IPOS09 - Screening For Depression What Works (June 2009)

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


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


Depression

13%

20%

57%

48%

38%

18%

Anxiety


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



ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%



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


=> acceptability

n=226 How=>



ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9% Other/Uncertain

2%

Use a QQ15%

ICD10/DSMIV13%



Cancer StaffCurrent Method (n=226)

Psychiatrists

[handout 6]



ICD10/DSMIV24%

Short QQ24%

Long QQ8%

Algorithm26%

Short QQ23%

ICD10/DSMIV0%



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

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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


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


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


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


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


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


FN = 60

PPV 28%

Oncologist Assessment Sp 80%

Sp 40%

NPV 88%

Probable Depression TP = 56


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

IPOS09 - Screening For Depression What Works (June 2009)

Health & Medicine

results hadst

hadst negative n

hadst positive n

ghq12 hadst

severe distress handout

defined distress

defined depression

clinical nurse specialists