Mari Lloyd-Williams

An Analysis of the Validity of the Hospital Anxiety and Depression Scale as a Screening Tool in Patients with Advanced Metastatic Cancer

Depression is difficult to diagnose in the terminally ill patient. As a result, it frequently is not treated. This has can have an adverse effect on quality of life and make the palliation of physical symptoms more difficult. In an effort to improve the detection of depression, many palliative care teams are using the Hospital Anxiety and Depression (HAD) scale as a screening tool. The HAD was devised for use in general medical settings and has not been validated for use in palliative care patients. One hundred patients receiving palliative care with an estimated prognosis of 6 months or less were invited to complete the HAD and a semi-structured psychiatric interview, the Present State Examination. The depression and anxiety subscales of the HAD showed poor efficacy for screening when used alone. The optimum threshold was at a combined cut-off of 19, which had a sensitivity of 68% and specificity of 67%. The major construct of the HAD is anhedonia, which may be present at the end of life due to increasing physical illness and may not be pathognomic of a depressive illness in this population. We recommend, therefore, that if the HAD is used as a screening tool in palliative care, it should be as a combined scale, but low sensitivity and specificity may lead to poor efficacy as a screening tool.

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 ≥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 patients 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.

A systematic review of teaching and learning in palliative care within the medical undergraduate curriculum

End of life care or palliative care has been acknowledged as important over the last 30 years and it is essential that doctors have core training in palliative care during their undergraduate training. There is little knowledge of the nature of teaching of palliative care within the undergraduate curriculum. This review was undertaken to determine the evidence to create an effective and appropriate undergraduate curriculum in palliative care. All relevant databases were electronically searched from 1966 until 2001 and selected contemporary work included. Key authors were contacted and grey literature and conference abstracts were searched. Efforts were made to quality grade any evaluation studies of teaching, learning and assessment. Two hundred and eighty abstract citations were obtained—192 papers were excluded due to lack of relevance to this study. Eighty-eight abstracts were obtained and forty-nine papers included in the review. There were no randomized controlled trials of educational interventions or open effect studies. All studies included were descriptive and were graded as level of evidence C. The main findings include lack of consistency in what undergraduates are taught about palliative care. Teaching tends to be fragmented, ad hoc and lacks co-ordination. There are difficulties in recruiting appropriate teachers. Palliative care is rarely formally assessed. Teaching focused more on the acquisition of knowledge and skills rather than attitudes. It is suggested that guidelines should be established within each medical school to develop an integrated curriculum for palliative care with due reference to the multidisciplinary nature of palliative care.

A survey of antidepressant prescribing in the terminally ill.

Depression is a symptom in a quarter of patients admitted to a palliative care unit, but little is known of how depression in terminally ill patients is treated. We reviewed 1046 consecutive patient admissions, of whom 106 (10%) were prescribed antidepressant medication while under the care of a palliative care team. Of these patients, 21 were prescribed antidepressants when under the care of the home care team, but 80 patients (76%) were started on medication during the final 2 weeks of life. There was consequently insufficient time for the medication to have any therapeutic effect. Seventeen patients were discharged home on antidepressant medication. Three patients were referred for a psychiatric assessment. Patients prescribed antidepressants were significantly younger (P = 0.002) than those who were not. There were no prescriptions for psychostimulants. Although the numbers of patients prescribed antidepressant medication were low in all disease groups, it was notable that patients with breast cancer were prescribed antidepressant medication more frequently than any other patient group. We conclude that there appears to be a need for a coordinated approach to both the assessment and the treatment of depression in terminally ill patients.

How children cope when a parent has advanced cancer.

Objective: When parents are diagnosed with cancer, children experience significant distress. There is little information regarding the nature of this distress and how children cope, particularly when a parent is diagnosed with advanced cancer. This study aimed to explore how children cope, and to identify areas where there may be barriers to children accessing support to enable them to cope.

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.

Which depression screening tools should be used in palliative care

Depression is a significant symptom for many palliative care patients, but is difficult to diagnose and therefore treat. In an effort to improve detection, there has been increasing interest in the use of screening tools. Many tools, however, have been developed for physically well patients and it is important that tools are validated for the populations in which they are used. The present study was carried out on behalf of the Association of Palliative Medicine, Science Committee, to assess the available evidence for using screening tools in palliative care. The single question ‘Are you depressed?’ was the tool with the highest sensitivity and specificity and positive predictive value. Where the Hospital Anxiety and Depression Scale and the Edinburgh Depression Scale are used, the validated cut-off thresholds for palliative care patients should be employed. Patients who report thoughts of self-harm or suicide need prompt assessment and evaluation.

Is asking patients in palliative care, "are you depressed?" Appropriate? Prospective study.

Depression is a serious problem that affects about a quarter of patients in palliative care.1 Diagnosing depression is difficult because most patients are understandably sad. Lack of recognition of depression can lead to further morbidity and a detrimental effect on the quality of life.2 Screening for depression attracts wide interest, but as patients are frail and unwell, a screening tool needs to be brief. Asking North American patients in palliative care the single question, “Are you depressed?” had perfect sensitivity and specificity and 100% positive predictive value compared with the schedule for affective disorders.3 Other studies of patients with stroke and elderly patients found that a single statement with a “yes” or “no” response correctly classified …

Revisiting biographical disruption: exploring individual embodied illness experience in people with terminal cancer.

Biographical accounts of illness offer useful insights into the social and adaptive processes of living with chronic illness. Yet there are concerns that the underlying theoretical assumptions of a reflexive self seeking to maintain meaning may not reflect the lived experience of individuals. A narrative emphasis may neglect the importance of emotional/felt experiences; while an analytical focus on disruptive processes may not adequately reflect the totality of actual events. In this study, we explored how well biographical theory supports understanding of individual lived experience. Narratives from 19 individuals identified from General Practice lists with a terminal diagnosis of cancer were analysed using the holistic-form approach described by Lieblich. Participants described an ongoing process of living their life, ‘managing’ disruptive events and maintaining an overall sense of well-being (narrative form = biographical flow). For a minority, continuity was lost when people’s capacity to continue living their everyday lives was overwhelmed (narrative form = fracture). The identified emphasis was on individual creative capacity in the face of terminal illness, highlighting the importance of embodied experience in understanding outcome and need. Maintaining continuity was draining: exhaustion precipitated fracture and thus need for external help to restore continuity. By focusing on feelings associated with overall narrative form, rather than individual disruptive events, we highlight the context in which disruptive events are experienced, and individual perceptions of their relative importance. We conclude that combining narrative and emotion offers new insights into the value of understanding of biographical accounts of illness in the context of individual creative capacity. We discuss the possibilities for new approaches to clinical assessment and management of need.

Information and communication when a parent has advanced cancer.

BACKGROUND Children whose parents are diagnosed with advanced cancer are found to experience high levels of distress. Research has reported communication and information as some of the factors that may contribute to levels of distress in children. There is little research however, regarding what type of information and what level of communication children consider important. AIMS This study explored childrens information needs and where and how or by whom they wanted to gain the information when a parent is diagnosed with advanced cancer. This was done in order to identify any unmet needs as well as to identify barriers that may exist in children accessing knowledge. METHOD Semi-structured interviews were conducted with ill (advanced cancer) and well parents and/or any children above the age of 7. Interviews were recorded and transcribed fully, and analysed using a constructionist grounded theory approach. RESULTS Twenty eight family participants were interviewed. Children described wanting honest information about parents health and treatment. Girls expressed a particular need for information regarding implications for their own health and possible future tests. Children described wanting information from a variety of sources including parents, health professionals, books, leaflets, and the internet. They expressed a need to have access to somebody who understood and who would keep their conversation confidential. Problems described in relation to accessing the desired amount of information and communication included not wanting to upset parents by asking them, not having access to professionals, and age inappropriate information. Parents identified informing children of their diagnosis and childrens questions and concerns as their main challenge. DISCUSSION The study suggests that improving communication within and outside of the family system will be beneficial to children whose parents have been diagnosed with advanced cancer. It suggests that such an improvement will increase support available to children and will impact on how children are able to cope with their situation.