Alex MitchellKaren LordPaul Symonds

Department of Cancer & Molecular Medicine, Leicester Royal Infirmary

Department of Liaison Psychiatry, Leicester General Hospital

Sept2010Sept2010

NCRS 2010

Validation of the Distress Thermometer using ADL:What is the relationship between distress and dysfunction?

Contents1. Strengths & limitations of DT

2. How to establish “clinical significance” simply

3. Link between distress and dysfunction

4. Lessons for DT cut-offs

Clinical Significance

DSMIV and PHQ9Includes a questionon function

1. Strengths & limitations of DT

Strengths => Mainly Acceptability

Limitations => Reliability and Validity

DT vs HADS-T Validity (n=660) Leicester2009

SE SP AUC CUT

DT – 71.9% 78.4% 0.814 cut point >=4

AnxT – 75.7% 73.4% 0.821 cut point >=5

DepT – 77.6% 82.2% 0.855 cut point >=3

AngT – 77.5% 77.6% 0.823 cut point >=2

HelpT - 69.1% 80.8% 0.809 cut point >=3

DT vs DSMIV DepressionSE SP PPV NPV

DTma (2007) 80.9% 60.2% 32.8% 92.9%

DTLeicesterBW 82.4% 68.6% 28.0% 98.3%

DTLeicesterBSA 100% 59.6% 26.8% 100%

BSA = British South Asian MA = meta-analysis (Mitchell 2007 JCO)

BW= British White

- 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: Practical Problems Spiritual/ Religious Concerns Physical Problems contd…

Childcare Loss of faith Changes in Urination

Housing Relating to God Fevers

Money Loss of meaning or purpose in life

Skin dry/ itchy

Transport Nose dry/ congested

Work/School Physical problems Tingling in hands/ feet

Pain Metallic taste in mouth

Family Problems Nausea Feeling swollen

Dealing with partner Fatigue Sexual

Dealing with children Sleep Hot flushes

Getting around

Emotional Problems Bathing/ Dressing

Depression Breathing

Fears Mouth sores Is there anything important you would like to add to the list?__________________________________________________________________________________________

Nervousness Eating

Sadness Indigestion

Worry Constipation

Anger Diarrhoea

Distress Thermometer

Distress Thermometer

DT contains only two anchorsIn its most common version.

Distress Thermometer – Pooled Table

ScoreRansom 2006

Tuinman2008

Mitchell 2009

Lord 2010

Hoffman 2004

Gessler2009

Clover 2009

Jacobsen 2005 Sum

Proportion

Zero 68 38 61 123 14 27 65 71 467 18.4%

One 72 31 42 68 5 26 39 46 329 12.9%

Two 77 22 35 44 5 18 30 54 285 11.2%

Three 65 37 42 46 8 23 45 46 312 12.3%

Four 51 29 29 30 8 7 21 31 206 8.1%

Five 41 46 62 40 11 13 41 48 302 11.9%

Six 38 32 23 28 2 16 26 31 196 7.7%

Seven 36 21 23 38 2 15 32 16 183 7.2%

Eight 18 12 18 29 6 9 19 15 126 5.0%

Nine 16 5 8 14 3 3 13 9 71 2.8%

Ten 9 4 7 20 4 0 9 13 66 2.6%

Sum 491 277 350 480 68 157 340 380 2543

Proportion 19.3% 10.9% 13.8% 18.9% 2.7% 6.2% 13.4% 14.9%

Distress Thermometer – Pooled

Proportion

18 .4 %

12 .9 %

11.2 %12 .3 %

8 .1%

11.9 %

5.0 %

2 .8 % 2 .6 %

7.7% 7.2 %

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Zero One Two Three Four Five Six Seven Eight Nine Ten

Insignificant SevereModerateMildMinimal

50%

Making a cut based on distribution frequency aloneIs difficult, or impossible.

British Journal of Cancer (2007) 96, 868 – 874

Making a cut based on distribution frequency aloneIs difficult, or impossible also for the HADS

3. Methods – How to Validate an Cut Point?

Establish validity with dysfunction not depression

8%

DT37%

DepT23%

AngT18%

AnxT47%

4%

7%

1%

1%

9%

3%

0%

2%

4%

15%

3%

2%

Nil41%

Non-Nil59%

DT

AnxT AngT

DepT

Distress overlaps with not just distress but anxiety and anger

SampleWe analysed data collected from Leicester Cancer Centre

from 2008-2010 involving 531 people approached by a research nurse and two therapeutic radiographers.

We examined distress using the DT and daily function using the question:

“How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?”

“Not difficult at all =0; Somewhat Difficult =1; Very Difficult =2; and Extremely Difficult =3”

18%

DepT23%

Distress69%

Dysfunction76%

0.3%

3% 2%

26%28% 22%

Of the 293 Non-Nil

DysfunctionDistress

DepTVirtually no one with depression has neither distress nor dysfunction, but many with dysfunction do not have depression

Dysfunction in 531 cancer patients

55.7%

34.3%

7.3%

2.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Unimpaired Mild Moderate Severe

Chart illustrated distribution of dysfunction in unselected cancer patients

Unimpaired by DT Score

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

1 2 3 4 5 6 7 8 9 10 11

Chart illustrated unimpaired function by DT score

Mean DT Scores?

Unimpaired Mild Moderate Severe

Mean DT Score 2.1 4.1 5.9 6.5

Std Deviation 2.54 3.0 2.56 3.59

Sample Size 296 182 39 14

Simplified DT Range* 0-3 4-5 6-7 8-10

DT distribution by Impairment

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

0 1 2 3 4 5 6 7 8 9 10

Distress Thermometer

Typically severely impared

Typically mod impared

Typically mildly impared

Typically unimpared

None at all

Based on the mean levels of dysfunction the following anchors are suggested

NB: a lower threshold cut of about 3 seems appropriate

Distress Thermometer

Extreme and incapacitating

Very Severe and very disabling

Moderately Severe and disabling

Moderate and quite disabling

Moderate and somewhat disabling

Mild-Moderate and slight disabling

Mild but not particularly disabling

Very mild and not disabling

Minimal but bearable

Minimal and not problematic

None at all

Based on the mean levels of dysfunction and typical verbal descriptions of distress the following anchors are suggested

Credits & Acknowledgments

Karen Lord Leicester Royal InfirmaryElena Baker-Glenn University of NottinghamPaul Symonds Leicester Royal InfirmaryChris Coggan Leicester General HospitalBurt Park University of NottinghamLorraine Granger Leicester Royal InfirmaryNadia Husain University of LeicesterKufre Sampson Leicester Royal Infirmary

For more information www.psycho-oncology.info