Detection of Depression in Cancer Settings:
Detection of Depression in Cancer Settings:
Using Evidence to Improve Clinical Practice
Using Evidence to Improve Clinical Practice
Alex Mitchell
Department of Cancer & Molecular Medicine
Leicester Royal Infirmary
Liaison AGM 2009
Liaison AGM 2009

Contents
Overview of mood complication of cancer
Current Detection Strategies
Routine Abilities of Cancer Clinicians
Willingness of Clinicians to Screen
Validity of the Current Methods
Phenomenology of Comorbid Depression
Scope for new tools (DT & ET)
Future of Screening

1. Overview of Mood Complications
1. Overview of Mood Complications

48%
Distress/Adjustment Disorder
N=10
57%
38%
20%
13%
18%
Anxiety
Depression
N=4
N=11

48%
Distress/Adjustment Disorder
57%
38%
20%
13%
18%
Major
Anxiety
Depression
Depression
Symptoms
Minor
Depression

PHQ9 Linear distribution
35
30
PHQ9 (Major Depression)
PHQ9 (Minor Depression)
25
PHQ9 (Non-Depressed)
20
15
10
5
0 ve
n
en
n
ro
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

None of above
15%
Major Depression
26%
Distressed
Patients
Minor Depression
12%
Subsyndromal
Depression
47%

2. Current Detection Strategies
2. Current Detection Strategies

Methods to Evaluate Depression
Unassisted Clinician Conventional Scales
Untrained Trained Short (5-10) Long (10+)
Ultra-Short (<5)
Other/Uncertain Other/Uncertain
9% 9%
ICD10/DSMIV ICD10/DSMIV
0% 0%
Other/Uncertain
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

=> accuracy

Methods to Evaluate Depression
Unassisted Clinician Conventional Scales
Untrained Trained Short (5-10) Long (10+)
Ultra-Short (<5)
Acceptability? Acceptability ? Acceptability ?
Accuracy?
Accuracy? Accuracy?

3. Willingness of Clinicians to Screen
3. Willingness of Clinicians to Screen

n=226 How=>

Cancer Staff Psychiatrists
Current Method (n=226)
Other/Uncertain
Other/Uncertain
9%
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
1,2 or 3 Sim ple
73%
QQ
15%

Cancer Staff Psychiatrists
Ideal Method (n=226)
Effective?
Long QQ
8%
Clinical Skills
Clinical Skills
Alone
Alone
Algorithm 20%
17%
26%
ICD10/DSMIV
24%
1,2 or 3 Sim ple
ICD10/DSMIV
1,2 or 3 Sim ple QQ
0%
QQ 24%
34%
Short QQ
23%
Short QQ
24%
Validity=>

3. Routine Abilities of Cancer Clinicians
3. Routine Abilities of Cancer Clinicians

1.00
Post-test Probability
0.90
NPV
PPV
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

5. Validity of the Current Methods
5. Validity of the Current Methods

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%

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
Post-test Probability
0.90
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

6. Phenomenology of Comorbid Depression
6. Phenomenology of Comorbid Depression

Somatic Bias in Mood Scales

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
h ed
dr iv
e
Sl e
e pd
is tu
rba
C on nc
e
c en
tr at
ion
/i n
dec
n=1523
is io
n
Dep
res
sed
m ood
A nx
Dim iet y
inis
h ed
c onc
e ntr
at ion
Dim Ins o
inis mn
ia
hed
int e
rest
/p lea
su re
Ps y
chi
ca nx i
ety
Hel
p less
nes
s
Wo
r th
les s
nes
s
Hop
e les s
nes
s
Som
ati c
a nx
iety
Tho
ug h
ts o
f de
ath
A ng
er
Exc
ess
ive
guil
t
Ps y
cho
mo
t or
c ha
ng e
Ind
ec i
siv e
nes
s
D ec
rea
s ed
app
eti t
e
Ps y
cho
mo
t or
agi
tati
Ps y on
cho
mo
t or
ret
ard
atio
n
D ec
rea
s ed
wei
g ht
L ac
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

Depressed Mood
1
Diminished interest/pleasure
S
e
Diminished drive
0.9 n
Loss of energy
s
Sleep disturbance
i
0.8
t
Diminished concentration
i
v
0.7
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
Audience?

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

Co-morbid Depression vs Primary Depressions

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 or
ta bi
tio
n d)
A (P
nx rim
ie
ty ar
y)
(C
*
om
A or
nx
ie bi
A ty d)
(P
pp
et rim
ite ar
(C y)
*
A om
C pp or
on bi
et
n=4069 vs 4982
ce ite d)
nt (P
ra ri
m
tio
C n ar
on (C y)
ce om
nt
ra or
tio bi
n d)
(P
Fa
rim
tig
ue ar
y)
(C
om
Fa or
tig bi
ue d)
(P
G ri
m
ui
lt ar
y)
(C
*
om
H
or
op G bi
el ui d)
lt
es
(P
sn
ri
es m
H s ar
op (C y)
el om
*
es
or
sn
bi
es d)
s
In (P
so
ri
m m
ni ar
a y)
(C
In om
*
so
m or
Lo
bi
ss ni
a d)
In (P
te ri
re m
st ar
Lo
(C y)
ss om
In
*
te or
re bi
d)
Lo st
w (P
M rim
oo
ar
d y)
(C
Lo om
w
*
M or
R oo bi
d
et d)
ar (P
da rim
tio
n ar
R y)
(C
et om
ar
or
da
bi
tio d)
n
Su (P
ic ri
m
id
e ar
(C y)
*
om
Su
W or
ic bi
id
ei d)
e
gh
(P
tL
ri
m
os
s
W ar
Co-morbid Depression vs Primary Depression
(C y)
ei om
gh
tL or
bi
os
s d)
(P
rim
ar
Primary Depression
y)
Comorbid Depression
*

Co-morbid Depression vs Medical Illness Alone

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)
ty
ce
(M
nt
ra ed
tio ic
n
C al
)
(C
on
*
om
ce
nt or
ra bi
tio d)
n
(M
Fa
ed
tig
ic
ue al
)
(C
*
om
H or
Fa
bi
op tig
n= 4069 vs 1217
d)
el ue
es
(M
sn
ed
es
s ic
H al
(C )
op
In *
om
el
so es
m or
sn bi
ni
a es d)
s
(a
(M
ny
In ed
ty
so ic
pe
m al
)
)(
C
ni
a
*
om
(a
ny or
bi
ty
Lo d)
pe
ss
)(
In M
te ed
re ic
st al
)
(C
Lo
*
ss om
In or
te bi
re d)
st
Lo
(M
w
M ed
ic
oo
d al
)
(C
*
om
Lo
w or
M bi
R oo d)
d
et
(M
ar
da ed
ic
tio
n al
)
(C
R
*
om
et
ar or
da bi
tio d)
n
(M
Su
ed
ic
ic
id
e al
)
(C
*
om
or
Su
W ic bi
id d)
ei e
gh (M
tL ed
os ic
s al
W )
(C
*
ei om
gh
W or
tL bi
or os d)
th
s
le (M
ss
ed
ne
ic
W ss
al
)
(C
or
th om
le or
ss
bi
ne d)
ss
(M
Co-morbid Depression vs Medical Illness Alone
ed
ic
Medical Illness Alone
Comorbid Depression
al
)

6. Scope for New Tools (DT and ET)
6. Scope for New Tools (DT and ET)

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
13.2
14.0
12.0
10.4
10.0
8.4
7.7
7.3
8.0
6.0
3.7
3.3
4.0
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
PHQ2 Two QQ
0.9
Sensitivity
PHQ9
0.8
HADS-T
0.7
DT (3v4)
0.6
PHQ2 Interest
0.5
HADS-D DT (4v5)
0.4
PHQ2 Depression
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

(3v4
)

7. Future of Screening
7. Future of Screening

1.00
0.90
0.80
Ten
Nine
0.70
Eight
0.60 Seven
Six
0.50
Five
Four
0.40
Three
Two
0.30
One
Zero
0.20
0.10
0.00
Distress Anxiety Depression Anger
Thermometer Thermometer Thermometer Thermometer

DT AngT
(38%) (26%)
2% 1%
0% DT
2% 0%
15% 0%
10%
8% 4%
0%
21% 2%
AnxT DepT
(65%) (30%)

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 AngT
AnxT=0.87
AngT=0.685

Vs DT DepT
HADS-D
AUC:
DT=0.67
DepT=0.75
AnxT AngT
AnxT=0.62
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?

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