This is the opening keynote lecture from the IX Congresso Portugues de Psico-Oncologia in Porto (Oporto) Portugal 22-oct-2010.

1. Alex Mitchell www.psycho-oncology.info
Department of Cancer & Molecular Medicine, Leicester Royal Infirmary
Department of Liaison Psychiatry, Leicester General Hospital
Portugal 2010Portugal 2010
IX Congresso Portugues de Psico-Oncologia
How do investigations inform clinical practice?
IX Congresso Portugues de Psico-Oncologia
How do investigations inform clinical practice?

2. T1. BackgroundT1. Background
Survivorship
Treatment rates

3. 10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases

4. 0
10
20
30
40
50
60
70
80
90
100
M
elanom
aBreast(fem
ale)U
rinary
bladder
Prostate
C
olon
Allsites
R
ectum
N
on-H
odgkin
lym
phom
a
O
vary
Leukem
ia
Lung
and
bronchus
Pancreas
1975-1977
1984-1986
1996-2004
Change
5 Year Survival in US Cancers

6. Suicidal ThoughtsSuicidal Thoughts
Studied 554 (411 BW 143 BSA).
We measured suicidal thoughts :
not at all 0; several days 1; more than half the days 2; nearly
every day 3. We report here, the proportion of people with any
suicidal thoughts (non zero scores).
All = 8%
Of major or minor depression. 22% had suicidal thoughts
Of major depression 36% had suicidal thoughts (45% BW)
Of those with distress 18.0%

7. % Receiving Any treatment for Depression% Receiving Any treatment for Depression
10.9
11.3
8.1
8.8
4.3
5.6
10.9
13.8
6.8
17.9
3.4
5.5
15.4
7.2
0
2
4
6
8
10
12
14
16
18
20
H
igh
Incom
e
B
elgium
France
G
erm
any
Israel
Italy
JapanN
etherlandsN
ew
Zealand
Spain
U
SALow
Incom
e
C
hina
C
olom
biaSouth
A
frica
U
kraine
Wang P et al (2007) Lancet 2007; 370: 841–50
n=84,850 face-to-face interviews

8. % Receiving Any treatment for Mental Health% Receiving Any treatment for Mental Health
7.2
34.6
5.7 6.3 6.4
11.7
19.1
14
8.9
3.9 3.2
5.7
32.7
5 5
7.7
11
16.1
6.5 6.2
2.3 1.8
0
5
10
15
20
25
30
35
40
AllPatients
MentalIllHealth
NoMentalIllHealth
Nochronicmedicalconditions
1chronicmedicalcondition
2chronicmedicalconditions
3chronicmedicalconditions
18-44years
45-64years
65-74years
75+
Cancer n=4878
No Cancer n=90,737
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

9. Q. Why Low Treatment Rates?Q. Why Low Treatment Rates?
Clinicians?
Patients?

10. 94.2%
37.4%
8 yrs N= 9282 NCS‐R

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

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

13. 0
0.05
0.1
0.15
0.2
0.25
0.3
Eight
N
ine
Ten
Eleven
Tw
elve
Thirteen
Fourteen
Fifteen
Sixteen
Seventeen
Eighteen
N
ineteen
Tw
entyTw
enty-one
Proportion Missed
Proportion Recognized
HADS-D

14. Testing Clinicians: A Meta-AnalysisTesting Clinicians: A Meta-Analysis
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
SE = 35.7%, SP = 89.0%, FC 81.3%.
Presented at IPOS2009

15. 0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Post-testProbability
Ave Confidence+
Ave Confidence-
Baseline Probability
Above Ave Confidence+
Above Ave Confidence-
High Confidence+
High Confidence-
Low confidence = more cautious, fewer false positives, more false negatives
High confidence = less cautious, more false positives, low false negatives
p180

16. 462 (42%)
Meetable Needs
1093 (100%)
Population
388 (84%)
Aware of Need
172 (44%)
Requested Help
80 (47%)
Needs Met
462 needs
17.3%
322 DSMIV
25%

17. Can tools (investigations) help?Can tools (investigations) help?

19. Q. How Common is the Problem?Q. How Common is the Problem?
Depression
Distress
Anxiety

20. Requires depressed mood for
most of the day, for most days
(by subjective account or
observation) for at least 2 years
The symptoms cause clinically
significant distress OR
impairment in social,
occupational, or other
important areas of functioning.
Requires persistently low mood two
(or more) of the following six
symptoms:
(1) poor appetite or overeating
(2) Insomnia or hypersomnia
(3) low energy or fatigue
(4) low self-esteem
(5) poor concentration or difficulty
making decisions
(6) feelings of hopelessness
DSM-IV Dysthymic disorder
Acute: if the disturbance lasts
less than 6 months
Chronic: if the disturbance
lasts for 6 months
These symptoms cause marked
distress that is in excess of
what would be expected from
exposure to the stressor OR
significant impairment in social
or occupational (academic)
functioning
Requires the development of
emotional or behavioral symptoms in
response to an identifiable stressor(s)
occurring within 3 months of the
onset of the stressor(s). Once the
stressor has terminated, the
symptoms do not persist for more
than an additional 6 months.
DSM-IV Adjustment disorder
2 weeksThese symptoms cause
clinically important distress OR
impair work, social or personal
functioning.
Requires two to four out of nine
symptoms with at least at least one
from the first two (depressed mood
and loss of interest).
DSM-IV Minor Depressive Disorder
2 weeksThese symptoms cause
clinically important distress OR
impair work, social or personal
functioning.
Requires five or more out of nine
symptoms with at least at least one
from the first two (depressed mood
and loss of interest).
DSM-IV Major Depressive Disorder
2 weeks unless symptoms are
unusually severe or of rapid
onset).
At least some difficulty in
continuing with ordinary work
and social activities
Requires two of the first three
symptoms (depressed mood, loss of
interest in everyday activities,
reduction in energy) plus at least two
of the remaining seven symptoms
(minimum of four symptoms)
ICD-10 Depressive Episode
DurationClinical SignificanceSymptoms

21. Depression
13%
20%
57%
48%
38%
18%
Anxiety
Adjustment Disorder
N=11
N=4
N=10
Comment: Slide illustrates meta-analytic
rates of mood disorder

22. Prevalence of depression in Palliative settings
20 studies involving 2655 individuals
16.9% (95% CI = 13.2% to 21.0%)
13.0% (95% CI = 11.6% to 14.5%) for MDD
p572
Proportion meta-analysis plot [random effects]
0.0 0.2 0.4 0.6
combined 0.17 (0.13, 0.21)
Maguire et al (1999) 0.05 (0.01, 0.14)
Akechi et al (2004) 0.07 (0.04, 0.11)
Kadan-Lottich et al (2005) 0.07 (0.04, 0.11)
Love et al (2004) 0.07 (0.04, 0.11)
Wilson et al (2004) 0.12 (0.05, 0.22)
Chochinov et al (1997) 0.12 (0.08, 0.18)
Wilson et al (2007) 0.13 (0.10, 0.17)
Kelly et al (2004) 0.14 (0.06, 0.26)
Chochinov et al (1994) 0.17 (0.11, 0.24)
Le Fevre et al (1999) 0.18 (0.10, 0.28)
Breitbart et al (2000) 0.18 (0.11, 0.28)
Meyer et al (2003) 0.20 (0.10, 0.35)
Minagawa et al (1996) 0.20 (0.11, 0.34)
Lloyd-Williams et al (2001) 0.22 (0.14, 0.31)
Hopwood et al (1991) 0.25 (0.16, 0.36)
Desai et al (1999) [late] 0.25 (0.10, 0.47)
Payne et al (2007) 0.26 (0.19, 0.33)
Lloyd-Williams et al (2003) 0.27 (0.17, 0.39)
Jen et al (2006) 0.27 (0.19, 0.36)
Lloyd-Williams et al (2007) 0.30 (0.24, 0.36)
proportion (95% confidence interval)

23. Prevalence of depression in Oncology settings
57 studies involving 9195 individuals across 12
countries.
The prevalence of depression was 17.3% (95% CI =
13.8% to 21.2%),
13.0% (95% CI = 11.6% to 14.5%) for MDD
p572
Proportion meta-analysis plot [random effects]
0.0 0.3 0.6 0.9
combined 0.1730 (0.1375, 0.2116)
Colon et al (1991) 0.0100 (0.0003, 0.0545)
Massie and Holland (1987) 0.0147 (0.0063, 0.0287)
Hardman et al (1989) 0.0317 (0.0087, 0.0793)
Derogatis et al (1983) 0.0372 (0.0162, 0.0720)
Lansky et al (1985) 0.0455 (0.0291, 0.0676)
Mehnert et al (2007) 0.0472 (0.0175, 0.1000)
Katz et al (2004) 0.0500 (0.0104, 0.1392)
Singer et al (2008) 0.0519 (0.0300, 0.0830)
Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)
Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)
Lee et al (1992) 0.0660 (0.0356, 0.1102)
Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)
Grassi et al (2009) 0.0826 (0.0385, 0.1510)
Grassi et al (1993) 0.0828 (0.0448, 0.1374)
Walker et al (2007) 0.0831 (0.0568, 0.1165)
Kawase et al (2006) 0.0851 (0.0553, 0.1240)
Coyne et al (2004) 0.0885 (0.0433, 0.1567)
Alexander et al (2010) 0.0900 (0.0542, 0.1385)
Love et al (2002) 0.0957 (0.0650, 0.1346)
Ozalp et al (2008) 0.0971 (0.0576, 0.1510)
Morasso et al (2001) 0.0985 (0.0535, 0.1625)
Costantini et al (1999) 0.0985 (0.0535, 0.1625)
Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)
Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)
Morasso et al (1996) 0.1121 (0.0593, 0.1877)
Prieto et al (2002) 0.1227 (0.0825, 0.1735)
Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)
Payne et al (1999) 0.1290 (0.0363, 0.2983)
Kugaya et al (1998) 0.1328 (0.0793, 0.2041)
Alexander et al (1993) 0.1333 (0.0594, 0.2459)
Gandubert et al (2009) 0.1597 (0.1040, 0.2300)
Razavi et al (1990) 0.1667 (0.1189, 0.2241)
Akizuki et al (2005) 0.1797 (0.1376, 0.2283)
Leopold et al (1998) 0.1887 (0.0944, 0.3197)
Devlen et al (1987) 0.1889 (0.1141, 0.2851)
Berard et al (1998) 0.1900 (0.1184, 0.2807)
Joffe et al (1986) 0.1905 (0.0545, 0.4191)
Berard et al (1998) 0.2100 (0.1349, 0.3029)
Maunsell et al (1992) 0.2146 (0.1605, 0.2772)
Grandi et al (1987) 0.2222 (0.0641, 0.4764)
Evans et al (1986) 0.2289 (0.1438, 0.3342)
Spiegel et al (1984) 0.2292 (0.1495, 0.3261)
Golden et al (1991) 0.2308 (0.1353, 0.3519)
Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)
Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)
Kathol et al (1990) 0.2961 (0.2248, 0.3754)
Green et al (1998) 0.3125 (0.2417, 0.3904)
Jenkins et al (1991) 0.3182 (0.1386, 0.5487)
Burgess et al (2005) 0.3317 (0.2672, 0.4012)
Hall et al (1999) 0.3722 (0.3139, 0.4333)
Morton et al (1984) 0.3958 (0.2577, 0.5473)
Baile et al (1992) 0.4000 (0.2570, 0.5567)
Passik et al (2001) 0.4167 (0.2907, 0.5512)
Bukberg et al (1984) 0.4194 (0.2951, 0.5515)
Massie et al (1979) 0.4850 (0.4303, 0.5401)
Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)
Levine et al (1978) 0.5600 (0.4572, 0.6592)
Plumb & Holland (1981) 0.7750 (0.6679, 0.8609)
proportion (95% confidence interval)

24. Distress Thermometer

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

26. Proportion
18 .4 %
12 .9 %
11.2 %
12 .3 %
8 .1%
11.9 %
5.0 %
2 .8 % 2 .6 %
7.7%
7.2 %
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
Zero One Two Three Four Five Six Seven Eight Nine Ten
Insignificant SevereModerateMildMinimal
p124
50%

27. ET - Table of Cut-PointsET - Table of Cut-Points
Distress
Thermometer
Anxiety
thermometer
Depression
Thermometer
Anger
Thermometer
Help
Thermometer Cut-point
Insignificant 39.0 25.6 50.1 55.7 54.3 0,1
Minimal 20.1 22.5 18.3 13.6 15.4 2,3
Mild 16.9 16.5 12.2 10.5 12.2 4,5
Moderate 12.0 14.5 9.8 6.6 6.6 6,7
Severe 11.9 20.8 9.5 13.6 11.2 8,9,10
p130

28. 8%
DT
37%
DepT
23%
AngT
18%
AnxT
47%
4%
7%
1%
1%
9%
3%
0%
2%
4%
15%
3%
2%
Nil
41%
Non-Nil
59%
DT
AnxT AngT
DepT

29. Q. Investigations => ScreeningQ. Investigations => Screening
What is available?

30. Observation
Interview
Visual
Self-Report
Depression
Screening
DISCS
VA-SES
ET/DT
HAMD-D
17
PhysicalGeneral
Signs of
DS
6
CDSS#10
MADRAS
10
Trained
Confident
Skilled
Clinician
Alone
YALE
SMILEY

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

33. Inadequate Data
(n=11)
No data (n= 250)
No reference standard
(n= 293)
Accuracy or Validity Analyses
(n= 210)
HADS Validity Analyses
(n=50)
HADS in Cancer
Initial Search (n= 768)
Scale
Types
Sample Size
(cases)
HADS-T
(n=26)
HADS-D
(n=14)
HADS-A
(n=10)
Less than 30
(n=22)
More than 100
(n=8)
30 to 100
(n=20)
Review articles (n= 16)
Depression
(n=22)
Any Mental Ill Health
(n=24)
Anxiety
(n=4)
Outcome
Measure
No interview standard
(n=149)

34. Validity of HADS vs depression (DSMIV)Validity of HADS vs depression (DSMIV)
SE 71.6% (68.3)
SP 82.6% (85.7)
Prev 13%
PPV 38%
NPV 95%

35. 0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Post-testProbability
HADS+
HADS-
Baseline Probability
HADS7v8+
HADS7v8-
Depression_HADS-d (7v8)

36. Q. Why only depression / anxiety?Q. Why only depression / anxiety?
?

38. 0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Distress
Thermometer
Anxiety
Thermometer
Depression
Thermometer
Anger
Thermometer
Ten
Nine
Eight
Seven
Six
Five
Four
Three
Two
One
Zero
Comment: Slide illustrates scores on ET
tool

39. DT DepTVs
HADS-A
AnxT AngT
AUC:
DT=0.82
DepT=0.84
AnxT=0.87
AngT=0.685

40. 6. How Valid Are the Tools6. How Valid Are the Tools

43. DT vs HADS-T Validity (n=660)DT vs HADS-T Validity (n=660)
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

44. 0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Post-testProbability
Baseline Probability
HADSd+
HADSd-
HADS-T+
HADS-T-
HADS-A+
HASD-A-
Depression_HADS

45. 0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Post-testProbability
1Q+
1Q-
Baseline Probability
DT+
DT-
2Q+
2Q-
HADSd+
HADSd-
HADS-T+
HADS-T-
BDI+
BDI-
EPDS+
EPDS-
HADS-A+
HASD-A-
Depression_all

46. 0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Post-testProbability
DT+ [N=4]
DT+ [N=4]
Baseline Probability
1Q+ [N=4]
1Q- [N=4]
2Q+
2Q-
DT/IT+
DT/IT-
HADST+ [N=13]
HADST+ [N=13]
PDI+
PDI-
Mitchell AJ. Short Screening Tools for Cancer Related Distress A Review and Diagnostic Validity Meta-analysis JNCI (2010) in press
Distress

47. Validity of DT vs depression (DSMIV)Validity of DT vs depression (DSMIV)
SE 80%
SP 60%
PPV 32%
NPV 93%

48. DT vs DSMIV DepressionDT vs DSMIV Depression
SE SP PPV NPV
DTma 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
BW= British White

49. Q. Problem with somatic symptoms?Q. Problem with somatic symptoms?

50. Approaches to Somatic Symptoms of Depression
Inclusive
Uses all of the symptoms of depression, regardless of whether they may or may not be secondary
to a physical illness. This approach is used in the Schedule for Affective Disorders and
Schizophrenia (SADS) and the Research Diagnostic Criteria.
Exclusive
Eliminates somatic symptoms but without substitution. There is concern that this might lower
sensitivity. with an increased likelihood of missed cases (false negatives)‫‏‬
Etiologic
Assesses the origin of each symptom and only counts a symptom of depression if it is clearly not
the result of the physical illness. This is proposed by the Structured Clinical Interview for DSM
and Diagnostic Interview Schedule (DIS), as well as the DSM-III-R/IV).
Substitutive
Assumes somatic symptoms are a contaminant and replaces these additional cognitive symptoms.
However it is not clear what specific symptoms should be substituted

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

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

55. Co-morbid Depression vs Primary Depression
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
A
gitation
(C
om
orbid)
A
gitation
(Prim
ary)
A
nxiety
(C
om
orbid)
A
nxiety
(Prim
ary)
A
ppetite
(C
om
orbid)
A
ppetite
(Prim
ary)
C
oncentration
(Com
orbid)
C
oncentration
(Prim
ary)
Fatigue
(C
om
orbid)
Fatigue
(Prim
ary)
G
uilt(C
om
orbid)
G
uilt(Prim
ary)
H
opelessness
(C
om
orbid)
H
opelessness
(Prim
ary)
Insom
nia
(C
om
orbid)
Insom
nia
(Prim
ary)
Loss
Interest(C
om
orbid)
Loss
Interest(P
rim
ary)
Low
M
ood
(C
om
orbid)
Low
M
ood
(P
rim
ary)
R
etardation
(C
om
orbid)
R
etardation
(Prim
ary)
Suicide
(C
om
orbid)
Suicide
(Prim
ary)
W
eightLoss
(C
om
orbid)
W
eightLoss
(P
rim
ary)
*
*
*
*
*
*
*
*
*
Comorbid Depression
Primary Depression
n=4069 vs 4982
Comment: Slide illustrates similar
symptoms profile in comorbid vs
primary depression

56. Co-morbid Depression vs Medical Illness Alone
n= 4069 vs 1217
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
A
nxiety
(C
om
orbid)
A
nxiety
(M
edical)
C
oncentration
(Com
orbid)
C
oncentration
(M
edical)
Fatigue
(C
om
orbid)
Fatigue
(M
edical)
H
opelessness
(C
om
orbid)
H
opelessness
(M
edical)
Insom
nia
(any
type)(C
om
orbid)
Insom
nia
(any
type)(M
edical)
Loss
Interest(C
om
orbid)
Loss
Interest(M
edical)
Low
M
ood
(C
om
orbid)
Low
M
ood
(M
edical)
R
etardation
(C
om
orbid)
R
etardation
(M
edical)
Suicide
(C
om
orbid)
Suicide
(M
edical)
W
eightLoss
(C
om
orbid)
W
eightLoss
(M
edical)
W
orthlessness
(C
om
orbid)
W
orthlessness
(M
edical)
Medical Illness Alone
Comorbid Depression
*
*
*
*
*
*
*
*
*
Comment: Slide illustrates distinct
symptoms profile in comorbid
depression vs medical illness alone

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

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

59. Q. How to Choose A Cut-OffQ. How to Choose A Cut-Off

60. British Journal of Cancer (2007) 96, 868 – 874

61. Distress Thermometer

62. Distress Thermometer – Pooled
Proportion
18 .4 %
12 .9 %
11.2 %
12 .3 %
8 .1%
11.9 %
5.0 %
2 .8 % 2 .6 %
7.7%
7.2 %
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
Zero One Two Three Four Five Six Seven Eight Nine Ten
Insignificant SevereModerateMildMinimal
p124
50%

63. PHQ9 Linear distribution
0
5
10
15
20
25
30
35
Zero
O
ne
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Eleven
Twelve
Thirteen
Fourteen
Fifteen
Sixteen
Seventeen
Eighteen
PHQ9 (Major Depression)
PHQ9 (Minor Depression)
PHQ9 (Non-Depressed)
Baker-Glen, Mitchell et al (2008)

64. SampleSample
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”

65. Dysfunction in 531 cancer patientsDysfunction in 531 cancer patients
55.7%
34.3%
7.3%
2.6%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Unimpaired Mild Moderate Severe

66. Unimpaired by DT ScoreUnimpaired by DT Score
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
1 2 3 4 5 6 7 8 9 10 11

67. 18%
DepT
23%
Distress
69%
Dysfunction
76%
0.3%
3% 2%
26%28% 22%
Of the 293 Non-Nil
Dysfunction
Distress
DepT

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

69. 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

72. T4. Screening in Cancer: ImplementationT4. Screening in Cancer: Implementation
Clinician Opinion
Patient Opinion

73. 1,2 or 3 Simple
QQ
24%
Clinical Skills
Alone
20%
ICD10/DSMIV
24%
Short QQ
24%
Long QQ
8%
Algorithm
26%
Short QQ
23%
ICD10/DSMIV
0%
Clinical Skills
Alone
17%
1,2 or 3 Simple
QQ
34%
Cancer Staff
Ideal Method (n=226)
Psychiatrists
Effective?
Comment: “Ideal” method of eliciting
symptoms of distress/depression according
to clinician

75. Comment: Slide illustrates actual gain in
meta-analysis of screening
implementation in primary care

76. 0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Post-testProbability
Clinical+
Clinical-
Baseline Probability
Screen+
Screen-
Comment: Slide illustrates Bayesian
curve comparison from RCT studies of
clinician with and without screening
This illustrates ACTUAL gain from
screening in Study from Christensen

77. 800 Patients Approached
100 Not Willing (13%) 700 Patients Willing (87%)
500 Staff Willing (71%)TAU
402 Data Collected (80%)Screen Data
Leicester: UptakeLeicester: Uptake T177 t680

78. Pre-Post Screen - DistressPre-Post Screen - Distress
Before After
Sensitivity of 49.7%
Specificity of 79.3%
PPV was 67.3%
NPV was 64.1%

79. Pre-Post Screen - DistressPre-Post Screen - Distress
Before After
Sensitivity of 49.7% 55.8% =>+5%
Specificity of 79.3% 79.8% =>+1%
PPV was 67.3% 70.9% =>+4%
NPV was 64.1% 67.2% =>+3%
There was a non-significant trend for improve detection sensitivity (Chi² =
1.12 P = 0.29).

80. Qualitative AspectsQualitative Aspects
DISTRESS
43% of CNS reported the tool helped them talk with the patient
about psychosocial issues esp in those with distress
28% said it helped inform their clinical judgement
DEPRESSION
38% of occasions reported useful in improving communication.
28.6% useful for informing clinical judgement

81. Next StepNext Step
269 Nurse-patient
interactions
Helped 65 (24%) Not Helped 204 (76%)
Unmet Needs 150 (55.8%)
Referred 23 (8.6%) Declined Helped 20 (7.4%)
No Unmet Needs 34 (12.6%)
p179

82. 2x2 Clinician Help Table : ACTUAL HELP2x2 Clinician Help Table : ACTUAL HELP
Clinician thinks:
Unmet Needs
Clinician thinks
no Unmet Needs
Patient Says:
Help Wanted (60)
Helped 21/35
(60%)
Helped 11/23
(48%)
Patient
Distressed
Helped 65/102
(63%)
Helped 31/62
(50%)
Patient Not
distressed or
Help Not Wanted
Helped 8/35
(23%)
Helped 20/117
(17%)

83. b. Intervention and helpb. Intervention and help
PREDICTORS
1. patient desire for help
2. number of unmet needs
3. clinicians confidence
4. patient reported anger
p179

84. RCT using DT Carlson et al 2010RCT using DT Carlson et al 2010
Screening for Distress in lung and breast cancer
outpatients: A randomized controlled trial Linda Carlson
Tom Baker Cancer Centre, University of Calgary
1) Minimal Screening: the Distress Thermometer (DT)
[n=365]
2) Full Screening: DT, Problem Checklist, Psychological
Screen for Cancer (PSSCAN) [n=391] a personalized
report
3) Triage: Full screening plus optional personalized phone
triage [378]

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