Rcpsych Workshop - Depression in medical settings (Mar11)

Alex Mitchell ajm80@le.ac.uk

Consultant in Liaison Psychiatry & Psycho-oncology

Diagnosing Depression in Medical Settings:

Symptoms and screening….60min workshop

RCPsych Workshop 2011

DSMVICD11

Symptoms

Under-served

Distress

Monitoring

Scales

Screening

Qualityof care

Older people

PhysicalIllness

DepressionDetection

Prescribing

Follow-up

Culturaleffects

Se Change

PhysiciansSpecialSymptoms

PrimaryCare

Impairment

Help Seeking

DSMVICD11

Symptoms

DistressScales

Screening

Qualityof care

Older people

PhysicalIllness

DepressionDetection

SpecialSymptoms

PrimaryCare

ContentsOverview Depression in medical settingsComorbidity | impairment | mortality

Prevalence of depression in medical settingsCancer | IHD | Stroke

Symptoms of Depression in medical settingsSame or different?.....older people?

Conventional screeningAccuracy | acceptability | Does it work?

New Screening innovationsWhy?

1.Overview: Depression in medical settings

Comorbidity | impairment | mortality

42.9 42.7

41.239.8

14.315.2

1.92.5

2.6 2.2 1.8 1.7 1.4 10.3 0.1

Depression Panic disorder PTSD Specific phobia Social phobia Bipolar disorder GAD Alcohol abuse Drug abuse

Yearly DOR

Unique

Impairment: Days totally out of role per year

Quality of life: Moussavi et al (2007) Lancet 2007; 370: 851–58

n=245 404 participants from 60 countries

Psychosomatic Med (2004) Barth et al

Mortality and IHD+depression

17.7 20.515.6

21.717.5 20.3

t or a

Depression Alone (=883)

Anixety Alone (n=314)

Depression and Anxiety (n = 439)

Young et al (2001) The Quality of Care for Depressive and Anxiety Disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61

% Receiving Any treatment for Depression (CIDI)

10.9 11.3

8.18.8

High Inc

omeBelg

France

German

Spain USALow

ChinaColom

biaSouth

caUkra

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

n=84,850 face-to-face interviews

=> In physical

% Receiving Any treatment for Mental Health% Receiving Any treatment for Mental Health

5.7 6.3 6.4

3.9 3.25.7

5 57.7

6.5 6.2

2.3 1.8

tal Il

itions

ical c

Cancer n=4878

No Cancer n=90,737

Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590

12mo Service Use 12mo Service Use (NIH, 2002)(NIH, 2002)

Two explanations=>

Audience:

How common are medical co-morbidities in depression?

Comorbid Physical Diagnoses in Elderly Depressed Patients

One Tw o Three+ None

Proctor EK, et al (2003) American Journal of Geriatric Psychiatry;11:329‐38.

Osteoa

lar di

l dise

: Ulce

al lit

First Episode MDD (n=6090)

Recurrent Episode MDD (n=4167)

Osteoa

rthrit

nic fa

l lith

First Episode MDD (n=6090)

Recurrent Episode MDD (n=4167)

Physical Comorbidity in Schizophrenia and Depression

SchizophreniaDepressionNHANES

Sokal 2004

J Nerv Ment Dis 192: 421–427

NHANES ‐ US Department of Health National Health and Nutrition Examination Survey , 1988 –1994

Prevalence Depression in medical settings

Methodological | Scale vs interview | Current vs 12mo vs lifetime

Cancer | IHD | Stroke

itatio

Suicide odds ratio

Juurlink (2004) 1354 older individuals who died of suicide in Ontario, CA

No disord

Conges

tive H

eart Fa

sion (

1)Diab

etes (

Corona

ry Arte

ry Dis (n

CVA (n=7

COPD (n=16

End-Stag

al Failu

Egede (2007) 12mo prevalence rates from the Data on 30,801 adults from the US 1999 National Health

National Health Interview Survey (NHIS) – CIDI‐SF

Prevalence of depression in Oncology settings

70 studies involving 10,071 individuals;14 countries.16.3% (95% CI = 13.9% to 19.5%)

Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3%

Proportion meta-analysis plot [random effects]

0.0 0.3 0.6 0.9

combined 0.1730 (0.1375, 0.2116)

Colon et al (1991) 0.0100 (0.0003, 0.0545)

Massie and Holland (1987) 0.0147 (0.0063, 0.0287)

Hardman et al (1989) 0.0317 (0.0087, 0.0793)

Derogatis et al (1983) 0.0372 (0.0162, 0.0720)

Lansky et al (1985) 0.0455 (0.0291, 0.0676)

Mehnert et al (2007) 0.0472 (0.0175, 0.1000)

Katz et al (2004) 0.0500 (0.0104, 0.1392)

Singer et al (2008) 0.0519 (0.0300, 0.0830)

Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)

Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)

Lee et al (1992) 0.0660 (0.0356, 0.1102)

Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)

Grassi et al (2009) 0.0826 (0.0385, 0.1510)

Grassi et al (1993) 0.0828 (0.0448, 0.1374)

Walker et al (2007) 0.0831 (0.0568, 0.1165)

Kawase et al (2006) 0.0851 (0.0553, 0.1240)

Coyne et al (2004) 0.0885 (0.0433, 0.1567)

Alexander et al (2010) 0.0900 (0.0542, 0.1385)

Love et al (2002) 0.0957 (0.0650, 0.1346)

Ozalp et al (2008) 0.0971 (0.0576, 0.1510)

Morasso et al (2001) 0.0985 (0.0535, 0.1625)

Costantini et al (1999) 0.0985 (0.0535, 0.1625)

Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)

Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)

Morasso et al (1996) 0.1121 (0.0593, 0.1877)

Prieto et al (2002) 0.1227 (0.0825, 0.1735)

Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)

Payne et al (1999) 0.1290 (0.0363, 0.2983)

Kugaya et al (1998) 0.1328 (0.0793, 0.2041)

Alexander et al (1993) 0.1333 (0.0594, 0.2459)

Gandubert et al (2009) 0.1597 (0.1040, 0.2300)

Razavi et al (1990) 0.1667 (0.1189, 0.2241)

Akizuki et al (2005) 0.1797 (0.1376, 0.2283)

Leopold et al (1998) 0.1887 (0.0944, 0.3197)

Devlen et al (1987) 0.1889 (0.1141, 0.2851)

Berard et al (1998) 0.1900 (0.1184, 0.2807)

Joffe et al (1986) 0.1905 (0.0545, 0.4191)

Berard et al (1998) 0.2100 (0.1349, 0.3029)

Maunsell et al (1992) 0.2146 (0.1605, 0.2772)

Grandi et al (1987) 0.2222 (0.0641, 0.4764)

Evans et al (1986) 0.2289 (0.1438, 0.3342)

Spiegel et al (1984) 0.2292 (0.1495, 0.3261)

Golden et al (1991) 0.2308 (0.1353, 0.3519)

Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)

Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)

Kathol et al (1990) 0.2961 (0.2248, 0.3754)

Green et al (1998) 0.3125 (0.2417, 0.3904)

Jenkins et al (1991) 0.3182 (0.1386, 0.5487)

Burgess et al (2005) 0.3317 (0.2672, 0.4012)

Hall et al (1999) 0.3722 (0.3139, 0.4333)

Morton et al (1984) 0.3958 (0.2577, 0.5473)

Baile et al (1992) 0.4000 (0.2570, 0.5567)

Passik et al (2001) 0.4167 (0.2907, 0.5512)

Bukberg et al (1984) 0.4194 (0.2951, 0.5515)

Massie et al (1979) 0.4850 (0.4303, 0.5401)

Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)

Levine et al (1978) 0.5600 (0.4572, 0.6592)

Plumb & Holland (1981) 0.7750 (0.6679, 0.8609)

proportion (95% confidence interval)

0 20 40 60 80 100

Time (months)

Meta regression using the random effects model on raw porportions Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size.

1a. Routine Recognition of Depression

Is depression a disease; disorder (syndrome) or normally distributed

Audience:

Is depression categorical or dimensional?

Graphical – two diseases

Healthy

Stroke# ofIndividualsWith symptom

Ischaemic change on mri

Point of Rarity

Comment: Slide illustrates the concept of discrimination using one symptom severity of “low mood”

Graphical – two disorders

Healthy

Diabetes

# ofIndividualsWith symptom

?Point of Rarity

Optimal cut

Graphical - Dimension

Non-Depressed

Depressed# ofIndividualsWith symptom

Severity of Low Mood

Comment: Slide illustrates added hypothetical distribution of mood scores in a population with hidden depression

Zero One

TwoThree

Five SixSev

htNine

TenElevenTwelv

nFourte

SixteenSeve

Eighteen

HADS-D

All visits (N =14,372) Primary care (N =3,605) Psychiatrists (N =293) Medical specialists (N=10,474)

Comment: Slide illustrates added proportion of all depression treated in each setting. Most depression is treated in primary care

J Gen Intern Med. 2006 September; 21(9): 926–930.

Comment: Slide illustrates added actual distribution of mood scores on the HADS in a cancer population with hidden depression from the Edinburgh cancer centre

Nine Ten

Eleven

Fiftee

Eighteen

Ninetee

Proportion MissedProportion Recognized

HADS-D

Recognition from WHO PPGHC Study (Ustun, Goldberg et al)

7470 69.6

61.5 59.656.7 56.7 55.6 54.2

45.7 43.939.7

22.2 21 19.3

Santia

Verona

Groningen

Berlin

Seattle

TOTALBangalo

reRio de J

Ibadan

Ankara

ghaiNagas

Audience:

What are the predictors of improved recognition?

0.210.22

0.02 0.020.01 0.01

0.010.01 0.01 0.01

10mins

15mins

20mins

25mins

30mins

35mins

40mins

45mins

50mins

55mins

60mins

65mins

70mins

Geraghty JGIM 2007

Comment: Slide illustrates diagnostic accuracy according to score on DT

11.815.4

30.4 28.9

41.9 42.9 40.7

66.771.4

26.124.4

19.4 19.0

22.2 14.3

43.546.7

38.7 38.1

25.921.4

5.911.1

Zero One Two Three Four Five Six Seven Eight Nine Ten

Judgement = Non-distressedJudgement = UnclearJudgement = Distressed

CNS in Oncology N=401

55.6 54.4

29.826.2 25.6 25.2 23.8 24

21.4 21.2

13.9 12.89.5

7.2 7 7 5.9 4.8 4.1 2.6 1.8 1.8 1.3 0.9 0.4 0.40

es; in

ite; o

f driv

; stre

ltatio

l labi

t affe

t or p

Comment: Slide illustrates which symptoms are asked about by GPS looking for depression

What do GPs Ask about:SleepAppetite

LowEnergy

GP Recognizes:Proportion of Individual Symptoms Recognised by GPs

36.4 34.631.6

21.616.7

13.39.1 8.3 8.3

Insomnia

hondri

terest

Tearfu

Anxiety

Pessim

Anorex

Not Copin

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

1,2 or 3 Simple QQ15%

Clinical Skills Alone73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9% Other/Uncertain

Use a QQ15%

ICD10/DSMIV13%

Cancer Staff Psychiatrists

Current MethodComment: Slide illustrates preferences of cancer clinicians vs psychiatrists for detecting depression

3. Symptoms of Comorbid Depression

Same or different?Older People?

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

Symptom Significance in Depression

(7 or) 8 symptoms (3+4)

(5 or )6 symptoms

4 symptoms (2+2)

2 or 3 symptoms

0 or 1 symptom

16 - 21UnspecifiedSevere

12 - 155 symptoms (Mj)

Moderate

8 -112-4 symptoms (minor)

4 - 71 or No core symptoms

Sub-syndromal

0 - 30 symptomHealthy

HADs D ScoreDSMIVDepression Severity

Change in practice – ICD10 2/4/6/8 + CS | DSMIV‐TR Mn => NOS

Symptoms Clinical Significance Duration

ICD-10 Depressive Episode Requires two of the first three symptoms (depressed mood, loss of interest in everyday activities, reduction in energy) plus at least two of the remaining seven symptoms (minimum of four symptoms)

At least some difficulty in continuing with ordinary work and social activities

2 weeks unless symptoms are unusually severe or of rapid onset).

DSM-IV Major Depressive Disorder Requires five or more out of nine symptoms with at least at least one from the first two (depressed mood and loss of interest).

These symptoms cause clinically important distress OR impair work, social or personal functioning.

2 weeks

DSM-IV Minor Depressive Disorder Requires two to four out of nine symptoms with at least at least one from the first two (depressed mood and loss of interest).

These symptoms cause clinically important distress OR impair work, social or personal functioning.

2 weeks

DSM-IV Adjustment disorder Requires the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months.

These symptoms cause marked distress that is in excess of what would be expected from exposure to the stressor OR significant impairment in social or occupational (academic) functioning

Acute: if the disturbance lasts less than 6 months Chronic: if the disturbance lasts for 6 months

DSM-IV Dysthymic disorder Requires persistently low mood two (or more) of the following six symptoms:

(1) poor appetite or overeating (2) Insomnia or hypersomnia(3) low energy or fatigue (4) low self-esteem (5) poor concentration or difficulty

making decisions (6) feelings of hopelessness

The symptoms cause clinically significant distress OR impairment in social, occupational, or other important areas of functioning.

Requires depressed mood for most of the day, for most days (by subjective account or observation) for at least 2 years

Audience:

Which of the following are recognized symptoms of MDD

Loss of confidenceLow motivation / driveWithdrawalAvoidanceSocial isolationWorryFeelings of dreadHelplessnessHopelessnessPsychic anxietySomatic anxietyAngerLack of reactive moodCognitive Change (=> memory complaints)Perceptual distortion

Which Are Recognized Symptoms of MDD?

=> plan

UNSURE

“Common” Symptoms of Depression

0.120.56Thoughts of death

0.330.59Psychic anxiety

0.120.61Worthlessness

0.420.69Anxiety

0.270.70Insomnia

0.120.81Diminished interest/pleasure

0.240.82Diminished concentration

0.320.83Sleep disturbance

0.270.87Concentration/indecision

0.320.87Loss of energy

0.300.88Diminished drive

0.180.93Depressed mood

Non-Depressed FrqDepressed FrqItem

Mitchell, Zimmerman et al n=2300

“Uncommon” Symptoms

0.060.16Increased weight

0.060.19Hypersomnia

0.070.19Increased appetite

0.060.22Lack of reactive mood

0.060.23Decreased weight

0.040.28Psychomotor retardation

0.090.34Psychomotor agitation

0.260.44Anger

0.110.45Decreased appetite

0.250.46Somatic anxiety

Non-Depressed ProportionDepressed ProportionItem

Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2009

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

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Depressed Mood

Diminished drive

Diminished interest/pleasure

Loss of energy

Sleep disturbance

Diminished concentration

Sensitivity

1 - Specificity

n=1523

Comment: Slide illustrates summary ROC curve sensitivity/1-specficity plot for each mood symptom

3a. Depression in Older People

Does it go unrecognized?

Are Somatic Symptoms Common in Older People?

Comorbid Physical Diagnoses in Elderly Depressed Patients

One Tw o Three+ None

Proctor EK, et al (2003) American Journal of Geriatric Psychiatry;11:329‐38.

QuestionsMore or less difficult to detect late-life depression?

More or less

Low moodAgitation InsomniaPoor concentration

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Routine Case-Finding Late-LifeRoutine Exclusion Late-lifeBaseline ProbabilityRoutine Case-Finding MixedRoutine Exclusion MixedRoutine Case-Finding YoungerRoutine Exclusion Younger

Comment: Slide illustrates detection of late life vs mid-life depression in primary care – GPs are least successful with late-life depression

More common in late-life depression

More common in early-life depression

Comment: Slide illustrates simple frequency of symptoms in late life vs mid-life depression

Anxiety

bined)

Anxiety

(Somatic

anxiet

Depres

Diminish

oncentra

Diminish

e Guilt

Helples

Increas

ppetite

Increas

Indecisi

of Ene

omotor Agita

omotor Retar

Sleep D

isturban

ombined)

Sleep D

isturban

omnia)

Sleep D

isturban

ce (In

somnia)

Thoughts

of Dea

thWorth

<55>54>59>64

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

Mid-life Depression

Late-life Depression

Comment: Slide illustrates actual phenomenology of late life depression

Poor concworthlessness

3b. Comorbid Depression

Back to Basics

Approaches to Somatic Symptoms of DepressionInclusiveUses all of the symptoms of depression, regardless of whether they may or may not be secondary to a physical illness. This approach is used in the Schedule for Affective Disorders and Schizophrenia (SADS) and the Research Diagnostic Criteria.

ExclusiveEliminates somatic symptoms but without substitution. There is concern that this might lower sensitivity. with an increased likelihood of missed cases (false negatives)

EtiologicAssesses the origin of each symptom and only counts a symptom ofdepression if it is clearly not the result of the physical illness. This is proposed by the Structured Clinical Interview for DSM and Diagnostic Interview Schedule (DIS), as well as the DSM-III-R/IV).

SubstitutiveAssumes somatic symptoms are a contaminant and replaces these additional cognitive symptoms. However it is not clear what specific symptoms should be substituted

Medically Unwell Alone

Primary Depression Alone

Secondary Depression

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

FatigueAnorexiaInsomnia

Concentration

Which are the least somatic scales?

Study: Coyne Thombs Mitchell

N= 4500; Pooled database study; All comparative studies

Physical illness+comorbid depressionVsPhysical illness aloneVs

Primary depression alone

Co-morbid Depression vs Primary Depression

Agitatio

n (Com

orbid)

Agitatio

n (Prim

Anxiety

orbid)

Anxiety

Appetite

(Comorb

Appetite

Concen

tratio

n (Comorb

Concen

tratio

n (Prim

Fatigu

e (Comorb

Fatigu

e (Prim

Guilt (

Comorbid)

Guilt (

Primar

Hopeles

s (Comorb

Hopeles

s (Prim

Insomnia

(Comor

Insomnia

Loss In

t (Comorb

Loss In

t (Prim

Low Mood (C

omorbid)

Low Mood (P

rimary

Retard

ation (

Comorbid)

Retard

ation (

Primary)

Suicide (

Comorbid)

Suicide (

Primar

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 vs primary depression

AgitationRetardation

Co-morbid Depression vs Medical Illness Alone

n= 4069 vs 1217

Anxiety

orbid)

Anxiety

Concen

tratio

n (Comorb

Concen

tratio

n (Med

Fatigu

e (Comorb

id)Fati

Medica

Hopeles

s (Comorb

Hopeles

s (Med

Insomnia

(any t

(Comorb

Insomnia

(any t

Loss In

t (Comorb

Loss In

t (Med

Low Mood (C

omorbid)

Low Mood (M

edical)

Retard

ation (

Comorbid)

Retard

ation (

Medica

Suicide (

Comorbid)

Suicide (

Medica

Weight L

oss (C

omorbid)

Weight L

oss (M

edical)

Worthles

s (Comor

Worthles

s (Med

Medical Illness Alone

Comorbid Depression

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

Medically Unwell Alone

FatigueAnorexiaInsomnia

Concentration

Medically Unwell

Primary Depression

Comment: Slide illustrates actual phenomenology of depressions in medical disease

Weight loss

AgitationRetardation

Anhedo

Appetite

ity in

al inter

Distinct

mood quali

tyFati

Gastro

symptoms

Hypers

Impair

ncentra

tion/at

tention

Insomnia

(Early

Insomnia

(Middle)

Insomnia

Interpers

onal se

nsitivi

Leaden

Mood (an

xious)

Mood (irr

itable

)Mood (

Mood rea

ctivit

y impair

Mood vari

ation b

e of d

Negati

ve outlo

ok (futu

Negati

ve outlo

ok (se

or phobic

symptoms

omotor agit

omotor slow

Somatic c

omplaint

Suicidal

ideatio

Sympath

etic ar

Weight d

Weight in

Rate in Depressed+MedicalRate in Depression AloneDifferential

ite in

ity im

More common inComorbid Depressions

Less common in Comorbid Depressions

4. Conventional Screening (in medical settings)

MethodsAccuracy

Observation

Interview

Visual

Self-Report

MoodScreening

VA-SES

HAMD-D17

PhysicalGeneral

Signs ofDS

CDSS#10

MADRAS10

Trained

ConfidentSkilledClinician

SMILEY

=> Is it accurate?

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%

Methods to Evaluate Depression

Unassisted Clinician Conventional Scales

Verbal Questions Visual-Analogue Test

Whooley/NICE

Distress Thermometer

Depression Thermometer

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

Clinical Skills Alone

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%

Clinical Skills Alone

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Clinician Positive (Fallowfield et al, 2001)

Clinician Negative (Fallowfield et al, 2001)

Baseline Probability

HADS-D Positive (Mata-analysis)

HADS-D Negative (Meta-analysis)

Comment: Slide illustrates Bayesian curve comparison from indirect studies of clinician and HADS

This illustrates POTENTIAL gain from screening

Benefit

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

lity HADS+

GDS30+

GDS30-

GDS15+

GHQ28+

GDS15-

GHQ28-

WHOOLEY2Q+

WHOOLEY2Q-

BDI-SF+

BDI-SF-

GHQ12+

GHQ12-

PHQ2 = HIGH NPV

Comment: Slide illustrates actual gain in meta-analysis of screening implementation in primary care

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Clinical+Clinical-Baseline ProbabilityScreen+Screen-

Comment: Slide illustrates Bayesian curve comparison from RCT studies of clinician with and without screening

This illustrates ACTUAL gain from screening in Study from Christensen

5. Enhanced Detection Strategies

Acceptability

Algorithm

Not just depression

Distress Thermometer

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

DT+ [N=4]DT+ [N=4]Baseline Probability1Q+ [N=4]1Q- [N=4]2Q+2Q-DT/IT+DT/IT-HADST+ [N=13]HADST+ [N=13]PDI+PDI-

Mitchell AJ. Short Screening Tools for Cancer Related Distress A Review and Diagnostic Validity Meta-analysis JNCI (2010) in press

Distress

Proportion

18 .4 %

12 .9 %

11.2 %12 .3 %

11.9 %

2 .8 % 2 .6 %

7.7% 7.2 %

Zero One Two Three Four Five Six Seven Eight Nine Ten

Insignificant SevereModerateMildMinimal

DepT23%

AngT18%

AnxT47%

Nil41%

Non-Nil59%

AnxT AngT

=86.4% =82.2%

=57.6%Beals AGP 2004

DepT23%

Distress69%

Dysfunction76%

26%28% 22%

Of the 293 Non-Nil

DysfunctionDistress

0.410.43

0.40 0.53

0.280.19

0.020.00 0.00 0.00

0.040.06

0.000.03

Zero One Tw o Three Four Five Six Seven Eight Nine Ten

3=Extremely Difficult”

2=Very Difficult

1=Somewhat Difficult

Unimpaired

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

HADSd+

HADSd-

HADS-T+

HADS-T-

HADS-A+

HASD-A-

Depression_HADS

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

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

Depression_all

SummaryQuestions

Rcpsych Workshop - Depression in medical settings (Mar11)

Health & Medicine

Transcript of Rcpsych Workshop - Depression in medical settings (Mar11)

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