IPOS10 t641 - A Definitive Meta-analysis to Ascertain the Optimal Screening Method for Depression in Cancer and Palliative Care

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A Definitive Meta-analysis to Ascertain the Optimal Screening Method for Depression in Cancer and Palliative Care. Part I  - Single Test Application

A Definitive Meta-analysis to Ascertain the Optimal Screening Method for Depression in Cancer and Palliative Care. Part I  - Single Test Application

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  • 1. T126 --Screening and Case Identification for Depression in T126 Screening and Case Identification for Depression in Cancer and Palliative Settings: Cancer and Palliative Settings: A Meta-Analysis of Diagnostic Validity Studies A Meta-Analysis of Diagnostic Validity Studies Alex Mitchell www.psycho-oncology.info Department of Cancer & Molecular Medicine, Leicester Royal Infirmary Department of Liaison Psychiatry, Leicester General Hospital IPOS2010 IPOS2010
  • 2. 1. Background What methods are used to detect mood disorders? How often do clinicians look for mood complications?
  • 3. Methods to Evaluate Depression Conventional Scales Short (5-10) Long (10+)
  • 4. Comment: This is a reminder of the structure of the HADS scale, this version adapter for cancer.
  • 5. Methods to Evaluate Depression Conventional Scales Short (5-10) Long (10+) Ultra-Short (<5)
  • 6. Methods to Evaluate Depression Unassisted Clinician Conventional Scales Untrained Trained Ultra-Short (<5) Short (5-10) Long (10+) Acceptability ? Accuracy? Accuracy? Routine Implementation vs Comment: schematic overview of methods to evaluate depression
  • 7. Comment: Frequency of cancer specialists n=226 enquiry about depression/distress from Mitchell et al (2008)
  • 8. Cancer Staff Psychiatrists Current Method (n=226) Other/Uncertain 9% Other/Uncertain ICD10/DSMIV 2% 0% ICD10/DSMIV 13% Short QQ 3% 1,2 or 3 Sim ple QQ 15% Clinical Skills Use a QQ Alone 15% 55% Clinical Skills Alone 73% 1,2 or 3 Sim ple QQ 15% Comment: Current preferred method of eliciting symptoms of distress/depression
  • 9. Validity of Methods to Evaluate Depression Unassisted Clinician Conventional Scales Untrained Trained Ultra-Short (<5) Short (5-10) Long (10+)
  • 10. 5. Meta-Analysis What can enhance detection?
  • 11. Methods There were 41 valid analyses; prevalence of depression was 24.3% (95% CI = 17.3% to 32.0%). 29 in oncology settings… 3x studies on the BDI-II, From 4 studies using the DT and remainder of studies involved the HADS. Only 12 in palliative settings (most HADS; non with DT) Inc 3x studies involving Two Questions and 3 studies of the EPDS Unfortunately most had not received independent validation.
  • 12. Common Methods DT BDI BDI fast screen PHQ-9 PHQ-2 / two stem questions GHQ-12 and GHQ-28 CES-D GDS-30 GDS-15 Zung SDS HADS-D HDRS.
  • 13. 1 Post-test Probability 0.9 Comment: At a prevalence of 20% GPs PPV is 40% and NPV 86% 0.8 0.7 0.6 0.5 PPV 0.4 0.3 Baseline Probability Depression+ 0.2 NPV Depression- 0.1 Pre-test Probability 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • 14. Palliative 1.00 Post-test Probability 0.90 0.80 0.70 0.60 HADS-D+ 0.50 HADS-D- Baseline Probability 0.40 2Q+ 2Q- EPDS+ 0.30 EPDS- 1Q+ 0.20 1Q- 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • 15. Non-Palliative 1.00 Post-test Probability 0.90 0.80 0.70 0.60 1Q+ 1Q- 0.50 Baseline Probability HADS-D+ HADS-D- 0.40 HADS-T+ HADS-T- BDI+ 0.30 BDI- HADS-A+ HASD-A- DT+ 0.20 DT- 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • 16. MDD - Palliative and Non-Palliative 1.00 Post-test Probability 0.90 0.80 0.70 0.60 1Q+ 1Q- 0.50 Baseline Probability DT+ DT- 2Q+ 2Q- 0.40 HADSd+ HADSd- HADS-T+ HADS-T- 0.30 BDI+ BDI- EPDS+ EPDS- HADS-A+ 0.20 HASD-A- 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • 17. Summary From 29 non-palliative- The optimal method was the BDI-II although the DT was good in a screening capacity. Across 12 palliative analyses (n=1760) – The optimal initial method was the two question approach.
  • 18. 5. Cancer Care – Cumulative Testing What repeat testing enhance detection?
  • 19. N = 1000 Cancer Population n = 200 n = 800 Depression No Depression Se 70% CNS Assessment Sp 55% Screen #1 Screen #1 +ve -ve PPV 28% NPV 88% TP = 140 TN =440 Possible case FP = 360 Probable Non-Case FN = 60 TN = 440 FP = 360 Se 70% PPV 28% Yield TP = 140 FN = 60 Sp 55% NPV 88%
  • 20. N = 1000 Cancer Population n = 200 n = 800 Depression No Depression Se 70% CNS Assessment Sp 55% Screen #1 Screen #1 +ve -ve PPV 28% NPV 88% TP = 140 TN =440 Possible case FP = 360 Probable Non-Case FN = 60 Sp 40% Oncologist Assessment Sp 80% Screen #2 Screen #2 +ve +ve PPV 44% NPV 77% TP = 56 TN =288 Probable Depression FP = 72 Probable Non-Case FN = 84 TN = 728 FP = 72 Se 28% PPV 44% Cumulative Yield TP = 56 FN = 144 Sp 91% NPV 83%
  • 21. Credits & Acknowledgments Elena Baker-Glenn University of Nottingham Paul Symonds Leicester Royal Infirmary Chris Coggan Leicester General Hospital Burt Park University of Nottingham Lorraine Granger Leicester Royal Infirmary Mark Zimmerman Brown University, Rhode Island James Coyne University of Pennsylvania Nadia Husain University of Leicester For more information www.psycho-oncology.info
  • 22. FURTHER READING: Screening for Depression in Clinical Practice An Evidence-Based guide ISBN 0195380193 Paperback, 416 pages Nov 2009 Price: £39.99