ipos07 - screening for distress in palliative settings [sept 2007]
DESCRIPTION
This is an academic workshop based presentation from Sept 2007's IPOS (Psycho-oncology) Conference, London re screening techniques for distress in palliative settingsTRANSCRIPT
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Alex MitchellHon. Senior Lecturer in Psycho-oncology,
Leicester Royal Infirmary
IPOS Workshop (Sept 2007)IPOS Workshop (Sept 2007)[email protected]@leicspart.nhs.uk
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0. BasicsTypes of screening
1. Mood Screening Methods
How do they compare?
2. Distress Thermometer
Evidence?
3. Implementing ScreeningUltra-screening in secondary care
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0. Basics0. Basics
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DefinitionDefinition
Screening:Short; Easy; some false +ve (low SpS PPV), few false –ve (High
Sens, NPV)
Diagnosis (case-finding)Accurate, Few false +ve or –ve
RatingSimple, patient rated, correl. With QoL and other outcomes
=> options
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Screening OptionsScreening Options
Unassisted, Untrainedeg. Level 1 cancer staff
Unassisted, trainedeg. Level 3 staff
Assisted, untrainedeg. Level 2 staff
Assisted, trainedeg. Level 4 staff
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YesYesGuilt or self-blame
DSMIVICD10Core Symptoms
YesNoSignificant change in weight
YesYesAgitation or slowing of movements
YesYesSuicidal thoughts or acts
NoYesPoor or increased appetite
NoYesLow self-confidence
YesYesPoor concentration or indecisiveness
YesYesDisturbed sleep
YesYes (core)Fatigue or low energy
Yes (core)Yes (core)Loss of interests or pleasure
Yes (core)Yes (core)Persistent sadness or low mood
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Do Clinicians Look for Depression?Do Clinicians Look for Depression?
Mitchell, Kaar, Coggan, Herdman (N=226) Psychooncology 2007
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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 Staff Psychiatrists
Mitchell, Kaar, Poster APA 2007Current Method
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1. Screening Methods1. Screening Methods
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20 Instruments for Depression20 Instruments for Depression
SDS (20)EPDS (10)
GDS (30,15)MADRAS (10)
DEPS (10)DADS (7)
Zung (20)DSMIV (9)
CES-D (20,10)PHQ9 (9)Distress Therm (1)
BSI (53)MOS-D (8)WHO-5 (5)
BDI (21,13)BDI (7)PHQ2 (2)
HAM-D (21)HADS (7)PHQ1
Long > 10Short > 5 < 11Ultra-short <6
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AudienceAudience
What are the issues for palliative care?
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=> Symptoms
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General Screening TestsGeneral Screening Tests
Center for Epidemiological Studies –Depression Scale (CES-D) Radloff et al. (1977)
20-item self-report scale that assesses mood and functioning over the past 7-days
Depressed affectPositive affectSomatic problemsInterpersonal problems
Can be abbreviated to 5-item version and validated in community, medical, and clinical samples.
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Razavi D, Delvaux N, Farvacques C and Robaye E (1990) Screening for adjustment disorders and major depressive disorders in cancer in-patients. Br J Psych 156: 79–83
N= 210 cancer in- patients
Cut-off 11
Cut-off 3
Cut-off 21
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2. The Distress Thermometer2. The Distress Thermometer
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Screening Tools- Distress thermometerScreening Tools- Distress thermometer
Developed at the Memorial Sloan-Kettering Cancer Institute from pain VAS
First reported in 1998
Best known example of ultra short screening questionnaire in cancer care
Recommended by the National Comprehensive Cancer Network as a screening measure for distress
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- Please circle the number (0-10) that best describes how much distress you have been experiencing in the past week, including today.
- What phone number would you like us to contact you on if necessary?
Please tick WHICH of the following is a cause of distress:
DiarrhoeaAnger
ConstipationWorry
IndigestionSadness
EatingNervousness
Is there anything important you would like to add to the list?__________________________________________________________________________________________
Mouth soresFears
BreathingDepression
Bathing/ DressingEmotional Problems
Getting around
Hot flushesSleepDealing with children
SexualFatigueDealing with partner
Feeling swollenNauseaFamily Problems
Metallic taste in mouthPain
Tingling in hands/ feetPhysical problemsWork/School
Nose dry/ congestedTransport
Skin dry/ itchyLoss of meaning or purpose in lifeMoney
FeversRelating to GodHousing
Changes in UrinationLoss of faithChildcare
Physical Problems contd…Spiritual/ Religious ConcernsPractical Problems
The distress thermometerThe distress thermometer
=> Validity
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Distribution of DT ScoresRansom (2006) PO (n=491)
13.814.7
15.7
13.2
10.4
8.47.7 7.3
3.7 3.3
1.8
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7 Score 8 Score 9 Score 10
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Does it WorkAs a rule in & rule out?Does it WorkAs a rule in & rule out?
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Theory of Diagnostic TestsTheory of Diagnostic Tests
Non-Depressed
Depressed# ofIndividuals
TestResult
Cut-off value
False +veFalse -ve
45%
55%
True -ve
93%
True +ve
7%
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Publications evaluating1item VAS against a diagnostic standard
Studies Excluded
Chochinov HM et al (1997) Am J Psychiatry 154:674–676
Akizuki N et al Psycho-Oncology 13: S1–S233 (2004)*
Akizuki N et al Cancer 2003;97:2605–13. *
Grassi L et al (2006) Psycho-Oncology s162 *
Hoffman et al (2004) Psychooncology.13:792–799 *
Ransom et al (2006) Psychoonc 15(7):604-12 *
Ultra-short tests mentioned in title or abstract
Primary Data Studies
90 5139
No Relevant Data Presented Ultra-short tests accuracy analysed in text
33
Jacobsen et al (2005) Cancer 103:1494–502. *
Williams et al (2005) Stroke. 2005; in press
Bula et al (2003)Age Aging Mar;32(2):231-3.
Patrick-Miller et al (2005) JCO 14S 2004: 6024 *
Studies Excluded Due toSTARD NON-Compliant
Haggman (2004) Phys Ther84:1157-1166.
Publications reporting2 or more combination
Chochinov HM et al (1997) Am J Psychiatry 154:674–676
Publications reporting1 verbal item
Gil et al (2005) Support Care Cancer (2005) 13: 600–606*
Lloyd-Williams et al (2003) (2003) - BMJ 2003;327:372–3
Chochinov HM et al (1997) Am J Psychiatry 154:674–676
Akizuki N et al (2004) Psycho-Oncology 13: S1–S233
Ozalp et al (2006) Psycho-Oncology (in press) *
* Study using the distress thermometer
Talelli et al (2004) J Neurol 251: 191 Suppl. 3
Avasarala et al (2003) Multiple Sclerosis 9 (3): 307-310.
Gori et al (1998) Arch GerontGeria 235-240 Suppl. 6
Akizuki N et al Cancer 2003;97:2605–13.
Akizuki N et al (2006) J Pain Symptom Manage 29:91–99
VAS – Visual analogue scale
Mehnert et al (2006) Zeitschrift Fur Psychiatrie Psychologie Und Psychotherapie 54 (3): 213-223 *
Jefford et al (2004) Br J Ca 91(5):900-906
Akechi T et al (2006) J Pain Symptom Manag 31: 5-12
Akechi T et al (2006) J Pain Symptom Manag 31: 5-12
Trask PC, et al Bone Marrow Transplant (2002) 29, 917–925.
Thorvalsdottir et al (2006)
Psycho-oncology 15(2) s430 *
Carter et al (2006) Psycho-
oncology 15(2) s105 *Studies Excluded due to a
Unavailable data
Kumar et al (2006) Psycho-oncology 15(2) s692 *
Andritsch et al (2006) Psycho-
oncology 15(2) s158 *
Publications evaluating1item VAS against a
severity scale
Gessler et al (2006) UK Psycho-
Oncology, 15: s107 *
4 5 5 910
Studies Excluded due toNon-cancer setting
Muszbek et al. Psycho-Oncology
2004; 13 s63 *
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PPV DT Distress = 55%; PPV Other Methods 65%
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3. Implementation3. Implementation
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AudienceAudience
What are the issues for palliative care?
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SCAN, SCID, PSE
BDI, MADRAS, Hamilton
HADS, EPDS, PHQ, CES-D
LONG
WHO5, PHQ2, NICE
SHORT
High NPVLow PPV
High NPVMed PPV
High NPVHigh PPV
MEDIUM
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Algorithm 1Algorithm 1Symptoms
Simple method
EndPossible Case
Help Given
Patient complaints
Screen -veScreen +ve
Help wanted?
No Help
No
Yes
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Algorithm 2Algorithm 2Everyone
Ultra-short method
Clinically worrying?
End
Possible Case
Help Given
Patient Concerns
Screen -veScreen +ve
Short method
Gold standard
Probable Case
MonitoringSeverity rating
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Algorithm NumbersAlgorithm NumbersSymptoms
Ultra-short method
Probable Non-Case
True Non-Cases
Probable Case
True Positive
50
4525
100
False +ve
25
50
False -ve
5
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ExtrasExtras
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Screening Evidence - YesScreening Evidence - Yes
USPSTF
good evidence that screening improves the accurate identification of depressed patients in primary care settings and that treatment of depressed adults identified in primary care settings decreases clinical morbidity.
Small benefits have been observed in studies that simply feed back screeningresults to clinicians.
Larger benefits have been observed in studies in which the communication of screening results is coordinated with effective follow-up and treatment.
Pignone, M. P., Gaynes, B. N., Rushton, J. L., et al (2002) Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 136, 765-776. => Gilbody
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Screening Evidence - NoScreening Evidence - No
Feedback results => 23%
Gilbody, S. M., House, A. O. & Sheldon, T. A. (2001) Routinely administered questionnaires for depression and anxiety: systematic review. BMJ, 322 (7283), 406-409. => NICE
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“Professionals operating at this level should be able to screen for psychological distress at key points in the patient pathway Recommendation 5.2”