Baker-Glenn University of NottinghamPaul Symonds Leicester Royal InfirmaryChris Coggan Leicester General HospitalBurt Park University of NottinghamLorraine Granger Leicester Royal InfirmaryMark Zimmerman Brown University, Rhode IslandBrett Thombs McGill University CanadaJames Coyne University of Pennsilvania
For more information www.psycho-oncology.info
Extras