Alex Mitchell Leicester Royal InfirmaryElena Baker-Glenn University of NottinghamPaul Symonds Leicester Royal InfirmaryChris Coggan Leicester General HospitalLouise Granger Leicester Royal InfirmaryKufrie Sampson Leicester Royal Infirmary
Team Mar 2008Team Mar 2008
Evidence Based Screening for Mood Disorders in Cancer Settings
What Is the Role of Asking:“Do You Need Help?”
1. Purpose of Screening?1. Purpose of Screening?
Purpose of ScreeningPurpose of Screening
(1)To detect people with unrecognized symptoms?
(2) To detect people in distress/emotional dis?
(3) To detect people in denial?
(4) To detect people in distress+denial?
(5) To detect people who want help?
(6) To detect people who need and want help
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
PHQ9 Linear distribution
0
5
10
15
20
25
30
35
Zero One Two
Three
Four
Five Six
Seven
Eight
Nine
TenElev
enTwelveThir
teen
Fourte
enFifte
enSixt
een
Sevente
enEigh
teen
PHQ9 (Major Depression)PHQ9 (Minor Depression)PHQ9 (Non-Depressed)
Baker-Glen, Mitchell et al (data on file)
Depression
13%
20%
57%
48%
38%
18%
Anxiety
Distress/Adjustment Disorder
Rate of anxiety 18% from StarkDistress 57% from Ransom DT
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%
DT
15%
DT(38%)
AngT(26%)
DepT(30%)
AnxT(65%)
8%
2%
4%
0%
10%
0%
0%
0%
2%
21%
1%
2%
2x2 Help Table2x2 Help Table
=>Agree discharge=> DelayPatient Says:Help Not Wanted
=> Refuse?=> InterventionPatient Says:Help Wanted
Clinician thinks:Help Not Needed
Clinician thinks:Help Needed
2. Background2. BackgroundWhy help is important in the literature
Arrol et al (2005) BMJArrol et al (2005) BMJ
Setting 19 general practitioners in six clinics in New Zealand. Participants 1025 consecutive patients receiving no psychotropic drugs.
After screening “is this something you would like help with?
The help question alone had a sensitivity of 75% and a specificity of 94%
The general practitioner with PHQ2 diagnosis had a sensitivity of 79% and a specificity of 94%
Arrol (2005) – Mj DepressionArrol (2005) – Mj Depression
47 CIDI cases with Major depression
25 (53%) wanted help
10 (21%) wanted the option of help
12 (25%) did not want help
Arrol (2005) – No DepressionArrol (2005) – No Depression
889 CIDI cases with Major depression
27 (3%) wanted help
24 (3%) wanted the option of help
838 (94%) did not want help
Graves et al (2005)Graves et al (2005)
333 Consecutive patients (N = 333) were recruited from an outpatient multidisciplinary lung cancer clinic to complete the Distress Thermometer, an associated Problem Symptom List
“Do you wish to get help for these problems?”
- 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
Graves et al (2005)Graves et al (2005)
61.6% of patients reported distress at a clinically significant level
22.5% of patients indicated interest in receiving help
30% of distress patients wanted help
Predictors of needing help were Emotional problems, pain, Fatigue
3. Our Study 3. Our Study
Baker-Glen, Mitchell et al (data on file)
MethodologyMethodology
Study I: Baker-Glen, Symonds, Granger “ET Validation”(a) n=129 chemotherapy attendees(b) n=86 chemotherapy f/u
Study II: Sampson, Symonds, Granger “ET Extension”(c) n=250 chemotherapy + late
Study III: Lord, Symonds, Granger “Coping”(d) n=250
Study IV: Mitchell, Symonds, Steward “SMI RCT”(e) n=300
See Gil F, Grassi L, Travado L, Tomamichel M, Gonzalez JR. for the SEPOS Group. Use of distress and depression thermometers to measure psychosocial morbidity among southern European cancer patients. Support Care Cancer, 13: 600–606, 2005
Help – Who Wants Help?Help – Who Wants Help?
20% said they wanted professional help for psychosocial issues.
Only 36% of those distressed on the DT wanted help.
Help – Do They Need It?Help – Do They Need It?
27% had major depression
62% had major or minor depression
88% had some distress (HADS, PHQ, DT)
Are Those Not Wanting Help OK?Are Those Not Wanting Help OK?
41/104 (39%) of decliners had no identifyablecondtion
=> 61% of those refusing help actually have a potentially serious psychosocial condition.
What Kind of Help is Wanted?What Kind of Help is Wanted?
19% wanted medication (eg antidepressants)
31% want self help guidelines
31% wanted group therapy
56% wanted illness information.
58% complementary therapies
62% face-to-face psychological support
Help – Who From?Help – Who From?
Nurse specialists (54%)
Family and friends (21%)
Spiritual advisor (8%)
Psychiatrist (4%).
Why Not Needed?Why Not Needed?
“getting help elsewhere” (57%)
“feel well” (41%)
“coping on my own” (31%)
“fear of stigma”, “fear of side effects”, “not likely to be effective for me”, and “don’t like to talk about problems” (all less than 10%)
4. Is Help a Predictor?4. Is Help a Predictor?
Help as a Predictor of Depression?Help as a Predictor of Depression?
0.860.390.880.36Help QQ AloneDSMIV Mj + Minor Depression
0.880.880.990.36Help QQ AND PHQ2DSMIV Mj + Minor Depression
0.920.270.830.47Help QQ AloneDSMIV Major Depression
NPVPPVSpecificitySensitivityPredictorOutcome
6. Future?6. Future?
Can This Be Used Clinically?Can This Be Used Clinically?
