POCOG - The Future of Psycho-Oncology (Aug 2011)

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This is an invited talk on the "The Future of Psycho-Oncology" given to the POCOG group of the University of Sydney (lead Phyllis Butow) in August 2011.

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POCOG - The Future of Psycho-Oncology (Aug 2011)

  1. 1. The Future of Psycho-oncology:The Future of Psycho-oncology:Research & ClinicalResearch & ClinicalAlex Mitchell www.psycho-oncology.infoDepartment of Cancer & Molecular Medicine, University of LeicesterDepartment of Liaison Psychiatry, Leicester General Hospital University of Sydney POCOG August 2011 University of Sydney POCOG August 2011
  2. 2. Hewitt Journal of Clinical Oncology, Vol 20, Issue 23, 2002: 4581-459040 % Receiving Any treatment for Mental Health 34.635 32.7 Cancer n=4878 No Cancer n=90,7373025 19.120 16.1 1415 11.7 11 8.910 7.7 7.2 6.5 5.7 5.7 5 6.3 6.4 6.2 5 5 3.9 3.2 2.3 1.8 0 l th l th 75+ s rs rs rs ti o n ie n t on ti o n ti o n H ea H ea y ea y ea y ea d it i n di P at n di n di l Il l l Il l 44 64 74 co n l co l co l co All nt a n ta 18- 45- 65- d i ca ca l d i ca d i ca Me Me edi me me me No cm n ic n ic n ic o ni hro hro hro c hr 1c 2c 3c No
  3. 3. Are you doing anything on your own for your mental stress, worry, or m changes? ood Do you feel your cancer care teamhas provided the education or support you need? At your last visit, did a m ber of your cancer care teamask you about m em ental stress, worry, or m changes? ood Were you given suggestions, other than taking medications, by your cancer care team? Were you offered a visit with a: Mental health provider, like a therapist, counselor, psychologist or psychiatrist? Have you been given medicines to take for mental stress, worry, or m changes? ood Over the past month, have you talked with your cancer care teamabout distress?If taking treatm has anyone fromyour cancer care teamasked you how well the treatm ent ent was working?Have you been sent to see another health care provider for treatm for your m ent ental stress, worry, or m changes? ood Have you received any treatm for m ent ental stress, worry, or m changes over the last ood m onth Are you currently seeing a: Pastoral care provider, like a chaplain, priest, or rabbi? 0 10 20 30 40 50 60 70 80 Cella (2008) Suport Care Cancer. 2008 Feb;16(2):151-9. Epub 2007 Jul
  4. 4. What about preventive cancer care?Do our vulnerable patients get enhanced access?
  5. 5. Mammography & MI Summary meta-analysis plot [random effects] Carney & Jones (2006) [mod mental illness] 0.620 (0.590, 0.660) Carney & Jones (2006) [mild mental illness] 0.980 (0.950, 1.010)OR 0.69 (95% CI = 0.62 to 0.77) Carney & Jones (2006) [severe mental illness] Carney & Jones (2006) [low severity] 0.380 (0.330, 0.430) 0.930 (0.890, 0.970)P < 0.0001 Carney & Jones (2006) [medium severity] Carney & Jones (2006) [high severity] 0.630 (0.570, 0.690) 0.340 (0.280, 0.420)N=29 Carney & Jones (2006) [low severity] 0.590 (0.450, 0.780) Carney & Jones (2006) [high severity] 0.560 (0.260, 1.210) Carney & Jones (2006) [medium severity] 0.470 (0.330, 0.670) Chochinov et al (2009) 0.640 (0.580, 0.710) Druss et al (2002) 0.780 (0.670, 0.910) Druss et al (2002) [dual diagnosis] 0.520 (0.340, 0.790) Druss et al (2008) [depression] 0.820 (0.790, 0.847) Druss et al (2008) [primary care] 1.350 (1.160, 1.610) Druss et al (2008) [specialist] 0.820 (0.690, 0.970) Green and Pope (2000) 1.370 (1.040, 1.810) Iezzoni et al (2001) 0.600 (0.400, 1.100) Lasser et al (2003) 0.350 (0.240, 0.510) Lindamer et al (2003) 0.040 (0.002, 0.250) Patten et al (2009) 0.800 (0.400, 1.600) Peytremann- Bridevaux et al (2008) 1.000 (0.800, 1.200) Pirraglia et al (2004) [severe depression] 0.840 (0.730, 0.970) Pirraglia et al (2004) [moderate depression] 1.010 (0.860, 1.180) Stecker et al (2007) 0.867 (0.662, 1.130) Werneke et al. (2006) [any mental illness] 0.910 (0.800, 1.040) Werneke et al. (2006) [severe mental illness] 0.400 (0.290, 0.550) Werneke et al. (2006) [psychosis] 0.330 (0.180, 0.610) masterton et al (2010) 0.670 (0.420, 1.075) Ludman et al (2010) 0.490 (0.310, 0.760) combined 0.692 (0.624, 0.768) 0.001 0.01 0.1 0.2 0.5 1 2 odds ratio (95% confidence interval)
  6. 6. What is Changing? Demographics Clinician Expectations Patient Involvement
  7. 7. Lower Emphasis Depression (MDD, DSMIV) Psychiatrist Judgement vs patient opinion Ineffective interventions Communication over Trust (diagnosis alone) Palliative differences without evidence
  8. 8. Increased Emphasis Early intervention & prevention Screening Implementation > Validity Distress (esp longitudinal) Outreach and primary care PROMs Peer support and SMI models of care
  9. 9. For the Future Anxiety disorders, Anger, Irritability, Adjustment Unpopular depressions (MnDD, ADD, Dysthymia) Function and QoL will be re-invented Psychosocial input into Rehabilitation approaches Acceptable Screening with intervention (RCTs) Symptom Research (back to basics)
  10. 10. Psycho-oncology is Growing! 2010 1990Depression 143 12Distress 121 14Screening 1700 481Communication 148 38
  11. 11. Change 1: Epidemiology of Cancer Survival Prevalence
  12. 12. 5 Year Survival in US Cancers (2008 American Cancer Society, Atlanta)1009080 1975-197770 1984-1986 1996-200460 Change5040302010 0 a r us a ia te on y e) s as m de om om i te r em ta al va ch tu ol re ad ls ph m os ec an C O on nc uk bl (fe Al lym Pr R el br Pa Le yM ar st d in ea an rin gk Br U ng od Lu -H on N Annual report to the national of status of cancer 1975 – 2005 J Natl Cancer Inst 2008;100: 1672 – 1694
  13. 13. 10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases
  14. 14. Australian Bureau of Statistics
  15. 15. Change 2: Clinician Behaviour Information Assisted decision making
  16. 16. InformationIn 196190% of US doctors indicated a preference for not telling a diagnosis of cancer.In 197997% indicated a preference for revealing a diagnosis of cancer. Novack DH, Plumer R, Smith RL, et al. Changes in physicians’ attitudes toward telling the cancer patient. JAMA 1979; 241: 897–900.
  17. 17. The oncologists were 32% accurate in predicting survival and overestimated survival 42% of the timePsychooncology. 2011 Feb;20(2):213-8. doi: 10.1002/pon.1727. Patientand oncologist estimates of survival in advanced cancer patients.Steven Kao SC, Butow P, Bray V, Clarke SJ, Vardy J.
  18. 18. J Clin Oncol. 2011 May 20;29(15):2077-84. Epub 2011 Apr 11. Supporting treatment decision making in advanced cancer: a randomized trial of adecision aid for patients with advanced colorectal cancer considering chemotherapy. Natasha Leighl NB, Shepherd HL, Butow PN
  19. 19. Change 3: Clear Evidence Base Prevalence of depression Relative risk of depression
  20. 20. Prevalence of depression in Oncology settings Plumb & Holland (1981) Proportion meta-analysis plot [random effects] 0.7750 (0.6679, 0.8609) Levine et al (1978) 0.5600 (0.4572, 0.6592) Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920) Massie et al (1979) 0.4850 (0.4303, 0.5401)70 studies involving 10,071 individuals;14 countries. Bukberg et al (1984) Passik et al (2001) 0.4194 (0.2951, 0.5515) 0.4167 (0.2907, 0.5512)16.3% (95% CI = 13.9% to 19.5%) Baile et al (1992) Morton et al (1984) Hall et al (1999) 0.4000 (0.2570, 0.5567) 0.3958 (0.2577, 0.5473) 0.3722 (0.3139, 0.4333) Burgess et al (2005) 0.3317 (0.2672, 0.4012) Jenkins et al (1991) 0.3182 (0.1386, 0.5487)Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3% Green et al (1998) 0.3125 (0.2417, 0.3904) Kathol et al (1990) 0.2961 (0.2248, 0.3754) Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249) Fallowfield et al (1990) 0.2565 (0.2054, 0.3131) Golden et al (1991) 0.2308 (0.1353, 0.3519) Spiegel et al (1984) 0.2292 (0.1495, 0.3261) Evans et al (1986) 0.2289 (0.1438, 0.3342) Grandi et al (1987) 0.2222 (0.0641, 0.4764) Maunsell et al (1992) 0.2146 (0.1605, 0.2772) Berard et al (1998) 0.2100 (0.1349, 0.3029) Joffe et al (1986) 0.1905 (0.0545, 0.4191) Berard et al (1998) 0.1900 (0.1184, 0.2807) Devlen et al (1987) 0.1889 (0.1141, 0.2851) Leopold et al (1998) 0.1887 (0.0944, 0.3197) Akizuki et al (2005) 0.1797 (0.1376, 0.2283) Razavi et al (1990) 0.1667 (0.1189, 0.2241) Gandubert et al (2009) 0.1597 (0.1040, 0.2300) Alexander et al (1993) 0.1333 (0.0594, 0.2459) Kugaya et al (1998) 0.1328 (0.0793, 0.2041) Payne et al (1999) 0.1290 (0.0363, 0.2983) Ibbotson et al (1994) 0.1242 (0.0776, 0.1853) Prieto et al (2002) 0.1227 (0.0825, 0.1735) Morasso et al (1996) 0.1121 (0.0593, 0.1877) Desai et al (1999) [early] 0.1111 (0.0371, 0.2405) Silberfarb et al (1980) 0.1027 (0.0587, 0.1638) Costantini et al (1999) 0.0985 (0.0535, 0.1625) Morasso et al (2001) 0.0985 (0.0535, 0.1625) Ozalp et al (2008) 0.0971 (0.0576, 0.1510) Love et al (2002) 0.0957 (0.0650, 0.1346) Alexander et al (2010) 0.0900 (0.0542, 0.1385) Coyne et al (2004) 0.0885 (0.0433, 0.1567) Kawase et al (2006) 0.0851 (0.0553, 0.1240) Walker et al (2007) 0.0831 (0.0568, 0.1165) Grassi et al (1993) 0.0828 (0.0448, 0.1374) Grassi et al (2009) 0.0826 (0.0385, 0.1510) Reuter and Hart (2001) 0.0761 (0.0422, 0.1244) Lee et al (1992) 0.0660 (0.0356, 0.1102) Pasacreta et al (1997) 0.0633 (0.0209, 0.1416) Sneeuw et al (1994) 0.0540 (0.0367, 0.0761) Singer et al (2008) 0.0519 (0.0300, 0.0830) Katz et al (2004) 0.0500 (0.0104, 0.1392) Mehnert et al (2007) 0.0472 (0.0175, 0.1000) Lansky et al (1985) 0.0455 (0.0291, 0.0676) Derogatis et al (1983) 0.0372 (0.0162, 0.0720) Hardman et al (1989) 0.0317 (0.0087, 0.0793) Massie and Holland (1987) 0.0147 (0.0063, 0.0287) Colon et al (1991) 0.0100 (0.0003, 0.0545) combined 0.1730 (0.1375, 0.2116) 0.0 0.3 0.6 0.9 proportion (95% confidence interval)
  21. 21. Prevalence of depression in Palliative settings24 studies involving 4007 individuals16.9% (95% CI = 13.2% to 20.3%) Proportion meta-analysis plot [random effects] Lloyd-Williams et al (2007) 0.30 (0.24, 0.36)14% major 9% minor adj 15% anx 10% Jen et al (2006) 0.27 (0.19, 0.36) Lloyd-Williams et al (2003) 0.27 (0.17, 0.39) Payne et al (2007) 0.26 (0.19, 0.33) Desai et al (1999) [late] 0.25 (0.10, 0.47) Hopwood et al (1991) 0.25 (0.16, 0.36) Lloyd-Williams et al (2001) 0.22 (0.14, 0.31) Minagawa et al (1996) 0.20 (0.11, 0.34) Meyer et al (2003) 0.20 (0.10, 0.35) Breitbart et al (2000) 0.18 (0.11, 0.28) Le Fevre et al (1999) 0.18 (0.10, 0.28) Chochinov et al (1994) 0.17 (0.11, 0.24) Kelly et al (2004) 0.14 (0.06, 0.26) Wilson et al (2007) 0.13 (0.10, 0.17) Chochinov et al (1997) 0.12 (0.08, 0.18) Wilson et al (2004) 0.12 (0.05, 0.22) Love et al (2004) 0.07 (0.04, 0.11) Kadan-Lottich et al (2005) 0.07 (0.04, 0.11) Akechi et al (2004) 0.07 (0.04, 0.11) Maguire et al (1999) 0.05 (0.01, 0.14) combined 0.17 (0.13, 0.21) 0.0 0.2 0.4 0.6 proportion (95% confidence interval)
  22. 22. Meta regression using the random effects model on raw porportions Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size. 0.4 0.3Proportion 0.2 0.1 0.0 0 20 40 60 80 100 Time (months)
  23. 23. Depression in LTCS vs healthy controls Relative risk meta-analysis plot (random effects) Bergdahl et al (2005) 0.76 (0.33, 1.53) Bruce et al (2002) 0.77 (0.47, 1.24) Stek et al (2004) 0.88 (0.50, 1.49) Tsai et al (2007) 1.48 (0.74, 2.03) Tsai et al (2005) 0.85 (0.35, 1.73) Rasic et al (2008) 0.99 (0.74, 1.32) Pirl et al (2009) 0.79 (0.52, 1.17) Dahl et al (2005) 0.96 (0.82, 1.13) Ramsey et al (2002) 1.42 (0.99, 2.03) Keating et al (2005) 1.00 (0.86, 1.16) Khan et al (2010) 1.08 (1.04, 1.13) Thorsen et al (2005) 1.06 (0.89, 1.26) Vistad et al (2007) 1.94 (0.95, 3.87) Kim et al (2010) 0.72 (0.63, 0.82) Ellman et al (1995) 0.58 (0.34, 0.98) combined [random] 0.97 (0.86, 1.09) 0.2 0.5 1 2 5 relative risk (95% confidence interval)
  24. 24. Change 4: Distress 6th Vital sign Patient Opinion
  25. 25. 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 ___________________________ ___
  26. 26. Ransom Tuinman Mitchell Lord Hoffman Gessler Clover Jacobsen ProportiScore 2006 2008 2009 2010 2004 2009 2009 2005 Sum onZero 68 38 61 123 14 27 65 71 467 18.4%One 72 31 42 68 5 26 39 46 329 12.9%Two 77 22 35 44 5 18 30 54 285 11.2%Three 65 37 42 46 8 23 45 46 312 12.3%Four 51 29 29 30 8 7 21 31 206 8.1%Five 41 46 62 40 11 13 41 48 302 11.9%Six 38 32 23 28 2 16 26 31 196 7.7%Seven 36 21 23 38 2 15 32 16 183 7.2%Eight 18 12 18 29 6 9 19 15 126 5.0%Nine 16 5 8 14 3 3 13 9 71 2.8%Ten 9 4 7 20 4 0 9 13 66 2.6%Sum 491 277 350 480 68 157 340 380 2543Proportion 19.3% 10.9% 13.8% 18.9% 2.7% 6.2% 13.4% 14.9%
  27. 27. Proportion20.0% Insignificant Minim al Mild Moderate Severe18.0%16.0%14.0%12.0%10.0% 18 .4 %8.0%6.0% 12 .9 % 12 . 3 % 11.9 % p124 11.2 %4.0% 8 .1% 7.7% 7.2 % 5. 0 %2.0% 2 .8 % 2 .6 %0.0% Zero One Tw o Three Four Five Six Seven Eight Nine Ten 50%
  28. 28. 100% 0.02 0.00 0.00 0.00 0.00 0.00 0.03 0.04 0.03 0.01 0.06 0.08 0.09 0.07 0.1790% 0.20 0.18 0.11 0.19 0.28 0.31 0.1880% 0.31 0.4770% 0.20 0.48 0.4060% 0.50 0.40 0.5350% 0.4540% 0.80 0.40 0.69 0.6230% 0.50 3=Extremely Difficult” 0.4320% 0.41 2=Very Difficult 0.32 0.33 0.27 0.2510% 1=Somewhat Difficult 0.20 Unimpaired 0% Zero One Tw o Three Four Five Six Seven Eight Nine Ten
  29. 29. Change 5: Know Clinicians Limitations How Often What method?
  30. 30. Comment: Frequency of cancer specialistsn=226 enquiry about depression/distress from Mitchell et al (2008)
  31. 31. 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
  32. 32. 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% Comment: “Ideal” method of eliciting symptoms of distress/depression according to clinician
  33. 33. 100.0 5.9 11.1 14.3 90.0 Comment: Slide illustrates diagnostic 21.4 accuracy according to score on DT 11.8 25.9 80.0 38.7 38.1 43.5 22.2 14.3 46.7 70.0 59.6 21.4 72.4 60.0 Judgement = Non-distressed 33.3 Judgement = Unclear 19.4 19.0 Judgement = Distressed 50.0 26.1 24.4 82.4 40.0 71.4 66.7 30.0 25.0 57.1 41.9 42.9 40.7 20.0 15.8 30.4 28.9 10.0 15.4 11.8 0.0 Zero One Two Three Four Five Six Seven Eight Nine Ten
  34. 34. Low confidence = more cautious, fewer false positives, more false negatives p1801.00 Post-test Probability0.900.800.700.60 Ave Confidence+0.50 Ave Confidence-0.40 Baseline Probability Above Ave Confidence+0.30 Above Ave Confidence- High Confidence+0.20 High Confidence-0.10 Pre-test Probability0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 High confidence = less cautious, more false positives, low false negatives
  35. 35. Change 6: Screening Evolves Ultra-short Brief Lengthy (conventional)
  36. 36. Comment: This is a reminder of thestructure of the HADS scale, this versionadapter for cancer.
  37. 37. Validity of HADS vs depression (DSMIV) SE 71.6% (68.3) SP 82.6% (85.7) Prev 13% PPV 38% NPV 95%
  38. 38. Somatic Bias in Mood Scales
  39. 39. General Physical Trained Self-Report Confident Skilled Clinician Alone Signs of DS 6 Depression DISCS Observation ScreeningStroke Aphasic methods Visual Depression Scale 21/10 VA-SES SMILEY ET/DT YALE Interview HAMD-D 17 MADRAS 10
  40. 40. Validity of Methods to Evaluate Depression Unassisted Clinician Conventional ScalesUntrained Trained Ultra-Short (<5) Short (5-10) Long (10+)
  41. 41. British Journal of Cancer (2007) 96, 868 – 874
  42. 42. Validity of DT vs depression (DSMIV) SE 80% SP 60% PPV 32% NPV 93%
  43. 43. Tools Compared_Palliative and Non-Palliative1.00 Post-test Probability0.900.800.700.600.50 1Q+ 1Q-0.40 Baseline Probability HADS-D+ HADS-D-0.30 HADS-T+ HADS-T- BDI+ BDI-0.20 HADS-A+ HASD-A- DT+0.10 DT- Pre-test Probability0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  44. 44. Tools Compared in Palliative Alone1.00 Post-test Probability0.900.800.700.60 HADS-D+0.50 HADS-D- Baseline Probability 2Q+0.40 2Q- EPDS+0.30 EPDS- 1Q+0.20 1Q-0.10 Pre-test Probability0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  45. 45. Change 7: Underserved needs
  46. 46. Underserved populations More preferred to receive sensitive information from their general practitioner (BSA 62.5% versus 33%
  47. 47. DT vs DSMIV Depression SE SP PPV NPVDTma 80.9% 60.2% 32.8% 92.9%DTLeicesterBW 82.4% 68.6% 28.0% 98.3%DTLeicesterBSA 100% 59.6% 26.8% 100%BSA = British South AsianBW= British White
  48. 48. Change 8: Help Appears!
  49. 49. Vs DT DepTHADS-AAUC:DT=0.82DepT=0.84AnxT=0.87 AnxT AngTAngT=0.685
  50. 50. DepT DT 23%37% 4% 3% 3% DT DepT 7% 1% Non-Nil 8% 0% Nil 9% 59% 41% 4% 1% AnxT 2% AngT 15% 2%AnxT AngT47% 18%
  51. 51. Change 9: Implementation RCTs What can enhance detection?
  52. 52. Comment: Slide illustrates actual gain inmeta-analysis of screeningimplementation in primary care
  53. 53. Pre-Post Screen - Distress Before AfterSensitivity of 49.7% 55.8% =>+5%Specificity of 79.3% 79.8% =>+1%PPV was 67.3% 70.9% =>+4%NPV was 64.1% 67.2% =>+3%There was a non-significant trend for improve detection sensitivity (Chi² = 1.12 P = 0.29).
  54. 54. Qualitative AspectsDISTRESS 43% of CNS reported the tool helped them talk with the patient about psychosocial issues esp in those with distress 28% said it helped inform their clinical judgementDEPRESSION 38% of occasions reported useful in improving communication. 28.6% useful for informing clinical judgement
  55. 55. Screen Routine vs At-Risk vs IdentifiedLow High?? Desire for Help Meetable Unmet Needs Follow-up Care
  56. 56. Next Step 269 Nurse-patient interactions Helped 65 (24%) Not Helped 204 (76%) Referred 23 (8.6%) Declined Helped 20 (7.4%) No Unmet Needs 34 (12.6%) Unmet Needs 150 (55.8%) p179
  57. 57. What is QUICATOUCH?Quick, Individually Customised Assessment using TOUCHscreens
  58. 58. Prevalence over time 35 30% patients over threshold Distress 25 Pain 20 15 10 5 0 1 2 3 4 5 6 7 8 Quarter of screening First occasion of screening (n=4543)
  59. 59. Change 10: Symptom Research Back to Basics Back to Basics
  60. 60. Clinical Clinical OverallTest Sensitivity Specificity PPV NPV Utility (+) Utility (‐) Correctlittle interest or pleasure in doing 73.5% 69.9% 50.8% 86.2% Poor Average 70.97things (0.374) (0.602)Feeling down, depressed or 83.7% 61.7% 48.1% 90.0% Poor Average 68.28hopeless (0.403) (0.555 86.7% 92.6% 83.2% 94.3% Good Excellent 90.86Trouble falling or staying asleep or (0.722 (0.873sleeping too much 81.9% 83.7% 68.0% 91.6% Average Good 83.15Feeling tired or having little energy (0.557) (0.767) 59.6% 89.3% 70.2% 83.9% Poor Good 80.47Poor appetite or overeating (0.419) (0.749)Feeling bad about yourself or that 54.2% 85.5% 61.2% 81.5% Poor Good 76.16you are a failure (0.332) (0.697)Trouble concentrating on things 69.3% 76.5% 55.6% 85.5% Poor Good 74.37such as reading (0.385) (0.65)4Thoughts that would be better off 19.3% 96.9% 72.7% 73.9% Poor Good 73.84dead (0.140) (0.717) 100% 91.6% 83.4% 100% Excellent Excellent 94.09Optimal two‐stage combination of (0.834) (0.916)items
  61. 61. Whole Sample Palliative Patients Non-Palliative PatientsSymptom MDD No MDD MDD No MDD MDD No MDDlittle interest or pleasure in 69.0% 7.80% 88.0% 9.93% 58.7%** 6.8%doing thingsFeeling down, depressed or 73.2% 6.60% 80.0% 7.95% 69.6% 6.0%hopelessTrouble falling or staying 85.9% 23.00% 88.0% 23.18% 84.8% 22.9%asleep or sleeping too muchFeeling tired or having little 94.4% 27.30% 92.0% 24.50% 95.7% 28.6%energyPoor appetite or overeating 81.7% 17.00% 88.0% 18.54% 78.3% 16.4%Feeling bad about yourself 88.7% 17.20% 80.0% 19.21% 93.5%* 16.4%or that you are a failureTrouble concentrating on 77.5% 6.40% 84.0% 8.61% 73.9% 5.4%things such as readingMoving or speaking so 84.5% 19.50% 88.0% 23.84% 82.6% 17.6%slowlyThoughts that would be 35.2% 3.90% 24.0% 3.31% 41.3% 4.2%better off dead
  62. 62. Most Useful Diagnostic Symptoms for Depression in..ONCOLOGY SETTINGS PALLIATIVE SETTINGS1 Trouble concentrating 1. little interest or pleasure in doing things2 Feeling down depressed or 2. Trouble concentrating on thingshopeless such as reading the3 Feeling bad about yourself or that 3. Feeling down depressed oryou are a failure hopeless4 little interest or pleasure in doing 4. Poor appetite or overeatingthings5 Moving or speaking so slowly that 5. Feeling tired or having littleother people could have noticed energy Trouble falling or staying asleep or sleeping too muchThoughts that would be better off dead or of Feeling bad about yourself or that you are a failurePoor appetite or overeating Moving or speaking so slowly that other people could have noticedTrouble falling or staying asleep or sleeping too much Thoughts that would be better off dead or ofFeeling tired or having little energy
  63. 63. Change 11: Intervention Research
  64. 64. Future of Psycho-oncology 2011 2011We have to address to basics firstWe have to work collaboratively clinicians & researchersWe have to put the patient at the centre

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