This document discusses methods for screening and identifying depression in cancer and palliative care settings. It conducted a meta-analysis of 41 diagnostic validity studies comparing various short screening tools like the Patient Health Questionnaire-9 (PHQ-9) and Hospital Anxiety and Depression Scale (HADS) to longer scales and clinician evaluation. For non-palliative settings, the optimal method was the Beck Depression Inventory-II although the Distress Thermometer was also good. In palliative care, the optimal initial method was a two question screen. Repeated screening over time using different methods can enhance detection rates compared to a single screening.

1. T126 --Screening and Case Identification for Depression in
T126 Screening and Case Identification for Depression in
Cancer and Palliative Settings:
Cancer and Palliative Settings:
A Meta-Analysis of Diagnostic Validity Studies
A Meta-Analysis of Diagnostic Validity Studies
Alex Mitchell www.psycho-oncology.info
Department of Cancer & Molecular Medicine, Leicester Royal Infirmary
Department of Liaison Psychiatry, Leicester General Hospital
IPOS2010
IPOS2010

2. 1. Background
What methods are used to detect mood disorders?
How often do clinicians look for mood complications?

3. Methods to Evaluate Depression
Conventional Scales
Short (5-10) Long (10+)

4. Comment: This is a reminder of the
structure of the HADS scale, this version
adapter for cancer.

5. Methods to Evaluate Depression
Conventional Scales
Short (5-10) Long (10+)
Ultra-Short (<5)

6. Methods to Evaluate Depression
Unassisted Clinician Conventional Scales
Untrained Trained Ultra-Short (<5) Short (5-10) Long (10+)
Acceptability ?
Accuracy? Accuracy?
Routine Implementation
vs Comment: schematic overview of
methods to evaluate depression

7. Comment: Frequency of cancer specialists
n=226 enquiry about depression/distress from
Mitchell et al (2008)

8. 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

11. Validity of Methods to Evaluate Depression
Unassisted Clinician Conventional Scales
Untrained Trained Ultra-Short (<5) Short (5-10) Long (10+)

12. 5. Meta-Analysis
What can enhance detection?

13. Methods
There were 41 valid analyses; prevalence of depression
was 24.3% (95% CI = 17.3% to 32.0%).
29 in oncology settings… 3x studies on the BDI-II, From 4
studies using the DT and remainder of studies involved
the HADS.
Only 12 in palliative settings (most HADS; non with DT)
Inc 3x studies involving Two Questions and 3 studies of
the EPDS
Unfortunately most had not received independent
validation.

14. Common Methods
DT
BDI
BDI fast screen
PHQ-9
PHQ-2 / two stem questions
GHQ-12 and GHQ-28
CES-D
GDS-30
GDS-15
Zung SDS
HADS-D
HDRS.

15. 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

16. Palliative
1.00
Post-test Probability
0.90
0.80
0.70
0.60
HADS-D+
0.50 HADS-D-
Baseline Probability
0.40 2Q+
2Q-
EPDS+
0.30
EPDS-
1Q+
0.20 1Q-
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

17. Non-Palliative
1.00
Post-test Probability
0.90
0.80
0.70
0.60
1Q+
1Q-
0.50
Baseline Probability
HADS-D+
HADS-D-
0.40 HADS-T+
HADS-T-
BDI+
0.30 BDI-
HADS-A+
HASD-A-
DT+
0.20 DT-
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

18. MDD - Palliative and Non-Palliative
1.00
Post-test Probability
0.90
0.80
0.70
0.60
1Q+
1Q-
0.50 Baseline Probability
DT+
DT-
2Q+
2Q-
0.40 HADSd+
HADSd-
HADS-T+
HADS-T-
0.30 BDI+
BDI-
EPDS+
EPDS-
HADS-A+
0.20 HASD-A-
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

19. Summary
From 29 non-palliative-
The optimal method was the BDI-II although the DT was
good in a screening capacity.
Across 12 palliative analyses (n=1760) –
The optimal initial method was the two question
approach.

20. 5. Cancer Care – Cumulative Testing
What repeat testing enhance detection?

21. N = 1000
Cancer Population
n = 200 n = 800
Depression No Depression
Se 70%
CNS Assessment Sp 55%
Screen #1 Screen #1
+ve -ve
PPV 28% NPV 88%
TP = 140 TN =440
Possible case FP = 360
Probable Non-Case FN = 60
TN = 440 FP = 360 Se 70% PPV 28%
Yield TP = 140 FN = 60 Sp 55% NPV 88%

22. N = 1000
Cancer Population
n = 200 n = 800
Depression No Depression
Se 70%
CNS Assessment Sp 55%
Screen #1 Screen #1
+ve -ve
PPV 28% NPV 88%
TP = 140 TN =440
Possible case FP = 360
Probable Non-Case FN = 60
Sp 40%
Oncologist Assessment Sp 80%
Screen #2 Screen #2
+ve +ve
PPV 44% NPV 77%
TP = 56 TN =288
Probable Depression FP = 72
Probable Non-Case FN = 84
TN = 728 FP = 72 Se 28% PPV 44%
Cumulative Yield TP = 56 FN = 144 Sp 91% NPV 83%

24. 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
James Coyne University of Pennsylvania
Nadia Husain University of Leicester
For more information www.psycho-oncology.info

25. FURTHER READING:
Screening for Depression in Clinical Practice An
Evidence-Based guide
ISBN 0195380193
Paperback, 416 pages
Nov 2009
Price: £39.99