Psychological aspects of cancer care for students 2011 (Apr11)

Alex MitchellConsultant in Liaison Psychiatry and Hon SnR Lecturer in

Psycho-oncology, University Hospitals Leicester

Undergraduates (Feb11)Undergraduates (Feb11)[email protected]@leicspart.nhs.uk

23

3

3

3

4

5

8

10

10

14

16

25

2

3

4

5

3

1

3

14

24

15UK Rank

(12th)

(10th)

(5th)

(4th)

(6th)

(15th)

(8th)

(3rd)

(1st)

(2nd)

All others

Lip, oral cavity

Leukaemia

NHL

Bladder

Oesophagus

Liver

Stomach

Colorectum

Prostate

Lung

world (%) uk (%)27

3

3

4

4

5

6

9

9

9

23

27

3

1

5

1

5

2

12

2

12

31UK Rank

(7th)

(18th)

(5th)

(19th)

(4th)

(13th)

(3rd)

(11th)

(2nd)

(1st)

All others

NHL

Thyroid

Ovary

Liver

Uterus

Stomach

Lung

Cervix

Colorectum

Breast

world(%) uk(%)

Males

Most commonly diagnosed cancers worldwide

Females

0

10

20

30

40

50

60

70

80

90

100

Melanom

aBrea

st (fe

male)

Urinary

bladde

r

Prostat

e

Colon

All site

s

Rectum

Non-H

odgkin

lymph

oma

Ovary

Leuk

emiaLu

ng and

bron

chus

Pancre

as

1975-19771984-19861996-2004Change

5 Year Survival in US Cancers (2008 American Cancer Society, Atlanta)

Annual report to the national of status of cancer 1975 – 2005 J Natl Cancer Inst 2008;100: 1672 – 1694

10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases

0

500

1000

1500

2000

2500

3000

3500

Breast

Prosta

teMela

noma

Colorectal

Lymph

oma

Uterus

Bladder

Lung

KidneyHea

dandne

ck

Cervix

Leuke

mia

Ovary

Brain

Stomac

hEso

phagus

Pancr

eas

raw 000'S

raw 000'S

Total prevalence = 13.8 million in 2010

Projected = 18.2million in 2020

Angela B. Mariotto J Natl Cancer Inst 2011;103:117–128

What is the prevalence of depression?

Levine PM, Silberfarb PM, Lipowski ZJ. Mental disorders in cancer patients. Cancer 1978;42:1385–91.

Dartmouth Medical School and the Norris Cotton Cancer Center, New Hampshire

Prevalence of depression in Oncology settings

70 studies involving 10,071 individuals;14 countries.16.3% (95% CI = 13.9% to 19.5%)

Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3%

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)

Levine et al (1978) 0.5600 (0.4572, 0.6592)

Plumb & Holland (1981) 0.7750 (0.6679, 0.8609)

proportion (95% confidence interval)

Prevalence of depression in Palliative settings

24 studies involving 4007 individuals 16.9% (95% CI = 13.2% to 20.3%)

14% major 9% minor adj 15% anx 10%

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)

0

500

1000

1500

2000

2500

3000

3500

Breast

Prosta

teMela

noma

Colorectal

Lymph

oma

Uterus

Bladder

Lung

KidneyHea

dandne

ck

Cervix

Leuke

mia

Ovary

Brain

Stomac

hEso

phagus

Pancr

eas

raw 000'S

DISTRESS

DEPRESSION

Total prevalence Dep = 2 million in 2010

Projected depression = 2.7 million in 2020

Popn Orange Country

=> Who is helped?

…but is the prevalence of depression high in long term survivors? (3+ years)

0 20 40 60 80 100

0.0

0.1

0.2

0.3

0.4

Time (months)

Pro

porti

on

Meta regression using the random effects model on raw porportions Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size.

% 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 Il

l Hea

lth

No

Men

tal Il

l Hea

lthN

o ch

ronic

med

ical

cond

itions

1 ch

ronic

med

ical c

ondi

tion

2 ch

roni

c m

edica

l con

ditio

ns3

chro

nic

med

ical c

ondi

tions

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

12mo Service Use 12mo Service Use (NIH, 2002)(NIH, 2002)

Two explanations=>

Two likely reasons…..

94.2%

37.4%

8 yrs N= 9282 NCS‐R

P Wang Harvard

In cancer?=>

Comment: Slide illustrates diagnostic accuracy according to score on DT

11.815.4

30.4 28.9

41.9 42.9 40.7

57.1

82.4

66.771.4

15.8

25.0

26.124.4

19.4 19.0

33.3

21.4

11.8

22.2 14.3

72.4

59.6

43.546.7

38.7 38.1

25.921.4

5.911.1

14.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Zero One Two Three Four Five Six Seven Eight Nine Ten

Judgement = Non-distressedJudgement = UnclearJudgement = Distressed

Illness PathwaysIllness Pathways

Symptoms

Occur

Help

Seeking

Symptoms

Recognized

Referral

Occurs

Symptoms

Validated

Treatment

Occurs

Many syndromes are easily overlooked by health professionals leading to unnecessary delays in treatment

Lag

time

Lag

time

Lag

time

Lag

time

Lag

time

years months weeks weeks days

Illness

BeginsIllness

Resolves

Illness Pathways – Oncology StudiesIllness Pathways – Oncology Studies

Symptoms

Occur

Help

Seeking

Symptoms

Recognized

Referral

Occurs

Symptoms

Validated

Treatment

Occurs

Many syndromes are easily overlooked by health professionals leading to unnecessary delays in treatment

Lag

time

Lag

time

Lag

time

Lag

time

Lag

time

years months weeks weeks days

Illness

BeginsIllness

Resolves

Fabida09 – Physical Symptoms & distress

Baker-Glenn08 – Need for help in cancer

Karr07 – Detection by cancer specialists

Mitchell10 – Detection by nurse specialists

Todd10 – RCT of PACT in cancer

Cancer in UKCancer in UK

Incident Cancer Cases:300,000+

Prevalent Cancer Survivors1-2 million est

Prevalent Cancer Survivors with sig. Burden /yr1 million

Prevalent Cancer Survivors with sig. Distress1 million

Prevalent Cancer Survivors with clinical Depression350,000

Three D’s

DysfunctionDistress

Depression

18%

DepT23%

Distress69%

Dysfunction76%

0.3%

3% 2%

26%28% 22%

Of the 293 Non-Nil

DysfunctionDistress

DepT

0.80

0.69

0.62

0.50

0.410.43

0.32

0.25

0.33

0.27

0.20

0.18

0.31

0.31

0.47

0.48

0.40

0.40 0.53

0.50

0.45

0.40

0.01

0.00

0.08

0.03

0.07

0.11

0.280.19

0.17

0.18

0.20

0.020.00 0.00 0.00

0.040.06

0.000.03

0.00

0.09

0.20

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Zero One Tw o Three Four Five Six Seven Eight Nine Ten

3=Extremely Difficult”

2=Very Difficult

1=Somewhat Difficult

Unimpaired

Cancer #s in LeicesterCancer #s in Leicester

Incident Cancer Cases:3000

Prevalent Cancer Survivors12,500 est

Prevalent Cancer Survivors with sign. Burden /yr6,000

Prevalent Cancer Survivors with sig Depression2,000

Meeting Psychological Needs in LeicesterMeeting Psychological Needs in Leicester

FTE in Psycho-oncology?

Psycho-oncology in LeicesterPsycho-oncology in Leicester

FTE in Psycho-oncology3.0

CNS in UHL35

UHL Ward Nurses, Chemo Nurses and Rx Radiographers100

CNS+McMillan+LOROS70

Oncologists and Haematologists and Palliative Consultants15

Psychological DistressPsychological Distress

Pool x Prev10,000 x 50% => 5000 (distress/anxiety)10,000 x 20% => 2000 (depression)

Depression / Staff2000 / 200 => 10 cases per staff member

8%

DT37%

DepT23%

AngT18%

AnxT47%

4%

7%

1%

1%

9%

3%

0%

2%

4%

15%

3%

2%

Nil41%

Non-Nil59%

DT

AnxT AngT

DepT

What is the Aim of Psycho-Oncology?What is the Aim of Psycho-Oncology?

1. Reduce distress & emotional disorders =>Desensitization by direct intervention

2. Promote detection & treatment by cancer staff=>Screening

3. Treat less common psychiatric disorders=> delirium, dementia, psychosis, mania

4. Promote Quality of life⇒ Regardless of stage, age, cancer type of prognosis

5. Do we influence survival?=> Observations vs interventional studies

0

10

20

30

40

50

60

70

80

Fatig

uePa

inLa

ck o

f ene

rgy

Wea

knes

sAp

petit

e lo

ssNe

rvou

snes

sW

eigh

t los

sDr

y m

outh

Depr

esse

d m

ood

Cons

tipat

ion

Wor

ryin

gIn

som

nia

Dysp

nea

Naus

eaAn

xiet

yIrr

itabi

lity

Bloa

ting

Coug

h

Cogn

itive

sym

ptom

sEa

rly s

atie

tyTa

ste

chan

ges

Sore

mou

th/

Drow

sine

ssEd

ema

Urin

ary

sym

ptom

sDi

zzin

ess

Dysp

hagi

aCo

nfus

ion

Blee

ding

Neur

olog

ical

Hoar

sene

ssDy

spep

sia

Skin

sym

ptom

sDi

arrh

eaPr

uritu

sHi

ccup

Self-Reported Symptoms in Cancer by FrqSelf-Reported Symptoms in Cancer by Frq

Very Common

Uncommon

Quite Common

Top 10 patient concernsTop 10 patient concerns

1 Anxiety 312

2 Family concerns 157

3 Independence/Role 122

4 Appearance 1115 Pain 866 Sleep 767 Fatigue/Energy 718 Finances 639 Weight 52

10 Breathing 49

Help SeekingHelp SeekingDo patients always ask for help when needed?

% 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

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%

Illness InformationIllness InformationAre we providing necessary information promptly and appropriately?

In 196190% of US doctors indicated a preference for not

telling a diagnosis of cancer.

In 197997% indicated a preference for revealing a diagnosis

of cancer.

Novack DH, Plumer R, Smith RL, et al. Changes in physicians’ attitudes toward telling the cancer patient. JAMA 1979; 241: 897–900.

Information DeliveryInformation Delivery

Trusted Sources of InformationTrusted Sources of Information

Women’s Information Preferences Women’s Information Preferences

Check with me that I understand what he/she is saying 99 1

Give me an opportunity to ask questions 99 1

Explain any medical terms 98 2

Listen to my fears and concerns 97 3

Summarize what he/she has told me 94 6

Emphasize the good aspects of my prognosis 90 10

Give me published information on my situation 88 12

Tell me where I can go for additional emotional help 80 20

Write down what he/she has told me 79 21

Give me emotional support 79 21

Talk to me about complementary therapies, 75 25

Give me an audio tape of the discussion 28 72

Check with me that I want to know my prognosis 63 37

N=100 Early breast cancer Lobb et al (2000) Health Expectations, 4, pp.48±57

Disclosure of DiagnosisDisclosure of Diagnosis

Family wishes

Palliative vs curative treatment

Overall prognosis

Need for compliance

Patient “emotionally strong”

Patient wishes to know

Patient is religious

Patient in younger

Diagnosis certain

Psychiatric DisordersPsychiatric DisordersWhat are the common psychiatric complications of cancer?

MoodPsychosis

Cognition

Unipolar Depression

Bipolar Affective Disorder

Adjustment Disorder

Anxiety Disorders

Post-Partum Affective Disorders

Organic Affective Disorders

Brief Reactive Psychosis

Schizophrenia

Persistent Delusional Disorder

Organic Psychosis

Delirium

Dementia

Organic Amnesic Syndrome

DepressionDepressionCan we better understand depression in the context of cancer?

Two+ Key symptoms:• persistent sadness or low mood; and/or• loss of interests or pleasure• fatigue or low energy.

Two+ associated symptoms:• disturbed sleep• poor concentration or indecisiveness• low self-confidence• poor or increased appetite• suicidal thoughts or acts• agitation or slowing of movements• guilt or self-blame.

=> Mild 4/10 Moderate 6/10 Severe 8/10

Core Symptoms ICD10 DSMIV

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

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

Fatigue or low energy Yes (core) Yes

Disturbed sleep Yes Yes

Poor concentration or indecisiveness

Yes Yes

Low self-confidence Yes No

Poor or increased appetite Yes No

Suicidal thoughts or acts Yes Yes

Agitation or slowing of movements

Yes Yes

Guilt or self-blame Yes Yes

Significant change in weight No Yes

Lung (43%)BrainHodgkin’s diseasepancreaslymphomaliverhead and neckBreast (35%)leukaemiamelanomacolonprostategynaecological (29.6%)

Zabora J, et al The prevalence of psychological distress by cancer site. Psycho-Oncology 2001;10(1):19 –28. n=4496,

Cancer RelatedPoor Quality of Life = StrongPain = Moderate - StrongLater stage disease / poorer prognosis = moderateGreater uncertainty about the future = moderategreater disease burden / complications = weak

Non-Cancer Relatedyounger age = weakLack social support = moderatePrevious depression = moderateAdditional difficulties = strong

Help!Help!

2x2 Help Table2x2 Help Table

Clinician thinks:Help Needed

Clinician thinks:Help Not Needed

Patient Says:Help Wanted

=> Intervention => Refuse?

Patient Says:Help Not Wanted

=> Delay =>Agree discharge

2x2 Clinician Help Table : ACTUAL HELP2x2 Clinician Help Table : ACTUAL HELP

Clinician thinks:Unmet Needs

Clinician thinks no Unmet Needs

Patient Says:Help Wanted

=> Intervention => Low grade

Patient Distressed => Intervention =>??

Patient Not distressed orHelp Not Wanted

=> Monitor? => discharge?

2x2 Clinician Help Table : ACTUAL HELP2x2 Clinician Help Table : ACTUAL HELP

Clinician thinks:Unmet Needs

Clinician thinks no Unmet Needs

Patient Says:Help Wanted

Helped 1/3 Helped 1/2

Patient Distressed

Helped 2/3 Helped 1/2

Patient Not distressed orHelp Not Wanted

Helped 1/4 Helped 1/6

Help – Who Wants Help?Help – Who Wants Help?

20% said they wanted professional help for psychosocial issues.

Only 36% of those distressed on the DT wanted help.

What Kind of Help is Wanted?What Kind of Help is Wanted?

19% wanted medication (eg antidepressants)

31% want self help guidelines

31% wanted group therapy

56% wanted illness information.

58% complementary therapies

62% face-to-face psychological support

Help – Who From?Help – Who From?

Nurse specialists (54%)

Family and friends (21%)

Spiritual advisor (8%)

Psychiatrist (4%).

Why Not Needed?Why Not Needed?

“getting help elsewhere” (57%)

“feel well” (41%)

“coping on my own” (31%)

“fear of stigma”, “fear of side effects”, “not likely to be effective for me”, and “don’t like to talk about problems” (all less than 10%)

Promoting recognition & treatmentPromoting recognition & treatment

Do Clinicians Look for Depression/Distress?Do Clinicians Look for Depression/Distress?

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

AA Formal QQ6%

Clinical Skills Alone63%

Refer to Specialist1%

Ultra-Short QQ30%

Mitchell, Kaar, Coggan, HerdmanN=226

Distress Thermometer – PooledDistress Thermometer – Pooled

Proportion

18 .4 %

12 .9 %

11.2 %12 .3 %

8 .1%

11.9 %

5.0 %

2 .8 % 2 .6 %

7.7% 7.2 %

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Zero One Two Three Four Five Six Seven Eight Nine Ten

Insignificant SevereModerateMildMinimal

p124

50%

Comment: Slide illustrates diagnostic accuracy according to score on DT

11.815.4

30.4 28.9

41.9 42.9 40.7

57.1

82.4

66.771.4

15.8

25.0

26.124.4

19.4 19.0

33.3

21.4

11.8

22.2 14.3

72.4

59.6

43.546.7

38.7 38.1

25.921.4

5.911.1

14.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Zero One Two Three Four Five Six Seven Eight Nine Ten

Judgement = Non-distressedJudgement = UnclearJudgement = Distressed

Phase II