IPOS09 - Screening For Depression What Works (June 2009)
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IPOS09 - Screening For Depression What Works (June 2009)

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This is a workshop delivered in the lead upto IPOS conference 2009. It outlines the case for and against screening for depression & distress in cancer settings. The middle part of the talk (B) is from ...

This is a workshop delivered in the lead upto IPOS conference 2009. It outlines the case for and against screening for depression & distress in cancer settings. The middle part of the talk (B) is from Matthew Loscalzo and not provided here.

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IPOS09 - Screening For Depression What Works (June 2009) IPOS09 - Screening For Depression What Works (June 2009) Presentation Transcript

  • IPOS2009 – Workshop IPOS2009 – Workshop Screening for Distress In Cancer: Screening for Distress In Cancer: A Practical & Theoretical Guide To What Really Works A Practical & Theoretical Guide To What Really Works Alex Mitchell alex.mitchell@leicspart.nhs.uk Leicester Royal Infirmary UK Matthew Loscalzo mloscalzo@coh.org City of Hope, CA Karen Clark kclark@coh.org Sheri & Les Biller Patient and Family Resource Center Chris Hosker chris.hosker@leedspft.nhs.uk Liaison Psychiatry, Leeds IPOS2009 IPOS2009
  • 8.30 -9.00: Coffee, welcome, outline & handouts Led by Mitchell 9.00 to 9.10: Audience Needs and Questions [10mins] Intro Led by Hosker 9.10: PART A “The Context” Talk Led by Mitchell 9.50 10mins discussion ALL 10.00 Audience Task 1 & 2 [30mins] Feedback Summary from Clark, Loscalzo 10.30: PART B – “New Methods & their Implementation” Talk Led by Loscalzo, Clark 11.00 Break [15mins] 11:15 Audience Task 3 & 4 [30mins] Feedback Summary from Hosker, Mitchell 11.45: PART C “Advanced methods” Led by Mitchell 12:15 Summary [15mins] ALL 12.30 Lunch
  • Part A. Context Part A. Context The issues - under recognition; identifying distress/adjustment; minor and subsyndromal disorders, problems with current tools Alex Mitchell alex.mitchell@leicspart.nhs.uk Leicester Royal Infirmary UK
  • 48% Distress/Adjustment Disorder N=10 57% 38% 20% [handout 1] 18% 13% Anxiety N=4 Depression N=11
  • 48% Distress/Adjustment Disorder 57% 38% 20% 18% 13% Anxiety Depression Major Depression Symptoms Minor Depression
  • None of above 15% Major Depression 26% Distressed Patients Minor Depression 12% Subsyndromal Depression 47%
  • Current Detection Strategies Current Detection Strategies
  • Methods to Evaluate Depression Unassisted Clinician Conventional Scales Untrained Trained Short (5-10) Long (10+) Ultra-Short (<5) Other/Unce rtain Other/Unce rtain 9% 9% ICD10/DSMIV ICD10/DSMIV Other/Uncertain 0% 0% 9% ICD10/DSMIV Short QQ Short QQ 0% 3% 3% Short QQ 3% 1,2 or 3 Sim ple 1,2 or 3 Sim ple QQ QQ 15% 15% 1,2 or 3 Sim ple QQ 15% Clinical Skills Clinical Skills Alone Alone 73% 73% Clinical Skills Alone 73% Verbal Questions Visual-Analogue Test PHQ2 Distress Thermometer WHO-5 Depression Thermometer Whooley/NICE => Table scales
  • [handout 2]
  • [handout 3] => accuracy
  • [handout 4]
  • PHQ9 Linear distribution 35 30 PHQ9 (Major Depression) 25 PHQ9 (Minor Depression) PHQ9 (Non-Depressed) 20 [handout 5] 15 10 5 0 ve n en ro n e o e ve n en n ur en ne x en t n gh ee Tw re Te ve n Si ee ee Ze Fo el Fi ev Ni te te O fte Th Ei nt Se Tw irt xt ur gh El Fi ve Th Si Fo Ei Se
  • Methods to Evaluate Depression Unassisted Clinician Conventional Scales Untrained Trained Short (5-10) Long (10+) Ultra-Short (<5) Acceptability? Acceptability ? Acceptability ? Accuracy? Accuracy? Accuracy? Implementation Implementation Implementation
  • Willingness of Clinicians to Screen Willingness of Clinicians to Screen => acceptability => acceptability
  • n=226 How=>
  • 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% [handout 6]
  • Cancer Staff Psychiatrists Ideal Method (n=226) Effective? Long QQ 8% Clinical Skills Clinical Skills Alone Alone Algorithm 20% 17% 26% ICD10/DSMIV 24% ICD10/DSMIV 1,2 or 3 Sim ple 0% 1,2 or 3 Sim ple QQ QQ 24% Short QQ 34% 23% Short QQ 24% [handout 6] Validity=>
  • Accuracy Accuracy =>Routine Abilities of Clinicians =>Routine Abilities of Clinicians => Validity of current tools => Validity of current tools
  • Testing Clinicians vs DT 114 ratings from clinical nurse specialists (CNS). 81 individuals (71%) scored above a cut-off of 3 (mild distress) 64 patients (56%) scored above a cut-off of 4 (moderate distress) 37 (32.4%) individuals scores above 5 (severe distress) [handout 7]
  • Results DT 3v4 (mild, high prevalence) DT 4v5 (moderate, medium prevalence) DT 5v6 (severe, low prevalence)
  • 1.00 Post-test Probability 0.90 0.80 0.70 0.60 0.50 0.40 Severe Distress CNS+ 0.30 Severe Distress CNS- Baseline Probability Mild Distress CNS+ 0.20 Mild Distress CNS- Mod Distress CNS+ Mod Distress CNS- 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
  • Testing Clinicians: A Meta-Analysis Methods 12 studies reported in 7 publications. Two studies examined detection of anxiety, 8 broadly defined depression (includes HADS-T), 3 strictly defined depression and 7 broadly defined distress. 9 studies involved medical staff and 2 studies nursing staff. Gold standard tools including GHQ60, GHQ12 HADS-T, HADS-D, Zung and SCID. The total sample size was 4786 (median 171). Results All cancer professionals showed a mean SE of 39.5% and SP 77.3%. Oncologists had a SE of 38.1% and SP of 78.6%; a fraction correct of 65.4%. By comparison nurses had a SE of 73% and SP of 55.4%; FC = of 60.0%. When attempting to detect anxiety, oncologists managed a SE of 35.7%, SP 89.0%, FC 81.3%. Individual Lecture 2-24June 2009: 9.00am (Category Communication Skills) Sess 13 Lect 3
  • 1.00 0.90 Post-test Probability PPV NPV 0.80 Doctor 0.458 0.724 0.70 Nurse 0.368 0.852 0.60 0.50 0.40 Nurse Positive 0.30 Nurse Negative Baseline Probability 0.20 Doctor Postive Doctor Negative 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 N=10 vs N=2
  • HADS Validity vs Structured Interview METHODS Against depression 9x studies of the HADS-D; 5x of the HADS-T and 2x of the HADS-A were identified. RESULTS HADS-T = HADS-D = HADS-A The clinical utility index (UI+, UI-) was 0.214 and 0.789 for the HADS-D. Sensitivity Specificity PPV NPV FC HADS-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% Individual Lecture 2; 24 June 2009: 3.30pm (Category Methods and Measurements); Session 273
  • 1.00 Post-test Probability 0.90 0.80 0.70 0.60 0.50 0.40 HADS-T Positive (N=5) HADS-T Negative (N=5) 0.30 Baseline Probability HADS-A Positive (N=2) HADS-A Negative (N=2) 0.20 HADS-D Positive (N=9) HADS-D Negative (N=9) 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
  • HADS vs Clinician
  • 1.00 0.90 Post-test Probability 0.80 0.70 0.60 0.50 0.40 Clinician Positive (Fallowfield et al, 2001) 0.30 Clinician Negative (Fallowfield et al, 2001) Baseline Probability 0.20 HADS-D Positive (Mata-analysis) HADS-D Negative (Meta-analysis) 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
  • Part B. New Tools & Implementation Part B. New Tools & Implementation Waiting room, computerized ratings, help question, implementation [30mins] Matthew Loscalzo mloscalzo@coh.org City of Hope, CA Karen Clark kclark@coh.org Sheri & Les Biller Patient and Family Resource Center
  • Part C. Advanced Methods Part C. Advanced Methods Adapting scales, custom scales, visual analogue scales, more on help, combination techniques Alex Mitchell alex.mitchell@leicspart.nhs.uk Leicester Royal Infirmary UK
  • Should We use Special Tools? Should We use Special Tools? =>Phenomenology of Comorbid Depression =>Phenomenology of Comorbid Depression
  • Cancer Specific Tools Generic / Distress Depression Anxiety RSCL BCFD FoP scale Rotterdam Symptom Checklist Brief Case Find for Depression Fear of disease progression scale DT / MT / IT / ET MEQ ?IES Distress thermometer Mood Evaluation QQ QSC-R23 MAX-PC Questionnaire on Stress in Cancer Memorial Anxiety Scale for Prostate Cancer PS-Scan Psychological Screen for Cancer ESAS Edmonton Symptom Assessment System (9VAS) Distress Barometer PDI Psychological Distress Inventory Hornheide Question Hornheide Questionnaire, Short Form (9)
  • Somatic Bias in Mood Scales [handout 2b]
  • 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 L os s of ene rg y Dim inis he dd r ive Sl e e pd is tu Con rba c en nc e tr at ion /i n dec n=1523 is ion D ep res sed mo od Dim A nx inis iet y he dc onc ent r at ion Dim Ins o inis he m nia d in t er est /p l e asu re Ps y chi ca nx i e ty Hel p less nes s Wo r th les s nes s Hop e les s nes s Som ati c anx iety Tho ug hts of dea th A ng er Exc ess ive guil Ps y t cho mo t or c ha ng e Ind ec i siv e nes D ec s rea s ed app eti t Ps y cho e mo t or agi Ps y tati cho on mo t or ret ard atio n D ec rea s ed wei L ac g ht ko f re act ive mo od Inc rea sed app et it e Hy p erso mn ia All Case Proportion Inc rea Depressed Proportion sed we ight Non-Depressed Proportion
  • 1 Depressed Mood S Diminished interest/pleasure e 0.9 Diminished drive n s Loss of energy i Sleep disturbance 0.8 t Diminished concentration i 0.7 v i t 0.6 y 0.5 0.4 0.3 0.2 0.1 1 - Specificity 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 n=1523
  • Approaches to Somatic Symptoms of Depression Inclusive Uses 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. Exclusive Eliminates somatic symptoms but without substitution. There is concern that this might lower sensitivity. with an increased likelihood of missed cases (false negatives) Etiologic Assesses 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). Substitutive Assumes somatic symptoms are a contaminant and replaces these additional cognitive symptoms. However it is not clear what specific symptoms should be substituted
  • A gi ta tio n (C A om 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 gi ta or bi tio A n d) nx (P ie rim ty ar (C y) * om A or nx ie bi A ty d) pp (P et rim ite ar (C y) C on A pp et om or bi * n=4069 vs 4982 ce ite d) nt (P ra ri C tio m on n ar ce (C y) nt om ra or tio bi n d) Fa (P tig rim ue ar (C y) om Fa or tig bi ue d) (P G ri m ui lt ar y) (C * om H op G or el ui bi es lt d) sn (P es ri H s m op (C ar el om y) * es sn or es bi In s d) so (P m ri ni m a ar (C y) In om * so Lo m or bi ss ni In a d) te (P re ri st m Lo ar ss (C y) om In * te or re bi Lo st d) w (P M rim oo d ar y) Lo (C w om * M or R oo bi et ar d d) da (P t io rim n ar R (C y) et om ar da or t io bi n d) Su (P ic ri id m e ar (C y) * om Su W ic or bi ei id d) gh e tL (P ri os m W s ar Co-morbid Depression vs Primary Depression ei (C y) gh om tL or os bi s d) (P rim ar Primary Depression y) Comorbid Depression *
  • A nx ie ty (C om 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 A or C nx bi on ie d) ce ty nt (M ra ed tio ic C n al on (C ) * ce om nt or ra bi tio d) n Fa (M t ig ed ue ic al (C ) * om H Fa or bi op t ig n= 4069 vs 1217 el ue d) es sn (M es ed H s ic al op (C ) In el om * so es m sn or bi ni a es d) (a s ny (M In ty ed so pe ic m al ni )( C ) a * (a om ny or Lo ty bi pe d) ss In )( te M re ed st ic al Lo (C ) * ss om In or te bi re d) Lo st w (M M ed oo ic d al ) (C * Lo om w or M bi R oo d) et d ar (M da ed tio ic n al R (C ) * et om ar or da bi t io d) n Su (M ic ed id ic e al ) (C * om Su or W ic id bi d) ei e gh (M tL ed os ic s al W (C ) * ei om gh W tL or or bi th os d) le s ss (M ne ed W ss ic al or (C ) th om le or ss ne bi ss d) (M Co-morbid Depression vs Medical Illness Alone ed ic Medical Illness Alone Comorbid Depression al )
  • New Tools (Ultra-Short) New Tools (Ultra-Short) => DT => DT => PHQ2 => PHQ2 => ET => ET => Help QQ => Help QQ
  • 20 Instruments for Depression Ultra-short <6 Short > 5 < 11 Long > 10 PHQ1 HADS (7) (1) HAM-D (21) (7) (6) PHQ2 (2) MADRAS (10) BDI (21) (13) (7) (2) WHO-5 (5) MOS-D (8) BSI (53) Distress Therm (1) EPDS (10) (8)(6)(5) CES-D (20) (13)(10) (6) DADS (7) Zung (20) PHQ9 (9) (2) GDS (30,15) (5)(4)(2) Personal HQ (16) MDI (11) DEPS (10)
  • [handout 4]
  • [handout 10]
  • Distress Thermometer - 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? Practicaltick WHICH of the following is a cause of distress: Please Problems Spiritual/ Religious Concerns Physical Problems contd… Childcare Loss of faith Changes in Urination Housing Relating to God Fevers Money Loss of meaning or purpose Skin dry/ itchy in life Transport Nose dry/ congested Work/School Physical problems Tingling in hands/ feet Pain Metallic taste in mouth Family Problems Nausea Feeling swollen Dealing with partner Fatigue Sexual Dealing with children Sleep Hot flushes Getting around Emotional Problems Bathing/ Dressing Depression Breathing Fears Mouth sores Is there anything important you would like to add to the list? Nervousness Eating ___________________________ Sadness Indigestion ___ ___________________________ Worry Constipation ___ Anger Diarrhoea ___________________________ ___ => Validity
  • Distribution of DT Scores Ransom (2006) PO (n=491) 18.0 15.7 16.0 14.7 13.8 14.0 13.2 12.0 10.4 10.0 8.4 7.7 8.0 7.3 6.0 3.7 4.0 3.3 1.8 2.0 0.0 Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7 Score 8 Score 9 Score 10
  • 1 0.9 PHQ2 Two QQ Sensitivity 0.8 PHQ9 0.7 HADS-T DT (3v4) 0.6 PHQ2 Interest 0.5 HADS-D DT (4v5) 0.4 PHQ2 Depression [handout 1] 0.3 0.2 0.1 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1 - Specificity
  • [handout 8]
  • 1.00 0.90 0.80 Ten 0.70 Nine Eight 0.60 Seven Six 0.50 Five Four 0.40 Three Two 0.30 One 0.20 Zero 0.10 0.00 Distress Anxiety Depression Anger Thermometer Thermometer Thermometer Thermometer
  • DT AngT (38%) (26%) 2% 1% 0% DT 2% 0% 10% 15% 0% 8% 4% 0% 21% 2% AnxT DepT (65%) (30%)
  • [handout 9] 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 alone vs 54.4% who would be recognised using the DT alone.
  • Vs DT DepT HADS-A AUC: DT=0.82 DepT=0.84 AnxT=0.87 AnxT AngT AngT=0.685
  • Vs DT DepT HADS-D AUC: DT=0.67 DepT=0.75 AnxT=0.62 AnxT AngT AngT=0.69
  • What Have We Learned? Overview of mood complication of cancer Not just depression Current Detection Strategies Too long Routine Abilities of Cancer Clinicians Low rule-in Willingness of Clinicians to Screen Modest Validity of the Current Methods HADS-D poor Phenomenology of Comorbid Depression Include somatic Scope for new tools (DT & ET) Potentially useful Future of Screening Help?
  • Advanced Methods Advanced Methods => Algorithms => Algorithms => Combinations => Combinations => Cost-benefits => Cost-benefits
  • 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%
  • 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%
  • [handout 11]
  • 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 Brett Thombs McGill University Canada James Coyne University of Pennsilvania For more information www.psycho-oncology.info
  • Extras