This is a talk delivered June 2009 to IPOS conference Vienna Austria. The topic is a small meta-analysis of clinicians accuracy in detecting depression in cancer settings.

1. IPOS2009 – Talk
IPOS2009 – Talk
How Accurate are Cancer Professionals’
How Accurate are Cancer Professionals’
Assessments of depression and distress:
Assessments of depression and distress:
A Meta-analysis of Diagnoses by Oncologists & Clinical Nurse Specialists
A Meta-analysis of Diagnoses by Oncologists & Clinical Nurse Specialists
Alex Mitchell alex.mitchell@leicspart.nhs.uk
NHS Consultant Liaison Psychiatrist, Leicester Royal Infirmary UK
Paul Symonds
Reader in Clinical Oncology, Leicester Royal Infirmary UK
Individual Lecture 2-24June 2009: 9.00am (Category Communication Skills) Sess 13 Lect 3

2. Background
Background

3. Methods to Evaluate Depression
Unassisted Clinician Conventional Scales
Untrained Trained Short (5-10) Long (10+)
Ultra-Short (<5)
Acceptability? Acceptability ? Acceptability ?
Accuracy? Accuracy? Accuracy?
Implementation Implementation Implementation

4. n=226 How=>

5. 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%
[handout 6]

6. Cancer Staff Psychiatrists
Ideal Method (n=226)
Effective?
Long QQ
8%
Clinical Skills Clinical Skills
Alone Alone
Algorithm 20%
17%
26%
ICD10/DSMIV
24%
ICD10/DSMIV 1,2 or 3 Sim ple
0% 1,2 or 3 Sim ple QQ
QQ 24%
Short QQ 34%
23%
Short QQ
24%
[handout 6]
Validity=>

7. Assessing Clinicians
Assessing Clinicians

9. Testing Clinicians vs DT
114 ratings from clinical nurse specialists (CNS).
81 individuals (71%) scored above a cut-off of 3 (mild distress)
64 patients (56%) scored above a cut-off of 4 (moderate distress)
37 (32.4%) individuals scores above 5 (severe distress)
[handout 7]

10. Results
DT 3v4 (mild, high prevalence)
DT 4v5 (moderate, medium prevalence)
DT 5v6 (severe, low prevalence)

11. 1.00
Post-test Probability
0.90
0.80
0.70
0.60
0.50
0.40
Severe Distress CNS+
0.30
Severe Distress CNS-
Baseline Probability
Mild Distress CNS+
0.20
Mild Distress CNS-
Mod Distress CNS+
Mod Distress CNS-
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

12. Assessing Clinicians – Meta-Analysis
Assessing Clinicians – Meta-Analysis

13. Testing Clinicians: A Meta-Analysis
Methods
12 studies reported in 7 publications. Two studies examined
detection of anxiety, 8 broadly defined depression (includes
HADS-T), 3 strictly defined depression and 7 broadly defined
distress.
9 studies involved medical staff and 2 studies nursing staff. Gold
standard tools including GHQ60, GHQ12 HADS-T, HADS-D,
Zung and SCID.
The total sample size was 4786 (median 171).

14. Testing Clinicians: A Meta-Analysis
Results
All cancer professionals
SE =39.5% and SP =77.3%.
Oncologists
SE =38.1% and SP = 78.6%; a fraction correct of 65.4%.
By comparison nurses
SE = 73% and SP = 55.4%; FC = of 60.0%.
When attempting to detect anxiety
oncologists managed a SE = 35.7%, SP = 89.0%, FC 81.3%.
Individual Lecture 2-24June 2009: 9.00am (Category Communication Skills) Sess 13 Lect 3

15. 1.00
0.90 Post-test Probability
PPV NPV
0.80
Doctor 0.458 0.724
0.70
Nurse 0.368 0.852
0.60
0.50
0.40
Nurse Positive
0.30
Nurse Negative
Baseline Probability
0.20
Doctor Postive
Doctor Negative
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
N=10 vs N=2

16. Cumulative Recognition
Cumulative Recognition
=> Combinations
=> Combinations

17. 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%

18. 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%

19. Poster session 3
(25 June 2009)
Poster category
1
(Communication
skills) Poster Nr.
18

20. 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
Brett Thombs McGill University Canada
James Coyne University of Pennsilvania
For more information www.psycho-oncology.info