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
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nx (P
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(C y)
*
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pp (P
et rim
ite ar
(C y)
C
on
A
pp
et
om
or
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*
n=4069 vs 4982
ce ite d)
nt (P
ra ri
C tio m
on n ar
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Co-morbid Depression vs Primary Depression
ei (C y)
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tL or
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(P
rim
ar
Primary Depression
y)
Comorbid Depression
*

A
nx
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(C
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0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
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0.9
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ce om
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tio d)
n
Fa (M
t ig ed
ue ic
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(C )
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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
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ss om
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Lo st
w (M
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(C
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Lo om
w or
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R oo d)
et d
ar (M
da ed
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ar or
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n
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or bi
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(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