Research report
Affective syndromes and their screening in cancer patients with early and stable disease: Italian ICD-10 data and performance of the Distress Thermometer from the Southern European Psycho-Oncology Study (SEPOS)

https://doi.org/10.1016/j.jad.2008.07.016Get rights and content

Abstract

Background

The assessment of mood and anxiety disorders secondary to cancer by using easy-to-administer instruments has been the object of recent research.

Methods

The aim of this study was to examine the accuracy of the short screening tool developed by the National Comprehensive Cancer Network Clinical Practice Guidelines for Distress Management, (0–10 point-scale Distress Thermometer) (DT) in detecting affective syndrome disorders in Italian cancer patients. The sample consisted of 109 cancer outpatients who were administered the ICD-10 psychiatric interview (CIDI), the DT and the Hospital Anxiety Depression Scale (HADS).

Results

Forty-four patients (40.4%) met the criteria for an ICD-10 diagnosis of affective syndromes. The DT was significantly associated with HADS-Total score (r = 0.66, p = 0.001). A cut-off ≥ 4 on the DT showed a sensitivity of 79.5% and a specificity of 75.4% (positive predictive value — PPV = 68.6%; negative predictive value — NPV = 84.5%). The cut-off score ≥ 10 on the HADS was associated with a sensitivity of 86% and a specificity of 81.5% (PPV = 76%; NPV = 89.9%). A cut-off score ≥ 5 on DT and ≥ 15 on HADS maximized sensitivity (78.6% and 85%, respectively) and specificity (83.1% and 96%, respectively) for patients with more severe affective syndromes (major depression, persistent depressive disorders).

Conclusions

The results suggest that simple instruments can be used as feasible tools in the screening of mood and anxiety disorders among cancer patients.

Introduction

Psychiatric morbidity secondary to cancer and its treatment has been the object if intense research over the last 20 years with data indicating that 40–45% cancer patients, in any phase of illness, meet the criteria for an ICD-10 or DSM-IV psychiatric diagnosis, of which Adjustment Disorders, Depressive Disorders and Anxiety Disorders are the most common (Grassi et al., 2005a, Grassi et al., 2005b, Grassi et al., 2005c). The consequences of these disturbances are extremely remarkable, including decreased levels of quality of life, maladaptive coping and abnormal illness behaviour, risk of suicide, increased length of stay in the hospital, poor response to primary chemotherapy, and, in some studies, risk of recurrence and death (Grassi and Riba, 2008). Two major problems exist about this area. The first regards the fact that assessing mood and anxiety disorders by using long-lasting structured psychiatric interviews is difficult and non-practicable in oncology clinical settings; the second, as an associated consequence of the first, is that these disorders result often under-recognized by oncologists and health care professionals.

For these reasons the need to examine the usefulness of more rapid screening instruments to be applied in cancer settings has been recommended (Carlson and Bultz, 2003). A simple tool, the 0–10 point Distress Thermometer, has been proposed by the panel (Holland et al., 2007) of the National Comprehensive Cancer Network (NCCN) Distress Management Guidelines starting from 1997 to the most recent 2008 edition (NCCN, 2008). The concept of distress as the sixth vital sign (such as blood pressure, temperature, heart frequency, breath, and pain) and the need to use the DT as a screening method in cancer patients has been repeatedly pointed out (Holland and Bultz, 2007).

A preliminary study by Roth et al. (1998) in 121 prostate cancer patients indicated that cut-offs of 5 on the DT and 15 on the HADS were sensitive and specific for psychiatric referral. Similar results were reported by Trask et al. (2002) among bone marrow transplant patients. More recent results have confirmed that, by using cut-off score of 4–5, the DT has good levels of specificity and sensitivity in detecting cancer patients resulting “depressive cases” or “anxiety-depressive cases”, as identified by other psychometric instruments, used as the comparative instrument for diagnosis. These data seem to be independent of cancer site and country where the study has been conducted such as USA (Jacobsen et al., 2005, Ransom et al., 2006), Turkey (Ozalp et al., 2007, Ozalp et al., 2008), Korea (Shim et al., 2007), and UK (Gessler et al., 2007). By using the Patient Health Questionnaire 9-Item Depression Module (PHQ-9) as a self-administered instrument that measures both the presence and severity of the nine symptoms of major depression according to the DSM-IV, Hegel et al. (2007) found that among 32 patients with depression the cut-off score of 7 on the DT showed a sensitivity of 0.81 and specificity of 0.85 in detecting major depression.

Implementation of the use of the DT in clinical settings, needs to have more data regarding the specificity and sensitivity of the DT in comparison with psychiatric interview not limiting, as almost all the studies did the evaluation on the properties of DT to a comparison with other psychometric instruments.

Since no data are available regarding DT when compared to a “gold” standard diagnostic psychiatric interview, the aim of the study reported here was to examine the accuracy of the DT in detecting mood and anxiety disorders, as assessed by using the WHO ICD-10 interview (WHO, 1997) as well as an extensively used psychometric instrument, such as the Hospital Anxiety and Depression Scale (HADS).

Section snippets

Patients and methods

The data presented here have been derived from a larger investigation (Southern European Psycho-Oncology Study — SEPOS) evaluating the general psychosocial consequences among cancer patients (Grassi et al., 2004), physicians' ability to elicit psychosocial problems with their patients (Travado et al., 2005) and culturally-relevant training methods in psychosocial aspects of cancer care in Southern European countries (Grassi et al., 2005a, Grassi et al., 2005b, Grassi et al., 2005c). Of the

Statistical analysis

Correlation analysis, t-Student test for independent samples and ANOVA were used when appropriate. Receiver Operating Characteristic (ROC) (Zweig and Campbell, 1993) analysis was used to evaluate the diagnostic accuracy of the psychometric instruments in comparison with the ICD-10. The sensitivity, specificity, positive predictive (PPV) and negative predictive values (NPV) of different scores on the NCCN-DT and HADS in discriminating between cases and non-cases on the ICD-10 were examined.

Socio-demographic and clinical characteristics

Of 132 patients approached for the study, 119 participated (90.1%). Complete data were available for 109 patients (83 females, 76.1% and 26 males, 23.9%) (age 57.5 ± 11.3). Most were married (n = 84, 77.1%) and retired (n = 60, 55%). The most frequent cancer sites were breast (n = 57, 52.3%) and gastrointestinal tract (n = 29, 26.6%). Stage was local (n = 43, 39.4%), loco-regional (n = 35, 32.1%) and metastatic (n = 31, 28.4%) (Table 1).

ICD-10 diagnoses and screening data

Forty-four patients (40.4%) received an ICD-10 psychiatric diagnosis,

Discussion

In this study, we examined the characteristics of the DT in detecting the most frequent psychiatric disorders among cancer patients, namely Adjustment, Depressive and Anxiety Disorders, as assessed through the ICD-10 structured psychiatric. The data were also compared with a commonly used psychological screening method in cancer settings, such as the HADS.

The DT showed to be an easy-to-administer tool with acceptable levels of sensitivity and specificity in detecting patients meeting the

Role of funding source

The study, as a part of the Project “Improving health staff's communication and assessment skills of psychosocial morbidity and quality of life in cancer patients: a study of Southern European countries”, (Principal Investigator Luigi Grassi, M.D., University of Ferrara, Italy) has been funded by the European Commission DG Health and Consumer Protection (Agreement with the University of Ferrara — SI2.307317 2000CVGG2-026). The University of Ferrara (Local Research Funds 2004–2007) and the

Conflict of interest

No actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within three (3) years of beginning the work submitted that could inappropriately influence, or be perceived to influence, the work.

Acknowledgements

Luzia Travado, Ph.D. (Centro Hospitalar de Lisboa Central, EPE, Hospital de S. José, Lisbon, Portugal) and Francisco Gil, Ph.D. (Catalan Institute of Oncology, Barcelona, Spain) are acknowledged for their cooperation in the general study.

The research group wish also to express their gratitude to Paul Packer for revising the manuscript.

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