15th IPOS debate on Screening for Distress by alex_j_mitchell in Rotterdam. Against the motion was Jim Coyne.

1. Screening for Distress Debate
Alex Mitchell
University of Leicester
www.twitter.com/_alexjmitchell
www.psycho-oncology.info
#ipos2013

8. …What are the sources of disagreement?

9. Areas of Disagreement:
1.How
to screen (which tool)
2.When to screen
3.How often to screen
4.Which screening population
5.Who should screen
6.Does screening work

10. ……in short
Should we screen at all?

11. But what are the alternatives to screening?

12. 1.
Diagnosis as usual (do nothing)
2.
Enhanced diagnosis (clinician = screen)
3.
Screen everyone
4.
Screen high risk (targeted screening)

13. 100.0
5.9
11.1
90.0
Comment: Slide illustrates diagnostic
accuracy according to score on DT
80.0
43.5
25.9
38.7
11.8
38.1
22.2
46.7
59.6
70.0
21.4
14.3
14.3
21.4
72.4
Judgement = Non-distressed
60.0
33.3
19.4
50.0
26.1
40.0
Judgement = Unclear
Judgement = Distressed
19.0
82.4
24.4
66.7
30.0
20.0
57.1
25.0
41.9
15.8
30.4
10.0
11.8
71.4
Three
40.7
Four
Five
Six
28.9
Two
42.9
15.4
0.0
Zero
One
Seven
Eight
Nine
Ten

14. Lessons from primary care….

16. Results disappointing
Acceptability overlooked
Most are not depressed
Many do not want help
Some are already Rx

17. Screening in Cancer

18. Missed diagnosis
GP =
CNS =
Oncologists

19. Screening tools (validity)

23. Depression
Distress
Brief / ultra-short
Multi-domain

27. Implementation evidence
Randomized
Non-Randomized

28. Q. What type of studies?
Q. How many +ve studies?
Q. What are the beneficial outcomes?
Q. What is the size of the effect?

29. Implementation Reviews

33. Implementation Studies

9 studies Distress =>

6 studies
=>
Referral
Communication

36. ….this is getting complex…….
………………..what is the overall effect?

37. Overall Effect of screening
Baseline CARE
x%
with screening
+10% (0-20%)

38. Overall Effect of screening
Baseline CARE
x%
with screening
+10%
+ follow-up
+treatment
+10%
+10%

39. What is holding back screening success?

40. BOTH. How Many Receive Ps Help? (n=2557)
Proportion meta-analysis plot [random effects]
Kadan-Lottick et al (2005)
0.89 (0.77, 0.96)
Plass and Koch (2001)
0.60 (0.46, 0.72)
Siedentopf et al (2009)
0.46 (0.35, 0.58)
Fritsche et al (2004)
0.43 (0.28, 0.59)
Bogaarts et al (2011)
0.38 (0.27, 0.49)
Söllner et al (2004)
0.35 (0.26, 0.45)
Shimizu et al (2005)
0.28 (0.18, 0.41)
Shimizu et al (2009)
0.25 (0.18, 0.33)
Merckaert et al (2009)
0.21 (0.17, 0.25)
Morasso et al (2010)
0.16 (0.05, 0.33)
Sharpe et al (2004)
0.15 (0.10, 0.22)
McDowell et al (2010)
0.14 (0.11, 0.18)
combined
0.35 (0.25, 0.46)
0.0
0.2
0.4
0.6
proportion (95% confidence interval)
0.8
1.0

41. 12mo Service Use (NIH, 2002)
40
34.6
32.7
35
Cancer n=4878
No Cancer n=90,737
30
25
19.1
20
16.1
% Receiving Any treatment for Mental Health
14
15
10
11.7 11
7.2
5.7
6.3
5.7 5
6.4
5
8.9
7.7
6.5
6.2
3.9
5
2.3
3.2
1.8
75+
y ea
rs
6574
ear
s
4564
y
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rs
1844
con
diti o
ns
hro
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di ca
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3c
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hro
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di ca
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con
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con
diti o
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hro
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di ca
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1c
con
d iti
No
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Me
n ta
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No
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Hea
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P
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0
Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical
Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590

43. Overall Effect of screening
Baseline CARE x =
35%
with screening
+10% (0-20%)
+ follow-up
+treatment
+10% (0-20%)
+10% (0-20%)

44. ……..So is screening successful or not?
…….It depends

45. Analogy: How do we reduce speeding drivers?
US deaths 10,000

48. Analogy
Aim is to reduce speed (and hence deaths)
Not simply to detect speeding!

49. Aim is to reduce distress (improving QoL)
Not simply to detect distress!

50. 1

51. 2

52. 3

53. 0. Summary
Screening can be ineffective or effective
Screening may be optional or mandated