Which symptoms are indicative of DSMIV depression in cancer settings? An analysis of the diagnostic significance of somatic and non-somatic symptoms

Depressive symptoms and their severity in a sample with lymphedema: a case-control investigation

Objectives

Depression is a condition that can be associated with other illnesses, especially chronic illnesses. Lower limb lymphedema is a chronic, disabling condition that can affect the quality of life and be related to psychological and psychosocial factors that interfere with people's lives. This study aims to characterize and analyze the depressive symptoms and their severity reported by people with lower limb lymphedema and compare them with a matched group without lymphedema.

Methods

A case-control study was carried out (n = 80) with participants divided into a case group (40 people with lower limb lymphedema) and a control group (40 people without lower limb lymphedema). Both groups were anthropometrically, sociodemographically, and clinically characterized. In the case group, a characterization of lymphedema was performed. Participants completed the Beck Depression Inventory-II.

Results

Individuals with lower limb lymphedema have higher BDI-II scores than the matched group without lymphedema. Somatic depressive symptoms were, in general, the most reported and the ones with the highest scores. The depressive symptoms most reported by the case group were tiredness or fatigue, loss of energy, and changes in sleeping. Tiredness or fatigue, loss of energy, and loss of interest in sex were the most severe depressive symptoms reported by individuals with lower limb lymphedema.

Conclusion

Considering the apparent tendency to depression, greater attention should be given to the mental health of people with lower limb lymphedema.

A prospective observational study for a Federated Artificial Intelligence solution for moniToring mental Health status after cancer treatment (FAITH): study protocol

BACKGROUND

Depression is a common condition among cancer patients, across several points in the disease trajectory. Although presenting higher prevalence rates than the general population, it is often not reported or remains unnoticed. Moreover, somatic symptoms of depression are common in the oncological context and should not be dismissed as a general symptom of cancer. It becomes even more challenging to track psychological distress in the period after the treatment, where connection with the healthcare system typically becomes sporadic. The main goal of the FAITH project is to remotely identify and predict depressive symptoms in cancer survivors, based on a federated machine learning (ML) approach, towards optimization of privacy.

METHODS

FAITH will remotely analyse depression markers, predicting their negative trends. These markers will be treated in distinct categories, namely nutrition, sleep, activity and voice, assessed in part through wearable technologies. The study will include 300 patients who have had a previous diagnosis of breast or lung cancer and will be recruited 1 to 5 years after the end of primary cancer. The study will be organized as a 12-month longitudinal prospective observational cohort study, with monthly assessments to evaluate depression symptoms and quality of life among cancer survivors. The primary endpoint is the severity of depressive symptoms as measured by the Hamilton Depression Rating Scale (Ham-D) at months 3, 6, 9 and 12. Secondary outcomes include self-reported anxiety and depression symptoms (HADS scale), and perceived quality of life (EORTC questionnaires), at baseline and monthly. Based on the predictive models gathered during the study, FAITH will also aim at further developing a conceptual federated learning framework, enabling to build machine learning models for the prediction and monitoring of depression without direct access to user's personal data.

DISCUSSION

Improvements in the objectivity of psychiatric assessment are necessary. Wearable technologies can provide potential indicators of depression and anxiety and be used for biofeedback. If the FAITH application is effective, it will provide healthcare systems with a novel and innovative method to screen depressive symptoms in oncological settings.

TRIAL REGISTRATION

Trial ID: ISRCTN10423782 . Date registered: 21/03/2022.

Impact of cognitive-affective and somatic symptoms in subthreshold depression transition in adults: Evidence from Depression Cohort in China (DCC)

BACKGROUND

Symptoms of subthreshold depression may differentially affect the illness transition. We examined the impact of cognitive-affective and somatic symptoms on different subthreshold depression transitions as well as risk factors influencing the aforementioned symptoms changes.

METHODS

Adults with subthreshold depression in the Depression Cohort in China were enrolled. Data collection was conducted at baseline, 6 and 12 months from 2019 to 2020. Cognitive-affective and somatic symptoms were assessed using the Patient Health Questionnaire-9. A total of 993 participants completed 12-month follow-up and were divided into persistent, intermittent and remission groups according to change in depressive symptoms. The longitudinal change of cognitive-affective and somatic symptoms in the three groups, as well as risk factors was analyzed using the generalized linear mixed-model.

RESULTS

There were 24.07 %, 34.04 % and 41.89 % of participants proceeding into persistent, intermittent and remission subthreshold depression groups, respectively. Cognitive-affective symptoms were the core symptoms for predicting the deterioration in persistent subthreshold depression (t = 2.48, P = 0.013), whereas somatic symptoms improved over time (t = -2.82, P = 0.005). Anxiety symptoms were the primary risk factors for worsening cognitive-affective symptoms (P < 0.001), following by insomnia symptoms, age, marital status, resilience and social functions. Somatic symptoms were affected by insomnia symptoms, anxiety symptoms and Body Mass Index successively.

LIMITATIONS

Major Depressive Episode was not explored in follow-up.

CONCLUSION

Cognitive-affective symptoms in subthreshold depression are at greater risk of illness deterioration. Future studies should endeavor to identify specific risk factors in different symptoms to forestall the transition from subthreshold to Major Depressive Disorder.

Kölner Fragebogen zur Sprachlosigkeit

Hintergrund

Mit dem Kölner Fragebogen zur Sprachlosigkeit (KFS) liegt erstmals ein validiertes Erhebungsinstrument zur Erfassung von Sprachlosigkeit vor. Die empirische Prüfung des KFS hinsichtlich seiner Eignung zur validen Unterscheidung von Personen mit gering und hoch ausgeprägter Sprachlosigkeit ist von zentraler Bedeutung für den klinischen Einsatz des Instruments.

Material und Methoden

Die Stichprobe umfasste die KFS-Daten von insgesamt 205 teilnehmenden Personen einer Onlineerhebung. Mithilfe mehrerer inferenzstatistischer Verfahren wurden die prädiktiven Eigenschaften des KFS-Item 12 analysiert, um es für die Bestimmung eines Schwellenwerts beim Einsatz des KFS nutzbar zu machen. Basierend auf dem 75. Perzentil des KFS-Item 12 erfolgte eine Dichotomisierung der Stichprobe mit anschließender „Receiver-operating-characteristic“(ROC)-Analyse zur KFS-Gesamtskala.

Ergebnisse

Die Ergebnisse der ROC-Analyse („area under the curve“ [AUC]: 0,863; p < 0,001) ergaben bei Verwendung des Youden-Index den optimalen Schwellenwert von >29, mit einer Sensitivität von 76 % und einer Spezifität von 79 % für die Gesamtskala des KFS.

Diskussion

Der Schwellenwert der KFS-Gesamtskala ist zur Differenzierung von Personen mit gering oder stark ausgeprägter Sprachlosigkeit geeignet. Das Item 12 des KFS kann zudem als Prädiktor einer potenziellen Sprachlosigkeit herangezogen werden.

Perceived social support, coping strategies, anxiety and depression among women with breast cancer: Evaluation of a mediation model

PURPOSE

Depression and anxiety are now considered as common adverse reactions to cancer. Prior research has shown that social support and functional coping strategies alleviate depressive and anxious symptoms of cancer patients but the exact relationship between social support and coping strategies in amelioration of the symptoms is yet to be elaborated.

METHODS

The current study examined the relationship between social support, coping strategies and depressive-anxious symptomatology and explored the possible role of coping strategies in mediating the relationship between social support, depression and anxiety in Iranian breast cancer patients (N = 221). Anxiety and depressive symptoms were measured using the Depression-Anxiety-Stress (DASS-21) scale, social support was measured using the Medical Outcome Survey, Social Support Scale (MOSS-SSS), and coping strategies were measured using the brief COPE.

RESULTS

All of the social support subscales were negatively correlated with depression and anxiety. Most of the coping strategies were negatively correlated with depressive-anxious symptoms. When controlling for covariates, mediation analysis revealed that active coping, positive reframing and acceptance partially mediated the association of social support of different types with depression. Positive reframing also partially mediated the relationship of the total social support and positive social interactions with anxiety.

CONCLUSIONS

High levels of social support may relieve depressive and anxious symptoms of breast cancer patients through functional coping. The management of breast cancer patients should also focus on providing patients with social support and educating them on the practice of functional coping strategies.

Depression in the medically ill

BACKGROUND

Depressive disorders are significantly more common in the medically ill compared to the general population. Depression is associated with worsening of physical symptoms, greater healthcare utilization and poorer treatment adherence. The present paper provides a critical review on the assessment and management of depression in the medically ill.

METHODS

Relevant articles pertaining to depression in the medically ill were identified, reviewed and synthesized qualitatively. A systematic review was not performed due to the large breadth of this topic, making a meaningful summary of all published and unpublished studies not feasible. Notable studies were reviewed and synthesized by a diverse set of experts to provide a balanced summary.

RESULTS

Depression is frequently under-recognized in medical settings. Differential diagnoses include delirium, personality disorders and depressive disorders secondary to substances, medications or another medical condition. Depressive symptoms in the context of an adjustment disorder should be initially managed by supportive psychological approaches. Once a mild to moderate major depressive episode is identified, a stepped care approach should be implemented, starting with general psychoeducation, psychosocial interventions and ongoing monitoring. For moderate to severe symptoms, or mild symptoms that are not responding to low-intensity interventions, the use of antidepressants or higher intensity psychotherapeutic interventions should be considered. Psychotherapeutic interventions have demonstrated benefits with small to moderate effect sizes. Antidepressant medications have also demonstrated benefits with moderate effect sizes; however, special caution is needed in evaluating side effects, drug-drug interactions as well as dose adjustments due to impairment in hepatic metabolism and/or renal clearance. Novel interventions for the treatment of depression and other illness-related psychological symptoms (e.g. death anxiety, loss of dignity) are under investigation.

LIMITATIONS

Non-systematic review of the literature.

CONCLUSION

Replicated evidence has demonstrated a bidirectional interaction between depression and medical illness. Screening and stepped care using pharmacological and non-pharmacological interventions is merited.

Frequency and network analysis of depressive symptoms in patients with cancer compared to the general population

BACKGROUND

The use of sum scores of depressive symptoms has been increasingly criticized and may be particularly problematic in oncological settings. Frameworks analyzing individual symptoms and their interrelationships such as network analysis represent an emerging alternative.

METHODS

We aimed to assess frequencies and interrelationships of 9 DSM-5 symptom criteria of major depression reported in the PHQ-9 questionnaire by 4020 patients with cancer and 4020 controls from the general population. We estimated unregularized Gaussian graphical models for both samples and compared network structures as well as predictability and centrality of individual symptoms.

RESULTS

Depressive symptoms were more frequent, but less strongly intercorrelated in patients with cancer than in the general population. The overall network structure differed significantly between samples (correlation of adjacency matrices: rho=0.73, largest between-group difference in any edge weight: 0.20, p < 0.0001). Post-hoc tests showed significant differences in interrelationships for four symptom pairs. The mean variance of symptoms explained by all other symptoms in the same network was lower among cancer patients than in the general population (29% vs. 43%).

LIMITATIONS

Cross-sectional data do not allow for temporal or causal inferences about the directions of associations and results from population-based samples may not apply to clinical psychiatric populations.

CONCLUSIONS

In patients with cancer, both somatic and cognitive/affective depression symptoms are less likely to be explained by other depressive symptoms than in the general population. Rather than assuming a consistent depression construct, future research should study individual depressive symptom patterns and their potential causes in patients with cancer.

Screening for depression in cancer patients using the PHQ-9: The accuracy of somatic compared to non-somatic items

BACKGROUND

The PHQ-9 is a standard screening tool for depressive disorders in cancer patients. As for the frequently reported symptom overlap with somatic disease, it has been debated whether somatic items are suitable for identifying depressive disorders in cancer patients. Thus, this study examines the diagnostic accuracy of somatic versus cognitive-emotional PHQ-9 items.

METHODS

The routine data of 4,705 patients, screened at the National Center for Tumor Diseases in Heidelberg between 2011 and 2016, was analyzed. For the single PHQ-9 items, receiver operating characteristics (ROC), sensitivity, specificity, positive, and negative predictive values (PPV and NPV), the Youden Index (YI), and the Clinical Utility Index (UI+/UI-) were applied for the diagnoses of major depressive disorder (MDD) and any depressive disorder (ADD).

RESULTS

The non-somatic items played a pivotal role in the diagnosis of MDD, whereas the diagnostic accuracy of the somatic items increased in the diagnosis of ADD. For both MDD and ADD, the best performance was achieved by the non-somatic items "little interest" and "feeling down."

LIMITATIONS

In this study, only one self-reported instrument was used (i.e., the PHQ-9). In other words, the diagnoses were not validated by clinical interviews or other self-reported instruments.

CONCLUSION

The somatic PHQ-9 items showed less discriminatory value than the non-somatic items. However, they may be useful as screening mechanisms for identifying at-risk cancer patients with mild/moderate depression. Disregarding the somatic items would lead to an underestimation of depressive syndromes and inadequate treatment of somatic symptoms.

Brief emotional screening in oncology: Specificity and sensitivity of the emotion thermometers in the Portuguese cancer population

Objective

This study aimed to determine the cutoff and the specificity and sensitivity of the Emotion Thermometers (ET) in a Portuguese sample of cancer patients.

Method

A total of 147 patients (mean age = 49.2; SD = 12.6) completed the ET, the Brief Symptom Inventory (BSI), and the Subjective Experiences of Illness Suffering Inventory. Data were collected in a cancer support institution and in a major hospital in the North of Portugal.

Result

The optimal cutoff for the Anxiety Thermometer was 5v6 (until 5 and 6 or more), which identified 74% of the BSI-anxiety cases and 70% of noncases. The Depression Thermometer cutoff was 4v5 (until 4 and 5 or more), which identified 85% of BSI-depression cases and 82% of noncases. Cutoff for the Anger Thermometer was 4v5 (until 4 and 5 or more), which identified 83% of BSI-hostility cases and 73% of noncases; for the Distress Thermometer, the optimal cutoff was 4v5 (until 4 and 5 or more), which identified 84% of the suffering cases and 73% of noncases. Finally, for the Help Thermometer, it was 3v4 (until 3 and 4 or more), which helped to identify 93% of the suffering cases and 64% of noncases.

Significance of results

Results supported the Portuguese version of the ET as an important screening tool for identifying the emotional distress in cancer patients.

Latent Profile Analyses of Depressive Symptoms in Younger and Older Oncology Patients

The aging of America will include a significant increase in the number of older patients with cancer, many of whom will experience significant depressive symptoms. Although geriatric depression is a well-studied construct, its symptom presentation in the context of cancer is less clear. Latent profile analysis was conducted on depressive symptoms in younger (40-64 years) and older (≥65 years) patients with cancer (N = 636). The sample was clinically heterogeneous (i.e., included all stages, dominated by advanced stage disease). Participants completed questionnaires including the Center for Epidemiological Studies Depression Scale, which was used for the latent profile analysis. A four-class pattern was supported for each age group. However, the four-class pattern was significantly different between the younger and older groups in terms of the item means within each corresponding latent class; differences were primarily driven by severity such that across classes, older adults endorsed milder symptoms. An unexpected measurement issue was uncovered regarding reverse-coded items, suggesting that they may generate unreliable scores on the Center for Epidemiological Studies Depression Scale for a significant subset of patients. The results indicate that cancer clinicians can expect to see depressive symptoms along a continuum of severity for patients of any age, with less severe symptoms among older patients.

Performance of four diagnostic approaches to depression in adults with cancer

OBJECTIVE

The potentially confounding influence of somatic symptoms in identifying depression in medically ill patients has long been of concern, resulting in several proposed alternative diagnostic approaches. These approaches have been compared in the cancer setting, but the strengths and weaknesses of the alternative approaches have rarely been examined. The purpose of the current study was to examine the performance of four approaches to depression assessment among ambulatory cancer patients.

METHOD

Outpatients were recruited from a large cancer center (N = 611). Participants had to be 40 years or older, English-speaking, and have a cancer diagnosis. All participants completed a sociodemographic questionnaire and a modified Patient Health Questionnaire-9 with additional items targeting the Endicott and Cavanaugh substitutive criteria.

RESULTS

Depression prevalence varied significantly by diagnostic approach, with the inclusive approach identifying the largest proportion as depressed (9.3%, n = 57), followed by the Endicott-substitutive (6.2%, n = 38), exclusive (4.6%, n = 28), and Cavanaugh-substitutive approach (1.8%, n = 11). Somatic items were significantly elevated across all four approaches.

CONCLUSIONS

The inclusive approach that retains use of somatic symptoms is appropriate when screening cancer patients for depression. The fact that somatic symptoms were more prevalent across approaches suggests that they may not inflate the prevalence of depression as much as some have feared. Rather, somatic items may explain variance in depressive symptoms beyond that explained by the presence of cancer and its treatment. Additionally, the Endicott items appeared useful for capturing depressive symptoms that are not included in the existing DSM criteria, and may have a place in clinical and research settings.

The burden of psychosocial morbidity related to cancer: patient and family issues

With cancer incidence increasing over time, attention to the burden of related psychiatric and psychosocial consequences of the disease and treatment is a major topic for both cancer patients and their caregivers. Among cancer patients, psychiatric (e.g. adjustment, anxiety, depressive disorders) and neuropsychiatric disorders (e.g. cognitive disorders secondary to treatment, delirium) have been shown to affect an average of 30-35% patients, with differences according to stage and type of cancer. Also other psychosocial syndromes (e.g. demoralization, health anxiety, irritable mood) not taken into account in usual nosological systems should be considered for their impact on the patient's quality-of-life. Also, it has been repeatedly reported that psychological distress reverberates substantially throughout the nuclear family, and that a family approach is necessary in cancer care, with the caregiver-patient dyad as a unit to be the focus and direction of assessment and intervention. In this review the most significant psychosocial disorders causing burden for cancer patients and their caregivers are examined, and the main methods of assessment for more proper referral and treatment are summarized.

Depressive Spectrum Disorders in Cancer: Diagnostic Issues and Intervention. A Critical Review

Depressive spectrum disorders, including major depression, persistent depression, minor and sub-syndromal depression, and other forms of depressive conditions, such as demoralization, are among the most common psychiatric consequences of cancer patients, affecting up to 60% of patients. In spite of the negative effects and the burden for cancer patients and their families, these disorders often remain under-recognized and undertreated. The present review aims at summarizing the relevant data concerning the diagnostic challenges within the depressive spectrum disorders among cancer patients. Also, the most relevant data relative to integrated intervention, including psychopharmacological and psychosocial treatment, for depression in cancer patients are critically evaluated. It is mandatory that health care professionals working in oncology (e.g., oncologists, surgeons, radiation oncologists, primary care physicians, nurses, social workers, psychologists) receive training in the diagnosis and integrated management of the different types of disorder within the spectrum of clinical depression.

Depressive spectrum disorders in cancer: prevalence, risk factors and screening for depression: a critical review

BACKGROUND

Although depression and mood-related disorders are common in persons with cancer, these conditions remain frequently overlooked in clinical practice. Negative consequences of depressive disorder spectrum have been reported (e.g. suicidal ideation, increase physical complications and somatic symptoms, negative influence on prognosis), indicating the need for routine screening, assessment and management.

METHODS

A search of the major databases (Medline, Embase, PsycLIT, PsycINFO, and the Cochrane Library) was conducted on the reviews and meta-analyses available in order to summarize relevant data concerning depressive disorders spectrum in terms of prevalence, risk factors, and screening and assessment among patients with cancer across the trajectory of the disease.

RESULTS

The data show a prevalence of depression and depressive disorders between 5% and 60% according to the different diagnostic criteria, the tools used in the studies (e.g. semi-structured psychiatric interview and psychometric questionnaires), as well as the stage and type of cancer. Furthermore, despite the significant health care resources devoted to cancer care and the importance of addressing depressive symptoms, assessment and management of depressive spectrum disorders in cancer patients remains suboptimal.

CONCLUSIONS

Routine screening and adequate assessment of depressive spectrum disorders is necessary in patients with cancer in order to effectively manage the multifaceted and complex consequences on cancer care.

Cytokines and depression in cancer patients and caregivers

OBJECTIVE

A better understanding of the biobehavioral mechanisms underlying depression in cancer is required to translate biomarker findings into clinical interventions. We tested for associations between cytokines and the somatic and psychological symptoms of depression in cancer patients and their healthy caregivers.

PATIENTS AND METHODS

The GRID Hamilton Rating Scale for Depression (Ham-D) was administered to 61 cancer patients of mixed type and stage, 26 primary caregivers and 38 healthy controls. Concurrently, blood was drawn for multiplexed plasma assays of 15 cytokines. Multiple linear regression, adjusted for biobehavioral variables, identified cytokine associations with the psychological (Ham-Dep) and somatic (Ham-Som) subfactors of the Ham-D.

RESULTS

The Ham-Dep scores of cancer patients were similar to their caregivers, but their Ham-Som scores were significantly higher (twofold, p=0.016). Ham-Som was positively associated with IL-1ra (coefficient: 1.27, p≤0.001) in cancer patients, and negatively associated with IL-2 (coefficient: -0.68, p=0.018) in caregivers. Ham-Dep was negatively associated with IL-4 (coefficient: -0.67, p=0.004) in cancer patients and negatively associated with IL-17 (coefficient: -1.81, p=0.002) in caregivers.

CONCLUSION

The differential severity of somatic symptoms of depression in cancer patients and caregivers and the unique cytokine associations identified with each group suggests the potential for targeted interventions based on phenomenology and biology. The clinical implication is that depressive symptoms in cancer patients can arise from biological stressors, which is an important message to help destigmatize the development of depression in cancer patients.

Towards a new conceptualization of depression in older adult cancer patients: a review of the literature

OBJECTIVES

Identifying depression in older adults with cancer presents a set of unique challenges, as it combines the confounding influences of cancer and its treatment with the developmental changes associated with aging. This paper reviews the phenomenology of depression in older adults, and individuals diagnosed with cancer.

METHOD

PsychInfo, PubMed, Web of Science, and Google Scholar databases were searched for English-language studies addressing the phenomenology, symptoms, or assessment of depression in older adults and those with cancer.

RESULTS

The Diagnostic and Statistical Manual for Mental Disorders (DSM) criteria that appear to be relevant to both older adults and cancer patients are anhedonia, concentration difficulties, sleep disturbances, psychomotor retardation/agitation, and loss of energy. Possible alternative criteria that may be important considerations included constructs such as loss of purpose, loneliness, and irritability in older adults. Among cancer patients, tearfulness, social withdrawal, and not participating in treatment despite ability to do so were identified as potentially important symptoms.

CONCLUSIONS

Current DSM criteria may not adequately assess depression in older cancer patients and alternative criteria may be important to inform the understanding and identification of depression in this population. Enhancing diagnostic accuracy of depression is important as both the over-diagnosis and under-diagnosis is accompanied with significant costs. Thus, continued research exploring the phenomenology and identifying effective indicators of depression in older cancer patients is needed.

Assessing depression in a geriatric cancer population

OBJECTIVE

To examine the ability of three popular self-report measures of depression to assess depression in a geriatric cancer setting.

METHOD

Cancer patients 70 years or older and on active treatment completed the Geriatric Depression Scale-Short Form, the Hospital Anxiety and Depression Scale, and the Center for Epidemiological Studies Depression Scale-Revised, and were interviewed using the depression module of the Structured Clinical Interview for DSM disorders (SCID) as the 'gold standard.' Analyses included calculating internal consistency, ROC curves, and the sensitivity and specificity to detect major depression (MDD) or minor depression (i.e. subthreshold depression).

RESULTS

In a sample of 201 cancer patients (85% White; 64% completed college degree or higher), all three of the self-report measures produced adequate internal consistency and predicted depression greater than chance. However, the published cutoff scores for detecting MDD produced inadequate sensitivity, suggesting these scores will miss as many as 33%-83% of geriatric cancer patients who are depressed. Revised cutoff scores were lower than published cutoff scores.

CONCLUSION

Although these measures produced good internal consistency and were better than chance at predicting depression in a geriatric cancer sample, the published cutoff scores for these measures did not perform well in predicting MDD nor minor depression. Of the three measures, the CES-D appeared to have the most utility. This data suggests that these popular screening measures may be inadequate for reliably identifying depression in a geriatric cancer population. Researchers and clinicians, therefore, should use caution when selecting depression measures for geriatric cancer patients and consider using the lower cut-off scores presented here.

Geriatric assessment findings independently associated with clinical depression in 1092 older patients with cancer: the ELCAPA Cohort Study

OBJECTIVE

We aim to assess the prevalence and associated factors of clinical depression in older patients with cancer.

METHODS

We studied a prospective cohort of cancer patients aged ≥ 70 years and referred to geriatric oncology clinics between 2007 and 2012. A multidimensional geriatric assessment was performed before choosing the cancer-treatment strategy. Clinical depression was diagnosed by senior geriatricians by a semi-structured interview. It encompassed criteria of the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) and of the International Classification of Diseases (10th edition). Multivariate logistic regression was performed.

RESULTS

Of 1121 consecutive patients, 1092 had available data (mean age, 80.4 years; women, 48.8%; metastases, 51.3%; cancer location: colorectal 21.1%, breast 16.8%, kidney, bladder or urinary tract 14.0%, and prostate 11.4%). The overall prevalence of clinical depression was 28.4% (95% confidence interval, 25.7-31.2). Factors independently associated with clinical depression by multivariate analysis adjusting for all following factors plus gender, and metastasis were impaired mobility (adjusted odds ratio [aOR], 2.35; 1.59-3.46), impaired functional status defined as Eastern Cooperative Oncology Group Performance Status ≥ 2 (aOR, 2.39; 1.66-3.43) or as activities of daily living < 6 (aOR, 2.43; 1.73-3.41), inpatient status (aOR, 1.68; 1.20-2.37), inadequate social support (aOR, 1.66; 1.16-2.37), cognitive impairment (aOR, 1.76; 1.24-2.49), polypharmacy defined as five or more non-antidepressant drugs (aOR, 1.65; 1.14-2.38), multimorbidity (aOR additional CIRS-G point , 1.08; 1.04-1.12), and cancer-related pain (aOR, 1.76; 1.26-2.46).

CONCLUSION

In older patients with as-yet untreated cancer at various sites and stages, clinical depression was highly prevalent. Clinical depression was independently associated with several geriatric assessment findings (impaired mobility and function, inadequate social support, cognitive impairment, polypharmacy, and multimorbidity) independently from gender, tumor site, and metastatic status.

What is the best tool for screening antenatal depression?

BACKGROUND

Antenatal depression (AD) can have devastating consequences. No existing scales are specifically designed to measure it. Common practice is to adapt scales originally developed for other circumstances. We designed this study to validate and determine the psychometric values for AD screening in Brazil.

METHODS

We collected clinical and socio-demographic data in the second gestational trimester. The following instruments were also administered during that period: MINI-PLUS, EPDS, BDI and HAM-D.

RESULTS

At the time of assessment, 17.34% of the patients were depressed, and 31.98% met the diagnostic criteria for lifetime major depression. All instruments showed an area under the curve in a receiver operating characteristic analysis greater than 0.85, with the BDI achieving a 0.90 and being the best-performing screening instrument. A score ≥11 on the EPDS (81.58% sensitivity, 73.33% specificity), ≥15 on the BDI (82.00% sensitivity, 84.26% specificity) and ≥9 on the HAM-D (87.76% sensitivity, 74.60% specificity) revealed great dichotomy between depressed and non-depressed patients. Spearman׳s rank correlation coefficients (ρ) among the scales had good values (EPDS vs. BDI 0.79; BDI vs. HAM-D 0.70, and EPDS vs. HAM-D 0.67).

LIMITATIONS

This study was transversal, assessing only women in the second gestational trimester. Results may be applicable only to the Brazilian population since psychometric properties may vary with the population under study. Major depression can amplify somatic symptomatology, affecting depressive rating scale data.

CONCLUSION

AD is highly prevalent in Brazil. To address the problem of under-recognition, physicians can use the EPDS, BDI and HAM-D to identify AD.

Oncologists' perception of depressive symptoms in patients with advanced cancer: accuracy and relational correlates

Background

Health care providers often inaccurately perceive depression in cancer patients. The principal aim of this study was to examine oncologist-patient agreement on specific depressive symptoms, and to identify potential predictors of accurate detection.

Methods

201 adult advanced cancer patients (recruited across four French oncology units) and their oncologists (N = 28) reported depressive symptoms with eight core symptoms from the BDI-SF. Various indices of agreement, as well as logistic regression analyses were employed to analyse data.

Results

For individual symptoms, medians for sensitivity and specificity were 33% and 71%, respectively. Sensitivity was lowest for suicidal ideation, self-dislike, guilt, and sense of failure, while specificity was lowest for negative body image, pessimism, and sadness. Indices independent of base rate indicated poor general agreement (median DOR = 1.80; median ICC = .30). This was especially true for symptoms that are more difficult to recognise such as sense of failure, self-dislike and guilt. Depression was detected with a sensitivity of 52% and a specificity of 69%. Distress was detected with a sensitivity of 64% and a specificity of 65%. Logistic regressions identified compassionate care, quality of relationship, and oncologist self-efficacy as predictors of patient-physician agreement, mainly on the less recognisable symptoms.

Conclusions

The results suggest that oncologists have difficulty accurately detecting depressive symptoms. Low levels of accuracy are problematic, considering that oncologists act as an important liaison to psychosocial services. This underlines the importance of using validated screening tests. Simple training focused on psychoeducation and relational skills would also allow for better detection of key depressive symptoms that are difficult to perceive.

Depression in advanced cancer--assessment challenges and associations with disease load

BACKGROUND

Patients with advanced cancer commonly experience multiple somatic symptoms and declining functioning. Some highly prevalent symptoms also overlap with diagnostic symptom-criteria of depression. Thus, assessing depression in these patients can be challenging. We therefore investigated 1) the effect of different scoring-methods of depressive symptoms on detecting depression, and 2) the relationship between disease load and depression amongst patients with advanced cancer.

METHODS

The sample included 969 patients in the European Palliative Care Research Collaborative-Computer Symptom Assessment Study (EPCRC-CSA). Inclusion criteria were: incurable metastatic/locally advanced cancer and ≥ 18 years. Biomarkers and length of survival were registered from patient-records. Depression was assessed using the Patient Health Questionnaire (PHQ-9) and applying three scoring-methods: inclusive (algorithm scoring including the somatic symptom-criteria), exclusive (algorithm scoring excluding the somatic symptom-criteria) and sum-score (sum of all symptoms with a cut-off ≥ 8).

RESULTS

Depression prevalence rates varied according to scoring-method: inclusive 13.7%, exclusive 14.9% and sum-score 45.3%. Agreement between the algorithm scoring-methods was excellent (Kappa = 0.81), but low between the inclusive and sum scoring-methods (Kappa = 0.32). Depression was significantly associated with more pain (OR-range: 1.09-1.19, p < 0.001-0.04) and lower performance status (KPS-score, OR-range = 0.68-0.72, p < 0.001) irrespective of scoring-method.

LIMITATIONS

Depression was assessed using self-report, not clinical interviews.

CONCLUSIONS

The scoring-method, not excluding somatic symptoms, had the greatest effect on assessment outcomes. Increasing pain and poorer than expected physical condition should alert clinicians to possible co-morbid depression. The large discrepancy in prevalence rates between scoring-methods reinforces the need for consensus and validation of depression definitions and assessment in populations with high disease load.

A differential item function analysis of somatic symptoms of depression in people with cancer

BACKGROUND

The overlap of somatic symptoms of depression with symptoms of cancer treatment is widely acknowledged and studied. However, this literature provides little guidance for clinicians as to whether these items should be used in assessing depression. The current study examined the appropriateness of using somatic items for assessment of depression in people with cancer.

METHODS

People with newly diagnosed breast, lung or colorectal cancer (n=251) completed the Patient Health Questionnaire-9 (PHQ9) shortly after cancer diagnosis but before cancer treatment (baseline), 4 months later, typically during or shortly after treatment, and 12 months later. Pharmacy data was used to classify participants as having low somatic symptoms or high somatic symptoms. Differential item function (DIF) compared the functioning of the somatic items of the PHQ9 in the low vs. high symptom groups and the chemotherapy vs. no chemotherapy groups at the 4-month assessment.

RESULTS

Significant DIF was not found on any of the four somatic items of the PHQ9 and differences in the item parameters of the somatic items were not consistent across the groups. However, fatigue and sleep indicated only mild depression. Only removing the fatigue item greatly affected the number screening positive for depression at 4 months (8.3%) but removing the other somatic items did not have as large an effect. Only one participant at baseline screened positive for depression by somatic symptoms alone (no psychological symptoms) and no participants screened positive by somatic symptoms alone at 4 months and 12 months.

LIMITATIONS

The sample size was small for DIF and consisted of mostly women with breast cancer.

CONCLUSIONS

Somatic symptoms of depression can continue to be administered to people with cancer, however the fatigue and sleep items should be used with caution.

Mental adjustment to cancer: the role of anxious and depressive symptoms under treatment

OBJECTIVE

Depression is a risk factor for poor quality of life and mental adjustment to cancer. This research aims to evaluate the course of mental adjustment to illness of cancer patients with anxious-depressive symptoms who receive antidepressant therapy (ADT).

METHOD

Eighty oncological patients with and without depressive symptoms were divided into three groups. Group 1: 30 depressed cancer patients who underwent ADT with SSRI; Group 2: 30 depressed cancer patients who refused ADT; Group 3: 20 non-depressed cancer patients. Patients were evaluated at tO and 4 (tl) and 12 (t2) weeks later through: Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Hospital Anxiety Depression Scale (HADS), and MINI-MAC.

RESULTS

HDRS and HARS mean scores were stable and under threshold across the study only in Group 3; at t2 they improved in Group 1 and worsened in Group 2. The improvements in anxiety and depression scores were associated with ADT and related to the changes in Mini-MAC helpless-hopeless, anxious preoccupations, cognitive avoidance and fighting spirit dimensions.

CONCLUSION

The improvement of mental adjustment to illness is directly related to the decrease of anxious-depressive symptoms among depressed cancer patients under antidepressant therapy.

Unlocking the diagnosis of depression in primary care: Which key symptoms are GPs using to determine diagnosis and severity?

OBJECTIVE

Diagnosing depression in primary care settings is challenging. Patients are more likely to present with somatic symptoms, and typically with mild depression. Use of assessment scales is variable. In this context, it is uncertain how general practitioners (GPs) determine the severity of depressive illness in clinical practice. The aim of the current paper was to identify which symptoms are used by GPs when diagnosing depression and when determining severity.

METHOD

A total of 1760 GPs participated in the RADAR Program, an educational program focusing on the diagnosis and management of clinical depression. GPs identified a maximum of four patients whom they diagnosed with depression and answered questions regarding their diagnostic decision-making process for each patient.

RESULTS

Overall, assessment of depression severity was influenced more by somatic symptoms collectively than emotional symptoms. Suicidal thoughts, risk of self-harm, lack of enjoyment and difficulty with activities were amongst the strongest predictors of a diagnosis of severe depression.

CONCLUSIONS

The conclusions are threefold: (1) collectively, somatic symptoms are the most important predictors of determining depression severity in primary care; (2) GPs may equate risk of self-harm with suicidal intent; (3) educational initiatives need to focus on key depressive subtypes derived from emotional, somatic and associated symptoms.

Reliability and validity of the Beck Depression Inventory-Fast Screen for medical patients in the general German population

BACKGROUND

The Beck Depression Inventory Fast Screen (BDI-FS) is a self-report instrument for the detection of depression in youths and adults. It measures the severity of the depression, corresponding to the non-somatic criteria for the diagnosis of a major depression according to DSM-5. Until now the psychometric properties of the instrument have not been studied in the general population.

METHODS

In 2012, a survey representative for the Federal Republic of Germany was conducted. In addition to the BDI-FS, further self-rating questionnaires as well as a demographic questionnaire were administered.

RESULTS

Altogether, 4480 people were surveyed with a return rate of 56.1% (N=2467 persons). Approximately 53% of those surveyed were women. The average age was 49.4 years (SD=18.0), with a range of 14-91 years. For the BDI-FS total-scores, a coefficient α of .84 was determined (women: α=.83; men: α=.85). In addition, a convergent validity (r=.67) was determined with the Patient Health Questionnaire (PHQ-9). The discriminant validity of the BDI-FS can be classified as satisfactory. Based on a confirmatory factor analysis, the one-dimensionality of the BDI-FS could be confirmed, achieving very good fit indices (total sample: RMSEA=.058, CFI=.990, TLI=.986). An additional invariance analysis regarding gender, different age groups and their interaction resulted in strict invariance for the different multi-group analyses.

LIMITATIONS

Studies regarding stability have yet to be undertaken. A standard diagnostic interview for depression was not included.

CONCLUSION

The results support the reliability and validity of the BDI-FS for use with the general German population. Although in the present studies the BDI-FS was superior to the PHQ-9 in terms of its ability to discriminate between depressive and somatic symptoms, in future investigations the diagnostic efficiency of the BDI-FS should be compared with this and other depression inventories (e.g., PHQ-2, PHQ-8, and CES-D).

How do palliative medicine specialists conceptualize depression? Findings from a qualitative in-depth interview study

BACKGROUND AND OBJECTIVE

Different professional conceptualizations of depression may complicate the clinical approach to depression in the palliative care setting. This study aimed to explore and characterize how palliative medicine specialists conceptualize depression.

METHODS

Palliative medicine specialists (i.e., consultants/attending physicians in palliative medicine) practicing in Australia were recruited. Participants were purposively sampled. Individual semi-structured, in-depth interviews were conducted to explore their conceptualizations of depression. Nine participants were interviewed to reach data saturation. Interview transcripts were analyzed for themes.

RESULTS

Four main themes were identified in relation to the conceptualization of depression: (1) depression is a varied concept--it was variously considered as abnormal, a medical problem, an emotional experience, a social product, and an action-oriented construct; (2) depression has unclear boundaries, with differentiation between depression and sadness being especially challenging; (3) depression is different in the palliative care setting--it was seen as more understandable, and distinct from depression that predates life-limiting illnesses; and (4) depression is a challenging issue.

CONCLUSIONS

Depression is conceptualized by palliative medicine specialists in divergent, ontologically heterogeneous and ill-defined ways. A unitary concept of depression was not evident in this study. The concepts of depression need to be actively debated and refined in clinical practice, medical education, and research in order for more sophisticated and consistent models to be developed. The distinction of de novo depression from recurrent or persistent forms of depression also warrants further study.

Validation of screening tools for antenatal depression in Malawi--a comparison of the Edinburgh Postnatal Depression Scale and Self Reporting Questionnaire

BACKGROUND

The detection of antenatal depression in resource-limited settings such as Malawi, Africa, is important and requires an accurate and practical screening tool. It is not known which questionnaire would be most suitable for this purpose.

METHOD

A rigorously translated and modified Chichewa version of the Edinburgh Postnatal Depression Scale (EPDS) was developed. The Chichewa EPDS and an existing Chichewa version of the Self Reporting Questionnaire (SRQ) were validated in women attending an antenatal clinic in rural Malawi, using DSM-IV major and major-or-minor depressive episode as the gold standard diagnoses, determined with Structured Clinical Interview for DSM-IV (SCID). Weighted test characteristics for each possible cut-off were calculated and Receiver Operator Characteristic (ROC) curves derived.

RESULTS

The participants were 224 pregnant women, 92 of whom were interviewed using the SCID. The area under the ROC curve (AUC) for detection of current major depressive disorder for the EPDS was 0.811 (95% CI 0.734-0.889) and for the SRQ was 0.833 (95% CI 0.770-0.897). AUC for major-or-minor depressive disorder for the EPDS was 0.767 (95% CI 0.695-0.839) and for the SRQ was 0.883 (95% CI 0.839-0.927). These were not significant differences. Internal consistency was high for both the SRQ (Cronbach's alpha 0.825) and the EPDS (Cronbach's alpha 0.904).

LIMITATIONS

Inter-rater reliability testing was not done. The relatively small sample size resulted in wide confidence intervals around AUCs. The study was conducted amongst antenatal clinic attenders only, limiting generalisability to all pregnant women in this setting.

CONCLUSION

The Chichewa versions of the EPDS and SRQ both show utility as brief screening measures for detection of antenatal depression in rural Malawi.

Which symptoms are indicative of depression in epilepsy settings? An analysis of the diagnostic significance of somatic and non-somatic symptoms

BACKGROUND

Depression is a common psychiatric co-morbidity in epilepsy. However, there have been no previous studies which have investigated the validity of individual symptoms for comorbid depression in epilepsy, in particular the diagnostic value of somatic and non-somatic symptoms.

METHODS

Patients with epilepsy diagnosed in a specialist epilepsy clinic were approached and completed several self-reported mood scales, prior to or immediately after their neurology outpatient consultations. Symptoms of depression were elicited using PHQ-9, BDI-II and HADS scales, comprising a total of 44 self report questions. 266 patients returned complete questionnaires of whom 18.0% met criteria for DSM-IV major depression according to the WHO Major Depression Inventory.

RESULTS

Against DSM-IV major depressive disorder (MDD), both somatic and non-somatic symptoms were valuable. The top five most useful questions relating to a diagnosis of MDD in epilepsy were "Moving or speaking so slowly that other people could have noticed" "Little interest or pleasure in doing things" "Feeling down depressed or hopeless" "Trouble concentrating on things such as reading" and "Feeling tired or having little energy." Four of these symptoms were rated as excellent initial screening questions for depression namely, "Moving or speaking so slowly that other people could have noticed" "Little interest or pleasure in doing things" "Feeling down depressed or hopeless" "Trouble concentrating on things such as reading." The item "Moving or speaking so slowly that other people could have noticed" from the PHQ9 was endorsed in about 90% of depressed patients with epilepsy but only about 6% of non-depressed patients.

CONCLUSION

These findings suggest that both somatic and non-somatic symptoms can be valuable when diagnosing depression in epilepsy and should be considered when designing scales for depression in epilepsy. Specific psychological symptoms and specific somatic symptoms are indicative of depression in epilepsy.

Prevalence of depression in cancer patients: a meta-analysis of diagnostic interviews and self-report instruments

Objective

We aimed to investigate the prevalence of depression in cancer patients assessed by diagnostic interviews and self-report instruments, and to study differences in prevalence between type of instrument, type of cancer and treatment phase.

Methods

A literature search was conducted in four databases to select studies on the prevalence of depression among adult cancer patients during or after treatment. A total of 211 studies met the inclusion criteria. Pooled mean prevalence of depression was calculated using Comprehensive Meta-Analysis.

Results

Hospital Anxiety and Depression Scale—depression subscale (HADS-D) ≥ 8, HADS-D ≥11, Center for Epidemiologic Studies ≥ 16, and (semi-)structured diagnostic interviews were used to define depression in 66, 53, 35 and 49 studies, respectively. Respective mean prevalence of depression was 17% (95% CI = 16–19%), 8% (95% CI = 7–9%), 24% (95% CI = 21–26%), and 13% (95% CI = 11–15%) (p < 0.001). Prevalence of depression ranged from 3% in patients with lung cancer to 31% in patients with cancer of the digestive tract, on the basis of diagnostic interviews. Prevalence of depression was highest during treatment 14% (95% CI = 11–17%), measured by diagnostic interviews, and 27% (95% CI = 25–30%), measured by self-report instruments. In the first year after diagnosis, prevalence of depression measured with diagnostic interviews and self-report instruments were 9% (95% CI = 7–11%) and 21% (95% CI = 19–24%), respectively, and they were 8% (95% CI = 5–12%) and 15% (95% CI = 13–17%) ≥ 1 year after diagnosis.

Conclusions

Pooled mean prevalence of depression in cancer patients ranged from 8% to 24% and differed by the type of instrument, type of cancer and treatment phase. Future prospective studies should disentangle whether differences in prevalence of depression are caused by differences in the type of instrument, type of cancer or treatment phase.

Diagnostic criteria for major depressive disorder in cancer patients: a review

OBJECTIVES

The lack of universal criteria makes diagnosing clinical depression in cancer patients a challenging task. We therefore review the current state of evidence regarding such diagnostic criteria for major depressive disorder in cancer patients.

METHODS

We conducted a literature search for studies which compare two or more sets of diagnostic criteria for depression in cancer patients. The results were extracted and summarized.

RESULTS

Three original studies were included in this review. One study supported the use of substitutive (Endicott) criteria. Another study showed the potential of an increased threshold approach and one had no conclusive findings.

CONCLUSION

There was no standard reference test and precise definition of alternative criteria in these studies. There are no recognized diagnostic criteria for depression in cancer patients despite an apparent need for such criteria.

Depressed patients with incurable cancer: Which depressive symptoms do they experience?

Objective:

Diagnosing depressive disorders in palliative care is challenging because of the overlap between some depressive symptoms and cancer-related symptoms, such as loss of appetite and fatigue. In order to improve future assessment of depression in palliative care, depressive symptoms experienced by patients receiving pharmacological treatment for depression were assessed and compared to the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for major depressive disorder.

Method:

Thirty Norwegian (n = 20) and Austrian (n = 10) patients with advanced cancer were included. Semistructured interviews on symptom experiences were conducted and transcribed verbatim. By the phenomenographic method, patients' symptom experiences were extracted and sorted by headings, first individually and then across patients. The patients subsequently rated 24 symptoms numerically including the DSM-IV depression criteria.

Results:

Lowered mood and a diminished motivational drive were prominent and reflected the two main DSM-IV symptom criteria. A relentless focus on their actual situation, restlessness, disrupted sleep, feelings of worthlessness, feelings of guilt, and thoughts of death as a solution were variably experienced. Appetite and weight changes, fatigue and psychomotor retardation were indistinguishable from cancer symptoms. All these symptoms reflected DSM-IV symptom criteria. Some major symptoms occurred that are not present in the DSM-IV symptom criteria: despair, anxiety, and social withdrawal. The numerical ratings of symptoms were mainly in accordance with the findings from the qualitative analysis.

Significance of results:

Despair, anxiety, and social withdrawal are common symptoms in depressed patients with incurable cancer, and, therefore, hypothesized as candidate symptom criteria. Other symptom criteria might need adjustment for improvement of relevance in this group of patients.

Prevalence of depression and its correlations: a cross-sectional study in Thai cancer patients

OBJECTIVES

Depression is common in cancer patients. However, only limited evidence is available for Asian populations. The authors therefore examine the prevalence of depression in Thai patients with cancer. In addition, associated factors were determined.

METHODS

This cross-sectional study was conducted in cancer patients admitted to a university hospital during December 2006--December 2007. The Patient Health Questionnaire (PHQ-9) was used to assess all cancer patients. Suicidal risk was assessed by using the Mini-International Neuropsychiatric Interview (MINI) in the module of suicidal risk assessment.

RESULTS

Of 108 cancer patients, 29.6% were diagnosed with a depressive disorder (mild, 14.8%; moderate, 5.6%; severe, 9.3%). However, only 25.0% of these were recognized as being depressed by the primary physician. According to the MINI., 28.1% of these depressed cancer patients had a moderate to severe level of suicidal risk. In addition, the findings suggest that increased risk of depression is significantly associated with increased pain score, lower number of cancer treatments (<2 methods), increased educational duration (>13 years), increased age (>50 years old) and being female.

CONCLUSIONS

The prevalence of depression is high in Thai cancer patients. However, depressive disorder in those patients is frequently undiagnosed. It is associated with several factors including pain, a number of cancer treatments, education duration, age and sex. To improve quality of life, increase compliance with treatments and prevent of suicide, screening for depressive disorders in this patient group is strongly recommended.

Prevalence of depression in breast cancer survivors: a systematic review of observational studies

BACKGROUND

Depression is common in breast cancer patients. The aim of this paper was to make a systematic review of its prevalence and associated factors oin breast cancer survivors.

MATERIALS AND METHODS

An extensive systematic electronic review (PUBMED, CINAHL, PsyINFO and Ovid) and handsearch were carried out to retrieve published articles up to November 2012, using Depression OR Dysthymia AND (Cancer OR Tumor OR Neoplasms as the keywords. Information about the design of the studies, measuring scale, characteristics of the participants, prevalence of depression and its associated factors from the included studies were extracted and summarized.

RESULTS

We identified 32 eligible studies that recruited 10,826 breast cancer survivors. Most were cross-sectional or prospective designed. The most frequent instrument used to screen depression was the Center for Epidemiological Studies for Depression (CES-D, n=11 studies) followed by the Beck Depression Inventory (BDI, n=6 studies) and the Hospital Anxiety and Depression Scale (HADS, n=6 studies). CES-D returned about similar prevalence of depression (median=22%, range=13-56%) with BDI (median=22%, range=17-48%) but higher than HADS (median=10%, range=1-22%). Depression was associated with several socio-demographic variables, cancer-related factors, treatment-related factors, subject psychological factors, lifestyle factors, social support and quality of life.

CONCLUSIONS

Breast cancer survivors are at risk for depression so that detection of associated factors is important in clinical practice.

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.