Liaison09 - Detection of Depression In Cancer Settings from Evidence to Practice [Mar09]

Alex Mitchell

Department of Cancer & Molecular MedicineLeicester Royal Infirmary

Liaison AGM 2009Liaison AGM 2009

Detection of Depression in Cancer Settings:

Using Evidence to Improve Clinical Practice

Detection of Depression in Cancer Settings:

Using Evidence to Improve Clinical Practice

ContentsContents

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

1. Overview of Mood Complications1. Overview of Mood Complications

Depression

13%

20%

57%

48%

38%

18%

Anxiety

Distress/Adjustment Disorder

N=11N=4

N=10

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

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)

Major Depression26%

Minor Depression12%

Subsyndromal Depression

47%

None of above15%

DistressedPatients

2. Current Detection Strategies2. Current 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 Alone

73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%

1,2 or 3 Simple QQ15%

Clinical Skills Alone

73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%

=> Table scales

=> accuracy

Methods to Evaluate Depression

Unassisted Clinician Conventional Scales

Ultra-Short (<5)Short (5-10) Long (10+)Untrained Trained

Acceptability? Acceptability ? Acceptability ?

Accuracy? Accuracy? Accuracy?

3. Willingness of Clinicians to Screen3. Willingness of Clinicians to Screen

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

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=>

3. Routine Abilities of Cancer Clinicians3. Routine Abilities of Cancer Clinicians

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

Nurse Positive

Nurse Negative

Baseline Probability

Doctor Postive

Doctor Negative

0.8520.368Nurse

0.7240.458Doctor

NPVPPV

N=10 vs N=2

5. Validity of the Current Methods5. Validity of the Current Methods

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%

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

Pos

t-tes

t 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)

6. Phenomenology of Comorbid Depression6. Phenomenology of Comorbid Depression

Somatic Bias in Mood Scales

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 driveDiminished 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

Audience?

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 Depressions

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

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

**

*

*

*

*

*

*

*

6. Scope for New Tools (DT and ET)6. Scope for New Tools (DT and ET)

- 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

(3v4)

7. Future of Screening7. Future of Screening

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.

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?

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