A prospective study to compare three depression screening tools in patients who are terminally ill
Introduction
Depression is a significant symptom for approximately one in four palliative care patients, and is especially common in those patients with more advanced metastatic disease [1], [2]. It is well known that depression is frequently missed and therefore goes untreated [3], [4]. One reason for this low rate of detection is thought to be nondisclosure by patients who may feel either that they are wasting the doctor's time or that they are in some way to blame for their distress and so they choose to hide their feelings. In addition, medical and nursing staff may not be confident eliciting psychological and psychiatric morbidity [5]. The exact prevalence of depressive disorders in palliative care patients is difficult to establish; rates from studies using structured diagnostic interviews or well-defined criteria vary from 5% to 32% for all depressive disorders [6]. Depression has no distinct biological markers or effective diagnostic test and it can be difficult to differentiate depression from “appropriate sadness” or grief reactions as the end of life approaches [7]. Importantly, there are many antidepressants available with acceptable side effect profiles; patients identified as depressed even within the last 4–6 weeks of life may still benefit from treatment [8], but few palliative care patients are prescribed antidepressant medication [9].
Doctors may attribute somatic symptoms of depression to the cancer illness, highlighting their tendency to separate mental from physical health [10]. The complex problem of deciding which symptoms may be attributable to cancer and which may be due to depression has been discussed by Endicott [11], who proposed that somatic symptoms should be substituted for nonsomatic symptoms in the patient with cancer. Endicott also stressed the importance of asking patients with cancer about suicidal ideation.
Unfortunately, staff may perceive inquiries of psychological symptoms as adding to the patient's distress and fear the consequences of asking direct questions about feelings. Research, however, has shown that patients do not feel such questions are stressful as long as they are asked in an empathetic way [12].
There is increasing interest in the use of screening scales within palliative care. The majority are self-completion rating scales consisting of a range of depressive symptoms. The Hospital Anxiety and Depression scale [13] is the most frequently used tool used in palliative care settings [6]; however, two recent articles [14], [15] reported relatively low sensitivity and specificity for this scale when used in patients with advanced metastatic disease. There is, therefore, a need to identify a brief and valid tool for the assessment of depression in this population.
This study investigates the performance of three different screening tools: (a) the Edinburgh depression scale [16]; (b) asking the single question, “are you depressed?” [17]; and (c) verbally self-rating their mood on a scale of 0–10. All three tools are validated against a semi-structured clinical psychiatric interview according to DSM-IV criteria.
Section snippets
Method
Patients attending a palliative care day unit were recruited into the study and were required to be able to understand both written and spoken English and to participate in a semi-structured interview. Full ethical approval for this study was obtained from the local ethics committee and all patients were required to give written consent prior to participation. Baseline demographic information was obtained on age, ethnicity, diagnosis, past history of depression, performance status (Eastern
Results
One-hundred and six patients were eligible to participate in the study during the 6-month study period, but only 74 were functionally able to complete all the rating instruments and the clinical interview.
The patients' ages ranged from 28 to 89 years old with a mean age of 67.89 years (SD 13.60) and median age of 70.5 years [interquartile range (IQR), 62–78]. The distribution of patients' ages was slightly skewed, which is concurrent with the expectation that cancer primarily develops in later
Discussion
Seventy-four patients consented to participate in clinical interviews and the three rating scales for this study. Although this number is small, it is larger than many other studies concerning palliative care patients. The prevalence of major depression in the present study was found to be 27%, which concurs with the expectation that approximately one in four patients admitted to a palliative care unit will have significant depressive symptoms [23]. In this study an equal number of men and
Conclusions
Our findings suggest that at the present time the Edinburgh depression scale is the most appropriate tool to use to screen for depression in palliative care patients. Asking patients to verbally rate their mood or asking patients the question “are you depressed?” is not sufficiently robust to be adopted within routine clinical practice.
References (28)
Improving the detection of psychiatric problems in cancer patients
Soc Sci Med
(1985)Modification of attitudes to influence survival from breast cancer
Lancet
(1999)- et al.
Criterion validation of the Edinburgh Postnatal Depression Scale as a screening tool for depression in patients with advanced metastatic cancer
J Pain Symptom Manage
(2000) - et al.
The Edinburgh Postnatal depression scale (EPDS) and the detection of major depressive disorders in early postpartumsome concerns about false negatives
J Affect Disord
(2000) - et al.
Psychiatric morbidity in terminal ill cancer patients
Cancer
(1996) - et al.
Depression in patients with lung cancerprevalence and risk factors derived from quality of life data
J Clin Oncol
(2000) Identifying patients at risk for, and treatment of major psychiatric complications of cancer
Support Care Cancer
(1995)Assessing and managing depression in the terminally ill patient
Ann Intern Med
(2002)- et al.
Depression in advanced diseasea systematic review. Part 1: Prevalence and case finding
Palliat Med
(2002) Depression in the dying disorder or distress
Prog Palliat Care
(1994)
The use of antidepressants in patients with advanced cancer
Support Care Cancer
A survey of antidepressant prescribing in the terminally ill
Palliat Med
Measurement of depression in patients with cancer
Cancer Suppl
Common psychiatric disorders in cancer patientsadjustment disorders and depressive disorders [Review]
Support Cancer Care
Cited by (49)
Clinically Significant Depressive Symptoms Are Prevalent in People With Extremely Short Prognoses—A Systematic Review
2021, Journal of Pain and Symptom ManagementDifferences in psychophysical well-being and signs of depression in couples undergoing their first consultation for assisted reproduction technology (ART): An Italian pilot study
2016, European Journal of Obstetrics and Gynecology and Reproductive BiologyEstablishing Cutoff Points for Defining Symptom Severity Using the Edmonton Symptom Assessment System-Revised Japanese Version
2016, Journal of Pain and Symptom ManagementCitation Excerpt :Thus, the results suggest that the ESAS-r Japanese version could accurately predict verbally rated severe symptom intensity. Second, the cutoff point of 2 on the ESAS-r depression item provided the most acceptable balance between sensitivity and specificity for diagnosing both the presence of depression and moderate/severe depression, in agreement with previous findings.13,14 However, for diagnosing the presence of depression, the cutoff point of 2 or more showed low sensitivity.
Elderly cancer patients' psychopathology: A systematic review aging and mental health
2015, Archives of Gerontology and GeriatricsCitation Excerpt :It has excellent sensitivity and specificity in aged community (Olin, Schneider, Eaton, Zemansky, & Pollock, 1992; Sharp & Lipsky, 2002) and primary-care samples (Lundh Hagelin et al., 2006), was specifically designed for use with aged populations, uses simple and consistent response alternatives, focuses on non-somatic symptoms in order to minimize overdiagnosis in medically ill populations, is available in European languages (Bach, Nikolaus, Oster, & Schlierf, 1995; Baker & Espino, 1997; Clement, Nassif, Leger, & Marchan, 1997; Mystakidou et al., 2013). Most other multi-item scales used in palliative care do not share these advantages (Chochinov, Wilson, Enns, & Lander, 1994, 1997; Durkin, Kearney, & O'Siorain, 2003; Endicott, 1984; Hotopf, Chidgey, Addington-Hall, & Ly, 2002; Lloyd-Williams, Dennis, & Taylor, 2004; Lloyd-Williams, Friedman, & Rudd, 2001; Lloyd-Williams & Payne, 2003; Meyer, Sinnot, & Seed, 2003). In a recent research study (Frazzetto et al., 2012) assessing elderly breast cancer survivors demonstrated that in patients with cancer experience, the grade of depression was significantly higher compared to healthy subjects.
Depression in terminally ILL patients: Dilemmas in diagnosis and treatment
2013, Journal of Pain and Symptom ManagementCitation Excerpt :The search yielded 112 results, of which we excluded reviews, opinion articles, and letters. We also excluded pure prevalence studies and ultimately included 11 studies that were reviewed in detail.10–20 Most studies were done in inpatients with advanced cancer.