Alex Mitchell www.psycho-oncology.info

Department of Cancer & Molecular Medicine, Leicester Royal Infirmary

Department of Liaison Psychiatry, Leicester General Hospital

IPOS 2010

T125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice:A Multicentre UK Study

T125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice:A Multicentre UK Study

1. Background

What are the issues in detection

How do PCPs compare?

What are the special issues in the older person

What are the issues in physical disease

% Receiving Any treatment for Depression

10.9 11.3

8.18.8

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

High Inc

omeBelg

ium

France

German

y

Israe

l

Italy

Japa

nNeth

erlan

dsNew

Zeala

nd

Spain USALow

Inco

me

ChinaColom

biaSouth

Afri

caUkra

ine

Wang P et al (2007) Lancet 2007; 370: 841–50

n=84,850 face-to-face interviews

Do we know what symptoms occur in MDD?

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Loss

of e

nerg

yDi

min

ishe

d dr

ive

Slee

p di

stur

banc

eCo

ncen

trat

ion/

inde

cisi

onDe

pres

sed

moo

d

Anxi

ety

Dim

inis

hed

conc

entr

atio

n

Inso

mni

aDi

min

ishe

d in

tere

st/p

leas

ure

Psyc

hic

anxi

ety

Help

less

ness

Wor

thle

ssne

ssHo

pele

ssne

ssSo

mat

ic a

nxie

tyTh

ough

ts o

f dea

th

Ange

rEx

cess

ive

guilt

Psyc

hom

otor

cha

nge

Inde

cisiv

enes

sDe

crea

sed

appe

tite

Psyc

hom

otor

agi

tatio

nPs

ycho

mot

or re

tard

atio

nDe

crea

sed

wei

ght

Lack

of r

eact

ive

moo

dIn

crea

sed

appe

tite

Hype

rsom

nia

Incr

ease

d w

eigh

t

All Case ProportionDepressed ProportionNon-Depressed Proportion

n=1523

Comment: Slide illustrates sensitivity and specificity of each mood symptom

-0.10

0.00

0.10

0.20

0.30

0.40

0.50A

nger

Anx

iety

Dec

reas

ed a

ppet

ite

Dec

reas

ed w

eigh

t

Dep

ress

ed m

ood

Dim

inis

hed

conc

entr

atio

n

Dim

inis

hed

driv

eD

imin

ishe

d in

tere

st/p

leas

ure

Exce

ssiv

e gu

ilt

Hel

ple

ssne

ss

Hop

eles

snes

s

Hyp

erso

mni

a

Incr

ease

d ap

peti

te

Incr

ease

d w

eigh

t

Inde

cisi

vene

ss

Inso

mni

aLa

ck o

f re

acti

ve m

ood

Loss

of

ener

gy

Psyc

hic

anxi

ety

Psyc

hom

otor

agi

tati

on

Psyc

hom

otor

cha

nge

Psyc

hom

otor

ret

arda

tion

Slee

p di

stur

banc

e

Som

atic

anx

iety

Thou

ghts

of

deat

h

Wor

thle

ssne

ss

Rule-In Added Value (PPV-Prev)Rule-Out Added Value (NPV-Prev)

Comment: Slide illustrates added value of each symptom when diagnosing depression and when identifying non-depressed

GP Recognition of Individual symptomProportion of Individual Symptoms Recognised by GPs

76.1

36.4 34.631.6

21.616.7

13.39.1 8.3 8.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Low m

ood

Insomnia

Hypoc

hondri

asis

Loss

of in

terest

Tearfu

lness

Anxiety

Loss

of en

ergy

Pessim

ism

Anorex

ia

Not Copin

g

O’Conner et al (2001) Depression in primary care.Int Psychogeriatr 13(3) 367-374.

Accuracy of GP’s Diagnoses

955927,6406553

667825,1254050GP -ve

501825152503GP +ve

DepressionABSENT

DepressionPRESENT

Sensitivity48%

PPV 42.8%

Specificity80.1%

NPV 85.1%

Prevalence 19%

N=35 studies

Mitchell, Vaze, Rao Lancet 2009

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10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

McCall et al (2007) Primary Care Psychiatry - Recognition by Severity

Comment: Slide illustrates raw number of people identified by severity on the GHQ. Although the % detection increases with severity, the absolute number decreased due to falling prevalence

GP Accuracy – Detection of Distress by GHQ Score

Medically Unwell Alone

Primary Depression Alone

Secondary Depression

Comment: Slide illustrates concept of phenomenology of depression in medical disease

FatigueAnorexiaInsomnia

Concentration

Study: Coyne Thombs MitchellN= 4500; Pooled database study; All comparative studies

Physical illness+comorbid depression

Vs

Physical illness alone

Vs

Primary depression alone

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

Agitatio

n (Com

orbid)

Agitatio

n (Prim

ary)

Anxiety

(Com

orbid)

Anxiety

(Prim

ary)

Appetite

(Comorb

id)

Appetite

(Prim

ary)

Concen

tratio

n (Comorb

id)

Concen

tratio

n (Prim

ary)

Fatigu

e (Comorb

id)

Fatigu

e (Prim

ary)

Guilt (

Comorbid)

Guilt (

Primar

y)

Hopeles

snes

s (Comorb

id)

Hopeles

snes

s (Prim

ary)

Insomnia

(Comor

bid)

Insomnia

(Prim

ary)

Loss In

teres

t (Comorb

id)

Loss In

teres

t (Prim

ary)

Low Mood (C

omorbid)

Low Mood (P

rimary

)

Retard

ation (

Comorbid)

Retard

ation (

Primary)

Suicide (

Comorbid)

Suicide (

Primar

y)

Weight L

oss (C

omorbid)

Weight L

oss (P

rimary

)

*

*

*

*

*

**

*

*

Comorbid Depression

Primary Depression

n=4069 vs 4982Comment: Slide illustrates similar symptoms profile in comorbid vsprimary depression

Medically Unwell Alone

Primary Depression Alone

Secondary Depression

Comment: Slide illustrates assumed overlap of primary and secondary depression

FatigueAnorexiaInsomnia

Concentration

Primary Depression Alone

Secondary Depression

Comment: Slide illustrates actual overlap of primary and secondary depression

AgitationRetardation

Co-morbid Depression vs Medical Illness Alone

n= 4069 vs 1217

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0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Anxiety

(Com

orbid)

Anxiety

(Med

ical)

Concen

tratio

n (Comorb

id)

Concen

tratio

n (Med

ical)

Fatigu

e (Comorb

id)Fati

gue (

Medica

l)

Hopeles

snes

s (Comorb

id)

Hopeles

snes

s (Med

ical)

Insomnia

(any t

ype)

(Comorb

id)

Insomnia

(any t

ype)

(Med

ical)

Loss In

teres

t (Comorb

id)

Loss In

teres

t (Med

ical)

Low Mood (C

omorbid)

Low Mood (M

edical)

Retard

ation (

Comorbid)

Retard

ation (

Medica

l)

Suicide (

Comorbid)

Suicide (

Medica

l)

Weight L

oss (C

omorbid)

Weight L

oss (M

edical)

Worthles

snes

s (Comor

bid)

Worthles

snes

s (Med

ical)

Medical Illness Alone

Comorbid Depression

**

*

*

*

*

*

*

*

Comment: Slide illustrates distinct symptoms profile in comorbid depression vs medical illness alone

Medically Unwell Alone

Primary Depression Alone

Secondary Depression

Comment: Slide illustrates concept of phenomenology of depressions in medical disease

FatigueAnorexiaInsomnia

Concentration

Medically Unwell

Primary Depression

Secondary Depression

Comment: Slide illustrates actual phenomenology of depressions in medical disease

Weight loss

AgitationRetardation

Elderly?

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0.100

0.200

0.300

0.400

0.500

0.600

0.700

0.800

Anger

Anxiety

(Com

bined)

Anxiety

(Psy

chic

anxie

ty)

Anxiety

(Somatic

anxiet

y)

Decre

ased

App

etite

Decre

ased

Weig

ht

Depres

sed M

ood

Diminish

ed C

oncentra

tion

Diminish

ed In

teres

tExc

essiv

e Guilt

Helples

snes

sHope

lessn

ess

Increas

ed A

ppetite

Increas

ed W

eight

Indecisi

venes

sLoss

of Ene

rgy

Psych

omotor Agita

tion

Psych

omotor Retar

datio

n

Sleep D

isturban

ce (C

ombined)

Sleep D

isturban

ce (H

ypers

omnia)

Sleep D

isturban

ce (In

somnia)

Thoughts

of Dea

thWorth

lessn

ess

<55>54>59>64

*

*

*

*

*

**

*

Comment: Slide illustrates diagnostic value of symptoms in late life vs mid-life depression – few have special significance

3. Cancer Care - Detection

How well do cancer specialists identify depression/distress?

How do doctors compare with nurses?

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

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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

Baseline Probability

Depression+

Depression-

PPV

NPV

Comment: At a prevalence of 20% GPs PPV is 40% and NPV 86%

Phase I

Comment: Slide illustrates diagnostic accuracy according to score on DT

11.815.4

30.4 28.9

41.9 42.9 40.7

57.1

82.4

66.771.4

15.8

25.0

26.124.4

19.4 19.0

33.3

21.4

11.8

22.2 14.3

72.4

59.6

43.546.7

38.7 38.1

25.921.4

5.911.1

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-distressedJudgement = UnclearJudgement = Distressed

ResultsLooking for just distress

detection sensitivity of 11.2% (95% CI 6.9% to 16.9%)

detection specificity of 98.3% (95% CI 95.2 to 99.7%).

Looking for any mental health complication their

sensitivity was 50.6%

specificity 79.4%

There was significantly better performance using the broad approach rather than a narrow focus 65.4% vs 56% (Chi² = 4.3,p = 0.037).

PredictorsExamining predictors, clinicians had better ability to

recognize higher severities of distress (adjusted R2= 0.87 p = 0.001). There was a trend for better recognition by community than chemotherapy nurses. There was no difference according to the stage or type of cancer.

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Pre-test Probability

Post

-test

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

SummaryDetection of depression is low in all groups

Detection of depression has some untested assumptions

Most clinicians are not using tools

Detection of distress is almost imperfect

=> Whose opinion is most important