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IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study
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IPOS10 -t125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study

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This is a talk from IPOS 2010 on Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study.

This is a talk from IPOS 2010 on Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study.

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  • 1. T125 --Identification of Patient Reported Distress by T125 Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study A Multicentre UK Study Alex Mitchell www.psycho-oncology.info Department of Cancer & Molecular Medicine, Leicester Royal Infirmary Department of Liaison Psychiatry, Leicester General Hospital IPOS 2010
  • 2. 1. Background What are the issues in detection How do PCPs compare? What are the special issues in the older person What are the issues in physical disease
  • 3. % Receiving Any treatment for Depression 20 17.9 18 n=84,850 face-to-face interviews 16 15.4 13.8 14 12 11.3 10.9 10.9 10 8.8 8.1 8 7.2 6.8 6 5.6 5.5 4.3 4 3.4 2 0 SA in n ly na a m e a l y ne ce e nd e s m r ic pa bi an m It a a nd ra u i an U ai la Sp Ch co om co gi Ja m Af Is kr rla a Fr el In er In Ze ol U h B he G w ut h C ew et g Lo So Hi N N Wang P et al (2007) Lancet 2007; 370: 841–50
  • 4. Do we know what symptoms occur in MDD?
  • 5. 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 specificity of each mood symptom A ng er Exc ess Comment: Slide illustrates sensitivity and 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
  • 6. -0.10 0.00 0.10 0.20 0.30 0.40 0.50 A nge r A nxie ty Decr ea s e d ap peti t e D ecr ea s e d we ig ht D epr es sed m ood Dimin is hed c onc entr a t ion identifying non-depressed Dimin is hed dr ive Dimin is hed int er est /p leasu re Exc e ss ive guilt Help le Comment: Slide illustrates added value of each ss nes s symptom when diagnosing depression and when Hope les sn e ss Hy pe rsom ni a Inc re a sed a ppet ite Inc re ased w eig ht Indec isiv e ness Ins om nia L ac k of re act iv e mo od L os s o f en erg y Ps ych i c a nx iety Ps ych o mot o r agi ta tion Ps yc ho mot o r c han ge Ps ych o mot o r ret ar datio n Sl eep dis tu rban ce Soma ti c a n x iety Rule-In Added Value (PPV-Prev) Thou g Rule-Out Added Value (NPV-Prev) hts o f de ath Wor t hle s snes s
  • 7. GP Recognition of Individual symptom Proportion of Individual Symptoms Recognised by GPs 80.0 76.1 70.0 60.0 50.0 40.0 36.4 34.6 31.6 30.0 21.6 20.0 16.7 13.3 9.1 8.3 8.3 10.0 0.0 s ng a d gy s ia st ty ism es oo si ni ex re xie pi er ia m ln m m te Co or en dr An so fu in i An w ss on ar In t of Lo No of Pe Te ch ss ss po Lo Lo Hy O’Conner et al (2001) Depression in primary care. Int Psychogeriatr 13(3) 367-374.
  • 8. N=35 studies Accuracy of GP’s Diagnoses Depression Depression PRESENT ABSENT GP +ve 2503 2515 5018 PPV 42.8% GP -ve 4050 25,125 6678 NPV 85.1% 6553 27,640 9559 Sensitivity Specificity Prevalence 19% 48% 80.1% Mitchell, Vaze, Rao Lancet 2009
  • 9. GP Accuracy – Detection of Distress by GHQ Score McCall et al (2007) Primary Care Psychiatry - Recognition by Severity 90 80 70 Comment: Slide illustrates raw number 60 of people identified by severity on the GHQ. Although the % detection increases with severity, the absolute 50 number decreased due to falling prevalence 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
  • 10. Comment: Slide illustrates concept of phenomenology of depression in medical disease Primary Depression Alone Fatigue Anorexia Insomnia Concentration Secondary Medically Unwell Alone Depression
  • 11. Study: Coyne Thombs Mitchell N= 4500; Pooled database study; All comparative studies Physical illness+comorbid depression Vs Physical illness alone Vs Primary depression alone
  • 12. 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 d) n A (P nx rim ie ty ar (C y) om * A or nx bi ie d) A ty pp (P et rim it e ar (C y) om A * C pp or n=4069 vs 4982 on et bi ce it e d) nt (P ra ri tio m C n ar on (C y) ce om nt or ra bi tio n d) Fa (P t ig rim ue ar y) (C om Fa or t ig bi ue d) (P G ri ui m lt ar (C y) om * H or op el G bi es ui d) lt sn (P es ri H s m op (C ar el om y) es * sn or bi es d) In s so (P ri m m ni ar a y) (C In om * so or Lo m bi ss ni d) In a te (P ri re st m Lo ar (C y) ss om In * te or re bi st d) Lo w (P M rim oo ar d y) (C Lo om w * M or R oo bi d) et d ar (P da rim t io n ar (C y) R et om ar or da bi t io d) n Co-morbid Depression vs Primary Depression Su (P ic ri id m primary depression e ar y) (C om * Su or W ic bi ei id d) gh e tL (P ri os m s ar W (C y) ei om gh symptoms profile in comorbid vs tL or Comment: Slide illustrates similar os bi d) s (P rim ar y) Prim ary Depression Com orbid Depression *
  • 13. Comment: Slide illustrates assumed overlap of primary and secondary depression Primary Depression Alone Fatigue Anorexia Insomnia Concentration Secondary Medically Unwell Alone Depression
  • 14. Comment: Slide illustrates actual overlap of primary and secondary depression Primary Depression Alone Secondary Depression Agitation Retardation
  • 15. 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 ) om * ce nt or ra bi tio d) n (M Fa ed t ig ic ue al (C ) * om or H Fa bi n= 4069 vs 1217 op t ig d) el ue es sn (M es ed H s ic al op (C ) In om * so el es or m sn bi ni d) a es (a s ny (M In ty ed so pe ic m )( al ) ni C a om * (a ny or ty bi Lo pe d) ss )( In M te ed r es ic al Lo t( C ) om * ss In or te bi r es d) Lo t( w M M ed ic oo al d ) (C om * Lo w or M bi d) R oo et d ar (M da ed t io ic n al ) (C R * et om ar or da bi t io d) n (M Su ed ic ic id e al ) (C * om Su or bi W ic id d) ei gh e (M t Lo ed ss ic al W (C ) om * ei gh or W t bi or Lo d) th Co-morbid Depression vs Medical Illness Alone ss le (M ss ne ed ss ic W (C al ) or th om le or ss bi ne d ) ss symptoms profile in comorbid (M ed ic Medical Illness Alone al ) Com orbid Depression Comment: Slide illustrates distinct depression vs medical illness alone
  • 16. Comment: Slide illustrates concept of phenomenology of depressions in medical disease Primary Depression Alone Fatigue Anorexia Insomnia Concentration Secondary Medically Unwell Alone Depression
  • 17. Comment: Slide illustrates actual phenomenology of depressions in medical disease Primary Depression Secondary Depression Weight loss Agitation Retardation Medically Unwell
  • 18. Elderly?
  • 19. A 0.000 0.100 0.200 0.300 0.400 0.500 0.600 0.700 0.800 nx ie A A ty ng nx (C er ie om ty (P bi ne A sy d) nx ch ie ic ty an (S xi om et >64 >59 >54 <55 at y) D ic ec an re xi as et ed y) A D pp ec et re ite as ed D W D ep ei im re gh in ss t is ed he M d C oo on d ce D nt im ra in tio is n he d * In te * Ex re ce st ss iv e G H ui el lt pl es sn H es op s el In es cr sn ea es se s d Ap In pe cr tit ea e se d W In ei de gh ci t si ve ne Lo ss Ps ss yc of ho E Ps m ne ot rg yc or y ho A Sl m gi * ee ta p ot tio D or n Sl is R ee tu et p rb ar D an da is ce tio tu n rb (C an om Sl ce bi ee (H ne p D yp d) is er tu so rb m an ni ce a) (In so Th m ou ni gh a) ts of symptoms in late life vs mid-life of W D ea or th th * le depression – few have special significance ss * Comment: Slide illustrates diagnostic value ne ss * * *
  • 20. 3. Cancer Care - Detection How well do cancer specialists identify depression/distress? How do doctors compare with nurses?
  • 21. 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
  • 22. 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
  • 23. Phase I
  • 24. 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 40.0 24.4 82.4 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
  • 25. Results Looking for just distress detection sensitivity of 11.2% (95% CI 6.9% to 16.9%) detection specificity of 98.3% (95% CI 95.2 to 99.7%). Looking for any mental health complication their sensitivity was 50.6% specificity 79.4% There was significantly better performance using the broad approach rather than a narrow focus 65.4% vs 56% (Chi² = 4.3,p = 0.037).
  • 26. Predictors Examining predictors, clinicians had better ability to recognize higher severities of distress (adjusted R2= 0.87 p = 0.001). There was a trend for better recognition by community than chemotherapy nurses. There was no difference according to the stage or type of cancer.
  • 27. Detection sensitivity = 50.6% 1.00 Detection specificity = 79.4% Post-test Probability Overall accuracy = 65.4%. 0.90 0.80 0.70 0.60 CHEMO+ 0.50 CHEMO- 0.40 Baseline Probability 0.30 COMMU+ COMMU- 0.20 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 Comment: Slide illustrates performance of chemotherapy vs community nurses in oncology
  • 28. Summary Detection of depression is low in all groups Detection of depression has some untested assumptions Most clinicians are not using tools Detection of distress is almost imperfect => Whose opinion is most important

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