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.

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
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e
nd
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m
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a
nd
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i
an
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ai
la
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co
om
co
gi
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m
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Is
kr
rla
a
Fr
el
In
er
In
Ze
ol
U
h
B
he
G
w
ut
h
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ew
et
g
Lo
So
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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

13. Study: Coyne Thombs Mitchell
N= 4500; Pooled database study; All comparative studies
Physical illness+comorbid depression
Vs
Physical illness alone
Vs
Primary depression alone

14. 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
*

15. Comment: Slide illustrates assumed overlap of
primary and secondary depression
Primary Depression Alone
Fatigue
Anorexia
Insomnia
Concentration
Secondary
Medically Unwell Alone Depression

16. Comment: Slide illustrates actual overlap
of primary and secondary depression
Primary Depression Alone
Secondary
Depression
Agitation
Retardation

17. 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
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so pe ic
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ni C
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(a
ny or
ty bi
Lo pe d)
ss )(
In M
te ed
r es ic
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t(
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om
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te bi
r es d)
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w M
M ed
ic
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(C
om
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w or
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d)
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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

18. Comment: Slide illustrates concept of
phenomenology of depressions in
medical disease
Primary Depression Alone
Fatigue
Anorexia
Insomnia
Concentration
Secondary
Medically Unwell Alone Depression

19. Comment: Slide illustrates actual
phenomenology of depressions in
medical disease
Primary Depression
Secondary
Depression
Weight loss
Agitation
Retardation
Medically Unwell

20. Elderly?

21. 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
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on d
ce
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im ra
in tio
is n
he
d
*
In
te
*
Ex re
ce st
ss
iv
e
G
H ui
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es
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cr sn
ea es
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d
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In pe
cr tit
ea e
se
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W
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de gh
ci t
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ve
ne
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yc of
ho E
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ot rg
yc or y
ho A
Sl m gi
*
ee ta
p ot
tio
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n
Sl is R
ee tu et
p rb ar
D an da
is ce tio
tu n
rb (C
an om
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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
*
*
*

22. 3. Cancer Care - Detection
How well do cancer specialists identify depression/distress?
How do doctors compare with nurses?

23. 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

24. 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

25. Phase I

26. 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

27. 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).

28. 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.

29. 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

30. 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