Research reportAffective 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)
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.
References (36)
- et al.
Cancer distress screening: needs, models, and methods
J. Psychosom. Res.
(2003) - et al.
Interrater reliability, prevalence, and relation to ICD-10 diagnoses of the Diagnostic Criteria for Psychosomatic Research in consultation-liaison psychiatry patients
Psychosomatics
(2004) - et al.
Psychosocial problems secondary to cancer: an Italian multicentre survey of consultation-liaison psychiatry in oncology. Italian Consultation-Liaison Group
Eur. J. Cancer
(2000) - et al.
Psychosocial morbidity and its correlates in cancer patients of the Mediterranean area: findings from the Southern European Psycho-Oncology Study (SEPOS)
J. Affect. Disord.
(2004) - et al.
Screening for anxiety and depression in cancer patients: the effects of disease and treatment
Eur. J. Cancer
(1994) - et al.
The ECLW Collaborative Study: III. Training and reliability of ICD-10 psychiatric diagnoses in the general hospital setting—an investigation of 220 consultants from 14 European countries. European Consultation Liaison Workgroup
J. Psychosom. Res.
(1996) - et al.
“Are you depressed?” Screening for depression in the terminally ill
Am. J. Psychiatry
(1997) - et al.
Detecting psychological distress in cancer patients: validity of the Italian version of the Hospital Anxiety and Depression Scale
Support. Care Cancer
(1999) - et al.
Psychiatric morbidity and its recognition by doctors in patients with cancer
Br. J. Cancer
(2001) - et al.
Screening for distress in cancer patients: is the distress thermometer a valid measure in the UK and does it measure change over time? A prospective validation study
Psychooncology
(2007)
Depression in cancer patients
Use of the Diagnostic Criteria for Psychosomatic Research (DCPR) in oncology
Psychother. Psychosom.
Psychiatric concomitants of cancer, screening procedures and training of health care professionals in oncology: the paradigms of psycho-oncology in the psychiatry field
A communication intervention for training Southern European oncologists to recognize psychosocial morbidity in cancer. I — development of the model and preliminary results on physicians' satisfaction
J. Cancer Educ.
Sensitivity and specificity of the distress thermometer for depression in newly diagnosed breast cancer patients
Psychooncology
Screening for distress in cancer patients: the NCCN rapid-screening measure
Psychooncology
National comprehensive Cancer Network (NCCN). The NCCN guideline for distress management: a case for making distress the sixth vital sign
J. Natl. Compr. Canc. Netw.
NCCN. Distress management
J. Natl. Compr. Canc. Netw.
Cited by (70)
‘Why should I fill out this questionnaire?’ A qualitative study of cancer patients' perspectives on the integration of e-PROMs in routine clinical care
2023, European Journal of Oncology NursingExploring and assessing demoralization in patients with non-psychotic affective disorders
2020, Journal of Affective DisordersCitation Excerpt :The study was approved by the Ethical Review Committee for Human Research at each participating institutions. The WHO Composite International Interview (CIDI) in its Italian version, used in other studies (Grassi et al., 2009; Andreas et al., 2017; Grassi et al., 2018), was administered to make a psychiatric diagnosis according to ICD-10. Demoralization was examined by means of the Demoralization Scale and the DCPR/D.
Mental health care in oncology. Contemporary perspective on the psychosocial burden of cancer and evidence-based interventions
2020, Epidemiology and Psychiatric SciencesUsing GHQ-12 to Screen Mental Health Issues in People with Emphysema
2023, Healthcare (Switzerland)