Assessing depression in palliative care patients using the visual analogue scale: a pilot study

Effects of work-related electronic communication during non-working hours after work from home and office on fatigue, psychomotor vigilance performance and actigraphic sleep: observational study on information technology workers

OBJECTIVES

This study examined the effects of work-related electronic communication (WREC) during non-working hours in the work from home or office setting on health.

METHODS

The study recruited 98 information technology workers in a 9-day observational study. They recorded work-life events (eg, work style (working mostly from home or the office) and duration of WREC during non-working hours) and subjective ratings (eg, current fatigue, sleepiness and depression) and wore a sleep actigraph to measure objective sleep variables before bedtime every day. They completed the Brief Psychomotor Vigilance Test (PVT-B) before bedtime for 4 days.

RESULTS

The frequency of WREC was significantly higher when working mostly from home than in the office (p<0.01). In addition, the duration of WREC was longer when working mostly from home than in the office (p<0.001). Linear or generalised linear mixed model analysis for fatigue, depression and PVT lapse revealed significant interaction effects between work style and WREC (all p<0.05). Post hoc analysis showed that the longer the WREC, the worse the fatigue and depression and the lower the lapse on working mostly from the office (all p<0.05).

CONCLUSIONS

Longer WREC is associated with worse fatigue and depression and lower lapse of PVT (higher alertness) before bedtime for working mostly from the office. Workers, especially those working from the office, should minimise WREC during non-working hours to maintain good health. Therefore, companies, managers and other relevant stakeholders should refrain from contacting workers during non-working hours.

A visual analog scale for the assessment of mild sleepiness in patients with obstructive sleep apnea and healthy participants

MOTIVATION:

Studies have shown poor clinical effectiveness of the Epworth Sleepiness Scale (ESS) due to its ambiguity of items and cultural applicability. This study aimed to investigate the efficacy of a Visual Analog Scale (VAS) to assess sleepiness, compared to ESS.

METHODS:

Thirty-two obstructive sleep apnea (OSA) patients and 32 healthy participants completed two visits, 1 month apart, during which they completed both ESS and VAS. Patients diagnosed with OSA were treated with Continuous positive airway pressure (CPAP) between visits. The agreement between the ESS and VAS scores in both patients with OSA and healthy participants was investigated using Pearson correlation and Area Under the receiver operating characteristics.

RESULTS:

The (mean ± standard deviation) Oxygen Desaturation Index for patients with OSA was 18.5 ± 5.7 events/hour and 1.7 ± 1.0 events/hour in the healthy participants. A reduction in sleepiness, following CPAP treatment occurred in patients with OSA, using the ESS (11.2 ± 5.5–4.7 ± 5.0 points, P < 0.001) and the VAS (50.2 ± 3.0–21.9 ± 26.5 mm, P < 0.001). There was no significant change in sleepiness, in healthy participants using the ESS (3.91 ± 3.14–3.34 ± 3.27 points (P < 0.48) or the VAS (15.58 ± 21.21–12.05 ± 14.75 mm, (P < 0.44). A Likert scale showed that the VAS was easier to use compared to ESS in visit 1 (VAS: 8.7 ± 1.9 points, ESS: 7.7 ± 2.6 points, (P < 0.001), and visit 2 (VAS: 9.5 ± 1.4 points, ESS: 8.6 ± 1.5 points, P < 0.001).

CONCLUSION:

These preliminary results suggest that the VAS can detect a change in sleepiness after CPAP treatment in patients with OSA and that the VAS was also easier to use compared to ESS.

A Single-Item Visual Analogue Scale (VAS) Measure for Assessing Depression Among College Students

There is an increased need for efficient, low-cost methods to collect information on a range of widely prevalent mental health outcomes in the general population that can be administered outside of clinical settings. We evaluate the validity of a single-item Visual Analogue Scale (VAS) for assessing the presence and severity of depression and compare its performance with the Patient Health Questionnaire (PHQ-9) depression scale using a large non-clinical sample (N = 1816) of college students from Switzerland. The VAS scale is strongly correlated with the PHQ-9 total score (0.61) and its 9 individual items (ranging from 0.19 to 0.67). ROC analysis shows that the VAS scale has high accuracy for detecting the presence and different levels (mild to severe) of depression corresponding to PHQ-9 cutoffs. The VAS depression scale represents a simple, easily implementable instrument that is suitable for mental health research in common settings and larger population-based studies.

Do Physicians Underestimate Pain in Terminal Cancer Patients? A Prospective Study in a Hospice Setting

OBJECTIVES

Unrelieved pain is present in a majority of terminal cancer patients. However, the treatment of pain in palliative and hospice care is affected by the lack of validated pain assessment. The goal of this study was to evaluate differences in pain evaluation between terminal cancer patients and physicians and evaluate the pain levels as a survival biomarker.

MATERIALS AND METHODS

Patients were evaluated every 7 days for a total of 4 assessments. Physicians evaluated patients' pain on an numeric rating scale (NRS) scale after clinical examination, after which the patients completed NRS, Quality of Life Questionnaire Core 15 Pal (QLQ-C15-PAL), and Edmonton Symptom Assessment System (ESAS) questionnaires.

RESULTS

On average, physicians minimally underestimated the pain level in patients (3.47 vs. 3.94 on an NRS scale). Pain was overestimated in 28% and underestimated in 46% of the patients. However, half of all underestimation was clinically meaningful, compared with 28% of the overestimation. For patients with an NRS score of ≥7, pain underestimation was both clinically and statistically significant (5.56 vs. 8.17). Pain ratings exhibited a very small correlation to survival (up to r=-0.22), limiting their use as a survival biomarker.

DISCUSSION

Although physicians can accurately assess mild pain in terminal cancer patients in the hospice setting, the underestimation of pain is still clinically significant in almost a quarter of patients, and especially pronounced in patients with higher levels of pain and in female patients. Hence, validated pain assessment is a necessity in hospice care, with the choice of pain evaluation tool dependent on patient and physician preference.

Symptom Management and Psychosocial Needs of Adults With Acute Myeloid Leukemia During Induction Treatment: A Pilot Study

BACKGROUND

Patients with a new diagnosis of acute myeloid leukemia (AML) are at risk of experiencing a high symptom burden due to the disease and its treatment, which includes a long period of hospitalization.

OBJECTIVE

The aim of this pilot work was to describe the multidimensional symptoms and health-related quality of life experienced by patients with a new diagnosis of AML across induction chemotherapy.

METHODS

A prospective, longitudinal descriptive study design was implemented to evaluate symptoms and health-related quality of life at the time of enrollment through 6 weeks postdiagnosis and identify who might be most at risk of experiencing high symptom burden.

RESULTS

A total of 19 participants were included in this analysis. Moderate to severe levels of distress were present in 25% to 50% of participants, depending on timing in treatment. Females and those with a previous history of a psychological disorder reported higher symptom burden during treatment.

CONCLUSIONS

Our findings indicate that adults with AML experience multiple distressing symptoms during the induction treatment.

IMPLICATIONS FOR PRACTICE

Timely routine multidimensional assessment of symptoms in individuals undergoing induction chemotherapy treatment for AML is critical as they may be experiencing multiple concurrent symptoms. Additional research to advance symptom assessment and amelioration of distressing symptoms to improve health-related quality of life is needed in this unique population.

Patients in palliative care-Development of a predictive model for anxiety using routine data

Introduction

Anxiety is one of the most common psychological symptoms in patients in a palliative care situation. This study aims to develop a predictive model for anxiety using data from the standard documentation routine.

Methods

Data sets of palliative care patients collected by the German quality management benchmarking system called Hospice and Palliative Care Evaluation (HOPE) from 2007 to 2011 were randomly divided into a training set containing two-thirds of the data and a test set with the remaining one-third. We dichotomized anxiety levels, proxy rated by medical staff using the validated HOPE Symptom and Problem Checklist, into two groups with no or mild anxiety versus moderate or severe anxiety. Using the training set, a multivariable logistic regression model was developed by backward stepwise selection. Predictive accuracy was evaluated by the area under the receiver operating characteristic curve (AUC) based on the test set.

Results

An analysis of 9924 data sets suggests a predictive model for anxiety in patients receiving palliative care which contains gender, age, ECOG, living situation, pain, nausea, dyspnea, loss of appetite, tiredness, need for assistance with activities of daily living, problems with organization of care, medication with sedatives/anxiolytics, antidepressants, antihypertensive drugs, laxatives, and antibiotics. It results in a fair predictive value (AUC = 0.72).

Conclusions

Routinely collected data providing individual-, disease- and therapy-related information contain valuable information that is useful for the prediction of anxiety risks in patients receiving palliative care. These findings could thus be advantageous for providing appropriate support for patients in palliative care settings and should receive special attention in future research.

Nurses' perceptions of depression in patients with cancer

OBJECTIVE

Our study aimed at examining nurses' perceptions of depression in cancer patients and their role in its management.

METHOD

We employed questionnaire-based semi-directed interviews. Participants were asked to classify 22 symptoms (related and specific to depression in cancer patients, related but not specific, and unrelated) as "very important," "important," "less important," or "not important" for the diagnosis of depression in cancer patients at two different timepoints (baseline and after a video education program). They were also asked to complete a questionnaire exploring their perceptions about depression and of their role in its systematic screening. We recruited nurses caring for cancer patients from four different departments (palliative care unit, hematology, medical oncology, and thoracic oncology) at an academic medical center.

RESULTS

We interviewed 18 nurses and found that they had a good general knowledge of depression in cancer patients, with the majority of them being able to distinguish specific and important symptoms from nonspecific symptoms. Some nurses considered depression as a second-line symptom, and most did not employ a screening tool in their daily practice. All considered that they had a role to play in the management of depression, even as they acknowledged lacking specific training for that task.

SIGNIFICANCE OF RESULTS

Our results suggest that limited resources—especially lack of training—affects nurses' ability to correctly manage depression in their cancer patients.

Effects of changes in water intake on mood of high and low drinkers

Objective

To evaluate the effects of a change in water intake on mood and sensation in 22 habitual high-volume (HIGH; 2-4 L/d) and 30 low-volume (LOW; <1.2 L/d) drinkers who were asked to respectively decrease and increase their daily water intake.

Method

During baseline HIGH consumed 2.5 L and LOW 1 L of water/day. During 3 controlled intervention days HIGH's water intake was restricted to 1 L/day whereas LOW's was increased to 2.5 L water/day. Several mood scales (Bond & Lader Visual Analog Scale (VAS), Profile of Mood States, Karolinska Sleepiness Scale, Thirst & Emotional VAS) were administered at different time points during the study. ANOVA including intervention, time point and intervention by time point as fixed effects on mean values (i.e.; baseline data vs. mean of 3 intervention days) for each mood scale was performed.

Results

At baseline HIGH and LOW were comparable in mood state, except for thirst scores (estimate = 17.16, p<0.001) and POMS depression-dejection scores (estimate = 0.55, p<0.05) which were both higher in the HIGH vs. LOW. In HIGH the restricted water intake resulted in a significant increase in thirst (p<0.001) and a decrease in contentedness (p<0.05), calmness (p<0.01), positive emotions (p<0.05) and vigor/activity (p<0.001). In LOW, increased water consumption resulted in a significant decrease in fatigue/inertia (p<0.001), confusion/bewilderment (p = 0.05) and thirst (p<0.001) and a trend to lower sleepiness (p = 0.07) compared to baseline.

Conclusion

Increasing water intake has beneficial effects in LOW, especially sleep/wake feelings, whereas decreasing water intake has detrimental effects on HIGH's mood. These deleterious effects in HIGH were observed in some sleep/wake moods as well as calmness, satisfaction and positive emotions.

Depression in palliative care patients: a survey of assessment and treatment practices of Australian and New Zealand palliative care specialists

Objective To explore the practices of members of the Australian and New Zealand Society of Palliative Medicine (ANZSPM) in assessing and treating depression in palliative care patients. Methods Semistructured questionnaires were forwarded to ANZSPM members in consecutive mail-outs to survey diagnostic and treatment practices for depression. Results The response rate was 62.3%. The median prevalence of depression, as perceived by respondents, in the present respondent patient populations was 20% (range 0%–90%); 57.1% of respondents always assessed for depression, whereas 42.9% assessed for depression sometimes. The majority (98.9%) of respondents relied on clinical interviews to assess depression; non-somatic symptoms of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria were more useful than somatic symptoms. The depression screening tools most frequently used were one- and two-item questions. Pharmacological and non-pharmacological methods were used to treat depression, with selective serotonin reuptake inhibitors the most frequently prescribed medications. Psycho-educational and supportive counselling were the most frequently used non-pharmacological interventions. Nominated measures to augment depression management included improving access to psychiatry, psychology and other allied health services, the development of a screening tool specific to palliative care patients and associated guidelines for depression management. Conclusions This is the first Australasian study to explore the practice of medical practitioners regarding depression in palliative patients. Incorporation of screening tool questions into palliative care assessment interviews may warrant future research. What is known about the topic? Depression in palliative care patients has a negative impact on quality of life; however, little is known about how Australasian palliative care medical practitioners manage depression in this patient population. What does this paper add? To the researchers’ knowledge, this is the first Australasian study that explores the practices of local palliative care specialists in the management of depression in palliative patients. What are the implications for practitioners? Overall management of depression in palliative care populations by Australasian practitioners is similar to that of their European colleagues. Consensus is that for assessment of depression in palliative patients, non-somatic symptoms of DSM-IV criteria are more useful than somatic symptoms. Practitioners report the need for improved access to psychiatric, psychological and other support services, for a palliative care-specific depression screening tool and for depression management guidelines applicable to palliative care patients.

DoloTest in General Practice Study: Sensitivity and Specificity Screening for Depression

Background. Coexistence of pain and depression has significant impact on the patient's quality of life and treatment outcome. DoloTest is a pain and HRQoL assessment tool developed to provide shared understanding between the clinician and the patient of the condition by a visual profile. Aim. To find the sensitivity and specificity of DoloTest as a screening tool for depression for patients in primary care. Methods. All patients coming to a primary care clinic were asked to fill in a DoloTest and a Major Depression Inventory. Results. 715 (68.5%) of 1044 patients entered the study. 34.4% came due to pain. 16.1% met depression criteria, and 26.8% of patients coming due to pain met criteria for depression. 65.6% of the men and 54.2% of the women meeting the criteria for depression came due to pain. Depressed patients had statistically significant higher scores on all DoloTest domains. Selecting the cutoff value for the domain "low spirits" to be "65" (0-100) for depression gave a sensitivity of 78% (70-85%) and a specificity of 95% (93-96%) for meeting depression criteria. Conclusion. DoloTest can with a high sensitivity and specificity identify persons meeting criteria for depression and is an easy-to-use screening tool to identify patients with the coexistence of pain and depression.

Influence of progressive fluid restriction on mood and physiological markers of dehydration in women

The present study evaluated, using a well-controlled dehydration protocol, the effects of 24 h fluid deprivation (FD) on selected mood and physiological parameters. In the present cross-over study, twenty healthy women (age 25 (SE 0.78) years) participated in two randomised sessions: FD-induced dehydration v. a fully hydrated control condition. In the FD period, the last water intake was between 18.00 and 19.00 hours and no beverages were allowed until 18.00 hours on the next day (23-24 h). Water intake was only permitted at fixed periods during the control condition. Physiological parameters in the urine, blood and saliva (osmolality) as well as mood and sensations (headache and thirst) were compared across the experimental conditions. Safety was monitored throughout the study. The FD protocol was effective as indicated by a significant reduction in urine output. No clinical abnormalities of biological parameters or vital signs were observed, although heart rate was increased by FD. Increased urine specific gravity, darker urine colour and increased thirst were early markers of dehydration. Interestingly, dehydration also induced a significant increase in saliva osmolality at the end of the 24 h FD period but plasma osmolality remained unchanged. The significant effects of FD on mood included decreased alertness and increased sleepiness, fatigue and confusion. The most consistent effects of mild dehydration on mood are on sleep/wake parameters. Urine specific gravity appears to be the best physiological measure of hydration status in subjects with a normal level of activity; saliva osmolality is another reliable and non-invasive method for assessing hydration status.

Methodological challenges in researching psychological distress and psychiatric morbidity among patients with advanced cancer: what does the literature (not) tell us?

Patients with advanced cancer experience multiple demands and losses that place them at risk for experiencing psychological distress. Researchers can face challenges in conducting research among this population because of their poor levels of physical and cognitive functioning. This paper aims to develop our understanding of these challenges. A systematic literature review was conducted of papers describing surveys in which a stated aim was to measure rates of psychological distress or psychiatric morbidity among patients with advanced cancer. We also included papers that focused on the development of assessment tools. Studies were identified through computerized (MEDLINE and PsycINFO) and manual searches for the years 1995-2009. Twenty-eight papers met the inclusion criteria. They describe findings in relation to a total of 3942 patients. The sample sizes ranged from 25 to 422 (median = 87). The main methodological challenge identified is the recruitment of large and representative samples. Significant portions of the advanced cancer population are excluded from distress studies or are refusing to take part. In conclusion, researchers can enhance the methodological knowledge base by presenting more detailed accounts of the participant recruitment and data collection processes. Future researchers should strive to develop more flexible methods of assessing distress among patients with advanced disease.

Depression assessment and classification in palliative cancer patients: a systematic literature review

The objective of this study was to review the literature on depression in palliative cancer care in order to identify which assessment methods and classification systems have been used in studies of depression. Extensive electronic database searches in PubMed, CancerLit, CINAHL, PsychINFO, EMBASE and AgeLine as well as hand search were carried out. In the 202 included papers, 106 different assessment methods were used. Sixty-five of these were only used once. All together, the Hospital Anxiety and Depression Scale (HADS) was the most commonly used assessment method. However, there were regional differences and while the HADS dominated in Europe it was quite seldom used in Canada or in the USA. Few prevalence and intervention studies used assessment methods with an explicit reference to a diagnostic system. There were in total few case definitions of depression. Among these, the classifications were in general based on cut-off scores (77%) and not according to diagnostic systems. The full range of the DSM-IV diagnostic criteria was seldom assessed, i.e. less than one-third of the assessments in the review took into account the duration of symptoms and 18% assessed consequences and impact upon patient functioning. A diversity of assessment methods had been used. Few studies classified depression by referring to a diagnostic system or by using cut-off scores. Evidently, there is a need for a consensus on how to assess and conceptualize depression and related conditions in palliative care.

Screening for emotional distress in cancer patients: a systematic review of assessment instruments

Screening for emotional distress is becoming increasingly common in cancer care. This systematic review examines the psychometric properties of the existing tools used to screen patients for emotional distress, with the goal of encouraging screening programs to use standardized tools that have strong psychometrics. Systematic searches of MEDLINE and PsycINFO databases for English-language studies in cancer patients were performed using a uniform set of key words (eg, depression, anxiety, screening, validation, and scale), and the retrieved studies were independently evaluated by two reviewers. Evaluation criteria included the number of validation studies, the number of participants, generalizability, reliability, the quality of the criterion measure, sensitivity, and specificity. The literature search yielded 106 validation studies that described a total of 33 screening measures. Many generic and cancer-specific scales satisfied a fairly high threshold of quality in terms of their psychometric properties and generalizability. Among the ultrashort measures (ie, those containing one to four items), the Combined Depression Questions performed best in patients receiving palliative care. Among the short measures (ie, those containing five to 20 items), the Center for Epidemiologic Studies–Depression Scale and the Hospital Anxiety and Depression Scale demonstrated adequate psychometric properties. Among the long measures (ie, those containing 21–50 items), the Beck Depression Inventory and the General Health Questionaire–28 met all evaluation criteria. The PsychoSocial Screen for Cancer, the Questionnaire on Stress in Cancer Patients–Revised, and the Rotterdam Symptom Checklist are long measures that can also be recommended for routine screening. In addition, other measures may be considered for specific indications or disease types. Some measures, particularly newly developed cancer-specific scales, require further validation against structured clinical interviews (the criterion standard for validation measures) before they can be recommended.

End-of-life issues in the acute and critically ill patient

The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.

Cognitive Dysfunction and Depression May Decrease Activities in Daily Life More Strongly Than Pain in Community-Dwelling Elderly Adults Living With Persistent Pain

BACKGROUND AND OBJECTIVES

Chronic pain, dementia, and depression may reduce activities of daily life in elderly people. We evaluated the correlation between pain intensity and daily activities, cognitive state, and depression, as well as their interrelationships in home-dwelling elderly people with chronic pain.

METHODS

Forty-one elderly home-dwelling people who suffered from long-lasting pain, and who participated in a rehabilitation program, were enrolled. Severity of pain at rest and after pain-provoked motion was assessed on a visual analog scale (VAS, 0 to 100) and a 5-point verbal rating scale (VRS). Cognitive status was assessed with the mini-mental state examination (MMSE, 0 to 30), depression on the geriatric depression scale (GDS, 0 to 15), and functional ability in daily life was assessed with the Barthel Index (0 to 100).

RESULTS

VAS and VRS scores correlated positively with each other. Rating pain at rest on the VRS (mean 1.0, median 1) correlated with severity of depression (GDS mean 5.4) (r = 0.3997, P < 0.01), while scores on the VAS did not. Pain ratings at rest did not correlate with the Barthel Index (mean 87.7), but the latter correlated positively with motion-evoked VRS pain scores (mean 2.8, median 3) (r = 0.42829, P < 0.01). The MMSE (mean 25.3) did not correlate with any pain parameter, but it correlated positively with the Barthel Index (r = 0.3660, P < 0.05). The Barthel Index correlated negatively with the GDS (r = -0.39969, P < 0.01).

CONCLUSION

In home-dwelling elderly people, chronic pain states do not seem to reduce daily activities as much as cognitive dysfunction and depression. The seemingly controversial finding of a positive correlation between daily activities and pain in motion, and lack of correlation with pain at rest, may be explained by a relatively low intensity of pain in our study people.

Recognizing Depression in Palliative Care Patients

Clinically significant depression is a common psychiatric disorder in patients with advanced and terminal diseases. Depression is often unrecognized and untreated and it causes major suffering to patients and families. Having adequate knowledge and skills to properly recognize depression in patients with advanced illnesses is essential for providing comprehensive end-of-life care. The objective of this paper is to review the key elements of the assessment of depression in palliative care patients. We also discuss the challenges of making the diagnosis, review the risk factors associated with depression and describe the features of the most common assessment tools that have been studied in this population. Finally, we highlight how to differentiate depression from normal grief, as the overlap between these conditions imposes a diagnostic challenge.

Factors that influence physicians' detection of distress in patients with cancer: can a communication skills training program improve physicians' detection?

BACKGROUND

No study to date has assessed the impact of skills acquisition after a communication skills training program on physicians' ability to detect distress in patients with cancer.

METHODS

First, the authors used a randomized design to assess the impact, on physicians' ability to detect patients' distress, of a 1-hour theoretical information course followed by 2 communication skills training programs: a 2.5-day basic training program and the same training program consolidated by 6 3-hour consolidation workshops. Then, contextual, patient, and communication variables or factors associated with physicians' detection of patients' distress were investigated. After they attended the basic communication skills training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Interviews with a cancer patient were recorded before training, after consolidation workshops for the group that attended consolidation workshops, and approximately 5 months after basic training for the group that attended basic training without the consolidation workshops. Patient distress was recorded with the Hospital Anxiety and Depression Scale before the interviews. Physicians rated their patients' distress on a visual analog scale after the interviews. Physicians' ability to detect patients' distress was measured through computing differences between physicians' ratings of patients' distress and patients' self-reported distress. Communication skills were analyzed according to the Cancer Research Campaign Workshop Evaluation Manual.

RESULTS

Fifty-eight physicians were evaluable. Repeated-measures analysis of variance showed no statistically significant changes over time and between groups in physicians' ability to assess patient distress. Mixed-effects modeling showed that physicians' detection of patients' distress was associated negatively with patients' educational level (P = 0.042) and with patients' self-reported distress (P < 0.000). Mixed-effects modeling also showed that physicians' detection of patient distress was associated positively with physicians breaking bad news (P = 0.022) and using assessment skills (P = 0.015) and supportive skills (P = 0.045).

CONCLUSIONS

Contrary to what was expected, no change was observed in physicians' ability to detect distress in patients with cancer after a communication skills training programs, regardless of whether physicians attended the basic training program or the basic training program followed by the consolidation workshops. The results indicated a need for further improvements in physicians' detection skills through specific training modules, including theoretical information about factors that interfere with physicians' detection and through role-playing exercises that focus on assessment and supportive skills that facilitate detection.

Screening for depression in nursing home palliative care patients

The purpose of the this study was to evaluate the existing tools for assessing depression in nursing home patients referred to palliative care services. The patients referred to palliative care were assessed for depression by a geriatric fellow and a psychiatrist (gold standard). The questions asked by the fellow were derived from the existing validated screening scales and diagnostic tools. The psychiatrist's assessment had a strong agreement with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; kappa = 0.400) and Geriatric Depression Scale (GDS; kappa = 0.462) and least agreement with the Cornell Scale for Depression in Dementia (CDS). However, depression in the most severe dementia patients (Mini-Mental State Examination = 0) was able to be assessed only by the CDS. Thus, although items from the DSM-IV and GDS may be used to ascertain depression in geriatric patients, to date there is no scale valid and reliable enough to effectively ascertain depression in the most severely demented patients.

A prospective study to compare three depression screening tools in patients who are terminally ill

Depression is a significant symptom for approximately one in four palliative care patients. This study investigates the performance of three screening tools. Patients were asked to verbally rate their mood on a scale of 0-10; to respond "yes" or "no" to the question "Are you depressed?," and to complete the Edinburgh depression scale. They were also interviewed using a semi-structured clinical interview according to DSM-IV criteria. Complete data was available for 74 patients. For the single question, a "yes" answer had a sensitivity of 55% and specificity 74%. The Edinburgh depression scale at a cut-off point of > or =13 had a sensitivity of 70% and specificity of 80%. The verbal mood item with a cut-off point of > or =3 had a sensitivity of 80% and specificity of 43%. The Edinburgh depression scale proved to be the most reliable instrument for detecting clinical depression in palliative care patients.

A prospective study to determine the association between physical symptoms and depression in patients with advanced cancer

Depression is a common symptom in patients with advanced cancer and patients who are depressed may also have physical symptoms which are difficult to palliate and which improve as their depression is appropriately treated. This study was carried out to determine if there was an association between depression and physical symptoms in patients with advanced cancer and to establish whether a seven-item verbal rating scale asking patients to verbally rate the severity of physical symptoms together with low mood could be used to screen for depression. The scale was validated against a semi-structured clinical interview according to DSM IV criteria. Seventy-four patients participated with an age range of 28-92 years. All patients had an ECOG performance status of two or three. The prevalence of major depression in this study was found to be 27% (95% C.I. 17-37%). The mean score on the verbal rating scale was 28.77 (median score 29.5) (95% C.I., 26.23 - 31.31; range 0-65). A cut-off of > or = 30 gave a sensitivity of 65% and specificity of 59%, with positive and negative predictive values of 37% and 82% respectively. The verbal mood item alone had an optimal cut-off point of 3, with a sensitivity of 80% and specificity of 43%. Patients diagnosed as being depressed according to psychiatric interview rated each symptom higher than nondepressed patients. The verbal mood item and total verbal rating score correlated with a high significance (rs = 0.607, P < 0.01), implying a relationship between a patient's subjective mood state and other symptoms. Both using the verbal scale and asking patients to verbally rate their mood alone had poor efficacy as a screening tool. However, there is a close association between physical symptoms and the presence of depression in palliative care patients.

End-of-life care in geriatric psychiatry

Depression, anxiety and delirium are relatively common during the final stages of terminal disease, and each can profoundly impact the quality of those last days for both patient and involved family. In this article the authors review the assessment and treatment of each syndrome in the context of palliative care for older adults. Treatment of mental disorders at the end of life warrants special consideration due to the need to balance the benefits of treatment against the potential burden of the intervention, especially those that might worsen quality of life. Dementia and the complications of depression and behavioral disturbance within dementia are also discussed. Finally, caregivers of dying patients are vulnerable to stress, depression, grief, and complicated bereavement. Interventions for caregivers who are debilitated by these states are briefly summarized.

Validation of a symptom measure suitable for use among palliative care patients in the community: CAMPAS-R

The purpose of the study was to investigate psychometric properties of CAMPAS-R, an instrument for prospectively monitoring patients' symptoms and needs during palliative care at home. CAMPAS-R was piloted for face and content validity and then administered alongside criterion measures to a home care sample. Cronbach's alpha was used to test internal consistency and criterion-related validity was tested by non-parametric correlation with Brief Pain Inventory (BPI), Hospital Anxiety and Depression Scale (HADS) and EORTC QLQ-C30. Predictive validity was assessed by relating CAMPAS-R scores to survival. One hundred and nine patients were recruited to the study. Good reliability and high correlations between CAMPAS-R and criterion measures were found. Predictive validity was demonstrated by significant differences in symptom scores between groups differing in length of survival. CAMPAS-R is acceptable to patients, families and primary care professionals and is a valid, reliable instrument, which has the benefit of being easy to score.

Improving the nursing management of patients in a hematology/oncology day unit: an action research project

This article reports on an action research project conducted in one hematology-oncology day unit in Queensland, Australia. The project consisted of three phases, each of which included observation, reflection, action, and evaluation. The first phase calculated the amount of time and the dedicated nursing hours required to administer the different chemotherapeutic protocols to patients in a number of hematology-oncology day units in Southeast Queensland. The second phase changed the patient booking and staff allocation systems following an evaluation of process and outcome measures and a patient survey. The patient survey measured both generic satisfaction and satisfaction with symptom management. The third phase introduced and evaluated the effectiveness of primary nursing and increased emphasis on patient education. The first two changes brought about by the action research process improved patient wait time, patient satisfaction, and symptom management. The changes implemented in phases 1 and 2 increased the amount of time available for nurses to engage in psychosocial care. The increased emphasis on education in phase 3 did not significantly improve patient knowledge related to self-care or appropriate health professional referral. To improve patient education, the development and implementation of a self-care education program is recommended.

The stability of depression scores in patients who are receiving palliative care

Depression occurs in approximately 25% of palliative care patients. It often is not recognized and is, therefore, not treated. This can lead to difficulties in the management of physical symptoms, such as pain, and also cause much distress to patients and their families. Many professionals working in palliative care are concerned that screening for depression may not be appropriate in a population of patients whose illness is changing rapidly. To explore the value of screening, all patients attending a palliative care day unit were invited to participate in a 12-week study in which they were requested to complete at weekly intervals a previously validated depression-screening tool for palliative care. Fifty patients participated. The scores of all patients who scored below the cut-off threshold at initial assessment showed a mean change of +/-0.56 (range -6 to +7) on the screening tool. This observation suggests that patients' scores on a self-completed scale that has been validated for use in the palliative care population remained largely stable during the last few months of life. Screening palliative care patients for depression at referral or first assessment may be useful in assessing depression within the palliative care setting.

Auricular acupuncture, education, and smoking cessation: a randomized, sham-controlled trial

OBJECTIVES

This study examined the effect of acupuncture alone and in combination with education on smoking cessation and cigarette consumption.

METHODS

We prospectively studied 141 adults in a quasi-factorial design using acupuncture, sham acupuncture, and education.

RESULTS

All groups showed significant reductions in smoking and posttreatment cigarette consumption, with the combined acupuncture-education group showing the greatest effect from treatment. The trend continued in follow-up; however, significant differences were not maintained. Greater pack-year history (i.e. the number of years smoking multiplied by baseline number of cigarettes smoked per year, divided by 20 cigarettes per pack) negatively correlated with treatment effect. Trend analysis suggested 20 pack-years as the cutoff point for this correlation.

CONCLUSIONS

Acupuncture and education, alone and in combination, significantly reduce smoking; however, combined they show a significantly greater effect, as seen in subjects with a greater pack-year history.

Screening for depression in palliative care patients: a review

Depression is a significant symptom for 25% of patients admitted to a palliative care unit, but many of these symptoms are not identified and therefore not treated. Reasons for failure to diagnose depression are misconceptions regarding low mood as being a normal part of a terminal illness and also the patients' reluctance to disclose their thoughts and feelings. Medical and nursing staff working within palliative care may also find difficulty in distinguishing between what could be called appropriate sadness and a treatable depressive illness. In an effort to improve the detection of depression, many professionals are using rating scales or tools in order to improve the diagnosis and treatment. This review discusses the complex issues of diagnosis of depression and highlights why certain tools may not be so useful or applicable in the palliative care population.