Original article
Fast screening of depression in cancer patients: the effectiveness of the HADS ecc_1217
528..533
L. CASTELLI, phd, Psycho-oncology Unit, Department of Neuroscience and Oncology, University of Turin, Turin, L. BINASCHI, psychd, Psycho-oncology Unit, Department of Neuroscience and Oncology, University of Turin, Turin, P. CALDERA, md, Psycho-oncology Unit, Department of Neuroscience and Oncology, University of Turin, Turin, A. MUSSA, md, Surgical Oncology Unit, Department of Oncology, University of Turin, Turin, & R. TORTA, md, Psycho-oncology Unit, Department of Neuroscience and Oncology, University of Turin, Turin, Italy CASTELLI L., BINASCHI L., CALDERA P., MUSSA A. & TORTA R. (2011) European Journal of Cancer Care 20, 528–533 Fast screening of depression in cancer patients: the effectiveness of the HADS In oncology clinics, there is an increasing need for fast and accurate screening scales and procedures in order to evaluate cancer patients for depression. The present study investigated the comparative effectiveness in recognising depressed patients of the Hospital Anxiety and Depression Scale (HADS), a self-report screening scale, and the Montgomery-Asberg Depression Rating Scale (MADRS), a semi-structured clinician-rated scale, in 151 patients affected by mixed cancer pathologies. With the MADRS, 73.5% of the patients were identified as depressed, whereas the HADS identified 36.4% and 58.3% as depressed, using the cut-offs of 11 and 8 respectively. The results suggest moderate agreement between the MADRS and the HADS when a cut-off of 8 is used (K-test: 0.44), while using a HADS cut-off of 11 gave a significantly higher underestimation of depressed patients (K-test: 0.29). In conclusion, the results suggest that the HADS can be useful as a sufficiently accurate first-step screening tool for depression in mixed oncology settings.
Keywords: depression, cancer, HADS, MADRS.
IN TR O D U C T I O N Depression is one of the most frequent emotional disorders affecting cancer patients. It has an unfavourable impact on their quality of life, their decision making regarding cancer treatment, caregiver distress, and increases their risk of suicide (Chochinov et al. 1995; Grassi et al. 1996; Colleoni et al. 2000; Fang et al. 2001; Massie 2004). The prevalence of depression and more generally of psychological distress in cancer patients is Correspondence address: Riccardo Torta, Psycho-oncology Unit, Department of Neuroscience, University of Turin, Corso Bramante 88, 10126 Turin, Italy (e-mail:
[email protected]).
Accepted 28 March 2010 DOI: 10.1111/j.1365-2354.2010.01217.x European Journal of Cancer Care, 2011, 20, 528–533
© 2010 Blackwell Publishing Ltd
extremely variable – from 0% to 58% – depending on the time and stage of the disease, age and sex of the patient and diagnostic instruments (Massie 2004). In addition, depression which is associated with the diagnosis of cancer and requires therapeutic intervention is often under-recognised and under-diagnosed (Hopwood & Stephens 2000; Néron et al. 2007; Thomas et al. 2010). For both patients and clinicians, the medical visit focuses mainly on somatic aspects and depression is often considered a ‘normal’ reaction to cancer. So there is an increasing need for a fast and accurate screening scale and procedure in order to screen cancer patients for depression (Pignone et al. 2000; Néron et al. 2007). As far as depression and psychological distress are concerned, many self-assessment tools are used for cancer patients in clinical practice. Among these tools, some of
Fast screening of depression in cancer patients
the most frequently used are the Hospital Anxiety and Depression Scale (HADS), the Brief Symptom Inventory, the Psychological Distress Inventory, the Beck Depression Inventory and the Distress Thermometer (Bulli et al. 2009; Lynch et al. 2010). These tools are all easy and fast to fill in and so are very useful for screening large numbers of cancer patients. Although the HADS is the most commonly used selfreport scale for depression in cancer patients, the question of its efficacy has not been defined (Herrmann 1997; Johnston et al. 2000; Néron et al. 2007). Specifically, no definitive conclusions have been drawn about the best cut-off to use in screening depressed patients (Zimmerman et al. 2004a; Néron et al. 2007; Walker et al. 2007). The HADS is easy to fill in, can be administered in the waiting period before the medical visit and takes about 2 min to be scored by the clinicians. If the score is higher than the cut-off, the patient’s mood state can be further explored by means of a clinician-rated interview, such as the Montgomery-Asberg Depression Rating Scale (MADRS) or the Structured Clinical Interview for DSM disorders (SCID-I), depending on the patient’s psychopathological status, and the availability of time and heathcare professionals. So the optimal procedure would be as follows: a first-step fast screening of all cancer patients with a self-rated tool for depression and a second-step clinical interview by healthcare professionals to be administered to those patients reporting a score above a specific cut-off. In this context, the first-step screening tool should represent a good balance between specificity and sensitivity. From a clinical standpoint, it is crucial that this first-step screening minimises the false negative cases (high sensitivity). This means that the majority of potentially depressed patients should be detected (Walker et al. 2007). The gold standard instrument for diagnosing the presence of a mood disorder (MD) is the SCID-I (APA 2000). The administration time of the SCID-I is quite long; for a psychiatric patient, it averages around 90 min. This is why it is not possible to screen all cancer patients for depression using this interview (Lynch et al. 2010). In addition, even if about 40% of patients with cancer could be diagnosed with a specific psychopathology such as an MD, about 15–20% show below-threshold symptoms which, although insufficient in number and intensity to evidence a psychiatric diagnosis, can still have serious consequences for the patient’s health and social relationships (Zabora et al. 1997; Miovic & Block 2007; Bonacchi et al. 2010). For these reasons, specific scales and clinician-rated interviews can be useful in order to screen those patients showing sub-threshold symptoms. © 2010 Blackwell Publishing Ltd
Although the SCID-I is the gold standard for diagnosing an MD, other specific scales can be useful in screening for depressive symptoms that could remain undetected by means of a categorical diagnosis made according to DSM-IV criteria. For this purpose, the MADRS is one of the most frequently used clinician-rated depression scales. The MADRS is used in the majority of psychopharmacological trials in order to assess depression. It takes about 15 min to administer and allows the severity of depressive symptoms to be quantified by an expert clinician. The MADRS does not rely only on patient insight/awareness about his or her depression state and so it can be considered more accurate with respect to the HADS and other self-report screening tools (Néron et al. 2007). Nevertheless, in clinics it is not possible to administer the MADRS as well as the SCID-I to all patients, for reasons of time and because the MADRS has to be administered by a depression expert clinician, who may often not be present in an oncology team. In this study we investigated the comparative effectiveness of a self-rated tool, the HADS, and a clinician-rated interview, the MADRS, in recognising depressed patients in oncology clinics. A previous study investigated the concordance between the HADS and the MADRS in recognising depression in 53 patients newly diagnosed with lung cancer (Castelli et al. 2009). The results showed a very high degree of depression (92%) in these patients and a substantial agreement between the MADRS and the HADS when a HADS cut-off of 8 was used. However, the group could be considered ‘self-selected’ and the study partially ‘biased’, since all the participants contacted the Psycho-oncology Unit of their own free will. The present study was conducted to overcome these limitations: all the patients were recruited and screened for depression directly at the oncology clinics, and different cancer pathologies were evaluated. As far as the HADS cut-off is concerned, there are no unequivocal indications in previous studies carried out on cancer patients (Kearns et al. 1982; Berard et al. 1998; Uchitomi et al. 2000; Ballenger et al. 2001; Bjelland et al. 2002). So the two most commonly used cut-offs of 8 and 11 were analysed to verify which came closer to the results of a semi-structured clinician-rated interview (MADRS). The two specific aims of the study were 1 to quantify the prevalence of depression in newly diagnosed cancer outpatients, using the MADRS as a reference for depression (Néron et al. 2007), and 529
CASTELLI et al.
Table 1. Demographic and clinical characteristics of the 151 oncological patients
Table 2. Items composing the HADS depression subscale
Sex
Male Female
84 67
Age
Mean Range SD
49.3 30–84 23.5
Marital status
Married Widowed Single Divorced
118 14 13 6
78.1% 9.4% 8.7% 3.8%
I I I I I I I
Colorectal Breast Gastric Ovarian Lung
48 39 32 17 15
32% 26% 21% 11% 10%
Local Loco-regional Metastatic
89 54 8
58.8% 35.8% 5.4%
Disease site
Extent of disease
55.6% 44.4%
2 to address the question of whether the HADS can be considered a valid first-step screening tool. To address this second aim, we compared the results of the HADS and the results of the MADRS.
MET H O D S Patients and procedure A total of 151 newly diagnosed consecutive outpatients of the Surgical Oncology Unit participated in the study. All subjects gave their written informed consent and the study was approved by the Hospital Ethics committee. The patients were evaluated between September 2007 and September 2008 after their first medical examination at the day hospital. Before psychological assessment, demographic data were collected through a semistructured interview (see Table 1). All patients completed the HADS and then, 30 min later, the MADRS. The patients were assessed for mood depression about 15 days after cancer diagnosis.
Depression assessment measures The MADRS is semi-structured clinician-rated interview composed of 10 questions rated from 0 to 6 (Montgomery & Asberg 1979) and total score ranges from 0 (absence of depression) to 60 (severe depression). The 10 questions of the MADRS assess the following constellation of symptoms: apparent sadness, reported sadness, inner tension, reduced sleep, reduced appetite, concentration difficulties, lassitude, inability to feel, pessimistic thoughts and suicidal thoughts. 530
HADS depression subscale still enjoy the things I used to enjoy can laugh and see the funny side of things feel cheerful feel as if I am slowed down have lost interest in my appearance look forward with enjoyment to things can enjoy a good book or TV programme
In the present study we used the Italian validated translation. Questions are answered on a 4-point scale from 0 to 3. HADS, Hospital Anxiety and Depression Scale.
The administration and scoring of the MADRS takes a trained clinician approximately 15 min, depending upon the severity of the symptoms and the difficulty of the interview. Its psychometric properties have been studied and validated extensively (Mulder et al. 2003). The MADRS should be administered by a psychologist or a psychiatrist with clinical experience of depressive disorders. Following the recommendations provided by Zimmerman, a MADRS cut-off of 11 was used to tally a patient as depressed (ⱖ11) or not (8 in a population from mixed oncology clinics. The present study confirmed our previous conclusion (Castelli et al. 2009) on a larger sample of 151 consecutive cancer patients. Lowering the HADS cut-off from 11 to 8 diminished the misclassification rate (false negative) from 38.4% to 20.5%. The latter percentage is still very high but it means the false negative rate is halved. In contrast, the false positive cases increased from 1.3% (HADS cutoff of 11) to 5.3% (HADS cut-off of 8). Nevertheless, from a clinical standpoint, it is more important to increase the sensitivity of a screening tool (lower number of false negatives) even if this is at the expense of the specificity (higher number of false positives) (Walker et al. 2007). In conclusion, the results further confirmed that depression is very frequent in newly diagnosed cancer patients. In addition, this study highlighted that using a HADS cut-off of 8 meant the rate of underestimation of depression was halved, and that this cut-off is preferable to the cut-off of 11 used when screening patients for subsequent
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