Alex Mitchell www.psycho-oncology.info Department of Cancer & Molecular Medicine, Leicester Royal Infirmary Department of Liaison Psychiatry, Leicester General Hospital Portugal 2010 Portugal 2010 IX Congresso Portugues de Psico-Oncologia How do investigations inform clinical practice?
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Keynote - How Do Investigations in Psycho-oncology Inform Clinical Practice? (Oct01
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Alex Mitchell www.psycho-oncology.info
Department of Cancer & Molecular Medicine, Leicester Royal Infirmary
Department of Liaison Psychiatry, Leicester General Hospital
not at all 0; several days 1; more than half the days 2; nearlyevery day 3. We report here, the proportion of people with any suicidal thoughts (non zero scores).
All = 8%Of major or minor depression. 22% had suicidal thoughtsOf major depression 36% had suicidal thoughts (45% BW)Of those with distress 18.0%
% Receiving Any treatment for Depression% Receiving Any treatment for Depression
10.9 11.3
8.18.8
4.3
5.6
10.9
13.8
6.8
17.9
3.4
5.5
15.4
7.2
0
2
4
6
8
10
12
14
16
18
20
High Inc
omeBelg
ium
France
German
y
Israe
l
Italy
Japa
nNeth
erlan
dsNew
Zeala
nd
Spain USALow
Inco
me
ChinaColom
biaSouth
Afri
caUkra
ine
Wang P et al (2007) Lancet 2007; 370: 841–50
n=84,850 face-to-face interviews
% Receiving Any treatment for Mental Health% Receiving Any treatment for Mental Health
7.2
34.6
5.7 6.3 6.4
11.7
19.1
14
8.9
3.9 3.25.7
32.7
5 57.7
11
16.1
6.5 6.2
2.3 1.8
0
5
10
15
20
25
30
35
40
All P
atie
nts
Men
tal I
ll Hea
lth
No
Men
tal I
ll He
alth
No
chro
nic m
edic
al co
nditi
ons
1 ch
roni
c m
edica
l con
ditio
n2
chro
nic
med
ical c
ondi
tions
3 ch
roni
c m
edica
l con
ditio
ns
18-4
4 ye
ars
45-6
4 ye
ars
65-7
4 ye
ars
75+
Cancer n=4878
No Cancer n=90,737
Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590
Testing Clinicians: A Meta-AnalysisTesting Clinicians: A Meta-Analysis
All cancer professionalsSE =39.5% and SP =77.3%.
OncologistsSE =38.1% and SP = 78.6%; a fraction correct of 65.4%.
By comparison nursesSE = 73% and SP = 55.4%; FC = of 60.0%.
When attempting to detect anxiety oncologists managedSE = 35.7%, SP = 89.0%, FC 81.3%.
Presented at IPOS2009
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
Ave Confidence+
Ave Confidence-
Baseline Probability
Above Ave Confidence+
Above Ave Confidence-
High Confidence+
High Confidence-
Low confidence = more cautious, fewer false positives, more false negatives
High confidence = less cautious, more false positives, low false negatives
p180
462 (42%)Meetable Needs
1093 (100%)Population
388 (84%)Aware of Need
172 (44%)Requested Help
80 (47%)Needs Met
462 needs
17.3%
322 DSMIV
25%
Can tools (investigations) help?Can tools (investigations) help?
Q. How Common is the Problem?Q. How Common is the Problem?
Depression
Distress
Anxiety
Requires depressed mood for most of the day, for most days (by subjective account or observation) for at least 2 years
The symptoms cause clinically significant distress OR impairment in social, occupational, or other important areas of functioning.
Requires persistently low mood two (or more) of the following six symptoms:
(1) poor appetite or overeating (2) Insomnia or hypersomnia(3) low energy or fatigue (4) low self-esteem (5) poor concentration or difficulty
making decisions (6) feelings of hopelessness
DSM-IV Dysthymic disorder
Acute: if the disturbance lasts less than 6 months Chronic: if the disturbance lasts for 6 months
These symptoms cause marked distress that is in excess of what would be expected from exposure to the stressor OR significant impairment in social or occupational (academic) functioning
Requires the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months.
DSM-IV Adjustment disorder
2 weeksThese symptoms cause clinically important distress OR impair work, social or personal functioning.
Requires two to four out of nine symptoms with at least at least one from the first two (depressed mood and loss of interest).
DSM-IV Minor Depressive Disorder
2 weeksThese symptoms cause clinically important distress OR impair work, social or personal functioning.
Requires five or more out of nine symptoms with at least at least one from the first two (depressed mood and loss of interest).
DSM-IV Major Depressive Disorder
2 weeks unless symptoms are unusually severe or of rapid onset).
At least some difficulty in continuing with ordinary work and social activities
Requires two of the first three symptoms (depressed mood, loss of interest in everyday activities, reduction in energy) plus at least two of the remaining seven symptoms (minimum of four symptoms)
ICD-10 Depressive Episode
DurationClinical SignificanceSymptoms
Depression
13%
20%
57%
48%
38%
18%
Anxiety
Adjustment Disorder
N=11N=4
N=10
Comment: Slide illustrates meta-analytic rates of mood disorder
Prevalence of depression in Palliative settings
20 studies involving 2655 individuals
16.9% (95% CI = 13.2% to 21.0%)
13.0% (95% CI = 11.6% to 14.5%) for MDD
p572
Proportion meta-analysis plot [random effects]
0.0 0.2 0.4 0.6
combined 0.17 (0.13, 0.21)
Maguire et al (1999) 0.05 (0.01, 0.14)
Akechi et al (2004) 0.07 (0.04, 0.11)
Kadan-Lottich et al (2005) 0.07 (0.04, 0.11)
Love et al (2004) 0.07 (0.04, 0.11)
Wilson et al (2004) 0.12 (0.05, 0.22)
Chochinov et al (1997) 0.12 (0.08, 0.18)
Wilson et al (2007) 0.13 (0.10, 0.17)
Kelly et al (2004) 0.14 (0.06, 0.26)
Chochinov et al (1994) 0.17 (0.11, 0.24)
Le Fevre et al (1999) 0.18 (0.10, 0.28)
Breitbart et al (2000) 0.18 (0.11, 0.28)
Meyer et al (2003) 0.20 (0.10, 0.35)
Minagawa et al (1996) 0.20 (0.11, 0.34)
Lloyd-Williams et al (2001) 0.22 (0.14, 0.31)
Hopwood et al (1991) 0.25 (0.16, 0.36)
Desai et al (1999) [late] 0.25 (0.10, 0.47)
Payne et al (2007) 0.26 (0.19, 0.33)
Lloyd-Williams et al (2003) 0.27 (0.17, 0.39)
Jen et al (2006) 0.27 (0.19, 0.36)
Lloyd-Williams et al (2007) 0.30 (0.24, 0.36)
proportion (95% confidence interval)
Prevalence of depression in Oncology settings
57 studies involving 9195 individuals across 12 countries.
The prevalence of depression was 17.3% (95% CI = 13.8% to 21.2%),
13.0% (95% CI = 11.6% to 14.5%) for MDD
p572
Proportion meta-analysis plot [random effects]
0.0 0.3 0.6 0.9
combined 0.1730 (0.1375, 0.2116)
Colon et al (1991) 0.0100 (0.0003, 0.0545)
Massie and Holland (1987) 0.0147 (0.0063, 0.0287)
Hardman et al (1989) 0.0317 (0.0087, 0.0793)
Derogatis et al (1983) 0.0372 (0.0162, 0.0720)
Lansky et al (1985) 0.0455 (0.0291, 0.0676)
Mehnert et al (2007) 0.0472 (0.0175, 0.1000)
Katz et al (2004) 0.0500 (0.0104, 0.1392)
Singer et al (2008) 0.0519 (0.0300, 0.0830)
Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)
Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)
Lee et al (1992) 0.0660 (0.0356, 0.1102)
Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)
Grassi et al (2009) 0.0826 (0.0385, 0.1510)
Grassi et al (1993) 0.0828 (0.0448, 0.1374)
Walker et al (2007) 0.0831 (0.0568, 0.1165)
Kawase et al (2006) 0.0851 (0.0553, 0.1240)
Coyne et al (2004) 0.0885 (0.0433, 0.1567)
Alexander et al (2010) 0.0900 (0.0542, 0.1385)
Love et al (2002) 0.0957 (0.0650, 0.1346)
Ozalp et al (2008) 0.0971 (0.0576, 0.1510)
Morasso et al (2001) 0.0985 (0.0535, 0.1625)
Costantini et al (1999) 0.0985 (0.0535, 0.1625)
Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)
Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)
Morasso et al (1996) 0.1121 (0.0593, 0.1877)
Prieto et al (2002) 0.1227 (0.0825, 0.1735)
Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)
Payne et al (1999) 0.1290 (0.0363, 0.2983)
Kugaya et al (1998) 0.1328 (0.0793, 0.2041)
Alexander et al (1993) 0.1333 (0.0594, 0.2459)
Gandubert et al (2009) 0.1597 (0.1040, 0.2300)
Razavi et al (1990) 0.1667 (0.1189, 0.2241)
Akizuki et al (2005) 0.1797 (0.1376, 0.2283)
Leopold et al (1998) 0.1887 (0.0944, 0.3197)
Devlen et al (1987) 0.1889 (0.1141, 0.2851)
Berard et al (1998) 0.1900 (0.1184, 0.2807)
Joffe et al (1986) 0.1905 (0.0545, 0.4191)
Berard et al (1998) 0.2100 (0.1349, 0.3029)
Maunsell et al (1992) 0.2146 (0.1605, 0.2772)
Grandi et al (1987) 0.2222 (0.0641, 0.4764)
Evans et al (1986) 0.2289 (0.1438, 0.3342)
Spiegel et al (1984) 0.2292 (0.1495, 0.3261)
Golden et al (1991) 0.2308 (0.1353, 0.3519)
Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)
Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)
Kathol et al (1990) 0.2961 (0.2248, 0.3754)
Green et al (1998) 0.3125 (0.2417, 0.3904)
Jenkins et al (1991) 0.3182 (0.1386, 0.5487)
Burgess et al (2005) 0.3317 (0.2672, 0.4012)
Hall et al (1999) 0.3722 (0.3139, 0.4333)
Morton et al (1984) 0.3958 (0.2577, 0.5473)
Baile et al (1992) 0.4000 (0.2570, 0.5567)
Passik et al (2001) 0.4167 (0.2907, 0.5512)
Bukberg et al (1984) 0.4194 (0.2951, 0.5515)
Massie et al (1979) 0.4850 (0.4303, 0.5401)
Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)
Mitchell AJ. Short Screening Tools for Cancer Related Distress A Review and Diagnostic Validity Meta-analysis JNCI (2010) in press
Distress
Validity of DT vs depression (DSMIV)Validity of DT vs depression (DSMIV)
SE 80%
SP 60%
PPV 32%
NPV 93%
DT vs DSMIV DepressionDT vs DSMIV Depression
SE SP PPV NPV
DTma 80.9% 60.2% 32.8% 92.9%
DTLeicesterBW 82.4% 68.6% 28.0% 98.3%
DTLeicesterBSA 100% 59.6% 26.8% 100%
BSA = British South Asian BW= British White
Q. Problem with somatic symptoms?Q. Problem with somatic symptoms?
Approaches 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
Medically Unwell Alone
Primary Depression Alone
Secondary Depression
Comment: Slide illustrates concept of phenomenology of depressions in medical disease
FatigueAnorexiaInsomnia
Concentration
Study: Coyne Thombs MitchellN= 4500; Pooled database study; All comparative studies
We analysed data collected from Leicester Cancer Centre from 2008-2010 involving 531 people approached by a research nurse and two therapeutic radiographers.
We examined distress using the DT and daily function using the question:
“How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?”
“Not difficult at all =0; Somewhat Difficult =1; Very Difficult =2; and Extremely Difficult =3”
Dysfunction in 531 cancer patientsDysfunction in 531 cancer patients
55.7%
34.3%
7.3%
2.6%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Unimpaired Mild Moderate Severe
Unimpaired by DT ScoreUnimpaired by DT Score
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
1 2 3 4 5 6 7 8 9 10 11
18%
DepT23%
Distress69%
Dysfunction76%
0.3%
3% 2%
26%28% 22%
Of the 293 Non-Nil
DysfunctionDistress
DepT
DT distribution by ImpairmentDT distribution by Impairment
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
0.18
0 1 2 3 4 5 6 7 8 9 10
Extreme and incapacitating
Very Severe and very disabling
Moderately Severe and disabling
Moderate and quite disabling
Moderate and somewhat disabling
Mild-Moderate and slight disabling
Mild but not particularly disabling
Very mild and not disabling
Minimal but bearable
Minimal and not problematic
None at all
T4. Screening in Cancer: ImplementationT4. Screening in Cancer: Implementation
Clinician Opinion
Patient Opinion
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?
Comment: “Ideal” method of eliciting symptoms of distress/depression according to clinician
Comment: Slide illustrates actual gain in meta-analysis of screening implementation in primary care
There was a non-significant trend for improve detection sensitivity (Chi² = 1.12 P = 0.29).
Qualitative AspectsQualitative Aspects
DISTRESS
43% of CNS reported the tool helped them talk with the patient about psychosocial issues esp in those with distress
28% said it helped inform their clinical judgement
DEPRESSION
38% of occasions reported useful in improving communication.
28.6% useful for informing clinical judgement
Next StepNext Step269 Nurse-patient
interactions
Helped 65 (24%) Not Helped 204 (76%)
Unmet Needs 150 (55.8%)
Referred 23 (8.6%) Declined Helped 20 (7.4%)
No Unmet Needs 34 (12.6%)
p179
2x2 Clinician Help Table : ACTUAL HELP2x2 Clinician Help Table : ACTUAL HELP
Clinician thinks:Unmet Needs
Clinician thinks no Unmet Needs
Patient Says:Help Wanted (60)
Helped 21/35 (60%)
Helped 11/23(48%)
Patient Distressed
Helped 65/102(63%)
Helped 31/62(50%)
Patient Not distressed orHelp Not Wanted
Helped 8/35(23%)
Helped 20/117(17%)
b. Intervention and helpb. Intervention and helpPREDICTORS
1. patient desire for help
2. number of unmet needs
3. clinicians confidence
4. patient reported anger
p179
RCT using DT Carlson et al 2010RCT using DT Carlson et al 2010
Screening for Distress in lung and breast cancer outpatients: A randomized controlled trial Linda Carlson Tom Baker Cancer Centre, University of Calgary
1) Minimal Screening: the Distress Thermometer (DT) [n=365]
2) Full Screening: DT, Problem Checklist, Psychological Screen for Cancer (PSSCAN) [n=391] a personalized report
3) Triage: Full screening plus optional personalized phone triage [378]
FURTHER READING:
Screening for Depression in Clinical Practice An Evidence-Based guide
ISBN 0195380193 Paperback, 416 pagesNov 2009Price: £39.99