Alex MitchellHon. Senior Lecturer in Psycho-oncology,

Leicester Royal Infirmary

IPOS Workshop (Sept 2007)IPOS Workshop (Sept 2007)alex.mitchell@leicspart.nhs.ukalex.mitchell@leicspart.nhs.uk

0. BasicsTypes of screening

1. Mood Screening Methods

How do they compare?

2. Distress Thermometer

Evidence?

3. Implementing ScreeningUltra-screening in secondary care

0. Basics0. Basics

DefinitionDefinition

Screening:Short; Easy; some false +ve (low SpS PPV), few false –ve (High

Sens, NPV)

Diagnosis (case-finding)Accurate, Few false +ve or –ve

RatingSimple, patient rated, correl. With QoL and other outcomes

=> options

Screening OptionsScreening Options

Unassisted, Untrainedeg. Level 1 cancer staff

Unassisted, trainedeg. Level 3 staff

Assisted, untrainedeg. Level 2 staff

Assisted, trainedeg. Level 4 staff

YesYesGuilt or self-blame

DSMIVICD10Core Symptoms

YesNoSignificant change in weight

YesYesAgitation or slowing of movements

YesYesSuicidal thoughts or acts

NoYesPoor or increased appetite

NoYesLow self-confidence

YesYesPoor concentration or indecisiveness

YesYesDisturbed sleep

YesYes (core)Fatigue or low energy

Yes (core)Yes (core)Loss of interests or pleasure

Yes (core)Yes (core)Persistent sadness or low mood

Do Clinicians Look for Depression?Do Clinicians Look for Depression?

Mitchell, Kaar, Coggan, Herdman (N=226) Psychooncology 2007

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 Staff Psychiatrists

Mitchell, Kaar, Poster APA 2007Current Method

1. Screening Methods1. Screening Methods

20 Instruments for Depression20 Instruments for Depression

SDS (20)EPDS (10)

GDS (30,15)MADRAS (10)

DEPS (10)DADS (7)

Zung (20)DSMIV (9)

CES-D (20,10)PHQ9 (9)Distress Therm (1)

BSI (53)MOS-D (8)WHO-5 (5)

BDI (21,13)BDI (7)PHQ2 (2)

HAM-D (21)HADS (7)PHQ1

Long > 10Short > 5 < 11Ultra-short <6

AudienceAudience

What are the issues for palliative care?

=> Symptoms

General Screening TestsGeneral Screening Tests

Center for Epidemiological Studies –Depression Scale (CES-D) Radloff et al. (1977)

20-item self-report scale that assesses mood and functioning over the past 7-days

Depressed affectPositive affectSomatic problemsInterpersonal problems

Can be abbreviated to 5-item version and validated in community, medical, and clinical samples.

Razavi D, Delvaux N, Farvacques C and Robaye E (1990) Screening for adjustment disorders and major depressive disorders in cancer in-patients. Br J Psych 156: 79–83

N= 210 cancer in- patients

Cut-off 11

Cut-off 3

Cut-off 21

2. The Distress Thermometer2. The Distress Thermometer

Screening Tools- Distress thermometerScreening Tools- Distress thermometer

Developed at the Memorial Sloan-Kettering Cancer Institute from pain VAS

First reported in 1998

Best known example of ultra short screening questionnaire in cancer care

Recommended by the National Comprehensive Cancer Network as a screening measure for distress

- 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 lifeMoney

FeversRelating to GodHousing

Changes in UrinationLoss of faithChildcare

Physical Problems contd…Spiritual/ Religious ConcernsPractical Problems

The distress thermometerThe 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

Does it WorkAs a rule in & rule out?Does it WorkAs a rule in & rule out?

Theory of Diagnostic TestsTheory of Diagnostic Tests

Non-Depressed

Depressed# ofIndividuals

TestResult

Cut-off value

False +veFalse -ve

45%

55%

True -ve

93%

True +ve

7%

Publications evaluating1item VAS against a diagnostic standard

Studies Excluded

Chochinov HM et al (1997) Am J Psychiatry 154:674–676

Akizuki N et al Psycho-Oncology 13: S1–S233 (2004)*

Akizuki N et al Cancer 2003;97:2605–13. *

Grassi L et al (2006) Psycho-Oncology s162 *

Hoffman et al (2004) Psychooncology.13:792–799 *

Ransom et al (2006) Psychoonc 15(7):604-12 *

Ultra-short tests mentioned in title or abstract

Primary Data Studies

90 5139

No Relevant Data Presented Ultra-short tests accuracy analysed in text

33

Jacobsen et al (2005) Cancer 103:1494–502. *

Williams et al (2005) Stroke. 2005; in press

Bula et al (2003)Age Aging Mar;32(2):231-3.

Patrick-Miller et al (2005) JCO 14S 2004: 6024 *

Studies Excluded Due toSTARD NON-Compliant

Haggman (2004) Phys Ther84:1157-1166.

Publications reporting2 or more combination

Chochinov HM et al (1997) Am J Psychiatry 154:674–676

Publications reporting1 verbal item

Gil et al (2005) Support Care Cancer (2005) 13: 600–606*

Lloyd-Williams et al (2003) (2003) - BMJ 2003;327:372–3

Chochinov HM et al (1997) Am J Psychiatry 154:674–676

Akizuki N et al (2004) Psycho-Oncology 13: S1–S233

Ozalp et al (2006) Psycho-Oncology (in press) *

* Study using the distress thermometer

Talelli et al (2004) J Neurol 251: 191 Suppl. 3

Avasarala et al (2003) Multiple Sclerosis 9 (3): 307-310.

Gori et al (1998) Arch GerontGeria 235-240 Suppl. 6

Akizuki N et al Cancer 2003;97:2605–13.

Akizuki N et al (2006) J Pain Symptom Manage 29:91–99

VAS – Visual analogue scale

Mehnert et al (2006) Zeitschrift Fur Psychiatrie Psychologie Und Psychotherapie 54 (3): 213-223 *

Jefford et al (2004) Br J Ca 91(5):900-906

Akechi T et al (2006) J Pain Symptom Manag 31: 5-12

Akechi T et al (2006) J Pain Symptom Manag 31: 5-12

Trask PC, et al Bone Marrow Transplant (2002) 29, 917–925.

Thorvalsdottir et al (2006)

Psycho-oncology 15(2) s430 *

Carter et al (2006) Psycho-

oncology 15(2) s105 *Studies Excluded due to a

Unavailable data

Kumar et al (2006) Psycho-oncology 15(2) s692 *

Andritsch et al (2006) Psycho-

oncology 15(2) s158 *

Publications evaluating1item VAS against a

severity scale

Gessler et al (2006) UK Psycho-

Oncology, 15: s107 *

4 5 5 910

Studies Excluded due toNon-cancer setting

Muszbek et al. Psycho-Oncology

2004; 13 s63 *

PPV DT Distress = 55%; PPV Other Methods 65%

3. Implementation3. Implementation

AudienceAudience

What are the issues for palliative care?

SCAN, SCID, PSE

BDI, MADRAS, Hamilton

HADS, EPDS, PHQ, CES-D

LONG

WHO5, PHQ2, NICE

SHORT

High NPVLow PPV

High NPVMed PPV

High NPVHigh PPV

MEDIUM

Algorithm 1Algorithm 1Symptoms

Simple method

EndPossible Case

Help Given

Patient complaints

Screen -veScreen +ve

Help wanted?

No Help

No

Yes

Algorithm 2Algorithm 2Everyone

Ultra-short method

Clinically worrying?

End

Possible Case

Help Given

Patient Concerns

Screen -veScreen +ve

Short method

Gold standard

Probable Case

MonitoringSeverity rating

Algorithm NumbersAlgorithm NumbersSymptoms

Ultra-short method

Probable Non-Case

True Non-Cases

Probable Case

True Positive

50

4525

100

False +ve

25

50

False -ve

5

ExtrasExtras

Screening Evidence - YesScreening Evidence - Yes

USPSTF

good evidence that screening improves the accurate identification of depressed patients in primary care settings and that treatment of depressed adults identified in primary care settings decreases clinical morbidity.

Small benefits have been observed in studies that simply feed back screeningresults to clinicians.

Larger benefits have been observed in studies in which the communication of screening results is coordinated with effective follow-up and treatment.

Pignone, M. P., Gaynes, B. N., Rushton, J. L., et al (2002) Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 136, 765-776. => Gilbody

Screening Evidence - NoScreening Evidence - No

Feedback results => 23%

Gilbody, S. M., House, A. O. & Sheldon, T. A. (2001) Routinely administered questionnaires for depression and anxiety: systematic review. BMJ, 322 (7283), 406-409. => NICE

“Professionals operating at this level should be able to screen for psychological distress at key points in the patient pathway Recommendation 5.2”