Alex MitchellHon. Senior Lecturer in Psycho-oncology,
Leicester Royal Infirmary
IPOS Symposium (Sept 2007)IPOS Symposium (Sept 2007)[email protected]@leicspart.nhs.uk
1. What Is the Purpose of Screening?
Detection Rates, Unassisted Rates, Who is looking?
2. What Is Ultra-Screening?
Vs case finding
3. Distress Thermometer
Evidence?
4. Implementing ScreeningUltra-screening in secondary care
1. Purpose of Screening?1. Purpose of Screening?
No Distress61%
Pooled Analysis of 38 studies
Setting: mostly oncologyInstruments: mixedPoint prevalence n=6400
Mitchell (2007) JCO
Distress
Distress39%
Anxiety38%
Depression19%
% 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
Accuracy 2x2 TableAccuracy 2x2 Table
PrevalenceSpecificitySensitivity
NPVTrue -VeFalse -VeTest -ve
PPVFalse +veTrue +veTest +ve
DepressionABSENT
DepressionPRESENT
Accuracy of GP’s DiagnosesAccuracy of GP’s Diagnoses
27,6406553
667825,1254050GP -ve
501825152503GP +ve
DepressionABSENT
DepressionPRESENT
Sensitivity38%
PPV 49.8%
Specificity90.1%
NPV 86.1%
Prevalence 19%
N=35 studiesn = 100035,000
Mitchell, Vaze, Rao Unpublished data
Unassisted AccuracyUnassisted Accuracy
Non-Depressed
Depressed
# ofIndividuals
TestResultCut-off / clinical decision
False +veFalse -ve
5%
90%
True -ve
38%
True +ve
50%
Optimum
Unassisted
2. Who Is Looking? 2. Who Is Looking?
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
86.8
55.6 54.4
43.3
36
29.826.2 25.6 25.2 23.8 24
21.4 21.2
13.9 12.89.5
7.2 7 7 5.9 4.8 4.1 2.6 1.8 1.8 1.3 0.9 0.4 0.40
10
20
30
40
50
60
70
80
90
100Sl
eep
distu
rban
ces;
inso
mni
a; e
arly
wake
ning
Loss
of a
ppet
ite; o
vere
ating
; wei
ght c
hang
es
Depr
esse
d m
ood;
hop
eles
snes
s; sa
d; g
loom
y
Apat
hy; l
etha
rgy;
tired
ness
; las
situd
e
Loss
of i
nter
est;
with
draw
al; in
diffe
renc
e; lo
nelin
ess
Loss
of e
nerg
y; lo
ss o
f driv
e; b
urnt
out
Loss
of l
ibido
; los
s of
sex
driv
e; im
pote
nce
Tear
s; we
eping
; cry
ing
Anxio
us; a
gita
ted;
irrit
able
; res
tless
, ten
se; s
tress
ed
Feel
ing
worth
less
; guil
ty; la
ck o
f sel
f este
em
Som
atic;
vege
tativ
e sy
mpt
oms;
mala
ise; m
ultip
le co
nsult
ation
s
Suici
de th
ough
ts; th
ough
t of s
elf in
jury
Loss
of c
once
ntra
tion;
poo
r mem
ory,
poo
r thi
nkin
g
Dim
inish
ed p
erfo
rman
ce; i
nabi
lity to
cop
e
Emot
ional
labil
ity; m
ood
swin
gs
Loss
of a
ffect
; flat
affe
ct; lo
ss o
f em
otio
n
Loss
of e
njoy
men
t or p
leas
ure;
lack
of h
umor
Beha
viour
al p
robl
ems;
agg
ress
ivene
ss; b
ehav
iour
al c
hang
es
Pess
imism
; neg
ative
atti
tude
s, w
orry
ing
Psyc
hom
otor
reta
rdat
ion;
slow
ness
Head
ache
s; d
izzin
ess
Appe
aran
ce; s
peec
h; e
xces
sive
smilin
g; va
guen
ess,
etc.
Heav
y us
e of
alco
hol, t
obac
co o
r dru
gs
Delu
sions
; hall
ucin
atio
ns; c
onfu
sion
Reac
tion
to p
roba
ble
caus
es o
r life
eve
nts
Fam
ily o
r pas
t hist
ory
of d
epre
ssio
n
Obs
essiv
e id
eatio
n; p
hobia
sLa
ck o
f ins
ight
Perio
d of
life
(men
opau
se)
Krupinski J, Tiller J (2001) The identification and treatment of depressionby general practitioners. Aust N Z J Psychiatry. 35:827– 832.
3. What is Ultra-Screening? 3. What is Ultra-Screening?
Test DurationTest Duration
Ultra-short screening tools were defined as those with 1-4 items taking less than 2 minutes to complete.
Short screening tools were defined as those with 5-14 items, taking between 2 and five minutes to complete.
Standard screening tools were defined as those with 15 or more items, taking more than five minutes to complete.
=> Tools table
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
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
=> Symptoms
Audience?Audience?
How do we know which are the best symptoms
for detecting depression?
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Loss
of
ener
gy
Dim
inis
hed
driv
e
Slee
p di
stur
banc
e
Con
cent
rati
on/i
ndec
isio
n
Dep
ress
ed m
ood
Anx
iety
Dim
inis
hed
conc
entr
atio
n
Inso
mni
a
Dim
inis
hed
inte
rest
/ple
asur
e
Psyc
hic
anxi
ety
Hel
ples
snes
s
Wor
thle
ssne
ss
Hop
eles
snes
s
Som
atic
anx
iety
Tho
ught
s of
dea
th
Ang
er
Exce
ssiv
e gu
ilt
Psyc
hom
otor
cha
nge
Inde
cisi
vene
ss
Dec
reas
ed a
ppet
ite
Psyc
hom
otor
agi
tati
on
Psyc
hom
otor
ret
arda
tion
Dec
reas
ed w
eigh
t
Lack
of
reac
tive
moo
d
Incr
ease
d ap
peti
te
Hyp
erso
mni
a
Incr
ease
d w
eigh
t
All Case ProportionDepressed ProportionNon-Depressed Proportion
Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2007 Submitted
N=1500
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 energySleep disturbance
Diminished concentration
Sensitivity
1 - Specificity
Mitchell, Zimmerman et al (submitted)Psychol Med
4. The Distress Thermometer4. 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
AudienceAudience
How do we know the “distress” paradigm
is best
See Gil F, Grassi L, Travado L, Tomamichel M, Gonzalez JR. for the SEPOS Group. Use of distress and depression thermometers to measure psychosocial morbidity among southern European cancer patients. Support Care Cancer, 13: 600–606, 2005
Does it WorkAs a rule in & rule out?Does it WorkAs a rule in & rule out?
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
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 *
PrevalenceSpecificitySensitivity
NPVTrue -VeFalse -VeTest -ve
PPVFalse +veTrue +veTest +ve
DepressionABSENT
DepressionPRESENT
Ultra-short Tests & DepressionUltra-short Tests & Depression
36033816787
27952643152Test -ve
18081173635Test +ve
DepressionABSENT
DepressionPRESENT
Sensitivity81%
PPV 32%
Specificity69%
NPV 93%
Prevalence 18%
N=17 studies 3603
Ultra-short Tests & DistressUltra-short Tests & Distress
368222071475
18911514337Test -ve
18316931138Test +ve
DistressABSENT
DistressPRESENT
Sensitivity77%
PPV 65%
Specificity68%
NPV 80%
Prevalence 39%
N=17studies 3682
Ultra-short Tests & AnxietyUltra-short Tests & Anxiety
22151372843
969776193Test -ve
1248596652Test +ve
AnxietyABSENT
AnxietyPRESENT
Sensitivity77%
PPV 55%
Specificity56%
NPV 80%
Prevalence 38%
N= 4 studies 2215
PPV DT Distress = 55%; PPV Other Methods 65%
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
5. Implementation5. Implementation