This is an invited presentation from the NCRS 2010 asking "what is the association between distress on the distress thermometer and dysfunction". This help to find a cut-off on the DT based on function.

1. NCRS 2010
Validation of the Distress Thermometer using ADL:
What is the relationship between distress and dysfunction?
Alex Mitchell
Karen Lord
Paul Symonds
Department of Cancer & Molecular Medicine, Leicester Royal Infirmary
Department of Liaison Psychiatry, Leicester General Hospital
Sept2010
Sept2010

2. Contents
1. Strengths & limitations of DT
2. How to establish “clinical significance” simply
3. Link between distress and dysfunction
4. Lessons for DT cut-offs

3. Clinical Significance
DSMIV and PHQ9
Includes a question
on function

4. 1. Strengths & limitations of DT
Strengths => Mainly Acceptability
Limitations => Reliability and Validity

5. DT vs HADS-T Validity (n=660) Leicester2009
SE SP AUC CUT
DT – 71.9% 78.4% 0.814 cut point >=4
AnxT – 75.7% 73.4% 0.821 cut point >=5
DepT – 77.6% 82.2% 0.855 cut point >=3
AngT – 77.5% 77.6% 0.823 cut point >=2
HelpT - 69.1% 80.8% 0.809 cut point >=3

6. DT vs DSMIV Depression
SE SP PPV NPV
DTma (2007) 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 Asian MA = meta-analysis (Mitchell 2007 JCO)
BW= British White

7. 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 ___________________________
___

8. Distress Thermometer
DT contains only two anchors
In its most common version.

9. Distress Thermometer – Pooled Table
Ransom Tuinman Mitchell Lord Hoffman Gessler Clover Jacobsen Proporti
Score 2006 2008 2009 2010 2004 2009 2009 2005 Sum 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%

10. Distress Thermometer – Pooled
Making a cut based on distribution frequency alone
Proportion
Is difficult, or impossible.
20.0%
Insignificant Minim al Mild Moderate Severe
18.0%
16.0%
14.0%
12.0%
10.0%
18 .4 %
8.0%
12 .9 %
6.0% 12 .3 %
11.9 %
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%

11. Making a cut based on
distribution frequency alone
Is difficult, or impossible also
for the HADS
British Journal of Cancer (2007) 96, 868 – 874

12. 3. Methods – How to Validate an Cut Point?
Establish validity with dysfunction not depression

13. Distress overlaps with not DepT
DT just distress but anxiety and
23%
37% anger
4% 3%
3%
DT DepT
7% 1%
Non-Nil 8% 0% Nil
9%
59% 41%
4% 1%
AnxT 2% AngT
15% 2%
AnxT AngT
47% 18%

14. Sample
We analysed data collected from Leicester Cancer Centre
from 2008-2010 involving 531 people approached by a
research nurse and two therapeutic radiographers.
We examined distress using the DT and daily function
using the question:
“How difficult have these problems made it for you to do
your work, take care of things at home, or get along
with other people?”
“Not difficult at all =0; Somewhat Difficult =1; Very
Difficult =2; and Extremely Difficult =3”

15. Of the 293 Non-Nil DepT
23%
Virtually no one with
depression has neither
0.3% DepT
distress nor dysfunction, but
many with dysfunction do
not have depression
3% 2%
18%
Dysfunction
Distress
28% 26% 22%
Dysfunction Distress
76% 69%

16. Dysfunction in 531 cancer patients
60.0%
55.7%
Chart illustrated distribution
50.0%
of dysfunction in unselected
cancer patients
40.0%
34.3%
30.0%
20.0%
10.0% 7.3%
2.6%
0.0%
Unimpaired Mild Moderate Severe

17. Unimpaired by DT Score
90.00%
80.00%
Chart illustrated unimpaired
function by DT score
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
1 2 3 4 5 6 7 8 9 10 11

18. Mean DT Scores?
Unimpaired Mild Moderate Severe
Mean DT Score 2.1 4.1 5.9 6.5
Std Deviation 2.54 3.0 2.56 3.59
Sample Size 296 182 39 14
Simplified DT Range* 0-3 4-5 6-7 8-10

19. DT distribution by Impairment
0.18
0.16
0.14
0.12
0.1
0.08
0.06
0.04
0.02
0
0 1 2 3 4 5 6 7 8 9 10

20. Distress Thermometer
Typically severely impared
Typically mod impared
Based on the mean levels of
Typically mildly impared
dysfunction the following
anchors are suggested
Typically unimpared NB: a lower threshold cut of
about 3 seems appropriate
None at all

21. Distress Thermometer Based on the mean levels of
dysfunction and typical
verbal descriptions of distress
the following anchors are
suggested
Extreme and incapacitating
Very Severe and very disabling
Moderately Severe and disabling
Moderate and quite disabling
Moderate and somewhat disabling
Mild-Moderate and slight disabling
Mild but not particularly disabling
Very mild and not disabling
Minimal but bearable
Minimal and not problematic
None at all

22. Credits & Acknowledgments
Karen Lord Leicester Royal Infirmary
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
Nadia Husain University of Leicester
Kufre Sampson Leicester Royal Infirmary
For more information www.psycho-oncology.info