Alex Mitchell www.psycho-oncology.info

Department of Cancer & Molecular Medicine, Leicester Royal Infirmary

Department of Liaison Psychiatry, Leicester General Hospital

IPOS2010IPOS2010

T126 - Screening and Case Identification for Depression inCancer and Palliative Settings:

A Meta-Analysis of Diagnostic Validity Studies

T126 - Screening and Case Identification for Depression in Cancer and Palliative Settings:

A Meta-Analysis of Diagnostic Validity Studies

1. Background1. Background

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+)

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

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

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

Validity of Methods to Evaluate Depression

Unassisted Clinician Conventional Scales

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

5. Meta-Analysis5. Meta-Analysis

What can enhance detection?

MethodsMethodsThere were 41 valid analyses; prevalence of depression

was 24.3% (95% CI = 17.3% to 32.0%).

29 in oncology settings… 3x studies on the BDI-II, From 4 studies using the DT and remainder of studies involved the HADS.

Only 12 in palliative settings (most HADS; non with DT)Inc 3x studies involving Two Questions and 3 studies of

the EPDS

Unfortunately most had not received independent validation.

Common MethodsCommon MethodsDTBDIBDI fast screenPHQ-9PHQ-2 / two stem questionsGHQ-12 and GHQ-28CES-DGDS-30GDS-15Zung SDSHADS-DHDRS.

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

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%

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

-test

Pro

babi

lity

HADS-D+

HADS-D-

Baseline Probability

2Q+

2Q-

EPDS+

EPDS-

1Q+

1Q-

Palliative

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

-test

Pro

babi

lity

1Q+1Q-Baseline ProbabilityHADS-D+HADS-D-HADS-T+HADS-T-BDI+BDI-HADS-A+HASD-A-DT+DT-

Non-Palliative

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

-test

Pro

babi

lity

1Q+1Q-Baseline ProbabilityDT+DT-2Q+2Q-HADSd+HADSd-HADS-T+HADS-T-BDI+BDI-EPDS+EPDS-HADS-A+HASD-A-

MDD - Palliative and Non-Palliative

SummarySummaryFrom 29 non-palliative-

The optimal method was the BDI-II although the DT was good in a screening capacity.

Across 12 palliative analyses (n=1760) –

The optimal initial method was the two question approach.

5. Cancer Care – Cumulative Testing5. Cancer Care – Cumulative Testing

What repeat testing enhance detection?

Cancer Population

CNS Assessment

Possible case

Depression

Screen #1+ve

n = 200 No Depression

Sp 55%

Se 70%

n = 800

N = 1000

TP = 140

FP = 360Probable Non-Case TN =440

FN = 60

PPV 28% NPV 88%

Screen #1-ve

YieldTP = 140

TN = 440

FN = 60

FP = 360

NPV 88%

PPV 28%

Sp 55%

Se 70%

Cancer Population

CNS Assessment

Possible case

Depression

Screen #1+ve

n = 200 No Depression

Sp 55%

Se 70%

n = 800

N = 1000

TP = 140

FP = 360Probable Non-Case TN =440

FN = 60

PPV 28%

Oncologist Assessment Sp 80%

Sp 40%

NPV 88%

Probable Depression TP = 56

FP = 72Probable Non-Case TN =288

FN = 84

PPV 44% NPV 77%

Screen #1-ve

Screen #2+ve

Screen #2+ve

Cumulative YieldTP = 56

TN = 728

FN = 144

FP = 72

NPV 83%

PPV 44%

Sp 91%

Se 28%

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 Island

James Coyne University of PennsylvaniaNadia Husain University of Leicester

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