[Workshop] The science of screening in Psycho-oncology (Oct10)

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This is workshop 1 from the IX Congresso Portugues de Psico-Oncologia in Porto (Oporto) Portugal 22-oct-2010.

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[Workshop] The science of screening in Psycho-oncology (Oct10)

  1. 1. Alex Mitchell www.psycho-oncology.info Department of Cancer & Molecular Medicine, Leicester Royal Infirmary Department of Liaison Psychiatry, Leicester General Hospital Portugal 2010Portugal 2010 WORKSHOP Day 1 Science of Screening: Definitions, analysis, screening tools, case-finding tools, prevalence, link with physical concerns WORKSHOP Day 1 Science of Screening: Definitions, analysis, screening tools, case-finding tools, prevalence, link with physical concerns
  2. 2. Schedule Day 1Schedule Day 1 930-10.00 – Introduction, groups and issues 10.00-11.00 – T1 Basic science of screening Break 11.30 – 12.30 – Group task #1 Lunch 1.30-2.30 – T2 Symptoms, Burden, Help, Needs in Cancer Break 3.00 – 4.00 – Evaluation of a screening paper
  3. 3. 10 Questions10 Questions 1. How do we understand screening studies 2. Can we design a screening study 3. Which instrument works best 4. Which is the most popular tool 5. How good are clinicians alone 6. Can the DT be improved 7. Is screening effective in clinical practice 8. What are the barriers to successful implementation 9. How can screening be improved 10. Do somatic symptoms interfere with the diagnosis
  4. 4. Incidence > Prevalence > SuvivorshipIncidence > Prevalence > Suvivorship Changing landscape of epidemiology
  5. 5. 10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases
  6. 6. 23 3 3 3 4 5 8 10 10 14 16 25 2 3 4 5 3 1 3 14 24 15 UK Rank (12th) (10th) (5th) (4th) (6th) (15th) (8th) (3rd) (1st) (2nd) All others Lip, oral cavity Leukaemia NHL Bladder Oesophagus Liver Stomach Colorectum Prostate Lung world (%) uk (%) 27 3 3 4 4 5 6 9 9 9 23 27 3 1 5 1 5 2 12 2 12 31 UK Rank (7th) (18th) (5th) (19th) (4th) (13th) (3rd) (11th) (2nd) (1st) All others NHL Thyroid Ovary Liver Uterus Stomach Lung Cervix Colorectum Breast world(%) uk(%) Males Most commonly diagnosed cancers worldwide Females
  7. 7. Cancer Death Rates* Among Men, US,1930-2005 *Age-adjusted to the 2000 US standard population. Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008. 0 20 40 60 80 100 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Lung & bronchus Colon & rectum Stomach Rate Per 100,000 Prostate Pancreas LiverLeukemia
  8. 8. Cancer Death Rates* Among Women, US,1930-2005 *Age-adjusted to the 2000 US standard population. Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008. 0 20 40 60 80 100 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Lung & bronchus Colon & rectum Uterus Stomach Breast Ovary Pancreas Rate Per 100,000
  9. 9. 0 10 20 30 40 50 60 70 80 90 100 M elanom aBreast(fem ale)U rinary bladder Prostate C olon Allsites R ectum N on-H odgkin lym phom a O vary Leukem ia Lung and bronchus Pancreas 1975-1977 1984-1986 1996-2004 Change 5 Year Survival in US Cancers
  10. 10. Distress Thermometer – Pooled Proportion 18 .4 % 12 .9 % 11.2 % 12 .3 % 8 .1% 11.9 % 5.0 % 2 .8 % 2 .6 % 7.7% 7.2 % 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0% Zero One Two Three Four Five Six Seven Eight Nine Ten Insignificant SevereModerateMildMinimal p124 50%
  11. 11. 94.2% 37.4% 8 yrs N= 9282 NCS‐R
  12. 12. N=23 studies; 50% some treatment 33% minimal treatment N=19 studies; 30% 1 in 1/12; 10% 3 in 3 months
  13. 13. T1. Basic Science of ScreeningT1. Basic Science of Screening Definitions Graphics
  14. 14. Diagnostic Testing……by application (who)Diagnostic Testing……by application (who) Routine Screening The systematic application of a test or inquiry, to all individuals who may have (or who have not sought medical help for that disorder) Targeted (High Risk) The highly selected application of a test or inquiry, to identify individuals at high risk of a specific disorder by virtue of known risk factors Adapted from Department of Health. Annual report of the national screening committee. London: DoH, 1997.
  15. 15. Diagnostic Testing……by aim (why)Diagnostic Testing……by aim (why) Screening Rule out those without the disorder with high accuracy (high NPV) Case-Finding Rule in those with the disorder with high accuracy (high PPV)
  16. 16. Diagnostic Testing……by method (how)Diagnostic Testing……by method (how) Screening A simple tool with high acceptability but good NPV Case-Finding An accurate tool with high PPV and NPV Rating Simple, patient rated, correl. With QoL and other outcomes
  17. 17. Defining Diagnostic Testing…by comparatorDefining Diagnostic Testing…by comparator Accuracy (aka convergent validity) The degree of approximation (veracity) to a robust comparator Validity (aka criterion validity) The degree of approximation (veracity) to a criterion reference Precision The degree of predictability (low SD) in the measure
  18. 18. Stage Type Purpose Description Pre-clinical Development Development of the proposed tool or test Here the aim is to develop a screening method that is likely to help in the detection of the underlying disorder, either in a specific setting or in all setting. Issues of acceptability of the tool to both patients and staff must be considered in order for implementation to be successful. Phase I_screen Diagnostic validity Early diagnostic validity testing in a selected sample and refinement of tool The aim is to evaluate the early design of the screening method against a known (ideally accurate) standard known as the criterion reference. In early testing the tool may be refined, selecting most useful aspects and deleting redundant aspects in order to make the tool as efficient (brief) as possible whilst retaining its value. Phase II_screen Diagnostic validity Diagnostic validity in a representative sample The aim is to assess the refined tool against a criterion (gold standard) in a real world sample where the comparator subjects may comprise several competing condition which may otherwise cause difficulty regarding differential diagnosis. Phase III_screen Implementation Screening RCT; clinicians using vs not using a screening tool This is an important step in which the tool is evaluated clinically in one group with access to the new method compared to a second group (ideally selected in a randomized fashion) who make assessments without the tool. Phase IV_screen Implementation Screening implementation studies using real-world outcomes In this last step the screening tool /method is introduced clinically but monitored to discover the effect on important patient outcomes such as new identifications, new cases treated and new cases entering remission. Development of Diagnostic Tests
  19. 19. Concepts: Se Sp PPV NPVConcepts: Se Sp PPV NPV
  20. 20. Accuracy 2x2 TableAccuracy 2x2 Table Depression PRESENT Depression ABSENT Test +ve True +ve False +ve PPV Test ‐ve False ‐Ve True ‐Ve NPV Sensitivity Specificity Prevalence Reference Standard Disorder Present Reference Standard No Disorder Test +ve A B A/A + B PPV Test -ve C D D/C + D NPV Total A / A + C Sn D / B + D Sp
  21. 21. Basic Measures of AccuracyBasic Measures of Accuracy Sensitivity (Se) a/(a + c) TP / (TP + FN) A measure of accuracy defined the proportion of patients with disease in whom the test result is positive: a/(a + c) Specificity (Sp) d/(b + d) TN / (TN + FP) A measure of accuracy defined as the proportion of patients without disease in whom the test result is negative Positive Predictive Value a/(a+b) TP / (TP + FP) A measure of rule‐in accuracy defined as the proportion of true positives in those that screen positive screening result, as follows Negative Predictive Value c/(c+d) TN / (TN + FN) A measure of rule‐out accuracy defined as the proportion of true negatives in those that screen negative screening result, as follows
  22. 22. Concepts => FiguresConcepts => Figures
  23. 23. Graphical – Screening principles Non-Depressed Depressed # of Individuals # of Individuals Severity of Depression
  24. 24. Graphical – Screening principles Non-Depressed Depressed # of Individuals Cut-Off # of Individuals Severity of Depression HighLow
  25. 25. Graphical – Screening principles Non-Depressed Depressed # of Individuals Cut-Off # of Individuals Severity of Depression HighLow High Sensitivity >>>> <<<< high Specificity
  26. 26. Graphical – Screening principles Non-Depressed Depressed # of Individuals Cut-Off # of Individuals Severity of Depression HighLow High Sensitivity >>>> <<<< low Specificity
  27. 27. Can This Help establish a syndrome?Can This Help establish a syndrome?
  28. 28. Example: A Clear Disease [#1]Example: A Clear Disease [#1] Disorder Number of Individuals False +veFalse +ve True -veTrue -ve Point of Partial Rarity Test Result No Disorder False -veFalse -ve True +veTrue +ve
  29. 29. Example: A Probable Syndrome [#2]Example: A Probable Syndrome [#2] Disorder Number of Individuals False +veFalse +ve False -veFalse -ve True -veTrue -ve True +veTrue +ve MMSE Cognitive Score No Disorder
  30. 30. Example: A Normally Distributed Trait [#3]Example: A Normally Distributed Trait [#3] Disorder Number of Individuals False +veFalse +ve False -veFalse -ve True -veTrue -ve True +veTrue +ve MMSE Cognitive Score No Disorder
  31. 31. Example: DementiaExample: Dementia Disease? Syndrome? Trait?
  32. 32. Hubbert et al (2005) BMC GeriatricsHubbert et al (2005) BMC Geriatrics MMSE scores for dementia (n=72) and non-dementia (n=2735) Huppert et al BMC Geriatrc 2005
  33. 33. Example: DepressionExample: Depression Disease Syndrome Trait
  34. 34. Thompson et al (2001) n=18,414 HADS-DThompson et al (2001) n=18,414 HADS-D 0 500 1000 1500 2000 2500 3000 Zero O ne Tw o Three Four Five Six Seven eight N ine Ten Eleven Tw elve Thirteen Fourteen Fifteen SixteenSeventeen Eighteen
  35. 35. PHQ9 Linear distribution 0 5 10 15 20 25 30 35 Zero O ne Two Three Four Five Six Seven Eight Nine Ten Eleven Twelve Thirteen Fourteen Fifteen Sixteen Seventeen Eighteen PHQ9 (Major Depression) PHQ9 (Minor Depression) PHQ9 (Non-Depressed) Baker-Glen, Mitchell et al (2008)
  36. 36. T1. Science ExamplesT1. Science Examples 2x2 tables workshop
  37. 37. Accuracy in wordsAccuracy in words Sensitivity The chance of testing positive among those with the condition The chance of rejecting the null hypothesis among those that do not satisfy the null hypothesis Specificity The chance of testing negative among those without the condition The chance of accepting the null hypothesis among those that satisfy the null hypothesis Positive Predictive Value The chance of having the condition among those that test positive The chance of not satisfying the null hypothesis among those that reject the null hypothesis Negative Predictive Value The chance of not having the condition among those that test negative The chance of satisfying the null hypothesis among those that accept the null hypothesis Type I Error or α (alpha) or p-Value or false positive rate The chance of testing positive among those without the condition The chance of rejecting the null hypothesis among those that satisfy the null hypothesis Type II Error or β (beta) or false negative rate The chance of testing negative among those with the condition The chance of accepting the null hypothesis among those that do not satisfy the null hypothesis False Discovery Rate or q-Value The chance of not having the condition among those that test positive The chance of satisfying the null hypothesis among those that reject the null hypothesis False Omission Rate The chance of having the condition among those that test negative The chance of not satisfying the null hypothesis among those that accept the null hypothesis
  38. 38. Rule-in AccuracyRule-in Accuracy Depression PRESENT Depression ABSENT Test +ve True +ve False +ve (type I error) PPV (discrimination) Test -ve False –Ve (type II error) True -Ve NPV Sensitivity (occurrence) Specificity Prevalence
  39. 39. Rule-Out AccuracyRule-Out Accuracy Depression PRESENT Depression ABSENT Test +ve True +ve False +ve PPV Test -ve False –Ve (type II error) True -Ve NPV (discrimination) Sensitivity Specificity (occurrence) Prevalence
  40. 40. Accuracy 2x2 TableAccuracy 2x2 Table Depression PRESENT Depression ABSENT Test +ve True +ve False +ve PPV Test -ve False -Ve True -Ve NPV Sensitivity Specificity Prevalence
  41. 41. Test vs Major DepressionTest vs Major Depression Depression PRESENT Depression ABSENT Test +ve 500 1500 2000 Test -ve 500 4500 5000 1000 6000 7000 Sensitivity 50% PPV 25% Specificity 75% NPV 90% Prevalence 14%
  42. 42. Test vs Major + Min DepressionTest vs Major + Min Depression Depression PRESENT Depression ABSENT Test +ve 500 1500 2000 Test -ve 500 500 1000 1000 2000 3000 Sensitivity 50% PPV 25% Specificity 33% NPV 50% Prevalence 33%
  43. 43. T2. Advanced TechniquesT2. Advanced Techniques Combined tests Added Value Cut-Offs Prevalence adjustments
  44. 44. Summary MeasuresSummary Measures Youden's J Sensitivity + Specificity – 1 Predictive Summary Index PPV + NPV – 1 Overall accuracy (fraction correct) TP+TN / TP+FP+TN+FN
  45. 45. Added ValueAdded Value Definition 1: The additional ability of a test to rule‐in or rule‐out compared with the baseline rate PPV minus Prevalence NPV minus prevalence Definition 2: The additional of a test to rule‐in or rule‐out compared with the unassisted rate PPV test minus PPV no test (assuming equal prevalence) LR+ test minus LR+ no test AUC test minus AUC no test
  46. 46. Reciprocal MeasuresReciprocal Measures Number Needed to Diagnose (NND) 1 / (Youden's J) Number Needed to Predict (NNP) 1 / (PSI) Number Needed to Screen (NNS) 1/(FC‐FiC)
  47. 47. -0.10 0.00 0.10 0.20 0.30 0.40 0.50 Anger Anxiety Decreasedappetite Decreasedweight Depressedmood Diminishedconcentration DiminisheddriveDiminishedinterest/pleasure Excessiveguilt Helplessness Hopelessness Hypersomnia Increasedappetite Increasedweight Indecisiveness Insomnia Lackofreactivemood Lossofenergy Psychicanxiety Psychomotoragitation Psychomotorchange Psychomotorretardation Sleepdisturbance Somaticanxiety Thoughtsofdeath Worthlessness Rule-In Added Value (PPV-Prev) Rule-Out Added Value (NPV-Prev)
  48. 48. Accuracy of Tests: Visual Post-test ProbabilitiesAccuracy of Tests: Visual Post-test Probabilities 0% 100%25% 75% Very unlikely Very likelylikelyunlikely 2 Questions Overall PHQ-2 WHO5 (1+3) 1 Question 3% - (37) - 63% = 60% 3% - (16) - 32% = 29% 3% - (16) - 32% = 29% 10% - (22) -50% = 54% 32% - (37) - 96% = 64% Henckel et al (2004) Eur Arch Psychiatry Clin Neuros CIDI (computer) Any Depression Henckel et al (2004) Eur Arch Psychiatry Clin Neuros CIDI (computer) Any Depression Arroll B et al (2003) BMJ CIDI (computer) Mj Depression CIDI (computer) Mj Depression
  49. 49. Murphy JM, Berwick DM, Weinstein MC, Borus JF, Budman SH, Klerman GL 1987 : Performance of screening and diagnostic tests: Application of Receiver Operating Characteristic ROC analysis. Arch Gen Psychiatry 44:550-555 Receiver Operating Characteristic
  50. 50. 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Pre-test Probability Post-testProbability Depression Present (Routine) Depression Absent (Routine) Depression Scales +ve (Median) Depression Scales -ve (Median) Prior Probability PPV=0.41 NPV=0. 97 Prevalence of 0.15
  51. 51. Group Work #1Group Work #1 930-10.00 – Introduction, groups and issues 10.00-11.00 – T1 Basic science of screening Break 11.30 – 12.30 – Group task #1 Lunch 1.30-2.30 – T2 Symptoms, Burden, Help, Needs in Cancer Break 3.00 – 4.00 – Evaluation of a screening paper
  52. 52. Cancer Mj Depression vs NonMjCancer Mj Depression vs NonMj Clinicians diagnosis using DSMIV vs SCAN/PSE 50 people with depression 200 without depression
  53. 53. Clinicians using DSMIVClinicians using DSMIV IF: Clinicians diagnosed 50 cases with depression IF: Their specificity was 95% Q. What was the sensitivity? Q. What was the prevalence? Q. What was the PPV? Q. What was overall accuracy
  54. 54. Test vs Major DepressionTest vs Major Depression Depression On SCAN Depression ABSENT Test +ve (Clinician) 40 10 50 Test -ve 10 190 50 200 Sensitivity 80% PPV 80% Specificity 95% NPV 95% Prevalence 0.20%
  55. 55. 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Pre-test Probability Post-testProbability NH NAs+ NH NAs- Baseline Probability
  56. 56. Cancer Mj+Mn Depression vs NonCancer Mj+Mn Depression vs Non Clinicians diagnosis using DSMIV vs SCAN/PSE 50 people with depression 200 without depression => 50 had minor depression
  57. 57. => Answer 2=> Answer 2
  58. 58. Test vs Major DepressionTest vs Major Depression Depression On SCAN Depression ABSENT Test +ve (Clinician) 50 0 50 Test -ve 50 150 200 100 150 Sensitivity 50% SN-OUT PPV 100% Specificity 100% SP-IN NPV 40% Prevalence 66.7%
  59. 59. 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Pre-test Probability Post-testProbability NH NAs+ NH NAs- Baseline Probability
  60. 60. Likelihood RatiosLikelihood Ratios Likelihood Ratio for Positive Tests The chance of testing positive among those with the condition; divided by the chance of testing positive among those without the condition Sensitivity / (1 - Specificity) [ TP / (TP + FN) ] / [ FP / (FP + TN) ] = PPV / Prevalence Likelihood Ratio for Negative Tests The chance of testing negative among those with the condition; divided by the chance of testing negative among those without the condition Specificity / (1 – Sensitivity) [ FN / (FN + TP) ] / [ TN / (TN + FP) ] = NPV / Prevalence
  61. 61. T3. Symptoms, Help, Needs in CancerT3. Symptoms, Help, Needs in Cancer Clinician Opinion Patient Opinion
  62. 62. Psychosocial Complications Help Seeking Symptoms Recognized Intervention Offered Help Accepted Complication Resolves Lag time Lag time Lag time Lag time Lag time years months weeks weeks days Cancer Onset Cancer Progress Lessons?
  63. 63. 462 (42%) Meetable Needs 1093 (100%) Population 388 (84%) Aware of Need 172 (44%) Requested Help 80 (47%) Needs Met 462 needs 17.3% 322 DSMIV 25%
  64. 64. T4. How Common is Distress?T4. How Common is Distress? Clinician Opinion Patient Opinion
  65. 65. Requires depressed mood for most of the day, for most days (by subjective account or observation) for at least 2 years The symptoms cause clinically significant distress OR impairment in social, occupational, or other important areas of functioning. Requires persistently low mood two (or more) of the following six symptoms: (1) poor appetite or overeating (2) Insomnia or hypersomnia (3) low energy or fatigue (4) low self-esteem (5) poor concentration or difficulty making decisions (6) feelings of hopelessness DSM-IV Dysthymic disorder Acute: if the disturbance lasts less than 6 months Chronic: if the disturbance lasts for 6 months These symptoms cause marked distress that is in excess of what would be expected from exposure to the stressor OR significant impairment in social or occupational (academic) functioning Requires the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months. DSM-IV Adjustment disorder 2 weeksThese symptoms cause clinically important distress OR impair work, social or personal functioning. Requires two to four out of nine symptoms with at least at least one from the first two (depressed mood and loss of interest). DSM-IV Minor Depressive Disorder 2 weeksThese symptoms cause clinically important distress OR impair work, social or personal functioning. Requires five or more out of nine symptoms with at least at least one from the first two (depressed mood and loss of interest). DSM-IV Major Depressive Disorder 2 weeks unless symptoms are unusually severe or of rapid onset). At least some difficulty in continuing with ordinary work and social activities Requires two of the first three symptoms (depressed mood, loss of interest in everyday activities, reduction in energy) plus at least two of the remaining seven symptoms (minimum of four symptoms) ICD-10 Depressive Episode DurationClinical SignificanceSymptoms
  66. 66. Depression 13% 20% 57% 48% 38% 18% Anxiety Adjustment Disorder N=11 N=4 N=10 Comment: Slide illustrates meta-analytic rates of mood disorder
  67. 67. Prevalence of depression in Palliative settings 20 studies involving 2655 individuals 16.9% (95% CI = 13.2% to 21.0%) 13.0% (95% CI = 11.6% to 14.5%) for MDD p572 Proportion meta-analysis plot [random effects] 0.0 0.2 0.4 0.6 combined 0.17 (0.13, 0.21) Maguire et al (1999) 0.05 (0.01, 0.14) Akechi et al (2004) 0.07 (0.04, 0.11) Kadan-Lottich et al (2005) 0.07 (0.04, 0.11) Love et al (2004) 0.07 (0.04, 0.11) Wilson et al (2004) 0.12 (0.05, 0.22) Chochinov et al (1997) 0.12 (0.08, 0.18) Wilson et al (2007) 0.13 (0.10, 0.17) Kelly et al (2004) 0.14 (0.06, 0.26) Chochinov et al (1994) 0.17 (0.11, 0.24) Le Fevre et al (1999) 0.18 (0.10, 0.28) Breitbart et al (2000) 0.18 (0.11, 0.28) Meyer et al (2003) 0.20 (0.10, 0.35) Minagawa et al (1996) 0.20 (0.11, 0.34) Lloyd-Williams et al (2001) 0.22 (0.14, 0.31) Hopwood et al (1991) 0.25 (0.16, 0.36) Desai et al (1999) [late] 0.25 (0.10, 0.47) Payne et al (2007) 0.26 (0.19, 0.33) Lloyd-Williams et al (2003) 0.27 (0.17, 0.39) Jen et al (2006) 0.27 (0.19, 0.36) Lloyd-Williams et al (2007) 0.30 (0.24, 0.36) proportion (95% confidence interval)
  68. 68. Prevalence of depression in Oncology settings 57 studies involving 9195 individuals across 12 countries. The prevalence of depression was 17.3% (95% CI = 13.8% to 21.2%), 13.0% (95% CI = 11.6% to 14.5%) for MDD p572 Proportion meta-analysis plot [random effects] 0.0 0.3 0.6 0.9 combined 0.1730 (0.1375, 0.2116) Colon et al (1991) 0.0100 (0.0003, 0.0545) Massie and Holland (1987) 0.0147 (0.0063, 0.0287) Hardman et al (1989) 0.0317 (0.0087, 0.0793) Derogatis et al (1983) 0.0372 (0.0162, 0.0720) Lansky et al (1985) 0.0455 (0.0291, 0.0676) Mehnert et al (2007) 0.0472 (0.0175, 0.1000) Katz et al (2004) 0.0500 (0.0104, 0.1392) Singer et al (2008) 0.0519 (0.0300, 0.0830) Sneeuw et al (1994) 0.0540 (0.0367, 0.0761) Pasacreta et al (1997) 0.0633 (0.0209, 0.1416) Lee et al (1992) 0.0660 (0.0356, 0.1102) Reuter and Hart (2001) 0.0761 (0.0422, 0.1244) Grassi et al (2009) 0.0826 (0.0385, 0.1510) Grassi et al (1993) 0.0828 (0.0448, 0.1374) Walker et al (2007) 0.0831 (0.0568, 0.1165) Kawase et al (2006) 0.0851 (0.0553, 0.1240) Coyne et al (2004) 0.0885 (0.0433, 0.1567) Alexander et al (2010) 0.0900 (0.0542, 0.1385) Love et al (2002) 0.0957 (0.0650, 0.1346) Ozalp et al (2008) 0.0971 (0.0576, 0.1510) Morasso et al (2001) 0.0985 (0.0535, 0.1625) Costantini et al (1999) 0.0985 (0.0535, 0.1625) Silberfarb et al (1980) 0.1027 (0.0587, 0.1638) Desai et al (1999) [early] 0.1111 (0.0371, 0.2405) Morasso et al (1996) 0.1121 (0.0593, 0.1877) Prieto et al (2002) 0.1227 (0.0825, 0.1735) Ibbotson et al (1994) 0.1242 (0.0776, 0.1853) Payne et al (1999) 0.1290 (0.0363, 0.2983) Kugaya et al (1998) 0.1328 (0.0793, 0.2041) Alexander et al (1993) 0.1333 (0.0594, 0.2459) Gandubert et al (2009) 0.1597 (0.1040, 0.2300) Razavi et al (1990) 0.1667 (0.1189, 0.2241) Akizuki et al (2005) 0.1797 (0.1376, 0.2283) Leopold et al (1998) 0.1887 (0.0944, 0.3197) Devlen et al (1987) 0.1889 (0.1141, 0.2851) Berard et al (1998) 0.1900 (0.1184, 0.2807) Joffe et al (1986) 0.1905 (0.0545, 0.4191) Berard et al (1998) 0.2100 (0.1349, 0.3029) Maunsell et al (1992) 0.2146 (0.1605, 0.2772) Grandi et al (1987) 0.2222 (0.0641, 0.4764) Evans et al (1986) 0.2289 (0.1438, 0.3342) Spiegel et al (1984) 0.2292 (0.1495, 0.3261) Golden et al (1991) 0.2308 (0.1353, 0.3519) Fallowfield et al (1990) 0.2565 (0.2054, 0.3131) Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249) Kathol et al (1990) 0.2961 (0.2248, 0.3754) Green et al (1998) 0.3125 (0.2417, 0.3904) Jenkins et al (1991) 0.3182 (0.1386, 0.5487) Burgess et al (2005) 0.3317 (0.2672, 0.4012) Hall et al (1999) 0.3722 (0.3139, 0.4333) Morton et al (1984) 0.3958 (0.2577, 0.5473) Baile et al (1992) 0.4000 (0.2570, 0.5567) Passik et al (2001) 0.4167 (0.2907, 0.5512) Bukberg et al (1984) 0.4194 (0.2951, 0.5515) Massie et al (1979) 0.4850 (0.4303, 0.5401) Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920) Levine et al (1978) 0.5600 (0.4572, 0.6592) Plumb & Holland (1981) 0.7750 (0.6679, 0.8609) proportion (95% confidence interval)
  69. 69. Distress Thermometer
  70. 70. Distress Thermometer – Pooled Table Score Ransom 2006 Tuinman 2008 Mitchell 2009 Lord 2010 Hoffman 2004 Gessler 2009 Clover 2009 Jacobsen 2005 Sum Proporti on Zero 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 2543 Proportion 19.3% 10.9% 13.8% 18.9% 2.7% 6.2% 13.4% 14.9%
  71. 71. Proportion 18 .4 % 12 .9 % 11.2 % 12 .3 % 8 .1% 11.9 % 5.0 % 2 .8 % 2 .6 % 7.7% 7.2 % 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0% Zero One Two Three Four Five Six Seven Eight Nine Ten Insignificant SevereModerateMildMinimal p124 50%
  72. 72. T5. Getting HelpT5. Getting Help Clinician Opinion Patient Opinion
  73. 73. Arrol et al (2005) BMJArrol et al (2005) BMJ Setting 19 general practitioners in six clinics in New Zealand. Participants 1025 consecutive patients receiving no psychotropic drugs. After screening “is this something you would like help with? The help question alone had a sensitivity of 75% and a specificity of 94% The general practitioner with PHQ2 diagnosis had a sensitivity of 79% and a specificity of 94%
  74. 74. Arrol (2005) – Mj DepressionArrol (2005) – Mj Depression 47 CIDI cases with Major depression 25 (53%) wanted help 10 (21%) wanted the option of help 12 (25%) did not want help
  75. 75. Arrol (2005) – No DepressionArrol (2005) – No Depression 889 CIDI cases with Major depression 27 (3%) wanted help 24 (3%) wanted the option of help 838 (94%) did not want help
  76. 76. 2x2 Help Table2x2 Help Table Clinician thinks: Help Needed Clinician thinks: Help Not Needed Patient Says: Help Wanted => Intervention => Refuse? Patient Says: Help Not Wanted => Delay =>Agree discharge
  77. 77. MethodologyMethodology Study I: Baker-Glen, Symonds, Granger “ET Validation” (a) n=129 chemotherapy attendees (b) n=86 chemotherapy f/u Study II: Sampson, Symonds, Granger “ET Extension” (c) n=250 chemotherapy + late Study III: Lord, Symonds, Granger “Coping” (d) n=250 Study IV: Mitchell, Symonds, Steward “SMI RCT” (e) n=300
  78. 78. Help – Who Wants Help?Help – Who Wants Help? 20% said they wanted professional help for psychosocial issues. Only 36% of those distressed on the DT wanted help.
  79. 79. Help – Do They Need It?Help – Do They Need It? 27% had major depression 62% had major or minor depression 88% had some distress (HADS, PHQ, DT)
  80. 80. Are Those Not Wanting Help OK?Are Those Not Wanting Help OK? 41/104 (39%) of decliners had no identifiable condition => 61% of those refusing help actually have a potentially serious psychosocial condition.
  81. 81. What Kind of Help is Wanted?What Kind of Help is Wanted? 19% wanted medication (eg antidepressants) 31% want self help guidelines 31% wanted group therapy 56% wanted illness information. 58% complementary therapies 62% face-to-face psychological support
  82. 82. Help – Who From?Help – Who From? Nurse specialists (54%) Family and friends (21%) Spiritual advisor (8%) Psychiatrist (4%).
  83. 83. Why Not Needed?Why Not Needed? “getting help elsewhere” (57%) “feel well” (41%) “coping on my own” (31%) “fear of stigma”, “fear of side effects”, “not likely to be effective for me”, and “don’t like to talk about problems” (all less than 10%)
  84. 84. 4. Is Help a Predictor?4. Is Help a Predictor?
  85. 85. Help as a Predictor of Depression?Help as a Predictor of Depression? Outcome Predictor Sensitivity Specificity PPV NPV DSMIV Major Depression Help QQ Alone 0.47 0.83 0.27 0.92 DSMIV Mj + Minor Depression Help QQ Alone 0.36 0.88 0.39 0.86 DSMIV Mj + Minor Depression Help QQ AND PHQ2 0.36 0.99 0.88 0.88
  86. 86. Can This Be Used Clinically?Can This Be Used Clinically?

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