Depression screening using the Patient Health Questionnaire-9 administered on a touch screen computer

Shortening the PHQ-9: a proof-of-principle study of utilizing Stochastic Curtailment as a method for constructing ultrashort screening instruments

OBJECTIVE

In primary care, screening instruments for mental health should be ultrashort to allow for routine usage. In this paper, Stochastic Curtailment is introduced as a method for constructing ultrashort screeners.

METHOD

In a post hoc diagnostic accuracy study using the item scores on the Patient Health Questionnaire depression module (PHQ-9) of a large sample (N=20, 685), Stochastic Curtailment was compared with two existing ultrashort versions of PHQ-9. The first was PHQ-2 (which includes the first two items of PHQ-9), and the second was a 'two-step' method (only if the PHQ-2 screened positive were all nine PHQ items administered). For PHQ-2 and two-step, both cut scores 2 and 3 were evaluated.

RESULTS

PHQ-2 showed the lowest and Stochastic Curtailment the highest diagnostic accuracy with reference to the classifications based on the full PHQ-9. To do so, Stochastic Curtailment used 3.08 items on average (S.D.=1.98), which was slightly less than two-step (M=3.18, S.D.=2.62) under its most accurate cut score (≥2).

CONCLUSIONS

It was concluded that Stochastic Curtailment is a promising method for constructing ultrashort screeners.

Impact of depression on health utility value in cancer patients

OBJECTIVE

The quality-adjusted life year, which is usually calculated from the health utility value, is now a standard measurement used in political decision-making in health. Although depression is the leading cause of decrement in health utility in general population, impact of comorbid depression among cancer patients has not been studied sufficiently. Therefore, this study aimed to measure the impact of depression on cancer patients' health utility score, according to the severity of depression.

METHODS

Impact of depression severity (measured by the Patient Health Questionnaire) on health utility score (measured by the EuroQoL-5 scale) was evaluated in a sample of 328 Japanese cancer patients, controlling for performance status, symptom burden, and demographic variables.

RESULTS

The patients with depression had significantly lower health utility value than those without depression (mean decrement = 0.14). Decrements in health utility of 0.13, 0.18, and 0.19 were observed for mild, moderate, and moderately severe to severe level of depression, respectively. The difference was significant between groups. Depression severity was a significant predictor for health utility (standardized coefficient beta = -0.25), which was comparable with physical symptom burden and performance status. Participants' age, gender, cancer stage, and comorbid illness were not significant. The model explained 37.9% of the variance.

CONCLUSIONS

Even mild level of depression caused clinically meaningful decrement in health utility value in cancer patients, which was comparable with decrements due to major physical complications of cancer. Influence of depression should be carefully investigated when interpreting the quality-adjusted life year among cancer patients. Copyright © 2015 John Wiley & Sons, Ltd.

Psychiatric considerations in the oncology setting

An aging population and advances in diagnostics and treatment have resulted in a rapidly growing population of people impacted by cancer. People live longer after a cancer diagnosis and tolerate more aggressive treatments than in the past. Younger patients struggle with diversions from the normal developmental milestones in career and relationships, while older patients deal with the dual challenges of aging and cancer. Cancer's transition from likely death to survival has increased interest in its impact on psychosocial issues and quality of life, rather than just longevity. In this article, the authors review the psychiatric diagnosis and management of the mental health issues most often encountered in oncology. Oncology treatment teams, including oncologists, nurses, social workers, and other ancillary staff, are often on the front lines of addressing psychiatric distress and clinical syndromes when psychiatrists are not easily available. The purpose of this review article is to highlight opportunities for nonpsychiatrists to improve identification and treatment of psychosocial distress and psychiatric syndromes and to request formal psychiatric consultation in appropriate situations. Psychotherapeutic, psychopharmacologic, cognitive, and behavioral-oriented interventions, as well as supportive interventions, are discussed for treating patients who are facing challenges during active cancer treatment, survivorship, and at the end of life. This review is not exhaustive but highlights the more common psychosomatic medicine and palliative care scenarios that impact cancer patient care. The importance of recognizing and addressing burnout and compassion fatigue in multidisciplinary professionals who care for those treated for cancer is also discussed given the secondary impact this can have on patient care.

Correlates of oncologist-issued referrals for psycho-oncology services: what we learned from the electronic voluntary screening and referral system for depression (eVSRS-D)

OBJECTIVE

Depression in cancer patients is under-recognized and under-treated. To better identify depression, we designed a voluntary depression screening system. Based on its data, we examined trends in oncologist-issued referrals for the psycho-oncology service (POS).

METHODS

The Electronic Voluntary Screening and Referral System for Depression (eVSRS-D) comprises self-screening, automated reporting, and referral guidance. Using touch-screen kiosks at a tertiary hospital in Korea, participants with cancer completed the Patient Health Questionnaire-9 at their convenience, received the results, and reported their willingness to participate in POS. At oncology appointments, oncologists received the screening reports and issued referrals following pre-recommended guidelines. The correlates of actual referrals were examined across all participants and within the willing and non-willing groups.

RESULTS

Among the 838 participants, 56.3% reported severe depression symptoms, 30.5% wanted a referral, and 14.8% were actually referred. The correlates of participants' desire for referral were more severe depression symptoms, being unmarried, and being metastasis and recurrence free. Among all participants, the correlates of actual referrals were unemployment, less severe depression symptoms, poorer performance, treatment status, and wanting a referral. The sole correlate of actual referrals within the non-willing group was poorer performance, and no significant correlates existed within the willing group. The non-referrals were mostly (87.1%) because of postponed decisions.

CONCLUSIONS

The eVSRS-D cannot definitively diagnose major depression but may efficiently self-select a population with significant depression symptoms. The patients' willingness to engage the POS most strongly predicted the actual referrals. Oncologist reviews of screening reports may not result in further depression severity-specific referrals.

Screening, evaluation, and management of cancer-related fatigue: Ready for implementation to practice?

Answer questions and earn CME/CNE Evidence regarding cancer-related fatigue (fatigue) has accumulated sufficiently such that recommendations for screening, evaluation, and/or management have been released recently by 4 leading cancer organizations. These evidence-based fatigue recommendations are available for clinicians, and some have patient versions; but barriers at the patient, clinician, and system levels hinder dissemination and implementation into practice. The underlying biologic mechanisms for this debilitating symptom have not been elucidated completely, hindering the development of mechanistically driven interventions. However, significant progress has been made toward methods for screening and comprehensively evaluating fatigue and other common symptoms using reliable and valid self-report measures. Limited data exist to support the use of any pharmacologic agent; however, several nonpharmacologic interventions have been shown to be effective in reducing fatigue in adults. Never before have evidence-based recommendations for fatigue management been disseminated by 4 premier cancer organizations (the National Comprehensive Cancer, the Oncology Nursing Society, the Canadian Partnership Against Cancer/Canadian Association of Psychosocial Oncology, and the American Society of Clinical Oncology). Clinicians may ask: Are we ready for implementation into practice? The reply: A variety of approaches to screening, evaluation, and management are ready for implementation. To reduce fatigue severity and distress and its impact on functioning, intensified collaborations and close partnerships between clinicians and researchers are needed, with an emphasis on system-wide efforts to disseminate and implement these evidence-based recommendations.

Clinic staff attitudes towards the use of mHealth technology to conduct perinatal depression screenings: a qualitative study

BACKGROUND

The use of mHealth technology is an innovative approach for screening low-income mothers for depression. Past studies show that the use of technology removes barriers such as literacy issues, language challenges, concerns about privacy and lack of transportation and can also increase reliability. However, little is known about staff attitudes and perceptions towards using mHealth technology for screening low-income women for depression in clinics.

METHODS

Four focus groups were conducted with staff members in a supplemental nutrition program for women, infants and children located in a public health clinic. A semi-structured focus group interview guide was used to examine staff perceptions related to depression screening with tablet technology. All interviews were audio recorded and transcribed verbatim. Thematic analysis was used to analyse all focus group data.

RESULTS

Three major benefits and two major barriers were found. The benefits of using technology for perinatal depression screenings were reduction of literacy and language barriers, reduction of redundancy and errors and increased privacy for clients. The barriers were increased network issues and responsibility for technology, which included fear of the devices being lost, stolen or broken.

IMPLICATIONS

Before implementing mHealth tablet technology for depression screening in a public health clinic, it is important to address the concerns of staff members to make the transition more effective. This study provides timely information on staff-perceived benefits and barriers when implementing mHealth technology in a public health setting.

Self-reported adherence to oral cancer therapy: relationships with symptom distress, depression, and personal characteristics

BACKGROUND

Therapeutic cancer chemotherapy is most successful when complete dosing is achieved. Because many newer therapeutic agents are oral and self-administered by the patient, adherence is a concern. The purpose of our analysis was to explore relationships between adherence, patient characteristics, and barriers to adherence.

METHODS

This secondary analysis utilized self-reported data from a randomized trial of self-care management conducted at two cancer centers in the US. Symptom distress was measured using the 15-item Symptom Distress Scale (SDS-15) and depression with the Patient Health Questionnaire-9 (PHQ-9). Adherence to oral medication was self-reported using the 8-item Morisky Medication Adherence Scale (MMAS-8). Measures were collected via Web-based, study-specific software ~8 weeks after treatment start date. Odds of low/medium adherence (score <8) were explored using univariate logistic regression. Given the number of factors and possible relationships among factors, a classification tree was built in lieu of a multivariable logistic regression model.

RESULTS

Of the eligible participants enrolled, 77 were on oral therapy and 70 had an MMAS score. Forty-nine (70%) reported a high adherence score (=8). Higher odds of low/medium adherence were associated with greater symptom distress (P=0.09), more depression (P=0.05), chemotherapy vs hormonal oral medication (P=0.03), being female (P=0.02), and being randomized to the control group in the parent trial (P=0.09). Conversely, high adherence was associated with working (P=0.08), being married/partnered (P=0.004), and being older (P=0.02). Factors identified as significantly related to low/medium adherence from the univariate logistic regression analyses were supported by the classification tree results.

CONCLUSION

Nonadherence to therapeutic oral medications in patients with cancer was associated with being unmarried/unpartnered, symptom distress, younger age, not working, and female sex. These findings may help to identify patients at risk for nonadherence and for whom supportive interventions to enhance adherence may be needed.

Utilizing a Personal Smartphone Custom App to Assess the Patient Health Questionnaire-9 (PHQ-9) Depressive Symptoms in Patients With Major Depressive Disorder

BACKGROUND

Accurate reporting of patient symptoms is critical for diagnosis and therapeutic monitoring in psychiatry. Smartphones offer an accessible, low-cost means to collect patient symptoms in real time and aid in care.

OBJECTIVE

To investigate adherence among psychiatric outpatients diagnosed with major depressive disorder in utilizing their personal smartphones to run a custom app to monitor Patient Health Questionnaire-9 (PHQ-9) depression symptoms, as well as to examine the correlation of these scores to traditionally administered (paper-and-pencil) PHQ-9 scores.

METHODS

A total of 13 patients with major depressive disorder, referred by their clinicians, received standard outpatient treatment and, in addition, utilized their personal smartphones to run the study app to monitor their symptoms. Subjects downloaded and used the Mindful Moods app on their personal smartphone to complete up to three survey sessions per day, during which a randomized subset of PHQ-9 symptoms of major depressive disorder were assessed on a Likert scale. The study lasted 29 or 30 days without additional follow-up. Outcome measures included adherence, measured by the percentage of completed survey sessions, and estimates of daily PHQ-9 scores collected from the smartphone app, as well as from the traditionally administered PHQ-9.

RESULTS

Overall adherence was 77.78% (903/1161) and varied with time of day. PHQ-9 estimates collected from the app strongly correlated (r=.84) with traditionally administered PHQ-9 scores, but app-collected scores were 3.02 (SD 2.25) points higher on average. More subjects reported suicidal ideation using the app than they did on the traditionally administered PHQ-9.

CONCLUSIONS

Patients with major depressive disorder are able to utilize an app on their personal smartphones to self-assess their symptoms of major depressive disorder with high levels of adherence. These app-collected results correlate with the traditionally administered PHQ-9. Scores recorded from the app may potentially be more sensitive and better able to capture suicidality than the traditional PHQ-9.

Feasibility of using algorithm-based clinical decision support for symptom assessment and management in lung cancer

CONTEXT

Distressing symptoms interfere with the quality of life in patients with lung cancer. Algorithm-based clinical decision support (CDS) to improve evidence-based management of isolated symptoms seems promising, but no reports yet address multiple symptoms.

OBJECTIVES

This study examined the feasibility of CDS for a Symptom Assessment and Management Intervention targeting common symptoms in patients with lung cancer (SAMI-L) in ambulatory oncology. The study objectives were to evaluate completion and delivery rates of the SAMI-L report and clinician adherence to the algorithm-based recommendations.

METHODS

Patients completed a web-based symptom assessment and SAMI-L created tailored recommendations for symptom management. Completion of assessments and delivery of reports were recorded. Medical record review assessed clinician adherence to recommendations. Feasibility was defined as 75% or higher report completion and delivery rates and 80% or higher clinician adherence to recommendations. Descriptive statistics and generalized estimating equations were used for data analyses.

RESULTS

Symptom assessment completion was 84% (95% CI=81-87%). Delivery of completed reports was 90% (95% CI=86-93%). Depression (36%), pain (30%), and fatigue (18%) occurred most frequently, followed by anxiety (11%) and dyspnea (6%). On average, overall recommendation adherence was 57% (95% CI=52-62%) and was not dependent on the number of recommendations (P=0.45). Adherence was higher for anxiety (66%; 95% CI=55-77%), depression (64%; 95% CI=56-71%), pain (62%; 95% CI=52-72%), and dyspnea (51%; 95% CI=38-64%) than for fatigue (38%; 95% CI=28-47%).

CONCLUSION

The CDS systems, such as SAMI-L, have the potential to fill a gap in promoting evidence-based care.

Experiencing reproductive concerns as a female cancer survivor is associated with depression

BACKGROUND

Young adult female cancer survivors have unmet reproductive concerns and informational needs that are associated with poorer quality of life. The purpose of this study was to examine the association between current reproductive concerns and moderate to severe depression among young survivors.

METHODS

This cross-sectional study included 200 female cancer survivors between the ages of 18 and 35 years who completed a Web-based survey measuring reproductive history, parenthood desires, reproductive concerns after cancer, and quality-of-life indicators.

RESULTS

The mean age of the participants was 28 years (standard deviation, 4.4 years), and almost two-thirds were diagnosed within 5 years of survey completion. A multivariate logistic regression analysis controlling for education, duration of survivorship, and social support revealed an association between experiencing reproductive concerns and moderate to severe depression (odds ratio for each 5-unit increase in the Reproductive Concerns After Cancer [RCAC] score, 1.30; 95% confidence interval, 1.06-1.60). Among those with moderate to severe depression, 23% had high RCAC scores, whereas 6% of those with minimal to mild depression did (P < .001).

CONCLUSIONS

A higher level of reproductive concerns was associated with greater odds of experiencing moderate to severe depression. Almost a quarter of survivors in this sample reported moderate to severe depression, and addressing reproductive concerns represents one potential area of intervention for improving the psychosocial health of young survivors.

Depression screening via a smartphone app: cross-country user characteristics and feasibility

BACKGROUND AND OBJECTIVE

Smartphone applications (apps) have the potential to be valuable self-help interventions for depression screening. However, information about their feasibility and effectiveness and the characteristics of app users is limited. The aim of this study is to explore the uptake, utilization, and characteristics of voluntary users of an app for depression screening.

METHODS

This was a cross-sectional study of a free depression screening smartphone app that contains the demographics, patient health questionnaire (PHQ-9), brief anxiety test, personalized recommendation based on the participant's results, and links to depression-relevant websites. The free app was released globally via Apple's App Store. Participants aged 18 and older downloaded the study app and were recruited passively between September 2012 and January 2013.

FINDINGS

8241 participants from 66 countries had downloaded the app, with a response rate of 73.9%. While one quarter of the participants had a previous diagnosis of depression, the prevalence of participants with a higher risk of depression was 82.5% and 66.8% at PHQ-9 cut-off 11 and cut-off 15, respectively. Many of the participants had one or more physical comorbid conditions and suicidal ideation. The cut-off 11 (OR: 1.4; 95% CI 1.2 to 1.6), previous depression diagnosis (OR: 1.3; 95% CI1.2 to 1.5), and postgraduate educational level (OR: 1.2; 95% CI 1.0 to 1.5) were associated with completing the PHQ-9 questionnaire more than once.

CONCLUSIONS

Smartphone apps can be used to deliver a screening tool for depression across a large number of countries. Apps have the potential to play a significant role in disease screening, self-management, monitoring, and health education, particularly among younger adults.

Patient cues and symptoms of psychosocial distress: what predicts assessment and treatment of distress by oncology clinicians?

OBJECTIVE

Psychosocial concerns arise after a cancer diagnosis and during treatment requiring oncology clinicians to initiate discussions to identify distress. This study examined patient-clinician communication about psychosocial concerns and predictors of assessment and treatment/referral for distress.

METHODS

Secondary analysis of existing dataset coded to explore patient-clinician communication during ambulatory visits in two comprehensive cancer centers was carried out. Sample included adult patients with various cancers and stages. Dataset included audio-recordings and symptom/QOL reports 4-6 weeks after starting treatment from all distressed patients (n = 66) in parent study and random sample of nondistressed patients (n = 23). Distressed patients had moderate-to-severe depression (Patient Health Questionnaire-9 scores ≥10) and/or poor emotional functioning (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire emotional function scores <50). Audio-recordings were coded to describe patient-clinician communication about psychosocial concerns using the coding scheme from the parent study plus Medical Interview Aural Rating System.

RESULTS

The remaining patients gave 222 cues of psychosocial concerns: 183 from 46 distressed patients and 39 from nine nondistressed patients. Distressed patients were younger, were female, had higher symptom burden, and/or gave more cues. Significantly, more distressed patients had at least one cue/visit. Clinicians initiated 62% of discussions overall with no statistical difference between distressed and nondistressed groups. More explicit cues and more than four cues predicted treatment/referral for distress.

CONCLUSIONS

Distressed patients were younger, were female, had higher symptom burden, and/or gave more verbal cues. Clinicians responded to explicit and more frequent cues by providing treatment and/or referrals for distress. Further exploration is needed regarding clinician factors related to assessment of psychosocial concerns.

Perceptions of health status and survival in patients with metastatic lung cancer

CONTEXT

Cognitive awareness of having a terminal illness is associated with critical treatment decisions and outcomes. However, little is known about the course and correlates of such perceptions in patients with metastatic lung cancer.

OBJECTIVES

We explored changes in perceptions of health status over time in patients with metastatic non-small cell lung cancer (NSCLC) and whether awareness of having a terminal illness was associated with survival.

METHODS

For this secondary analysis of clinical trial data, we assessed perceptions of health status at baseline, 12, 18, and 24 weeks. At each time point, patients with metastatic NSCLC completed a measure of quality of life (Functional Assessment of Cancer Therapy-Trial Outcome Index) and also reported whether they were "relatively healthy," "seriously but not terminally ill," or "seriously and terminally ill." We reviewed patients' medical records to gather data on clinical characteristics.

RESULTS

At baseline, 49.3% reported being relatively healthy, whereas the remainder self-identified as seriously but not terminally ill (38.2%) or seriously and terminally ill (12.5%). Over multiple assessments, 24.8% reported having a terminal illness. Adjusting for known prognostic factors, patients' time-varying perceptions of health status remained a significant predictor of survival (hazards ratio = 1.50, 95% CI = 1.07-2.09, P = 0.019).

CONCLUSION

A minority of patients with metastatic NSCLC acknowledged being terminally ill. Those reporting that they were seriously and terminally ill had shorter survival compared with those who did not consider themselves terminally ill, even after adjusting for decline in physical and functional well-being.

Recommendations for the implementation of distress screening programs in cancer centers: report from the American Psychosocial Oncology Society (APOS), Association of Oncology Social Work (AOSW), and Oncology Nursing Society (ONS) joint task force

In 2015, the American College of Surgeons (ACoS) Commission on Cancer will require cancer centers to implement screening programs for psychosocial distress as a new criterion for accreditation. A joint task force from the American Psychosocial Oncology Society, the Association of Oncology Social Work, and the Oncology Nursing Society developed consensus-based recommendations to guide the implementation of this requirement. In this review, the authors provide recommendations regarding each of the 6 components necessary to meet the ACoS standard: 1) inclusion of psychosocial representation on the cancer committee, 2) timing of screening, 3) method/mode of screening, 4) tools for screening, 5) assessment and referral, and 6) documentation.

Treatment of depression in adults with cancer: a systematic review of randomized controlled trials

BACKGROUND

Depression is a leading cause of disease burden worldwide and is especially problematic in people with chronic diseases, including cancer. Although depression can be effectively treated in the general population using antidepressant medication and psychological treatments, these treatments may have different benefits and harms in cancer patients. Previous reviews have not adequately addressed this topic. We therefore aimed to determine which, if any, treatments are effective for patients with diagnoses of both cancer and depression.

METHOD

We conducted a systematic review of relevant randomized controlled trials identified through searches of Medline, EMBASE, PsycINFO and The Cochrane Central Register of Controlled Trials (CENTRAL).

RESULTS

Seven relatively small trials met the selection criteria. These provided some evidence that antidepressant medication, given alone or in combination with a psychological treatment, may be effective. We found no good evidence for psychological treatments given alone or for any other forms of treatment.

CONCLUSIONS

There is very limited evidence from clinical trials to guide the treatment of cancer patients with a diagnosis of depression, especially for psychological treatments. High quality trials of treatments for depression in patients with cancer are urgently needed.

Risk factors for depression in patients undergoing hematopoietic cell transplantation

Despite the prevalence and known adverse impacts of depression after hematopoietic cell transplantation (HCT), little is known about the trajectory of depression occurring after HCT, or which pretransplantation risk factors might help predict new or worsening post-HCT depression. This secondary analysis evaluated the relationships between pre-HCT patient-reported outcomes and demographic characteristics and post-HCT depression. A total of 228 adult HCT patients were evaluated pre-HCT (T1) and again at 6 to 7 weeks post-HCT (T2), using touch-screen computers in the transplantation clinic during participation in a larger trial. Measures evaluated included the Symptom Distress Scale, the EORTC QLQ-C30 for quality of life, a single-item pain intensity question, and the Patient Health Questionnaire 9 for measurement of depression. At T1, rates of depression were quite low, with only 6% of participants reporting moderate or higher depression. At T2, however, the prevalence of moderate or higher depression was 31%. We observed a strong linear relationship in PHQ-9 scores between T1 and T2 (P < .0001). Depression score at T1 was a significant predictor of depression score at T2 (P = .03), as was poorer emotional function at T1 (P < .01). Our results indicate that post-HCT depression is common, even in patients with a low pre-HCT depression score. Frequent screening for symptoms of depression at critical time points, including 6 to 7 weeks post-HCT, are needed in this population, followed by referrals to supportive care as appropriate.

A multidimensional scale to measure the reproductive concerns of young adult female cancer survivors

PURPOSE

Concerns about fertility and parenthood are important to many young adult (YA) female cancer survivors and are associated with poorer quality of life. We aimed to develop a new scale to comprehensively measure these concerns so that they can be better addressed.

METHODS

Scale development involved: (1) seven focus groups to identify reproductive concerns among YA female cancer survivors and develop potential scale items followed by pilot testing and cognitive interviews to refine items, (2) administering surveys to 204 YA female survivors and conducting principal components analysis (PCA) with oblique rotation to identify underlying factors in the multidimensional scale, and (3) identification of preliminary construct validity evidence.

RESULTS

We subjected 37 potential scale items to PCA, which indicated a six-factor solution. After removing low-loading and cross-loading items, we selected the three top loading items representing each factor. The 18-item Reproductive Concerns After Cancer scale (α = 0.82) assesses concerns about fertility potential, partner disclosure, child's health, personal health, acceptance, and becoming pregnant. As hypothesized, women who wanted to have a baby (p < 0.001) and those for whom having a biological child was very important (p < 0.05) had higher mean scores, indicating higher concerns.

CONCLUSIONS

The scale demonstrated good internal consistency and evidence of construct validity and holds promise for future clinical and research applications.

IMPLICATIONS FOR CANCER SURVIVORS

An effective tool to identify concerns related to fertility and parenthood is essential for meeting the long-term reproductive health needs of young women who have survived cancer.

Impact of psychological screening on routine outpatient care of hematopoietic cell transplantation survivors

Hematopoietic cell transplantation recipients are at high risk for psychological distress, with reported prevalence rates as high as 40%. Although published guidelines advocate periodic routine screening, it is unclear how screening affects management of psychological symptoms at routine post-HCT outpatient clinic visits. We hypothesized that providers will be more likely to act on patients' psychological symptoms if a screening survey is completed and reviewed before a clinic visit. We used a brief, diagnostically focused Patient Health Questionnaire (PHQ), to assess for depressive disorders, anxiety, substance abuse, and problems in occupational or interpersonal functioning (functional disruption). Adult HCT survivors were randomized to complete the PHQ before meeting with their medical provider (n = 50; experimental group) or afterwards (n = 51; control group). Providers used the experimental group PHQ results at their discretion during the visits. Both providers and patients rated their satisfaction with management of psychological concerns after the visit. The prevalence of clinically significant depression (21%), anxiety (14%), or suicidal ideation (8%) did not differ between the 2 groups. Patients in the experimental group were significantly more likely to have discussion of psychological symptoms than the control group (68% versus 49%, P = .05). Medical providers were significantly more satisfied with the management of psychological issues for the experimental group (P < .001). Patients with depression or anxiety were significantly more likely to prefer the PHQ be used at future visits (P = .02 and P = .001, respectively). These findings suggest an informative yet brief self-report psychological screen can be easily integrated into routine care of hematopoietic cell transplantation survivors, stimulates discussion of psychological symptoms, and improves provider satisfaction with psychological symptom management. Future research will evaluate whether serial prospective administration improves patient outcomes.

Detecting Mood Disorder in Resource-Limited Primary Care Settings: Comparison of a self-administered screening tool to general practitioner assessment

Objectives

Although efficacious treatments for mood disorders are available in primary care, under-diagnosis is associated with under-treatment and poorer outcomes. This study compares the accuracy of self-administered screening tests with routine general practitioner (GP) assessment for detection of current mood disorder.

Methods

197 consecutive patients attending primary care centres in Santiago, Chile enrolled in this cross-sectional study, filling out the Patients Health Questionnaire-9 (PHQ-9) for depression and the Mood Disorder Questionnaire (MDQ) for bipolar disorder, after routine GP assessment. Diagnostic accuracy of these self-administered tools was compared with GP assessment, with gold standard diagnosis established by a structured diagnostic interview with trained clinicians (SCID-I).

Results

The sample was 75% female, with a mean age of 48.5 (SD 16.8); 37% had a current mood disorder (positive SCID-I result for depression or bipolar disorder). Sensitivity of the screening instruments (SI) was substantially higher than GP assessment (SI: 0.8, [95% CI 0.71, 0.81], versus GP: 0.2, [95% CI 0.12, 0.25]: p-value < 0.0001), without sacrifice in specificity (SI: 0.9, [95% CI 0.86, 0.96], versus GP: 0.9, [95% CI 0.88, 0.97]: p-value = 0.7). This led to improvement in both positive predictive value (SI: 0.8, [95% CI 0.82, 0.90], versus GP: 0.6, [95% CI 0.50, 0.64]: p-value < 0.001) and negative predictive value (SI: 0.9, [95% CI 0.78, 0.91] versus GP: 0.7, [95% CI 0.56, 0.72]: p-value < 0.01).

Conclusion

Self-administered screening tools are more accurate than GP assessment in detecting current mood disorder in low-income primary care. Such screening tests may improve detection of current mood disorder if implemented in primary care settings.

Validation of the telephone-administered PHQ-9 against the in-person administered SCID-I major depression module

BACKGROUND

We assessed item-to-item correspondence between the Patient Health Questionnaire-9 (PHQ-9) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) major depression episode portion of the major depressive module.

METHOD

Four hundred and ninety-eight soldiers in the Ohio National Guard were administered the PHQ-9 and SCID-I. Data were analyzed using chi-square analyses, logistic regression, receiver operating characteristic (ROC) curve analyses and diagnostic efficiency statistics.

RESULTS

To screen for depression effectively, results indicate use of the cardinal first two items, items representing fatigue, appetite and sleep changes with an item level cut-off point of two, and the item representing suicidal ideation with item level cut-off point of one. Further, total PHQ-9 scores significantly predicted SCID-I major depressive episode (MDE) and diagnosis (MDD) with moderate accuracy. Lastly, the cut-off total score of 10 had the optimal balance of sensitivity and specificity compared to other PHQ-9 scoring options.

LIMITATIONS

Differences in timeline of administration of the measures, differences in "worst episode" reference between the measures, and use of a specific military population are some of the limitations.

CONCLUSIONS

This validation study provides guidelines for the use of the telephone-administered PHQ-9 in assessing the lifetime prevalence of a major depressive episode and diagnosis in non-clinical populations, with implications for clinical use.

Affect-focused psychodynamic psychotherapy for depression and anxiety through the Internet: a randomized controlled trial

Background. Psychodynamic psychotherapy is a psychological treatment approach that has a growing empirical base. Research has indicated an association between therapist-facilitated affective experience and outcome in psychodynamic therapy. Affect-phobia therapy (APT), as outlined by McCullough et al., is a psychodynamic treatment that emphasizes a strong focus on expression and experience of affect. This model has neither been evaluated for depression nor anxiety disorders in a randomized controlled trial. While Internet-delivered psychodynamic treatments for depression and generalized anxiety disorder exist, they have not been based on APT. The aim of this randomized controlled trial was to investigate the efficacy of an Internet-based, psychodynamic, guided self-help treatment based on APT for depression and anxiety disorders. Methods. One hundred participants with diagnoses of mood and anxiety disorders participated in a randomized (1:1 ratio) controlled trial of an active group versus a control condition. The treatment group received a 10-week, psychodynamic, guided self-help treatment based on APT that was delivered through the Internet. The treatment consisted of eight text-based treatment modules and included therapist contact (9.5 min per client and week, on average) in a secure online environment. Participants in the control group also received online therapist support and clinical monitoring of symptoms, but received no treatment modules. Outcome measures were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). Process measures were also included. All measures were administered weekly during the treatment period and at a 7-month follow-up. Results. Mixed models analyses using the full intention-to-treat sample revealed significant interaction effects of group and time on all outcome measures, when comparing treatment to the control group. A large between-group effect size of Cohen's d = 0.77 (95% CI: 0.37-1.18) was found on the PHQ-9 and a moderately large between-group effect size d = 0.48 (95% CI: 0.08-0.87) was found on the GAD-7. The number of patients who recovered (had no diagnoses of depression and anxiety, and had less than 10 on both the PHQ-9 and the GAD-7) were at post-treatment 52% in the treatment group and 24% in the control group. This difference was significant, χ(2)(N = 100, d f = 1) = 8.3, p < .01. From post-treatment to follow-up, treatment gains were maintained on the PHQ-9, and significant improvements were seen on the GAD-7. Conclusion. This study provides initial support for the efficacy of Internet-delivered psychodynamic therapy based on the affect-phobia model in the treatment of depression and anxiety disorders. The results support the conclusion that psychodynamic treatment approaches may be transferred to the guided self-help format and delivered via the Internet.

Course of depression, mental health service utilization and treatment preferences in women receiving chemotherapy for breast cancer

OBJECTIVE

This prospective study aimed to estimate the prevalence and course of depression during chemotherapy in women with Stage I-III breast cancer, identify potential risk factors for depression and determine which treatments for depression were being used and which were most preferred.

METHOD

Thirty-two women were followed over consecutive chemotherapy infusions, with 289 assessments conducted altogether (mean, 9.0 assessments/subject). Current depression, anxiety, physical symptoms and mental health service use were recorded during each assessment. A linear mixed effects model was used to identify factors associated with depression. Patients also ranked depression treatment preferences. We referred patients with more severe depression for treatment.

RESULTS

Clinically significant depression was identified in 37.5% of patients. Depression severity tended to peak at 12-14 weeks and 32 or more weeks of chemotherapy. Depression severity was associated with anxiety severity, physical symptom burden, non-White race, receiving one's first chemotherapy regimen, Adriamycin-Cytoxan chemotherapy and chemotherapy duration. Most (65.5%) patients preferred evidence-based treatments for depression, and 66.7% of depressed patients were using such treatments.

CONCLUSIONS

Depression is common in women receiving chemotherapy for breast cancer. Most patients prefer evidence-based depression treatments. We recommend regular screening for depression during chemotherapy to ensure adequate detection and patient-centered treatment.

Depression, survival, and epidermal growth factor receptor genotypes in patients with metastatic non-small cell lung cancer

OBJECTIVE

Although depression appears to be associated with worse survival from cancer, the underlying mechanisms of this association are unknown. Tumor epidermal growth factor receptor (EGFR) genotype is a known predictor of survival in metastatic non-small cell lung cancer (NSCLC) and appears to be associated with depression. We hypothesized that tumor EGFR genotype may account for a relationship between depression and survival in this population. We investigated this possible relationship in a cohort of patients with metastatic NSCLC, in which we had previously demonstrated an association between depression and worse survival.

METHOD

A cohort of 151 patients with newly diagnosed metastatic NSCLC were enrolled and followed in a randomized controlled trial of early palliative care. At enrollment, 150 had depression assessed with the Patient Health Questionnaire-9 (PHQ-9), and categorical scoring for major depressive syndrome (MDS) was used for analyses. Patients with tumor tissue available underwent EGFR genotyping. Associations with survival were tested using Cox proportional hazards models, adjusting for potential confounders.

RESULTS

Twenty-one patients (14.0%) met criteria for MDS. Forty-four patients (29.3%) had EGFR genotyping, and 17 (38.6%) of these harbored EGFR mutations. Patients with EGFR mutations had significantly lower PHQ-9 scores (p = 0.03), and none met criteria for depression. EGFR mutations were significantly associated with superior survival (p = 0.02). When both depression and EGFR genotype were simultaneously entered into the model, only EGFR mutations remained significantly associated with survival (p = 0.02), and the effect of depression was attenuated.

SIGNIFICANCE OF RESULTS

Depression is associated with worse survival in metastatic NSCLC, and this relationship may be at least partially explained by tumor EGFR genotype. Further study into whether depression could be associated with specific biologic properties of cancer that vary by genotype is warranted.

Sadness in the SUN: using computerized screening to analyze correlates of depression and adherence in HIV-infected adults in the United States

We used a standardized screening tool to examine frequency of depression and its relation to antiretroviral medication adherence among HIV-infected persons on highly active antiretroviral therapy (HAART) in the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN Study). This is a prospective observational cohort of 700 HIV-infected patients enrolled between March 2004 and June 2006 in four U.S. cities, who completed a confidential audio computer-assisted self-interview [ACASI] with behavioral risk and health-related questions at baseline and 6-month follow-up visits, including the nine-question PRIME-MD depression screener and a validated 3-day antiretroviral adherence question. Among 539 eligible participants receiving HAART, 14% had depression at baseline (22% women, 12% men). In multivariable analysis using generalized estimating equations (GEE) to account for repeated measurements through 24 months of follow-up, persons who reported depression on a given ACASI were twice as likely to report nonadherence to antiretrovirals on the same ACASI (Odds ratio [OR] 2.02, 95% CI: 1.15, 3.57] for mild/moderate depression versus none); such persons were also less likely to have HIV viral load<400 copies/mL. Self-administered computerized standardized screening tools can identify at-risk individuals with depression who may benefit from interventions to improve antiretroviral adherence.

Performance and touch characteristics of disabled and non-disabled participants during a reciprocal tapping task using touch screen technology

Touch screens are becoming more prevalent in everyday environments. Therefore, it is important that this technology is accessible to those with varying disabilities. The objective of the current study was to evaluate performance and touch characteristics (forces, impulses, and dwell times) of individuals with and without a movement disorder during a reciprocal tapping touch screen task. Thirty-seven participants with a motor control disability and 15 non-disabled participants participated. Outcome measures include number of correct taps, dwell time, exerted force, and impulse. Results indicate non-disabled participants had 1.8 more taps than participants with fine motor control disabilities and 2.8 times more than those with gross motor impairments (p<0.05). Additionally, people with gross motor control disabilities demonstrated longer dwell times and greater impulses (p<0.05). The average force used to activate the buttons was 6.2 N, although the button activation force was 0.98 N. Differences in reciprocal tapping and touch characteristics exist between those with and without motor control disabilities. Understanding how people (including those with disabilities) interact with touch screens may allow designers and engineers to ultimately improve usability of touch screen technology.

Meta-analysis of screening and case finding tools for depression in cancer: evidence based recommendations for clinical practice on behalf of the Depression in Cancer Care consensus group

BACKGROUND

To examine the validity of screening and case-finding tools used in the identification of depression as defined by an ICD10/DSM-IV criterion standard.

METHODS

We identified 63 studies involving 19 tools (in 33 publications) designed to help clinicians identify depression in cancer settings. We used a standardized rating system. We excluded 11 tools without at least two independent studies, leaving 8 tools for comparison.

RESULTS

Across all cancer stages there were 56 diagnostic validity studies (n=10,009). For case-finding, one stem question, two stem questions and the BDI-II all had level 2 evidence (2a, 2b and 2c respectively) and given their better acceptability we gave the stem questions a grade B recommendation. For screening, two stem questions had level 1b evidence (with high acceptability) and the BDI-II had level 2c evidence. For every 100 people screened in advanced cancer, the two questions would accurately detect 18 cases, while missing only 1 and correctly reassure 74 with 7 falsely identified. For every 100 people screened in non-palliative settings the BDI-II would accurately detect 17 cases, missing 2 and correctly re-assure 70, with 11 falsely identified as cases. The main cautions are the reliance on DSM-IV definitions of major depression, the large number of small studies and the paucity of data for many tools in specific settings.

CONCLUSIONS

Although no single tool could be offered unqualified support, several tools are likely to improve upon unassisted clinical recognition. In clinical practice, all tools should form part of an integrated approach involving further follow-up, clinical assessment and evidence based therapy.

Touchscreen questionnaire patient data collection in rheumatology practice: development of a highly successful system using process redesign

OBJECTIVE

While questionnaires have been developed to capture patient-reported outcomes (PROs) in rheumatology practice, these instruments are not widely used. We developed a touchscreen interface designed to provide reliable and efficient data collection. Using the touchscreen to obtain PROs, we compared 2 different workflow models implemented separately in 2 rheumatology clinics.

METHODS

The Plan-Do-Study-Act methodology was used in 2 cycles of workflow redesign. Cycle 1 relied on off-the-shelf questionnaire builder software, and cycle 2 relied on a custom programmed software solution.

RESULTS

During cycle 1, clinic 1 (private practice model, resource replete, simple flow) demonstrated a high completion rate at the start, averaging between 74% and 92% for the first 12 weeks. Clinic 2 (academic model, resource deficient, complex flow) did not achieve a consistent completion rate above 60%. The revised cycle 2 implementation protocol incorporated a 15-minute "nurse visit," an instant messaging system, and a streamlined authentication process, all of which contributed to substantial improvement in touchscreen questionnaire completion rates of ∼80% that were sustained without the need for any additional clinic staff support.

CONCLUSION

Process redesign techniques and touchscreen technology were used to develop a highly successful, efficient, and effective process for the routine collection of PROs in a busy, complex, and resource-depleted academic practice and in typical private practice. The successful implementation required both a touchscreen questionnaire, human behavioral redesign, and other technical solutions.

Effect of touch screen button size and spacing on touch characteristics of users with and without disabilities

OBJECTIVE

The aim of this study was to investigate the effect of button size and spacing on touch characteristics (forces, impulses, and dwell times) during a digit entry touch screen task. A secondary objective was to investigate the effect of disability on touch characteristics.

BACKGROUND

Touch screens are common in public settings and workplaces. Although research has examined the effect of button size and spacing on performance, the effect on touch characteristics is unknown.

METHOD

A total of 52 participants (n = 23, fine motor control disability; n = 14, gross motor control disability; n = 15, no disability) completed a digit entry task. Button sizes varied from 10 mm to 30 mm, and button spacing was 1 mm or 3 mm.

RESULTS

Touch characteristics were significantly affected by button size. The exerted peak forces increased 17% between the largest and the smallest buttons, whereas impulses decreased 28%. Compared with the fine motor and nondisabled groups, the gross motor group had greater impulses (98% and 167%, respectively) and dwell times (60% and 129%, respectively). Peak forces were similar for all groups.

CONCLUSION

Button size but not spacing influenced touch characteristics during a digit entry task. The gross motor group had significantly greater dwell times and impulses than did the fine motor and nondisabled groups.

APPLICATION

Research on touch characteristics, in conjunction with that on user performance, can be used to guide human computer interface design strategies to improve accessibility of touch screen interfaces. Further research is needed to evaluate the effect of the exerted peak forces and impulses on user performance and fatigue.

Depression and survival in metastatic non-small-cell lung cancer: effects of early palliative care

PURPOSE

In a randomized trial, early palliative care (EPC) in patients with metastatic non-small-cell lung cancer (NSCLC) was observed to improve survival. In a secondary analysis, we explored the hypothesis that the survival benefit resulted from improving depression.

PATIENTS AND METHODS

In total, 151 patients with newly diagnosed metastatic NSCLC participated in a randomized trial of EPC integrated with standard oncology care versus standard oncology care alone. Depression was assessed at baseline and at 12 weeks with the Patient Health Questionnaire-9 (PHQ-9) and was scored diagnostically by using Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria for major depression syndrome (MDS). Depression response was considered ≥ 50% reduction in PHQ-9 scores at 12 weeks. Survival differences were tested with log-rank and Cox proportional hazards models.

RESULTS

At baseline, 21 patients (14%) met MDS criteria. MDS significantly predicted worse survival (hazard ratio, 1.82; P = .02). Patients assigned to EPC had greater improvements in PHQ-9 scores at 12 weeks (P < .001); among patients with MDS, those receiving EPC had greater rates of depression response at 12 weeks (P = .04). However, improvement in PHQ-9 scores was not associated with improved survival, except in a sensitivity analysis in which patients who died before 12 weeks were modeled to have worse depression. The group randomly assigned to EPC remained independently associated with survival after adding improvement in PHQ-9 scores to the survival model.

CONCLUSION

Depression predicted worse survival in patients with newly diagnosed metastatic NSCLC. Although EPC was associated with greater improvement in depression at 12 weeks, the data do not support the hypothesis that treatment of depression mediated the observed survival benefit from EPC.

Integrating psychosocial care into cancer services

Despite substantial evidence that patients with cancer commonly have significant psychosocial problems, for which we have evidence-based treatments, many patients still do not receive adequate psychosocial care. This means that we risk prolonging life without adequately addressing the quality of that life. There are many challenges to improving the current situation, the major one of which is organizational. Many cancer centers lack a system of psychosocial care that is integrated with the cancer care of the patient. Psychosocial care encompasses a range of problems (emotional, social, palliative, and logistical). The integration must occur with the cancer care of the patient at all stages (from screening to palliative care) and across all clinical sites of care (inpatient and outpatient cancer services as well as primary care). In this article, we consider the challenges we face if we are to provide such integrated psychosocial services. We focus on the collaborative care service model. This model comprises systematic identification of need, integrated delivery of care by care managers, appropriate specialist supervision, and the stepping of care based on systematic measurement of outcomes. Several trials of this approach to the management of depression in patients with cancer have found it to be both feasible to deliver and effective. It provides a model for services to meet other psychosocial needs. We conclude by proposing the key components of an integrated psychosocial service that could be implemented now and by considering what we need to do next if we are to succeed in providing better and more comprehensive care to our patients.

Helping cancer survivors return to work: what providers tell us about the challenges in assisting cancer patients with work questions

INTRODUCTION

Cancer patients and survivors report receiving little work-related advice from healthcare providers about how to manage their work during treatment or when to return after completing primary treatment. This study explores the extent to which health professionals involved with colorectal cancer patients address work matters during active treatment.

METHODS

Eighteen health professionals from oncology, occupational health and general practice were interviewed. Interviews were transcribed verbatim and analysed using thematic analysis.

RESULTS

Health professionals provide conflicting and limited information to patients regarding ability to work during treatment, or when to return to work thereafter. Lack of knowledge about impacts of treatment and symptoms on work ability and sustainability, particularly in relation to different occupations and work tasks resulted in providers offering minimal guidance to patients. Current practices relied on providers' previous experiences with employed patients, rather than a sound evidence-base.

CONCLUSIONS

The type of work-related information given to patients by providers is not systematic. It is necessary to develop a better knowledge base about the impacts of cancer and its treatment on work ability, sustainability and return to work that would help providers to offer more tailored advice to patients, consistently. Therefore, it is appropriate to recommend that formal training for providers is necessary. Enhancing the quality of information and training for health professionals to provide better work-related support to patients during the early stages of treatment could enable individuals to manage their work more effectively and facilitate a successful transition from patient to survivor.

The impact of colorectal cancer and self-efficacy beliefs on work ability and employment status: a longitudinal study

We examined how colorectal cancer patients' treatment and symptom management impacted perceptions of work ability and subsequent work decisions. Fifty patients completed questionnaires at baseline (post-surgery/pretreatment), 3 months and 6 months. Questionnaires assessed fatigue, depression, quality-of-life (QoL), cancer self-efficacy, job self-efficacy (JSE) and work ability. Factors related to perceived work ability were occupation (β= 0.31, P= 0.0005) and QoL (β= 0.42, P= 0.01) at baseline, treatment type (β=-0.19, P= 0.05) at 3 months, and JSE at 3 months (β= 0.57, P= 0.0005) and 6 months (β= 0.50, P= 0.006). Factors related to being on sick leave were lower levels of JSE (OR = 2.20, 95% CI: 1.17-4.13) at baseline and being employed in a manual occupation (OR = 0.03, 95% CI: 0.00-0.86), and perceived work ability (OR = 3.05, 95% CI: 1.00-12.80) at 6 months. Along with self-assessed work ability at baseline (β= 0.67, P= 0.0005), receiving chemotherapy or a combination of treatments (β=-0.24, P= 0.05) were the strongest predictors of poorer perceptions of follow-up work ability. Self-efficacy beliefs may add to understanding and should be considered in future research.

Patient reported outcomes in routine care: advancing data capture for HIV cohort research

INTRODUCTION

Computerized collection of standardized measures of patient reported outcomes (PROs) provides a novel paradigm for data capture at the point of clinical care. Comparisons between data from PROs and Electronic Health Records (EHR) are lacking. We compare EHR and PRO for capture of depression and substance abuse and their relationship to adherence to antiretroviral therapy (ART).

METHODS

This retrospective study includes HIV-positive patients at an HIV clinic who completed an initial PRO assessment April 2008-July 2009. The questionnaire includes measures of depression (PHQ-9) and substance abuse (ASSIST). Self-reported ART adherence was modeled using separate logistic regression analyses (EHR vs PRO).

RESULTS

The study included 782 participants. EHR vs PRO diagnosis of current substance abuse was 13% (n = 99) vs 6% (n = 45) (P < .0001), and current depression was 41% (n = 317) vs 12% (n = 97) (P < .0001). In the EHR model, neither substance abuse (OR = 1.25; 95% CI = 0.70-2.21) nor depression (OR = 0.93; 95% CI = 0.62-1.40) was significantly associated with poor ART adherence. Conversely, in the PRO model, current substance abuse (OR = 2.78; 95% CI = 1.33-5.81) and current depression (OR = 1.93; 95% CI = 1.12-3.33) were associated with poor ART adherence.

DISCUSSIONS

The explanatory characteristics of the PRO model correlated best with factors known to be associated with poor ART adherence (substance abuse; depression). The computerized capture of PROs as a part of routine clinical care may prove to be a complementary and potentially transformative health informatics technology for research and patient care.

Consumer empowerment in health care amid the internet and social media

OBJECTIVES

Consumer empowerment in health and rapid change in health information and communication technologies have their roots in broader social trends. This article reviews the activities at the intersection of consumer empowerment and technology.

DATA SOURCES

Technical reports, white papers, books, journal articles, and Web sites.

CONCLUSION

Social trends are visible in the integration of information and communication technologies into health care, in both searching for and sharing information on the Internet, in the use of social media to create new types of interactions with family, providers, and peers, and in the e-patient, who integrates these new roles and new technologies.

IMPLICATIONS FOR NURSING PRACTICE

Changes in both patients and technology will impact oncology nursing practice as new, patient-centered, interactions emerge.

Tumor epidermal growth factor receptor genotype and depression in stage IV non-small cell lung cancer

INTRODUCTION

Depression appears to be associated with worse survival from cancer, but underlying mechanisms for this association are unknown. In the present study, we explored the degree to which tumor genotype may be associated with depression in patients with non-small cell lung cancer (NSCLC). We examined differences in depression severity and rates of positive screens for major depressive disorder among newly diagnosed patients with stage IV NSCLC and known epidermal growth factor receptor (EGFR) genotype.

METHODS

Newly diagnosed patients (n = 53) with metastatic NSCLC attending an initial thoracic oncology consultation completed self-report questionnaires regarding demographics, smoking behavior, and depression before meeting with their oncologist. Biopsy samples were subsequently genotyped, including screening for EGFR mutations. We conducted a retrospective chart review to obtain clinical data, including tumor stage, performance status, and EGFR genotype.

RESULTS

Twelve patients (22.6%) tested positive for EGFR mutation. No EGFR mutation-positive cases met the screening criteria for major depressive disorder, in comparison with 29.3% of patients with wild-type EGFR (p = .03). Mutations of EGFR were also associated with lower depression severity than with wild-type EGFR, independent of gender, performance status, and smoking history (p < .05). This finding persisted for both the cognitive-affective and somatic domains of depression symptoms.

CONCLUSIONS

EGFR mutations were associated with lower depression severity and lower rates of probable major depressive disorder in patients with metastatic NSCLC, based on mood screening performed before results of genotyping were known. Findings support further work to explore the directionality of the associations and potential biological pathways to depression.

Effectiveness of QUICATOUCH: a computerised touch screen evaluation for pain and distress in ambulatory oncology patients in Newcastle, Australia

OBJECTIVE

To describe the change in pain and distress over time to demonstrate the effectiveness of the QUICATOUCH program in an outpatient oncology population.

METHODS

Descriptive study of the first 29 months of the QUICATOUCH program (13 736 assessments for 5775 patients). A longitudinal cohort design was used to examine the patients with three or more assessments (8129 assessments for 1778 patients). Effectiveness of this complex intervention (repeated assessment, clinician report and referral to speciality psycho-oncology service) was examined using: reduction in proportion over threshold for pain and distress, predictors of mean pain and distress scores and comparison of the number of new patients treated by the psycho-oncology service during the study and in the preceding 29 months.

RESULTS

Pain and distress declined during the study. The risk of being over threshold at endpoint was reduced for pain (odds ratio (OR) 0.70, confidence interval (CI) 95% 0.60-0.81) and for distress (OR 0.58 CI 95% 0.49-0.68) with baseline as referent level. Three variables predicted the mean pain: clinic type, current radiotherapy treatment and distress score; and five predicted mean distress: time, gender, clinic type, age and pain score. There was an increase of 40% (533v747) in new patients treated by the psycho-oncology service.

CONCLUSIONS

The QUICATOUCH assessment for pain and distress was implemented into usual clinical practice with reasonable coverage of patients for modest cost. It was effective in monitoring the patients over time, contributed to a reduction in pain and distress, whilst appropriately increasing the number of new patients reaching psychological treatment as part of the clinical service.

Initial Development of the Mental Health Assessment and Dynamic Referral for Oncology (MHADRO)

The Mental Health Assessment and Dynamic Referral for Oncology (MHADRO) is a program that conducts a computerized assessment of physical, psychological, and social functioning related to oncology treatment, prints personalized summary reports for both the patient and the provider, and for those who provide consent, faxes a referral and assessment summary report to a matched mental health treatment provider (i.e., dynamic referral). The functionality, feasibility, and end user satisfaction of the MHADRO were tested in a comprehensive care center. Of the 101 participants enrolled, 61 (60%) exhibited elevated distress on at least one of the mental health indices, and, of these, 12 (20%) chose a dynamic referral for mental health services. Patients and health care providers exhibited high levels of satisfaction with the program. The MHADRO has potential for assisting in meeting the psychosocial needs faced by individuals with cancer and should be tested further for its facilitation of mental health treatment initiation.

Enhancing patient-provider communication with the electronic self-report assessment for cancer: a randomized trial

PURPOSE

Although patient-reported cancer symptoms and quality-of-life issues (SQLIs) have been promoted as essential to a comprehensive assessment, efficient and efficacious methods have not been widely tested in clinical settings. The purpose of this trial was to determine the effect of the Electronic Self-Report Assessment-Cancer (ESRA-C) on the likelihood of SQLIs discussed between clinicians and patients with cancer in ambulatory clinic visits. Secondary objectives included comparison of visit duration between groups and usefulness of the ESRA-C as reported by clinicians.

PATIENTS AND METHODS

This randomized controlled trial was conducted in 660 patients with various cancer diagnoses and stages at two institutions of a comprehensive cancer center. Patient-reported SQLIs were automatically displayed on a graphical summary and provided to the clinical team before an on-treatment visit (n = 327); in the control group, no summary was provided (n = 333). SQLIs were scored for level of severity or distress. One on-treatment clinic visit was audio recorded for each participant and then scored for discussion of each SQLI. We hypothesized that problematic SQLIs would be discussed more often when the intervention was delivered to the clinicians.

RESULTS

The likelihood of SQLIs being discussed differed by randomized group and depended on whether an SQLI was first reported as problematic (P = .032). Clinic visits were similar with regard to duration between groups, and clinicians reported the summary as useful.

CONCLUSION

The ESRA-C is the first electronic self-report application to increase discussion of SQLIs in a US randomized clinical trial.

Addressing mental health epidemic among university students via web-based, self-screening, and referral system: a preliminary study

The prevalence and severity of mental health problems in college and university communities are alarming. However, the majority of students with mental disorders do not seek help from professionals. To help students assess their mental conditions and encourage them to take an active role in seeking care, we developed a web-based self-screening, referral, and secure communication system and evaluated it at the University of Washington for 17 months. The system handled more than 1000 screenings during the study period. Of the subjects who used the system, 75% noted that the system helped them to make a decision to receive help from professionals. The system was able to provide outreach to students with mental health concerns effectively, allow them to self-screen their conditions, and encourage them to receive professional assistance. The system provided students with 24/7 web-based access to the clinic, and more than 50% of the system use was made during off-hours. The system was well received by patients, referral managers, and care providers, and it was transferred to the clinic for daily clinical use. We believe that a web-based system like ours could be used as one way to tackle the growing epidemic of mental health problems among college and university students.

Routine psychosocial distress screening in radiotherapy: implementation and evaluation of a computerised procedure

BACKGROUND

To implement distress screening in routine radiotherapy practice and to compare computerised and paper-and-pencil screening in terms of acceptability and utility.

METHODS

We used the Stress Index RadioOncology (SIRO) for screening. In phase 1, 177 patients answered both a computerised and a paper version, and in phase 2, 273 patients filled out either the computerised or the paper assessment. Physicians received immediate feedback of the psycho-oncological results. Patients, nurses/radiographers (n=27) and physicians (n=15) evaluated the screening procedure.

RESULTS

The agreement between the computerised and the paper assessment was high (intra-class correlation=0.92). Patients' satisfaction did not differ between the two administration modes. Nurses/radiographers rated the computerised assessment less time consuming (3.7 vs 18.5%), although the objective data did not reveal a difference in time demand. Physicians valued the psycho-oncological results as interesting and informative (46.7%). Patients and staff agreed that the distress screening did not lead to an increase in the discussion of psychosocial issues in clinician-patient encounters.

CONCLUSION

The implementation of a distress screening was feasible and highly accepted, regardless of the administration mode. Communication trainings should be offered in order to increase the discussion of psychosocial topics in clinician-patient encounters.

Effects of a computer-supported interactive tailored patient assessment tool on patient care, symptom distress, and patients' need for symptom management support: a randomized clinical trial

OBJECTIVE

To examine the effects of a computer-assisted, interactive tailored patient assessment (ITPA) tool in oncology practice on: documented patient care, symptom distress, and patients' need for symptom management support during treatment and rehabilitation.

DESIGN AND METHODS

For this repeated measures clinical trial at a university hospital in Norway, 145 patients starting treatment for leukemia or lymphoma were randomly assigned to either an intervention (n=75) or control group (n=70). Both groups used the ITPA for symptom assessments prior to inpatient and outpatient visits for up to one year. The assessment summary, which displayed patients' self-reported symptoms, problems, and distress in rank-order of the patient's need for support, was provided to physicians and nurses in the intervention group only but not in the control group.

RESULTS

Significantly more symptoms were addressed in the intervention group patient charts versus those of the control group. Symptom distress in the intervention group decreased significantly over time in 11 (58%) of 19 symptom/problem categories versus 2 (10%) for the control group. Need for symptom management support over time also decreased significantly more for the intervention group than the control group in 13 (68%) symptom categories.

CONCLUSION

This is the first study to show that an ITPA used in an interdisciplinary oncology practice can significantly improve patient-centered care and patient outcomes, including reduced symptom distress and reduced need for symptom management support.

Screening for major depression in cancer outpatients: the diagnostic accuracy of the 9-item patient health questionnaire

BACKGROUND

Systematic screening for depression has been recommended for patients who have medical conditions like cancer. The 9-item Patient Health Questionnaire (PHQ-9) is becoming widely used, but its diagnostic accuracy has not yet been tested in a cancer patient population. In this article, the authors report on the performance of the PHQ-9 as a screening instrument for major depressive disorder (MDD) in patients with cancer.

METHODS

Data obtained from a depression screening service for patients who were attending clinics of a Regional Cancer Centre in Edinburgh, United Kingdom were used. Patients had completed both the PHQ-9 and a 2-stage procedure to identify cases of MDD. Performance of the PHQ-9 in identifying cases of MDD was determined using receiver operating characteristic (ROC) analysis.

RESULTS

Data were available on 4264 patients. When scored as a continuous measure, the PHQ-9 performed well with an area under the ROC curve of 0.94 (95% confidence interval [CI], 0.93-0.95). A cutoff score of ≥ 8 provided a sensitivity of 93% (95% CI, 89%-95%), a specificity of 81% (95% CI, 80%-82%), a positive predictive value (PPV) of 25%, and a negative predictive value (NPV) of 99% and could be considered optimum in a screening context. The PHQ-9 did not perform as well when it was scored using an algorithm with a sensitivity of 56% (95% CI, 55%-57%), a specificity of 96% (95% CI, 95%-97%), a PPV of 52%, and an NPV of 97%.

CONCLUSIONS

The PHQ-9 scored as a continuous measure with a cutoff score of ≥ 8 performed well in identifying MDD in cancer patients and should be considered as a screening instrument in this population.