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Detection of Depression in Cancer Settings:
Detection of Depression in Cancer Settings:

     Using Evidence to Improve Cl...
Contents

Overview of mood complication of cancer

  Current Detection Strategies

     Routine Abilities of Cancer Clinic...
1. Overview of Mood Complications
1. Overview of Mood Complications
48%


          Distress/Adjustment Disorder
                                 N=10

                                      ...
48%


          Distress/Adjustment Disorder


                                               57%

38%
                   ...
PHQ9 Linear distribution

35



30

                                                                                      ...
None of above
          15%
                              Major Depression
                                     26%




  ...
2. Current Detection Strategies
2. Current Detection Strategies
Methods to Evaluate Depression



                 Unassisted Clinician                                                   ...
=> accuracy
Methods to Evaluate Depression



 Unassisted Clinician                      Conventional Scales

Untrained Trained       ...
3. Willingness of Clinicians to Screen
3. Willingness of Clinicians to Screen
n=226   How=>
Cancer Staff                                                                       Psychiatrists
           Current Method...
Cancer Staff                                           Psychiatrists
              Ideal Method (n=226)

                 ...
3. Routine Abilities of Cancer Clinicians
3. Routine Abilities of Cancer Clinicians
1.00



             Post-test Probability
  0.90

                                                                   NPV
...
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 th...
1.00


           Post-test Probability
0.90



0.80



0.70



0.60



0.50



0.40

                                    ...
HADS vs Clinician
1.00



           Post-test Probability
0.90



0.80



0.70



0.60



0.50



0.40


                                  ...
6. Phenomenology of Comorbid Depression
6. Phenomenology of Comorbid Depression
Somatic Bias in Mood Scales
0.00
                                                                  0.10
                                              ...
Depressed Mood
 1
                              Diminished interest/pleasure
          S
          e
                     ...
Approaches to Somatic Symptoms of Depression


Audience?
Approaches to Somatic Symptoms of Depression


Inclusive
Uses all of the symptoms of depression, regardless of whether the...
Co-morbid Depression vs Primary Depressions
A
                              gi
                                ta
                                   tio
             ...
Co-morbid Depression vs Medical Illness Alone
A
                                          nx
                                            ie
                            ...
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
         ex...
Distribution of DT Scores
                                                                     Ransom (2006) PO (n=491)
18...
1



                                                  PHQ2 Two QQ
              0.9
Sensitivity


                       ...
(3v4
       )
7. Future of Screening
7. Future of Screening
1.00


0.90


0.80
                                                               Ten
                                    ...
DT                                      AngT
(38%)                                     (26%)
          2%                 ...
ET vs DT (n=130)

 Of 63% DT low scorers
 51% recorded emotional difficulties on
 the new Emotion Thermometers (ET)
 tool
...
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        ...
Credits & Acknowledgments

  Elena Baker-Glenn      University of Nottingham
  Paul Symonds           Leicester Royal Infi...
Liaison09 - Detection of Depression In Cancer Settings from Evidence to Practice [Mar09]
Liaison09 - Detection of Depression In Cancer Settings from Evidence to Practice [Mar09]
Liaison09 - Detection of Depression In Cancer Settings from Evidence to Practice [Mar09]
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Liaison09 - Detection of Depression In Cancer Settings from Evidence to Practice [Mar09]

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This is a 30min presentation given to the Liaison Faculty in Prague 20-Mar-09 in the Psycho-oncology slot. It attempts to draw together all the latest research about which tool and scales to detect emotional problems. It superceedes the 2008 presentations.

Published in: Health & Medicine
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Liaison09 - Detection of Depression In Cancer Settings from Evidence to Practice [Mar09]

  1. 1. 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
  2. 2. 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
  3. 3. 1. Overview of Mood Complications 1. Overview of Mood Complications
  4. 4. 48% Distress/Adjustment Disorder N=10 57% 38% 20% 13% 18% Anxiety Depression N=4 N=11
  5. 5. 48% Distress/Adjustment Disorder 57% 38% 20% 13% 18% Major Anxiety Depression Depression Symptoms Minor Depression
  6. 6. 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
  7. 7. None of above 15% Major Depression 26% Distressed Patients Minor Depression 12% Subsyndromal Depression 47%
  8. 8. 2. Current Detection Strategies 2. Current Detection Strategies
  9. 9. 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
  10. 10. => accuracy
  11. 11. Methods to Evaluate Depression Unassisted Clinician Conventional Scales Untrained Trained Short (5-10) Long (10+) Ultra-Short (<5) Acceptability? Acceptability ? Acceptability ? Accuracy? Accuracy? Accuracy?
  12. 12. 3. Willingness of Clinicians to Screen 3. Willingness of Clinicians to Screen
  13. 13. n=226 How=>
  14. 14. 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%
  15. 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=>
  16. 16. 3. Routine Abilities of Cancer Clinicians 3. Routine Abilities of Cancer Clinicians
  17. 17. 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
  18. 18. 5. Validity of the Current Methods 5. Validity of the Current Methods
  19. 19. 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%
  20. 20. 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
  21. 21. HADS vs Clinician
  22. 22. 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
  23. 23. 6. Phenomenology of Comorbid Depression 6. Phenomenology of Comorbid Depression
  24. 24. Somatic Bias in Mood Scales
  25. 25. 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
  26. 26. 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
  27. 27. Approaches to Somatic Symptoms of Depression Audience?
  28. 28. 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
  29. 29. Co-morbid Depression vs Primary Depressions
  30. 30. 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 *
  31. 31. Co-morbid Depression vs Medical Illness Alone
  32. 32. 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 )
  33. 33. 6. Scope for New Tools (DT and ET) 6. Scope for New Tools (DT and ET)
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. (3v4 )
  38. 38. 7. Future of Screening 7. Future of Screening
  39. 39. 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
  40. 40. DT AngT (38%) (26%) 2% 1% 0% DT 2% 0% 15% 0% 10% 8% 4% 0% 21% 2% AnxT DepT (65%) (30%)
  41. 41. 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.
  42. 42. Vs DT DepT HADS-A AUC: DT=0.82 DepT=0.84 AnxT AngT AnxT=0.87 AngT=0.685
  43. 43. Vs DT DepT HADS-D AUC: DT=0.67 DepT=0.75 AnxT AngT AnxT=0.62 AngT=0.69
  44. 44. 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?
  45. 45. 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

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