Alex Mitchell www.psycho-oncology.info

Department of Cancer & Molecular Medicine, Leicester Royal Infirmary

Department of Liaison Psychiatry, Leicester General Hospital

Oncology Seminar Series Nov 2009Oncology Seminar Series Nov 2009

Evidence Based Screening for Depression in CancerImproving the Accuracy of Health Professionals In Oncology

Evidence Based Screening for Depression in CancerImproving the Accuracy of Health Professionals In Oncology

1. Background1. Background

How common is Depression in cancer?

How common is Distress in cancer?

Implications for => mortality

Depression

13%

20%

57%

48%

38%

18%

Anxiety

Distress/Adjustment Disorder

N=11N=4

N=10

Comment: Slide illustrates meta-analytic rates of mood disorder

Implications for MortalityImplications for Mortality

Comment: Slide illustrates new 2009 meta-analysis on mortality vs depression

Introducing the Distress Thermometer

6 8 72 776 5

514 1 3 8 3 6

18 16 9

3 8 3 1 2 23 7

2 9 4 6

3 22 1

125

4

6 1

4 23 5

4 2

2 9

6 2

2 3

2 3

18

87

14

5

5

8

8

11

2

2

6

34

71

4654

46

31

48

31

16

15

913

0

50

100

150

200

250

300

Zero One Two Three Four Five Six Seven Eight Nine Ten

Jacobsen 2005Hoffman 2004Mitchell 2009Tuinman 2008Ransom 2006

Distress = 50%

Comment: Slide illustrates pooled scores on DT from five studies

2. Tools and Scales2. Tools and Scales

What methods are used to detect mood disorders?

How often do clinicians look for mood complications?

Methods to Evaluate Depression

Conventional Scales

Short (5-10) Long (10+)

Methods to Evaluate Depression

Conventional Scales

Ultra-Short (<5)Short (5-10) Long (10+)

Methods to Evaluate Depression

Unassisted Clinician Conventional Scales

Ultra-Short (<5) Short (5-10) Long (10+)Untrained Trained

Routine Implementation

Acceptability ?

Accuracy? Accuracy?

vsComment: schematic overview of methods to evaluate depression

“Validated” Tools“Validated” Tools

Comment: Slide illustrates potential pool of validated tools in cancer

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

1,2 or 3 Simple QQ15%

Clinical Skills Alone73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9% Other/Uncertain

2%

Use a QQ15%

ICD10/DSMIV13%

Clinical Skills Alone55%

1,2 or 3 Simple QQ15%

Cancer StaffCurrent Method (n=226)

Psychiatrists

Comment: Current preferred method of eliciting symptoms of distress/depression

1,2 or 3 Simple QQ24%

Clinical Skills Alone20%

ICD10/DSMIV24%

Short QQ24%

Long QQ8%

Algorithm26%

Short QQ23%

ICD10/DSMIV0%

Clinical Skills Alone17%

1,2 or 3 Simple QQ34%

Cancer StaffIdeal Method (n=226)

Psychiatrists

Effective?

Comment: “Ideal” method of eliciting symptoms of distress/depression according to clinician

3. Cancer Care - Meta-Analysis3. Cancer Care - Meta-Analysis

How well do CNS recognize distress?

How well do CNS recognize depression?

How well do oncologist do?

CNS = Clinical Nurse Specialists

Local Study: Recognition by CNS in oncologyLocal Study: Recognition by CNS in oncology

N=350 nurse specialists’ assessments (2008-2009)

2/3rd Chemotherapy suite LRI

1/3rd Community Northampton, Kettering, Breast Ca GGH

Mostly early or mixed cancer (1/3 late)

“Is you patient suffering significant distress, depression, anxiety, anger or are they well or are you unsure?”

0.00

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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

Pos

t-tes

t Pro

babi

lity

CHEMO+

CHEMO-

Baseline Probability

COMMU+

COMMU-

Detection sensitivity = 50.6%Detection specificity = 79.4%Overall accuracy = 65.4%.

Comment: Slide illustrates performance of chemotherapy vs community nurses in oncology

13.1

16.7

28.6 28.6

41.443.5 43.5

56.5

83.3

62.5

71.4

0

10

20

30

40

50

60

70

80

90

Zero One Two Three Four Five Six Seven Eight Nine Ten

Series1Series2

Comment: Slide illustrates diagnostic accuracy according to score on DT

Testing Clinicians: A Meta-AnalysisTesting Clinicians: A Meta-Analysis

Methods (currently unpublished)

13 studies reported in 8 publications. 2 anxiety4 depression7 broadly defined distress.9 studies involved medical staff / 4 studies nursing staff.

Gold standard tools including GHQ60, GHQ12 HADS-T, HADS-D, Zung and SCID.

The total sample size was 4786 (median 171)

OncologistsSE =38.1% and SP = 78.6%; a fraction correct of 65.4%.

Oncologists vs Nurses vs GPs

Who is better?

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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

-test

Pro

babi

lity

GP+GP-Baseline ProbabilityNurse+Nurse-Oncologist+Oncologists-

Comment: Doctors appear to be more successful at ruling-in or giving a diagnosis, nurses more successful at ruling out

4. Cancer Care – Screening Data4. Cancer Care – Screening Data

What resources are available locally re identification

How much difference does a screening tool make?

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

Introducing the Emotion ThermometersIntroducing the Emotion Thermometers

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0.90

1.00

DistressThermometer

AnxietyThermometer

DepressionThermometer

AngerThermometer

TenNineEightSevenSixFiveFourThreeTwoOneZero

Comment: Slide illustrates scores on ET tool

DT DepTVsHADS-A

AnxT AngT

AUC:DT=0.82DepT=0.84AnxT=0.87AngT=0.685

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10

20

30

40

50

60

70

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Self-Reported Symptoms in Cancer by FrqSelf-Reported Symptoms in Cancer by Frq

-30

-20

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Self-Reported Symptoms in Cancer by FrqSelf-Reported Symptoms in Cancer by Frq

More common in Late stages More common in early stages

Summary & PlansSummary & Plans

2006 – Examined screening habits- Meta-analysis of DT

2007 - Validated ET- Meta-analysis of verbal methods

2008 – Pilot (community) screening data, viability- Network –wide training L2

2009 – Nursing Recognition- Chemotherapy screen implementation- Meta-analysis of all tools

2010 – Radiotherapy screen implementation– RCT of screen + intervention

Credits & Acknowledgments

Elena Baker-Glenn University of NottinghamPaul Symonds Leicester Royal InfirmaryChris Coggan Leicester General HospitalBurt Park University of NottinghamLorraine Granger Leicester Royal InfirmaryMark Zimmerman Brown University, Rhode IslandBrett Thombs McGill University CanadaJames Coyne University of PennsylvaniaNadia Husain Leicester General HospitalJoanne Herdman Leicester General HospitalJo Kavanagh Leicester Royal Infirmary

For more information www.psycho-oncology.info

FURTHER READING:

Screening for Depression in Clinical Practice An Evidence-Based guide

ISBN 0195380193 Paperback, 416 pagesNov 2009Price: £39.99