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Psycho-Oncology

Psycho-Oncology (in press)


Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1228

Acceptability of common screening methods used to


detect distress and related mood disorders}preferences
of cancer specialists and non-specialists
Alex J. Mitchell1,2*, Stephen Kaar3, Chris Coggan4 and Joanne Herdman4
1
Liaison Psychiatry, University of Leicester, Brandon Unit, Leicester, UK
2
Leicester General Hospital, Leicester, UK
3
Medical School, University of Leicester, UK
4
Psycho-oncology, Leicester General Hospital, Leicester, UK

* Correspondence to: Liaison Abstract


Psychiatry, Department of
Cancer & Molecular Medicine, A new questionnaire of clinicians attitudes and practices in relation to screening for mood
University of Leicester, Leicester disorder was distributed to 300 cancer professionals (specialists and non-specialists) working
Royal Infirmary LE1 5WW, UK. across the UK. From 226 (75.3%) health professionals working in cancer care who responded,
E-mail: alex.mitchell@leicspart. approximately two-thirds always or regularly attempted to detect mood disorder during
nhs.uk consultations but a substantial minority relied on patients spontaneously mentioning an emotional
issue. The highest rate of routine questioning was performed by clinicians working in palliative
medicine (76.3%) as well as nurse specialists working in all areas (72%). Despite these relatively
high rates of enquiry, 10% or less of all specialists used a validated questionnaire, most preferring
to rely on their own clinical skills or recalling the two simple questions of the short Patient Health
Questionnaire (PHQ2). Sta suggested that ideal screening practice was to use one, two or three
simple questions or a short validated questionnaire but not to refer to a specialist for a diagnosis.
The main barrier to successful screening was lack of time but insucient training and low
confidence were also influential. Once distress was detected, 90% of nurses but only 40% of
doctors were prepared to give distressed patients as much time as they needed. Predictors of
clinicians willingness to use more advanced screening methods were length of follow-up
appointments and time clinicians were prepared to spend detecting distress. We suggest that
future field studies of screening tools should also measure the issue of acceptability.
Received: 1 February 2007 Copyright # 2007 John Wiley & Sons, Ltd.
Revised: 30 March 2007
Accepted: 19 April 2007 Keywords: screening; detection; anxiety; distress; depression; Distress Thermometer; cancer and
oncology

Introduction secondary care two simple questions analogous to


those used in the Patient Health Questionnaire
According to the UK National Screening Commit- (PHQ2) are recommended with grade B evidence
tee screening is a clinical action by which members [3]. These are During the last month, have you
of a defined population, who do not necessarily often been bothered by feeling down, depressed or
perceive they are at risk of, or are already aected hopeless? and During the last month, have you
by a disease or its complications, are asked a often been bothered by having little interest or
question or oered a test, to identify those pleasure in doing things?
individuals who are more likely to be helped than In the US, the National Comprehensive Cancer
harmed by further tests or treatment to reduce the Network (NCCN) [4], suggest To ensure that
risk of a disease or its complications [1]. In the distress in cancer patients is recognized, the panel
context of cancer care in the UK, the Guidelines recommends that all patients be assessed in the
for Supportive & Palliative Care from the National waiting room using a simple diagnostic tool
Institute for Health and Clinical Excellence (NICE) comprising of the Distress Thermometer (DIS-
endorse that Professionals operating at this level A) to assess the level of distress and the accom-
should be able to screen for psychological distress panying Problem List, to identify the causes for
at key points in the patient pathway (Recommen- distress. The panel also mentions the 27-item
dation 5.2) [2]. This document does not mention Functional Assessment of Cancer Therapy-General
a specific tool but in the 2004 NICE guidance (FACT-G) quality-of-life scale [5] and the Brief
on Management of depression in primary and Symptom Index which has both an 18-item and a

Copyright # 2007 John Wiley & Sons, Ltd.


A. J. Mitchell et al.

43-item version [6]. The Distress Thermometer is a completed the questionnaire prior to their first
single item visual analogue scale which has gained clinic appointment with feedback to sta. Patients
much popularity [7]. Yet screening (even as part of reported being equally satisfied with the treatment
a package of care) remains controversial with some in both groups but more quality-of-life issues were
authorities cautioning against routine screening, at identified by the intervention patients (48.9% vs
least in primary care settings due to the diculty 23.6%). McLachlan et al. collected data on self-
demonstrating clinical improvements [8]. Never- reported needs, quality of life and psychosocial
theless, the case for screening appears convincing in symptoms from 450 people with cancer. For a
high-risk groups, in those where treatment is randomly chosen two-thirds, this information was
particularly eective, and for clinicians who have made available to the health-care team and for the
a low baseline detection rate [9,10]. Distress, remaining one-third not revealed. Additionally, in
anxiety and depression are certainly common the intervention arm a nurse was also present
during the course of cancer [11,12]. Further, during this consultation and formulated an in-
eective treatments are available [13,14]. Without dividualized management plan based on the issues
screening we also know that syndromal anxiety and raised in the summary report and pre-specified
depression are often overlooked or under-treated expert psychosocial guidelines. Six months after
by busy cancer professionals [1519]. randomization there were no significant dierences
The success of screening programmes in cancer between the two arms in any domain or regarding
settings is not limited by a paucity of instruments satisfaction with care. However, for the subgroup
or lack of field testing. Numerous questionnaires of patients who were moderately or severely
and visual analogue scales have been introduced in depressed at baseline, there was a significant
an attempt to aid the detection of distress, anxiety reduction in depression for the intervention arm
and depression [20]. The most commonly studied [27]. Detmar and colleagues in the Netherlands [28]
has been the Hospital Anxiety and Depression Design Prospective, randomized clinicians to re-
Scale (HADS), used in three large-scale ceive summaries of the EORTC QLQ-C30 score
(n 5500) studies examining the rate of mood before appointments. It was found that HROoL
disorders in patients with cancer. Ibbotson et al. issues were discussed significantly more frequently
looked at 513 patients with mixed cancers and in the intervention than in the control group and in
found a total distress rate of 17% [21]. In an sub-group analysis there was better identification
Australian study, Pascoe et al. used the HADS at a in some but not all HRQoL domains. Boyes and
lower cut-o (total HADS score 58) and found colleagues in Australia asked patients to complete a
prevalence rates of 31% for distress, 12% for computerized screen assessing their psychosocial
anxiety and 7% for depression [22]. Sharp et al. well-being while waiting to see the oncologist
surveyed 3071 patients who completed the HADS during each visit. This included the HADS scale.
on touch-screen computers and the scores were Responses were immediately scored and summary
linked to clinical variables on the hospital database reports were placed in each patients file for
[23]. Twenty-two percent had distress (defined by a oncologists attention [29]. There was no eect on
total HADS score 515 ), 23% had anxiety and levels of anxiety, depression and perceived needs
16% had depression. Two other very large studies among those who received the intervention but
using dierent instruments found distress rates in only three intervention patients reported that their
more than one-third of patients. Zabora et al. used oncologists discussed the feedback report with
the Brief Symptom Inventory, and found preva- them. Velikova and colleagues in Leeds recruited
lence rates of 35% for distress, 24% for anxiety 28 oncologists treating 286 cancer patients and
and 19% for depression [24]. Fallowfield et al. randomly assigned them to an intervention group
surveyed 2297 patients using the GHQ12 and with feedback of results to physicians, an attention-
found an overall distress rate of 36.4% [25]. control group who completed the questionnaires
Yet despite great enthusiasm developing ques- without feedback and a control group with no
tionnaires to detect emotional complications of questionnaires [30]. The questionnaires of choice
cancer, few groups have been able to implement a were the EORTC-Core Quality of Life Question-
successful screening programme for mood disorder naire and touch-screen version of the HADS. A
and of the handful of implementation studies, most positive eect on emotional well-being was asso-
have focussed on global health-related quality-of- ciated with feedback of data but not with instru-
life (HRQoL) measures. Taenzer and colleagues ment completion. Although more frequent
[26] asked patients to complete a computerized discussion of chronic non-specific symptoms
version of the European Organization for Research was found in the intervention group (without
and Treatment of Cancer (EORTC) QLQ-C30 prolonging encounters), there was no detecta-
Questionnaire. Patients were assigned to either a ble eect on patient management. Recently,
usual care control group who completed the Rosenbloom and colleagues randomly assigned
EORTC QLQ-C30 paper version after the clinic 213 patients with metastatic breast, lung or color-
appointment and an experimental group, which ectal cancer to usual care; quality-of-life assessment

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
DOI: 10.1002/pon
Acceptability of common screening methods

or HRQoL assessment followed by a structured Table 1. Types of mood screening instruments, based on
interview (with presentation to the treating nurse). number of items
There were no significant dierences in HRQoL Ultra-short screening tools were defined as those with 14 items, typically
and treatment satisfaction outcomes at 3 and 6 taking less than 2 min to complete
months. Examples: Single Question Are you depressed, Distress Thermometer.
These studies suggest that screening for psycho- Short screening tools were defined as those with 514 items, typically taking
social issues in cancer settings may not be sucient between 2 and 4 min to complete
Examples: Edinburgh Postnatal Depression Scale, HADS
even when accompanied by feedback of results to
Standard screening tools were defined as those with 15 or more items,
clinicians and that additional steps are probably typically taking 4 min or longer to complete
required to enhance well-being. Further, any Examples: Beck Depression Inventory, Brief Symptom Index (BSI18)
potential benefit is likely to be limited by the
perceived value to cancer clinicians and their Adapted from Mitchell AJ, Coyne JC. Do ultra-short screening instruments
willingness to use the suggested method. In the accurately detect depression in primary care?}a pooled analysis and
context of a research trial the use of a questionnaire meta-analysis of 22 studies. Br J Gen Pract 2007;57:144151.
is closely monitored. In routine practice a vital
consideration is whether the screening procedure is
acceptable to patients and sta alike [31]. Although
the diagnostic validity of mood screening has been care, both cancer specialists and non-specialists
examined in cancer care, the willingness of and those working in palliative and non-palliative
clinicians to employ these methods routinely has settings. We divided the sample into three major
rarely been examined [32]. The aim of this study specialty groups: cancer specialists working in
was to examine the acceptability of common palliative medicine (group 1); cancer specialists
screening methods designed to detect mood working in medical oncology (group 2); and non-
disorder in a mixed clinically representative group specialists working in related medical areas but
of health professionals involved in cancer care. with substantial contact with cancer patients
We focussed on type and length of screening (group 3). None were specialists in psychosocial
method rather than all possible specific scales issues and all were working within the National
(see Table 1). Health Service. The purpose of analysing these
groups separately was to see if those working in
end-of-life settings (group 1) or those working full
Methods time with cancer patients (groups 1 and 2) would be
more or less sympathetic to patient needs than
A working group (A. J. M., J. H., C. C.) was other groups. Additionally, we asked sta to
formed to design a new questionnaire of clinicians specify their profession (e.g. doctor, nurse, phy-
attitudes and practices in relation to screening for siotherapist) and their years of experience working
mood disorder. The group had expertise in in the field. Questionnaires were given out in two
psychiatry (A. J. M.) nursing (C. C.) and psychol- independent centres (Leicestershire, Northampton-
ogy (J. H.). For the purposes of this survey we shire, and Rutland Cancer Network and the
defined mood disorder as syndromal depression, Greater Manchester & Cheshire Cancer Network).
syndromal anxiety in accord with ICD10 Questionnaires were also distributed at several
and DSMIV criteria but also included clinically National Cancer meetings during 2006 including
significant distress which may be coded as an the 8th Annual Conference National Lung Cancer
adjustment disorder (F43) in ICD10. Research Forum For Nurses Brighton which attracted
has suggested that adjustment disorder is the clinicians from across the UK. Results were
most common form of emotional complication collated by two researchers (A. J. M., S. K.) and
during the course of cancer [33]. Additionally, the analysed in StatsDirect 2.5.7.
National Cancer Institute considers adjustment
disorder on a continuum of distress with syndro-
mal depression and anxiety [34]. The questionnaire Results
was piloted locally with a group of 25 cancer
clinicians in Leicester and then revised based on Three hundred questionnaires were distributed and
feedback from these cancer specialists into a we received completed questionnaires from 226
final version (see Appendix A). The questionnaire health professionals working with cancer patients
consisted of both open and closed questions. including 170 clinical nurse specialists, 50 doctors.
Answers from the questionnaire were divided into The remainder were from miscellaneous groups
three areas: (a) screening preferences1; (b) barriers including speech therapy, occupational therapy
to screening (primary and secondary reasons); and and dieticians. Almost 50% (n 114) were from
(c) predictors of screening practices. sta working in palliative settings (group 1), 84
We chose to survey a representative sample of from those in oncology (group 2) and 28 in related
health professionals working primarily in cancer areas including haematology, surgery, dermatology,

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
DOI: 10.1002/pon
A. J. Mitchell et al.

plastic surgery, respiratory medicine (group 3). The Current methods of detecting mood disorder
average numbers of years of experience in cancer Only 5.9% of all sta reported using a formal
care was 11.7 years (SD 7.0). questionnaire. The majority (62.2%) relied on their
own clinical judgement but 30.0% attempted to
remember and use one, two or three simple
Part A. Screening preferences questions (for example from the PHQ2). The
remaining 1.5% said they would ask a specialist
Willingness to routinely look for mood disorder for diagnostic help (see Figure 2)
In total, 23.5% of sta reported always using Amongst those working in palliative care
some form of assessment for distress, depression or (group 1) 10.3% of all sta reported using a formal
anxiety, 40.0% regularly assessed and 21.2% questionnaire, but in oncology (group 2) this
occasionally assessed. This left 13.7% who relied proportion was only 1.4% and in related disci-
on patients mentioning a problem in order to plines (group 3) it was only 4.1%. The dierence
detect mood disorder and 1.8% of respondents between palliative care and oncology practices was
who were not sure what they did or had no significant (Chi2 5:0; p 0:025 Fishers exact
consistent approach. Thus, across the whole test for small samples two-sided p 0:0305). The
sample 63.3% of clinicians always or regularly proportion of doctors who used a formal ques-
screened for distress/depression whereas 36.7% did tionnaire was only 2.3% compared to 7.2% in
not.
There were dierences in willingness to screen
based on specialty and profession. Amongst sta
working in palliative care (group 1) 76.3%
always or regularly screened, but in oncology
(group 2) this proportion was 58.3% and in related
disciplines (group 3) it was only 25% (see Figure 1).
This dierence between palliative care and other
disciplines was significant (Chi2 6:74; p 0:0094)
and the dierence between oncology and related
disciplines showed a strong trend towards signifi-
cance (Chi2 3:54; p 0:06). The dierence be-
tween specialists in cancer care (groups 1 and 2)
compared to non-specialists (group 3) was significant
but the dierence between oncologists and pallia-
tive care physicians was not significant. Looking at
professional groups, 72% of nurses always or
regularly used a clear detection method but only
40% of doctors did so. This dierence was Figure 2. Clinicians preferred method of screening for
statistically significant (Chi2 4:2; p 0:041). depression, distress and anxiety (B&W version)

Figure 1. Preferred mood screening method in cancer professionals (B&W version)

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
DOI: 10.1002/pon
Acceptability of common screening methods

nurse specialists (p ns). The proportion of Time given to distressed patients per appointment
doctors using one, two or three simple questions Across all sta there was considerable flexibility in
was 20.5% compared to 34.0% in nurse specialists; the time that could be allocated to a distressed
again this dierence was not significantly dierent. patient. In fact the most common answer given by
77.8% was as much time as needed. There were
Clinicians optimal method of screening for mood no specialty dierences here, but amongst nurses
disorder 89% were prepared to give as much time as needed
Amongst all sta, the optimum practical screening compared to 40% of doctors. This dierence was
method suggested was the one, two or three simple highly significant (Chi2 8:2; p50.005). In fact
questions which was selected by 42.3% of sta, 32% of doctors would limit their time to only
followed by a short screening questionnaire by 510 min for distressed patients compared to 3.2%
34.3%. Combining these 76.6% would probably be of nurses who would give the equivalent time of
prepared to utilize an ultra-short or single-item 510 min (most preferring to give longer periods)
method. Interestingly, 16% opted for an algorithm (see Figure 3).
approach and 7% wanted to refer cases to a
specialist or more experienced colleague. The only Part C. Predictors of screening practices
statistically significant group dierence was that
colleagues in related disciplines (group 3) wanted to The predictors of clinicians willingness to use
refer for help more often (in 30.8% of cases) advanced screening methods was examined using
(Chi2 10:6; p 0:001 compared to groups 1 and 2). regression analysis. Potential predictors were years
of clinical experience, time given to new patient
appointments, time given to follow-up appoint-
Part B. Barriers to screening ments, time clinicians were prepared to spend
detecting distress and time clinicians were prepared
Limitations to screening in clinical practice
to dealing with distress (if it occurred). There were
The primary barriers to screening in this sample three predictors which were significant on their
were time (57.8%), lack of training on screening own. These were time given to new patient
methods (16.9%) and low personal skills or appointments, time given to follow-up appoint-
confidence about diagnosis (13.3%) (see Table 2). ments and time clinicians were prepared to spend
Only 3% of clinicians avoided screening for detecting distress. However, in multiple regression,
distress/depression because they felt patients were only duration of follow-up appointments was
uncomfortable and only 4% avoided screening significant although the time clinicians were pre-
because of lack of personal interest in the area. pared to spend detecting distress remained as a
Analysing secondary barriers to screening the most strong trend (see Table 3), explaining a modest
common addition factors were lack of training and 11% of the variance.
skills. Indeed 77% of non-specialists (group 3)
cited either low skills or training as barriers
compared to 62% of cancer specialists (groups 1 Discussion
and 2) (p ns).
Amongst 226 health professionals working in
cancer care, approximately two-thirds attempted
Length of consultation for new patients appointments
to detect mood disorder during routine appoint-
There was a range of times allocated to new patient ments and about one-third only occasionally did so
contacts but the mean was 27 min. However, 51% or relied on patients spontaneously mentioning a
of all sta had 20 min or less to assess a new patient problem (see Table 4 for explanation). Detmar
and only 16.1% had 60 min or more (see figure). et al. noted that the latter approach is likely to be
There were no significant group dierences here problematic because 25% of patients would only
although 20% of nurses had 60 min or longer discuss emotional concerns and daily activities
compared to 6% of doctors. when invited to do so [35]. Most people find
mental health issues, in particular, dicult to
discuss [36]. In fact in primary care 45% of patients
Table 2. Perceived primary barriers to clinician screening experiencing high levels of distress did not disclose
Lack of time (%) 57.8
their symptoms because they felt embarrassed or
Lack training/support (%) 16.9 were reluctant to bother their doctors and 20%
Low skills confidence (%) 13.3 were primarily deterred from disclosure by the
Lack of interest (%) 4.0 doctors behaviour [37]. It is perhaps not surprising
Patients dislike screening (%) 3.1 therefore that if unassisted, oncologists are able to
Cultural barriers (%) 3.1 detect about 30% of actual psychiatric morbidity
Lack resources (%) 0.9
(with an accompanying false-positive rate of 34%).
Lack privacy/environment (%) 0.9
However, the case for routine screening is not yet

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
DOI: 10.1002/pon
A. J. Mitchell et al.

Figure 3. Time clinicians are prepared to allocate to distress patients (B&W version)

Table 3. Multiple regression analysis of predictors of use of advanced screening methods


R square 0.109 Standard

Coefficients Error t Stat p-Value

Intercept 2.177 0.218229 9.97994 1.57E"19


Years of experience "0.003 0.009619 "0.29519 0.768135
New patient appointment duration 0.005 0.004386 1.27284 0.204443
Follow-up appointment duration 0.011 0.004592 2.451953 0.015002
How much time to detect distress 0.012 0.006505 1.906072 0.057968
Time dealing with this distress 0.002 0.003401 0.525871 0.599517

unequivocally proven. Only two studies to date in relatively high rates of enquiry, 10% or less of all
cancer settings have shown a dierential eect on specialists used a formal questionnaire, most
detection of quality-of-life issues following imple- preferring to rely on their own clinical skills
mentation of a screening programme [26,28], and (62.2%) or recalling simple questions (30%), for
no group has proven screening benefits cancer- example, those of the PHQ2 and also recom-
related distress, depression or anxiety. Further mended by NICE Unipolar Depression guidance.
work is clearly required using dierent methods Again a higher proportion of those working in
as well as dierent outcomes. palliative medicine used a validated questionnaire
In this study the highest rate of routine enquiry compared to those in oncology or related special-
(76.3%) was conducted by clinicians in palliative ities (10.3, 1.4, 4.1, respectively). Current clinical
care and the lowest (25%) in medical disciplines practices diered from what sta felt was ideal
linked with cancer care such as haematology and practice with one, two or three simple questions
general surgery, a dierence that was significant. being the most popular method followed by a short
Also significant was the higher rate of routine validated questionnaire. As a group, only 7% said
assessment carried out by nurse specialists they would refer such cases to a colleague or
(72%) compared to doctors (40%). Despite these specialist for routine diagnosis but 30.8% of

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
DOI: 10.1002/pon
Acceptability of common screening methods

Table 4. Grades of complexity of detection methods for more advanced screening methods. The use of
psychosocial issues longer methods compared with the use of clinical
Patent Reported skills alone or not screening at all was associated
Relies upon spontaneous report from patients with longer length of follow-up appointments and
more willingness to spend time detecting distress.
Unassisted Clinical This study is not the first to note dierences in
Relies upon clinical skills alone, without specific training practice between cancer clinicians. Morita and
colleagues compared attitudes of 697 oncologists
Trained Clinical
Relies upon clinical skills following specific training
and palliative care clinicians regarding terminal
sedation [44]. Palliative care specialists were more
Single Item Screen likely to choose psychiatric treatment. Jennens
Use a single item in addition to clinical ability et al. found significant dierences regarding the
perceived role of chemotherapy in metastatic lung
Multi-Item Screen cancer between the various specialty groups [45]. In
Use a multiple item method in addition to clinical ability particular, fewer medical oncologists (6%) were
Multi-Modal Screen
pessimistic compared with palliative care physi-
Uses a questionnaire or instrument that covers several domains (e.g. QoL cians (31%) or pulmonary physicians (22%).
and distress) Only one previous study has examined screening
preferences in cancer care, and this focussed on
Structured or Semi-Structured Interview doctors working in palliative medicine [32]. Mari
An in-depth assessment with operationalized methodology Lloyd-Williams group surveyed 134 doctors across
the UK during 2002 and found that 73% routinely
assessed patients for depression. This rate is almost
non-specialists in related disciplines (group 3) identical to our finding of 76% amongst palliative
wanted to refer which might reflect their related medicine specialists but this figure refers to multi-
lack of perceived experience (see below). This could professional sta. Given the dierences by profes-
be problematic in reality as 45% of hospices have sionals we performed a sub-group analysis and
no access to a psychologist or a psychiatrist [38]. found this rate held for doctors working in
The primary barrier to successful screening was palliative medicine with a routine assessment rate
sucient time, noted by almost 60% of respon- of 75%. In the study from LloydWilliams and
dents. In fact over half of clinicians had 20 minutes colleagues, 50% said they never used a formal
or less to assess new patients. If clinicians cannot method, 10% used a simple one question test and
give more time to new and follow-up appointments 27% used the 14-item Hospital Depression and
then innovative screening techniques such as Anxiety Scale. In this study we found a slightly
computerized tools may be needed, or screening higher proportion who relied on clinical skills
may be moved to the waiting room or conducted alone, specifically 58% of those working in
by multi-professional sta [23,26,29]. Insucient palliative medicine (group 1), 65% of those work-
training and low confidence were also important, ing in oncology (group 2) and 70.8% of those
cited as the primary reason for not screening by working in related disciplines (group 3). We also
30.3% of sta (see Table 2). However, combining found a lower proportion who were willing to use a
primary and secondary reasons, 77% of non- formal questionnaire and further those who were
specialists (group 3) cited either low skills or willing were almost exclusively nurse specialists.
training as a barrier. In previous work clinicians Only 3% of clinicians avoided screening for
confidence influenced the likelihood of employing distress/depression because they felt patients were
mood screening [39]. There has been a considerable uncomfortable. One key recommendation regard-
research examining the merits of communication ing successful implementation is acceptability of
skills training for cancer professionals [40,41]. the method to patients and sta alike. Research in
Despite many participant reported benefits, it has other areas has generally found a high rate of
been dicult to show improvements in decision- patient acceptability for mood screening although
making skills or patient reported benefits. Addi- short questionnaires are generally preferred to
tionally, no study has observed any improvement longer ones [46]. Gemmill et al. asked 479 women
in clinicians ability to detect distress [42,43]. with post-natal depression about the acceptability
Therefore, it is not immediately obvious that the of the 10-item Edinburgh Postnatal Depression
solution may be more training. Scale (EPDS) [47], 81.2% indicated that they
Ninety-six percent appeared to have an interest were Comfortable or Very Comfortable with
in detecting mood disorder in their patients and the instrument and 97% agreed that the screening
90% of nurses were prepared to give distress was desirable. In primary care, Zimmermans
patients as much time as they needed. However, group asked 601 patients in the US to complete a
for doctors this percentage was only 40%. We self-report questionnaire for 15 psychiatric disor-
looked at predictors of clinicians willingness to use ders [48]. Nearly 40% of patients thought their

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
DOI: 10.1002/pon
A. J. Mitchell et al.

doctor should ask a few questions about emotional clinicians cite favourable practice rather than what
well-being every time they had a consultation, but actually occurs. Our relatively high response rate of
25.1% suggested on yearly check-ups and 34.4% 75% would help minimize this eect but further
preferred to be asked only when a problem is studies are required of observed practice. A second
suspected. Only 2.6% did not want any such limitation is the relatively small sub-group sizes,
questions to be asked. Regarding the use of a brief particularly group 3. A further limitation is that it
questionnaire on emotional problems only 18.5% is dicult to take into account variability in clinical
disliked the idea of a questionnaire. Acceptability practice, for example, a clinician who decides to use
of mood screening for sta has only been examined a screening method only when a patient mentions
in primary care. Bermejo et al. looked at attitudes certain risk factors such as chronic pain or
to screening using the PHQ9 amongst 1034 patients isolation but does not do so as a routine.
and 17 GPs in South Baden, Germany [49]. In conclusion, whilst most health professionals
Although 75.8% of the patients evaluated it as working in cancer care are interested in detecting
feasible for routine use 62.5% of GPs rated the mood disorder there is considerable uncertainty
questionnaire as too long. Two-thirds of the about what instrument to use (if any) which
physicians reported problems in motivating the mirrors the lack of national guidance on this topic.
patients to fill out the questionnaire. Several other Most clinicians currently use their own clinical
studies of clinician acceptability have been con- skills, whether they have received training in this
ducted in the US. In a survey of 662 primary care area or not. Ultra-short methods (the PHQ2 or the
physicians, only 4% used a formal psychosocial Distress Thermometer) would appear to be accep-
assessment instrument [50]. A survey of 621 table to about three quarters of clinicians. How-
primary care physicians, 474 general internists, ever, recent questions have been raised about the
and 255 obstetricians/gynaecologists showed that validity of these methods in primary care and in
low rates of routine questioning/screening was cancer settings [54,55]. The very low acceptability
widespread, conducted by 9% and diagnosis based rate of validated questionnaires which take more
on formal criteria by 33.7% [51]. This corresponds than a few minutes mean that screening for mood/
approximately to the largest survey of patient distress based on traditional mood severity scales
screening experience. In 7301 primary care pa- may not be easily adopted into clinical practice.
tients, 21% reported receiving screening (enquiry Acceptability should form part of the evaluation of
about) depression and anxiety [52]. More robust any proposed screening programme.
analysis was conducted by Tia-Seale et al. who
surveyed 389 patients and 33 physicians but
checked practices by videotaping clinical interac- Acknowledgements
tions. Primary care physicians assessed depression Pilot data were previously presented at IPOS 2006
in only 14% of visits and almost never with a (www.ipos2006.it). Declaration: We have no declarations,
formal instrument. White patients were almost no conflicts of interest, no financial ties. We have received no
grant support for this article.
seven times more likely than non-white patients to
be assessed for depression but depression assess-
ment was less likely to occur in gender and racially Note
concordant patientphysician dyads [53]. 1. By screening, we mean screening for mood disorder
Limitations of this study should be discussed. including depression and anxiety as well as screening for
There is a possibility of respondent bias whereby significant distress.

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
DOI: 10.1002/pon
Acceptability of common screening methods

Appendix A. Questionnaire of Clinicians Screening Habits

Clinicians Preference for Distress Management Questionnaire


Instructions}Before introducing a screening tool to detect distress (depression/anxiety/body image problems) we would like to
ask several questions regarding the practical aspects of screening in your working environment.

Enter your name (leave blank for anonymous) Return Address

Please state your designation (e.g. Cancer Nurse Specialist) Dr AJ Mitchell

Your profession (e.g. nursing) Liaison Psychiatry,

Years of experience in cancer care (approx) Brandon Mental Health Unit,

Your department or hospital Leicester General Hospital,


Leicester LE5 4PW

Existing Do you routinely screen for psychological distress in your patients?


Practice

YOUR Always Regularly Not Sure Occasionally No. I rely on patients mentioning a problem
RATING

How If yes (above), how do you assess this distress? (tick all that are applicable)
YOUR Clinically 1,2,3 A formal Ask a Computerized Other
RATING (no special simple screening colleague tool
method) questions questionnaire (e.g. nurse
sp. in clinic)

Barriers What are the limitations to screening in your environment? (tick any that apply to you)
YOUR Time Skills/ Interest in area Cultural Not my job Patients dislike screening Other
RATING training barrier

Time On average, how long is a typical NEW patient appointment/contact in your service?
YOUR 55mins 510mins 1015mins 1520mins 2030mins 3060mins 460mins
RATING

Time On average, how long is a typical FOLLOW UP appointment/contact in your service?


YOUR 55mins 510mins 1015mins 1520mins 2030mins 3060mins 460mins
RATING

Screening How much time would you be willing and able to allocate to DETECTING distress per appointment?
YOUR 0mins (none) 01min 12mins 55mins 510mins 1020mins 420mins
RATING

QQ Options Considering the above, which of the following screening methods would best suit your service?
YOUR Ask someone else 13 simple A short A longer An algorithm
RATING (e.g. nurse questions (10 item) (20+ item) approach
specialist) questionnaire questionnaire (starts short,
longer if needed)

Treatment If someone was upset, how much time would you be willing/able to spend dealing with this distress?
YOUR 0mins (none) 01min 12mins 55mins 510mins 1020mins 420mins/as needed
RATING

Referral Out of 100 upset patients, about how many would you ideally like to refer for more specialist help?
YOUR 010 (few) 1033 (some) 3449 (nearly half) 5074 (most) 7599 (Nearly all) 100 (all)
RATING

Professionals Who are the most appropriate clinicians to deal with the psychological distress that you see?
YOUR Yourself Nurse Mental health Nurse Clinical Psychiatrist Other
RATING Specialist Psychologist

Help What additional factor do you think would most help you to effectively assess psychological distress?

PLEASE DESCRIBE

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
DOI: 10.1002/pon
A. J. Mitchell et al.

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Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
DOI: 10.1002/pon

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