Research shows that the prevalence of depression in oncology patients and survivors is approximately 16.3%, with a range of 10-20% depending on cancer type, stage of illness, and other factors. Studies consistently find that cancer patients have a 1.5 to 3-fold increased risk of depression compared to the general population without cancer, after controlling for other variables. There is a clear evidence base developed over decades of research demonstrating high rates of depression and other mood disorders in cancer patients and survivors.

1. The Future of Psycho-oncology:
The Future of Psycho-oncology:
Research & Clinical
Research & Clinical
Alex Mitchell www.psycho-oncology.info
Department of Cancer & Molecular Medicine, University of Leicester
Department of Liaison Psychiatry, Leicester General Hospital
University of Sydney POCOG August 2011
University of Sydney POCOG August 2011

2. Hewitt Journal of Clinical Oncology, Vol 20, Issue 23, 2002: 4581-4590
40
% Receiving Any treatment for Mental Health
34.6
35 32.7 Cancer n=4878
No Cancer n=90,737
30
25
19.1
20
16.1
14
15
11.7 11
8.9
10 7.7
7.2 6.5
5.7 5.7 5 6.3 6.4 6.2
5
5 3.9 3.2
2.3 1.8
0
l th
l th
75+
s
rs
rs
rs
ti o n
ie n t
on
ti o n
ti o n
H ea
H ea
y ea
y ea
y ea
d it i
n di
P at
n di
n di
l Il l
l Il l
44
64
74
co n
l co
l co
l co
All
nt a
n ta
18-
45-
65-
d i ca
ca l
d i ca
d i ca
Me
Me
edi
me
me
me
No
cm
n ic
n ic
n ic
o ni
hro
hro
hro
c hr
1c
2c
3c
No

3. Are you doing anything on your own for your mental stress, worry, or m changes?
ood
Do you feel your cancer care teamhas provided the education or support you need?
At your last visit, did a m ber of your cancer care teamask you about m
em ental stress,
worry, or m changes?
ood
Were you given suggestions, other than taking medications, by your cancer care team?
Were you offered a visit with a: Mental health provider, like a therapist, counselor,
psychologist or psychiatrist?
Have you been given medicines to take for mental stress, worry, or m changes?
ood
Over the past month, have you talked with your cancer care teamabout distress?
If taking treatm has anyone fromyour cancer care teamasked you how well the treatm
ent ent
was working?
Have you been sent to see another health care provider for treatm for your m
ent ental stress,
worry, or m changes?
ood
Have you received any treatm for m
ent ental stress, worry, or m changes over the last
ood
m onth
Are you currently seeing a: Pastoral care provider, like a chaplain, priest, or rabbi?
0 10 20 30 40 50 60 70 80
Cella (2008) Suport Care Cancer. 2008 Feb;16(2):151-9. Epub 2007 Jul

4. What about preventive cancer care?
Do our vulnerable patients get enhanced access?

5. Mammography & MI Summary meta-analysis plot [random effects]
Carney & Jones (2006) [mod mental illness] 0.620 (0.590, 0.660)
Carney & Jones (2006) [mild mental illness] 0.980 (0.950, 1.010)
OR 0.69 (95% CI = 0.62 to 0.77) Carney & Jones (2006) [severe mental illness]
Carney & Jones (2006) [low severity]
0.380 (0.330, 0.430)
0.930 (0.890, 0.970)
P < 0.0001 Carney & Jones (2006) [medium severity]
Carney & Jones (2006) [high severity]
0.630 (0.570, 0.690)
0.340 (0.280, 0.420)
N=29
Carney & Jones (2006) [low severity] 0.590 (0.450, 0.780)
Carney & Jones (2006) [high severity] 0.560 (0.260, 1.210)
Carney & Jones (2006) [medium severity] 0.470 (0.330, 0.670)
Chochinov et al (2009) 0.640 (0.580, 0.710)
Druss et al (2002) 0.780 (0.670, 0.910)
Druss et al (2002) [dual diagnosis] 0.520 (0.340, 0.790)
Druss et al (2008) [depression] 0.820 (0.790, 0.847)
Druss et al (2008) [primary care] 1.350 (1.160, 1.610)
Druss et al (2008) [specialist] 0.820 (0.690, 0.970)
Green and Pope (2000) 1.370 (1.040, 1.810)
Iezzoni et al (2001) 0.600 (0.400, 1.100)
Lasser et al (2003) 0.350 (0.240, 0.510)
Lindamer et al (2003) 0.040 (0.002, 0.250)
Patten et al (2009) 0.800 (0.400, 1.600)
Peytremann- Bridevaux et al (2008) 1.000 (0.800, 1.200)
Pirraglia et al (2004) [severe depression] 0.840 (0.730, 0.970)
Pirraglia et al (2004) [moderate depression] 1.010 (0.860, 1.180)
Stecker et al (2007) 0.867 (0.662, 1.130)
Werneke et al. (2006) [any mental illness] 0.910 (0.800, 1.040)
Werneke et al. (2006) [severe mental illness] 0.400 (0.290, 0.550)
Werneke et al. (2006) [psychosis] 0.330 (0.180, 0.610)
masterton et al (2010) 0.670 (0.420, 1.075)
Ludman et al (2010) 0.490 (0.310, 0.760)
combined 0.692 (0.624, 0.768)
0.001 0.01 0.1 0.2 0.5 1 2
odds ratio (95% confidence interval)

6. What is Changing?
Demographics
Clinician Expectations
Patient Involvement

7. Lower Emphasis
Depression (MDD, DSMIV)
Psychiatrist Judgement vs patient opinion
Ineffective interventions
Communication over Trust (diagnosis alone)
Palliative differences without evidence

8. Increased Emphasis
Early intervention & prevention
Screening Implementation > Validity
Distress (esp longitudinal)
Outreach and primary care
PROMs
Peer support and SMI models of care

9. For the Future
Anxiety disorders, Anger, Irritability, Adjustment
Unpopular depressions (MnDD, ADD, Dysthymia)
Function and QoL will be re-invented
Psychosocial input into Rehabilitation approaches
Acceptable Screening with intervention (RCTs)
Symptom Research (back to basics)

10. Psycho-oncology is Growing!
2010 1990
Depression 143 12
Distress 121 14
Screening 1700 481
Communication 148 38

11. Change 1: Epidemiology of Cancer
Survival
Prevalence

12. 5 Year Survival in US Cancers (2008 American Cancer Society, Atlanta)
100
90
80
1975-1977
70 1984-1986
1996-2004
60 Change
50
40
30
20
10
0
a
r
us
a
ia
te
on
y
e)
s
as
m
de
om
om
i te
r
em
ta
al
va
ch
tu
ol
re
ad
ls
ph
m
os
ec
an
C
O
on
nc
uk
bl
(fe
Al
lym
Pr
R
el
br
Pa
Le
y
M
ar
st
d
in
ea
an
rin
gk
Br
U
ng
od
Lu
-H
on
N
Annual report to the national of status of cancer 1975 – 2005 J Natl Cancer Inst 2008;100: 1672 – 1694

13. 10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases

14. Australian Bureau of Statistics

15. Change 2: Clinician Behaviour
Information
Assisted decision making

16. Information
In 1961
90% of US doctors indicated a preference for not
telling a diagnosis of cancer.
In 1979
97% indicated a preference for revealing a diagnosis
of cancer.
Novack DH, Plumer R, Smith RL, et al. Changes in physicians’ attitudes toward
telling the cancer patient. JAMA 1979; 241: 897–900.

17. The oncologists were 32% accurate in
predicting survival and overestimated
survival 42% of the time
Psychooncology. 2011 Feb;20(2):213-8. doi: 10.1002/pon.1727. Patient
and oncologist estimates of survival in advanced cancer patients.
Steven Kao SC, Butow P, Bray V, Clarke SJ, Vardy J.

18. J Clin Oncol. 2011 May 20;29(15):2077-84. Epub 2011 Apr 11. Supporting treatment decision making in advanced cancer: a randomized trial of a
decision aid for patients with advanced colorectal cancer considering chemotherapy. Natasha Leighl NB, Shepherd HL, Butow PN

19. Change 3: Clear Evidence Base
Prevalence of depression
Relative risk of depression

20. Prevalence of depression in Oncology settings Plumb & Holland (1981)
Proportion meta-analysis plot [random effects]
0.7750 (0.6679, 0.8609)
Levine et al (1978) 0.5600 (0.4572, 0.6592)
Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)
Massie et al (1979) 0.4850 (0.4303, 0.5401)
70 studies involving 10,071 individuals;14 countries. Bukberg et al (1984)
Passik et al (2001)
0.4194 (0.2951, 0.5515)
0.4167 (0.2907, 0.5512)
16.3% (95% CI = 13.9% to 19.5%) Baile et al (1992)
Morton et al (1984)
Hall et al (1999)
0.4000 (0.2570, 0.5567)
0.3958 (0.2577, 0.5473)
0.3722 (0.3139, 0.4333)
Burgess et al (2005) 0.3317 (0.2672, 0.4012)
Jenkins et al (1991) 0.3182 (0.1386, 0.5487)
Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3%
Green et al (1998) 0.3125 (0.2417, 0.3904)
Kathol et al (1990) 0.2961 (0.2248, 0.3754)
Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)
Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)
Golden et al (1991) 0.2308 (0.1353, 0.3519)
Spiegel et al (1984) 0.2292 (0.1495, 0.3261)
Evans et al (1986) 0.2289 (0.1438, 0.3342)
Grandi et al (1987) 0.2222 (0.0641, 0.4764)
Maunsell et al (1992) 0.2146 (0.1605, 0.2772)
Berard et al (1998) 0.2100 (0.1349, 0.3029)
Joffe et al (1986) 0.1905 (0.0545, 0.4191)
Berard et al (1998) 0.1900 (0.1184, 0.2807)
Devlen et al (1987) 0.1889 (0.1141, 0.2851)
Leopold et al (1998) 0.1887 (0.0944, 0.3197)
Akizuki et al (2005) 0.1797 (0.1376, 0.2283)
Razavi et al (1990) 0.1667 (0.1189, 0.2241)
Gandubert et al (2009) 0.1597 (0.1040, 0.2300)
Alexander et al (1993) 0.1333 (0.0594, 0.2459)
Kugaya et al (1998) 0.1328 (0.0793, 0.2041)
Payne et al (1999) 0.1290 (0.0363, 0.2983)
Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)
Prieto et al (2002) 0.1227 (0.0825, 0.1735)
Morasso et al (1996) 0.1121 (0.0593, 0.1877)
Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)
Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)
Costantini et al (1999) 0.0985 (0.0535, 0.1625)
Morasso et al (2001) 0.0985 (0.0535, 0.1625)
Ozalp et al (2008) 0.0971 (0.0576, 0.1510)
Love et al (2002) 0.0957 (0.0650, 0.1346)
Alexander et al (2010) 0.0900 (0.0542, 0.1385)
Coyne et al (2004) 0.0885 (0.0433, 0.1567)
Kawase et al (2006) 0.0851 (0.0553, 0.1240)
Walker et al (2007) 0.0831 (0.0568, 0.1165)
Grassi et al (1993) 0.0828 (0.0448, 0.1374)
Grassi et al (2009) 0.0826 (0.0385, 0.1510)
Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)
Lee et al (1992) 0.0660 (0.0356, 0.1102)
Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)
Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)
Singer et al (2008) 0.0519 (0.0300, 0.0830)
Katz et al (2004) 0.0500 (0.0104, 0.1392)
Mehnert et al (2007) 0.0472 (0.0175, 0.1000)
Lansky et al (1985) 0.0455 (0.0291, 0.0676)
Derogatis et al (1983) 0.0372 (0.0162, 0.0720)
Hardman et al (1989) 0.0317 (0.0087, 0.0793)
Massie and Holland (1987) 0.0147 (0.0063, 0.0287)
Colon et al (1991) 0.0100 (0.0003, 0.0545)
combined 0.1730 (0.1375, 0.2116)
0.0 0.3 0.6 0.9
proportion (95% confidence interval)

21. Prevalence of depression in Palliative settings
24 studies involving 4007 individuals
16.9% (95% CI = 13.2% to 20.3%) Proportion meta-analysis plot [random effects]
Lloyd-Williams et al (2007) 0.30 (0.24, 0.36)
14% major 9% minor adj 15% anx 10% Jen et al (2006) 0.27 (0.19, 0.36)
Lloyd-Williams et al (2003) 0.27 (0.17, 0.39)
Payne et al (2007) 0.26 (0.19, 0.33)
Desai et al (1999) [late] 0.25 (0.10, 0.47)
Hopwood et al (1991) 0.25 (0.16, 0.36)
Lloyd-Williams et al (2001) 0.22 (0.14, 0.31)
Minagawa et al (1996) 0.20 (0.11, 0.34)
Meyer et al (2003) 0.20 (0.10, 0.35)
Breitbart et al (2000) 0.18 (0.11, 0.28)
Le Fevre et al (1999) 0.18 (0.10, 0.28)
Chochinov et al (1994) 0.17 (0.11, 0.24)
Kelly et al (2004) 0.14 (0.06, 0.26)
Wilson et al (2007) 0.13 (0.10, 0.17)
Chochinov et al (1997) 0.12 (0.08, 0.18)
Wilson et al (2004) 0.12 (0.05, 0.22)
Love et al (2004) 0.07 (0.04, 0.11)
Kadan-Lottich et al (2005) 0.07 (0.04, 0.11)
Akechi et al (2004) 0.07 (0.04, 0.11)
Maguire et al (1999) 0.05 (0.01, 0.14)
combined 0.17 (0.13, 0.21)
0.0 0.2 0.4 0.6
proportion (95% confidence interval)

22. Meta regression using the random effects model on raw porportions
Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size.
0.4
0.3
Proportion
0.2
0.1
0.0
0 20 40 60 80 100
Time (months)

23. Depression in LTCS vs healthy controls
Relative risk meta-analysis plot (random effects)
Bergdahl et al (2005) 0.76 (0.33, 1.53)
Bruce et al (2002) 0.77 (0.47, 1.24)
Stek et al (2004) 0.88 (0.50, 1.49)
Tsai et al (2007) 1.48 (0.74, 2.03)
Tsai et al (2005) 0.85 (0.35, 1.73)
Rasic et al (2008) 0.99 (0.74, 1.32)
Pirl et al (2009) 0.79 (0.52, 1.17)
Dahl et al (2005) 0.96 (0.82, 1.13)
Ramsey et al (2002) 1.42 (0.99, 2.03)
Keating et al (2005) 1.00 (0.86, 1.16)
Khan et al (2010) 1.08 (1.04, 1.13)
Thorsen et al (2005) 1.06 (0.89, 1.26)
Vistad et al (2007) 1.94 (0.95, 3.87)
Kim et al (2010) 0.72 (0.63, 0.82)
Ellman et al (1995) 0.58 (0.34, 0.98)
combined [random] 0.97 (0.86, 1.09)
0.2 0.5 1 2 5
relative risk (95% confidence interval)

24. Change 4: Distress
6th Vital sign
Patient Opinion

25. Distress thermometer
- Please circle the number (0-10) that best describes how much distress you have been
experiencing in the past week, including today.
- What phone number would you like us to contact you on if necessary?
Practicaltick WHICH of the following is a cause of distress:
Please Problems Spiritual/ Religious Concerns Physical Problems contd…
Childcare Loss of faith Changes in Urination
Housing Relating to God Fevers
Money Loss of meaning or purpose Skin dry/ itchy
in life
Transport Nose dry/ congested
Work/School Physical problems Tingling in hands/ feet
Pain Metallic taste in mouth
Family Problems Nausea Feeling swollen
Dealing with partner Fatigue Sexual
Dealing with children Sleep Hot flushes
Getting around
Emotional Problems Bathing/ Dressing
Depression Breathing
Fears Mouth sores Is there anything important you
would like to add to the list?
Nervousness Eating
___________________________
Sadness Indigestion ___
___________________________
Worry Constipation ___
Anger Diarrhoea ___________________________
___

26. Ransom Tuinman Mitchell Lord Hoffman Gessler Clover Jacobsen Proporti
Score 2006 2008 2009 2010 2004 2009 2009 2005 Sum on
Zero 68 38 61 123 14 27 65 71 467 18.4%
One 72 31 42 68 5 26 39 46 329 12.9%
Two 77 22 35 44 5 18 30 54 285 11.2%
Three 65 37 42 46 8 23 45 46 312 12.3%
Four 51 29 29 30 8 7 21 31 206 8.1%
Five 41 46 62 40 11 13 41 48 302 11.9%
Six 38 32 23 28 2 16 26 31 196 7.7%
Seven 36 21 23 38 2 15 32 16 183 7.2%
Eight 18 12 18 29 6 9 19 15 126 5.0%
Nine 16 5 8 14 3 3 13 9 71 2.8%
Ten 9 4 7 20 4 0 9 13 66 2.6%
Sum 491 277 350 480 68 157 340 380 2543
Proportion 19.3% 10.9% 13.8% 18.9% 2.7% 6.2% 13.4% 14.9%

27. Proportion
20.0%
Insignificant Minim al Mild Moderate Severe
18.0%
16.0%
14.0%
12.0%
10.0%
18 .4 %
8.0%
6.0%
12 .9 %
12 . 3 %
11.9 % p124
11.2 %
4.0% 8 .1%
7.7%
7.2 %
5. 0 %
2.0%
2 .8 % 2 .6 %
0.0%
Zero One Tw o Three Four Five Six Seven Eight Nine Ten
50%

28. 100% 0.02
0.00 0.00 0.00 0.00 0.00
0.03 0.04 0.03
0.01
0.06
0.08
0.09
0.07
0.17
90% 0.20
0.18 0.11
0.19
0.28
0.31
0.18
80%
0.31
0.47
70% 0.20
0.48
0.40
60%
0.50
0.40 0.53
50% 0.45
40% 0.80 0.40
0.69
0.62
30%
0.50
3=Extremely Difficult” 0.43
20% 0.41
2=Very Difficult 0.32
0.33
0.27
0.25
10% 1=Somewhat Difficult 0.20
Unimpaired
0%
Zero One Tw o Three Four Five Six Seven Eight Nine Ten

29. Change 5: Know Clinicians Limitations
How Often
What method?

30. Comment: Frequency of cancer specialists
n=226 enquiry about depression/distress from
Mitchell et al (2008)

31. Cancer Staff Psychiatrists
Current Method (n=226)
Other/Uncertain
9% Other/Uncertain
ICD10/DSMIV 2%
0% ICD10/DSMIV
13%
Short QQ
3%
1,2 or 3 Sim ple
QQ
15%
Clinical Skills
Use a QQ Alone
15% 55%
Clinical Skills
Alone
73% 1,2 or 3 Sim ple
QQ
15%
Comment: Current preferred method of eliciting
symptoms of distress/depression

32. Cancer Staff Psychiatrists
Ideal Method (n=226)
Effective?
Long QQ
8%
Clinical Skills Clinical Skills
Alone Alone
Algorithm 20%
17%
26%
ICD10/DSMIV
24%
ICD10/DSMIV 1,2 or 3 Sim ple
0% 1,2 or 3 Sim ple QQ
QQ 24%
Short QQ 34%
23%
Short QQ
24%
Comment: “Ideal” method of eliciting
symptoms of distress/depression according
to clinician

33. 100.0
5.9
11.1
14.3
90.0 Comment: Slide illustrates diagnostic 21.4
accuracy according to score on DT 11.8
25.9
80.0 38.7 38.1
43.5 22.2 14.3
46.7
70.0 59.6
21.4
72.4
60.0 Judgement = Non-distressed
33.3 Judgement = Unclear
19.4 19.0 Judgement = Distressed
50.0
26.1
24.4 82.4
40.0
71.4
66.7
30.0
25.0 57.1
41.9 42.9 40.7
20.0 15.8
30.4 28.9
10.0
15.4
11.8
0.0
Zero One Two Three Four Five Six Seven Eight Nine Ten

34. Low confidence = more cautious, fewer false positives, more false negatives p180
1.00 Post-test Probability
0.90
0.80
0.70
0.60
Ave Confidence+
0.50
Ave Confidence-
0.40 Baseline Probability
Above Ave Confidence+
0.30
Above Ave Confidence-
High Confidence+
0.20
High Confidence-
0.10
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
High confidence = less cautious, more false positives, low false negatives

35. Change 6: Screening Evolves
Ultra-short
Brief
Lengthy (conventional)

36. Comment: This is a reminder of the
structure of the HADS scale, this version
adapter for cancer.

37. Validity of HADS vs depression (DSMIV)
SE 71.6% (68.3)
SP 82.6% (85.7)
Prev 13%
PPV 38%
NPV 95%

41. Somatic Bias in Mood Scales

42. General Physical
Trained
Self-Report
Confident
Skilled
Clinician
Alone
Signs of
DS
6
Depression DISCS
Observation Screening
Stroke Aphasic methods Visual
Depression
Scale
21/10 VA-SES
SMILEY
ET/DT
YALE
Interview
HAMD-D
17 MADRAS
10

43. Validity of Methods to Evaluate Depression
Unassisted Clinician Conventional Scales
Untrained Trained Ultra-Short (<5) Short (5-10) Long (10+)

44. British Journal of Cancer (2007) 96, 868 – 874

45. Validity of DT vs depression (DSMIV)
SE 80%
SP 60%
PPV 32%
NPV 93%

46. Tools Compared_Palliative and Non-Palliative
1.00
Post-test Probability
0.90
0.80
0.70
0.60
0.50
1Q+
1Q-
0.40 Baseline Probability
HADS-D+
HADS-D-
0.30 HADS-T+
HADS-T-
BDI+
BDI-
0.20 HADS-A+
HASD-A-
DT+
0.10 DT-
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

47. Tools Compared in Palliative Alone
1.00 Post-test Probability
0.90
0.80
0.70
0.60
HADS-D+
0.50 HADS-D-
Baseline Probability
2Q+
0.40
2Q-
EPDS+
0.30
EPDS-
1Q+
0.20 1Q-
0.10
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

48. Change 7: Underserved needs

49. Underserved populations
More preferred to receive
sensitive information from their
general practitioner (BSA 62.5%
versus 33%

50. DT vs DSMIV Depression
SE SP PPV NPV
DTma 80.9% 60.2% 32.8% 92.9%
DTLeicesterBW 82.4% 68.6% 28.0% 98.3%
DTLeicesterBSA 100% 59.6% 26.8% 100%
BSA = British South Asian
BW= British White

51. Change 8: Help Appears!

54. Vs DT DepT
HADS-A
AUC:
DT=0.82
DepT=0.84
AnxT=0.87 AnxT AngT
AngT=0.685

55. DepT
DT
23%
37%
4% 3%
3%
DT DepT
7% 1%
Non-Nil 8% 0% Nil
9%
59% 41%
4% 1%
AnxT 2% AngT
15% 2%
AnxT AngT
47% 18%

56. Change 9: Implementation RCTs
What can enhance detection?

58. Comment: Slide illustrates actual gain in
meta-analysis of screening
implementation in primary care

59. Pre-Post Screen - Distress
Before After
Sensitivity of 49.7% 55.8% =>+5%
Specificity of 79.3% 79.8% =>+1%
PPV was 67.3% 70.9% =>+4%
NPV was 64.1% 67.2% =>+3%
There was a non-significant trend for improve detection sensitivity (Chi² =
1.12 P = 0.29).

60. Qualitative Aspects
DISTRESS
43% of CNS reported the tool helped them talk with the patient
about psychosocial issues esp in those with distress
28% said it helped inform their clinical judgement
DEPRESSION
38% of occasions reported useful in improving communication.
28.6% useful for informing clinical judgement

61. Screen
Routine vs At-Risk vs Identified
Low High
?? Desire for Help
Meetable Unmet Needs
Follow-up Care

62. Next Step 269 Nurse-patient
interactions
Helped 65 (24%) Not Helped 204 (76%)
Referred 23 (8.6%) Declined Helped 20 (7.4%)
No Unmet Needs 34 (12.6%)
Unmet Needs 150 (55.8%)
p179

63. What is QUICATOUCH?
Quick, Individually Customised Assessment using TOUCHscreens

64. Prevalence over time
35
30
% patients over threshold
Distress
25
Pain
20
15
10
5
0
1 2 3 4 5 6 7 8
Quarter of screening
First occasion of screening (n=4543)

65. Change 10: Symptom Research Back to Basics
Back to Basics

67. Clinical Clinical Overall
Test Sensitivity Specificity PPV NPV Utility (+) Utility (‐) Correct
little interest or pleasure in doing 73.5% 69.9% 50.8% 86.2% Poor Average 70.97
things (0.374) (0.602)
Feeling down, depressed or 83.7% 61.7% 48.1% 90.0% Poor Average 68.28
hopeless (0.403) (0.555
86.7% 92.6% 83.2% 94.3% Good Excellent 90.86
Trouble falling or staying asleep or
(0.722 (0.873
sleeping too much
81.9% 83.7% 68.0% 91.6% Average Good 83.15
Feeling tired or having little energy (0.557) (0.767)
59.6% 89.3% 70.2% 83.9% Poor Good 80.47
Poor appetite or overeating (0.419) (0.749)
Feeling bad about yourself or that 54.2% 85.5% 61.2% 81.5% Poor Good 76.16
you are a failure (0.332) (0.697)
Trouble concentrating on things 69.3% 76.5% 55.6% 85.5% Poor Good 74.37
such as reading (0.385) (0.65)4
Thoughts that would be better off 19.3% 96.9% 72.7% 73.9% Poor Good 73.84
dead (0.140) (0.717)
100% 91.6% 83.4% 100% Excellent Excellent 94.09
Optimal two‐stage combination of
(0.834) (0.916)
items

68. Whole Sample Palliative Patients Non-Palliative Patients
Symptom MDD No MDD MDD No MDD MDD No MDD
little interest or pleasure in
69.0% 7.80% 88.0% 9.93% 58.7%** 6.8%
doing things
Feeling down, depressed or
73.2% 6.60% 80.0% 7.95% 69.6% 6.0%
hopeless
Trouble falling or staying
85.9% 23.00% 88.0% 23.18% 84.8% 22.9%
asleep or sleeping too much
Feeling tired or having little
94.4% 27.30% 92.0% 24.50% 95.7% 28.6%
energy
Poor appetite or overeating
81.7% 17.00% 88.0% 18.54% 78.3% 16.4%
Feeling bad about yourself
88.7% 17.20% 80.0% 19.21% 93.5%* 16.4%
or that you are a failure
Trouble concentrating on
77.5% 6.40% 84.0% 8.61% 73.9% 5.4%
things such as reading
Moving or speaking so
84.5% 19.50% 88.0% 23.84% 82.6% 17.6%
slowly
Thoughts that would be
35.2% 3.90% 24.0% 3.31% 41.3% 4.2%
better off dead

69. Most Useful Diagnostic Symptoms for Depression in..
ONCOLOGY SETTINGS PALLIATIVE SETTINGS
1 Trouble concentrating 1. little interest or pleasure in doing
things
2 Feeling down depressed or 2. Trouble concentrating on things
hopeless such as reading the
3 Feeling bad about yourself or that 3. Feeling down depressed or
you are a failure hopeless
4 little interest or pleasure in doing 4. Poor appetite or overeating
things
5 Moving or speaking so slowly that 5. Feeling tired or having little
other people could have noticed energy
Trouble falling or staying asleep or sleeping too much
Thoughts that would be better off dead or of Feeling bad about yourself or that you are a failure
Poor appetite or overeating Moving or speaking so slowly that other people could
have noticed
Trouble falling or staying asleep or sleeping too much
Thoughts that would be better off dead or of
Feeling tired or having little energy

70. Change 11: Intervention Research

72. Future of Psycho-oncology 2011
2011
We have to address to basics first
We have to work collaboratively clinicians & researchers
We have to put the patient at the centre