Introduction: Even though depression has serious and wide-ranging effects on outcomes in palliative care, errors in the identification of depressed patients are common.
Objectives: To examine the clinical validity of widely publicised one-and two-question screening tools for depression in two palliative care settings. Also, to examine the construct validity and acceptability of a new empirically derived algorithm.
Method: Participants were Australian palliative care patients in an inpatient hospice (n–22) or the community (n –69). Patients completed an unstructured interview about their feelings, questions relevant to three reference standards, two screening questions for depression and questions about the acceptability of the screening questions.
Results: The clinical validity of the one-and two-question screening tools did not generalise across the two care settings. In contrast, the algorithm met stringent criteria for clinical validity for two reference standards in both settings. The algorithm also selectively identified patients whose unstructured interviews referred to themes consistent with depression. The algorithm includes potentially sensitive questions about anhedonia and depressed affect. However, almost all patients and staff reported that asking such questions soon after referral was acceptable.
Conclusions:A four-question algorithm designed to identify patients who warrant follow-up for depression showed clinical validity, generalizability and construct validity, and the content was acceptable to patients and clinicians.
World Health Organization . National cancer control programmes: polices and managerial guidelines (second edition). Geneva: WHO , 2002.
2.
Chochinov HM , Wilson KG , Enns M , Lander S . Prevalence of depression in the terminally ill: effects of diagnostic criteria and symptom threshold judgements . Am J Psychiatry. 1994; 15: 537–540 .
3.
Durkin I , Kearney M , O’Siorain L . Psychiatric disorder in a palliative care unit . Palliat Med. 2003; 17: 212–218 .
4.
Hotopf M , Chidgey J , Addington-Hall J , Ly KL . Depression in advanced disease: a systematic review Part 1. Prevalence and case finding . Palliat Med. 2002; 16: 18–97 .
5.
Lloyd-Williams M , Riddleston H . The stability of depression in patients who are receiving palliative care . J Pain Sympt Manage. 2002; 24: 593–597 .
6.
Meyer HAM , Sinnott C , Seed PT . Depressive symptoms in advanced cancer. Part 2. Depression over time; the role of the palliative care professional . Palliat Med. 2003; 17: 604–607 .
7.
Lin EHB , Katon W , Von Korff M . Effect of improving depression care on pain and functional outcomes among older adults with arthritis. A randomised controlled trial . JAMA. 2003; 290: 2428–2434 .
8.
Smith EM , Gomm SA , Dickens CM . Assessing the independent contribution to quality of life from anxiety and depression in patients with advanced cancer . Palliat Med. 2003; 17: 509–513 .
9.
Faller H , Bülzebruck H . Coping and survival in lung cancer: a 10-year follow-up . Am J Psychiatry. 2002; 159: 2105–2107 .
10.
Cassileth BR , Lusk EL , Strouse TB . A psychological analysis of cancer patients and their next-of-kin . Cancer. 1985; 55: 72–76 .
11.
DiMatteo MR , Lepper HS , Croghan TW . Depression is a risk factor for non-compliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence . Arch Intern Med. 2000; 160: 2101–2107 .
12.
Passik SD , Kirsh KL , Theobald D , Donaghy K , Holtsclaw E , Edgerton S . Use of a depression screening tool and a fluoxetine-based algorithm to improve the recognition and treatment of depression in cancer patients: a demonstration project . J Pain Sympt Manage. 2002; 24: 318-318 .
13.
Spiegel D . Cancer and depression . Br J Psychiatry. 1996; 168 (Suppl 30): 109–116 .
14.
Akechi T , Okamura T , Sugawara Y , Nakano T , Shima Y , Uchitomi Y . Suicidality in terminally ill Japanese patients with cancer . Cancer. 2004; 100: 183–191 .
15.
Kelly B , Burnett KB , Pelusi D , Badger S , Varghese F , Robertson M . Factors associated with the wish to hasten death: a study of patients with terminal illness . Psychol Med. 2003; 33: 75–81 .
16.
Christakis NA . Timing of referral of terminally ill patients to an outpatient hospice . J Gen Intern Med. 1994; 9: 314–320 .
17.
Hinton J . Which patients with terminal cancer are admitted from home care?Palliat Med. 1994; 8: 197–210 .
18.
Unutzer J , Patrick DL , Simon G , Grembowski D , Walker E , Rutter C . Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a 4-year prospective study . JAMA. 1997; 277: 1618–1623 .
19.
Sullivan PS , Dworkin MS . Prevalence and correlates of fatigue among persons with HIV infection . J Pain Sympt Manage. 2003; 25: 329–333 .
20.
Lloyd-Williams M , Friedman T , Rudd N . A survey of antidepressant prescribing in the terminally ill . Palliat Med. 1999; 13: 243–248 .
21.
Lloyd-Williams M , Spiller J , Ward J . Which depression screening tools should be used in palliative care?Palliat Med. 2003; 17: 40–43 .
22.
Wilson K , Chochinov HM , de Faye B , Breitbart W . Diagnosis and management of depression in palliative care. In Chochinov M , Breitbart W eds. Handbook of psychiatry in palliative medicine. New York: Oxford University Press , 2000: 25–49.
23.
Lloyd-Williams M , Payne S . A qualitative study of clinical nurse specialists’ views on depression in palliative care patients . Palliat Med. 2003; 17: 334–338 .
24.
US Preventative Task Force . Screening for depression: recommendations and rationale . Ann Intern Med. 2002; 136: 760–764 .
25.
NIH Consensus and State-of-the-Science Statements . Symptom management in cancer: pain, depression, and fatigue. 2002; 19(4): 1–29 .
26.
Stiefel F , Die Trill M , Berney A , Nunez Olarte JM , Razavi D . Depression in palliative care: a pragmatic report from the Expert Working Group of the European Association for Palliative Care . Support Care Cancer. 2001; 9: 477–488 .
27.
Urch C , Chamberlain J , Field G . The drawback of the Hospital Anxiety and Depression Scale in the assessment of depression in hospice patients . Palliat Med. 1998; 12: 395–396 .
28.
Endicott J . Measurement of depression in patients with cancer . Cancer. 1984; 53: 2243–2248 .
29.
Bruera E , Kuehn N , Miller MJ , Selmser P , Macmillan K . The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients . J Palliat Care. 1991; 7: 6–9 .
30.
Lloyd-Williams M , Friedman T , Rudd N . An analysis of the validity of the Hospital Anxiety and Depression Scale as a screening tool in patients with advanced metastatic cancer . J Pain Sympt Manage. 2001; 22: 990–996 .
31.
Chochinov HM , Wilson KG , Enns M , Lander S . ‘Are you depressed?’ Screening for depression in the terminally ill . Am J Psychiatry. 1997; 154: 674–675 .
32.
Lloyd-Williams M , Dennis M , Taylor F . A prospective study to compare three depression screening tools in patients who are terminally ill . Gen Hosp Psychiatry. 2004; 26: 384–389 .
33.
Lloyd-Williams M , Dennis M , Taylor F , Baker I . Is asking patients in palliative care, ‘Are you depressed?’ appropriate? Prospective study . (Letter). BMJ. 2003; 327: 372–373 .
34.
Meyer HAM , Sinnott C , Seed PT . Depressive symptoms in advanced cancer. Part 1. Assessing depression: the mood evaluation questionnaire . Palliat Med. 2003; 17: 596–603 .
35.
Whooley MA , Avins AL , Miranda J , Browner W . Case-finding instruments for depression: two questions are as good as many . J Gen Intern Med. 1997; 12: 439–445 .
36.
Arroll B , Khin N , Kerse N . Screening for depression in primary care with two verbally asked questions: cross sectional study . BMJ. 2003; 327: 1144–1166 .
37.
Brody DS , Hahn SR , Spitzer RL , Kroenke K , Linzer M , deGruy FV . Identifying patients with depression in the primary care setting: a more efficient method . Arch Intern Med. 1998; 158: 2469–2475 .
38.
National Institute for Clinical Excellence . Depression: the management of depression in primary and secondary care. NICE guideline. Second consultation. In National Health Service, UK , 2003. Retrieved 28 June 2004 from http://www.nice.org.uk/page.aspx?0=20093
39.
Folstein MF , Folstein SE , McHugh PR . ‘Mini-mental status’: a practical method for grading the cognitive state of patients for clinicians . J Psychiatr Res. 1975; 12: 189–198 .
40.
American Psychiatric Association . Diagnostic and statistical manual of mental disorders, fourth edition. Washington DC: American Psychiatric Association , 1994.
41.
Jorm A , Mackinnon A . Psychogeriatric Assessment Scales: user’s guide and materials, second edition. Canberra: ANUTECH Pty Ltd , 1995.
42.
Spitzer RL , Williams RB , Kroenke K . Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study . JAMA. 1994; 272: 1749–1756 .
43.
World Health Organization . The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. Geneva: World Health Organization , 1993.
44.
Jorm AF , Mackinnon AJ , Henderson AS , Scott R , Christensen H , Korten AE . The Psychogeriatric Assessment Scales: a multidimensional alternative to categorical diagnoses of dementia and depression in the elderly . Psychol Med. 1995; 25: 447–460 .
45.
Mackinnon A , Mulligan R . The Psychogeriatric Assessment Scales (PAS): psychometric properties in French and German speaking populations . Int J Geriatr Psychiatry. 2001; 16: 892–899 .
46.
Stacey BG . The Depression Scale of the Psychogeriatric Assessment Scales . Aust J Ageing. 1998; 17: 132–134 .
47.
Cohen J . A coefficient of agreement for nominal scales . Educ Psychol Measure. 1960; 20: 37–46 .
48.
Landis JR , Koch GG . The measurement of observer agreement for categorical data . Biometrics. 1977; 33: 159–174 .
49.
Strauss A , Corbin B . Basics of qualitative research. Newbury Park, CA: Sage , 1990.
50.
Hinton J . Psychiatric consultation in fatal illness . J R Soc Med. 1972; 65: 29–32 .
51.
Lloyd-Williams M , Friedman T , Rudd N . Criterion validation of the Edinburgh Postnatal Depression Scale as a screening tool for depression in patients with advanced metastatic cancer . J Pain Sympt Manage. 2000; 20: 259–265 .
52.
Hopwood P , Howell A , Maguire P . Screening for psychiatric morbidity in patients with advanced breast cancer: validation of two self-report questionnaires . Br J Cancer. 1991; 64: 353–356 .
53.
Stockton M . Screening for depression and anxiety in the hospice in-patient population: validation study and three screening tools . Paper presented at Fifth Congress of the European Association for Palliative Care 1997, 10–13September. London, 1997.
54.
Lawrie I , Lloyd-Williams M , Taylor F . How do palliative medicine physicians assess and manage depression?Palliat Med. 2004; 18: 234–238 .
55.
Massie MJ , Holland JC . The cancer patient with pain: psychiatric complications and their management . J Pain Sympt Manage. 1992; 7: 99–109 .
56.
Kirsh KL , Passik S , Holtsclaw E , Donaghy K , Theobald D . I get tired for no reason: a single item screening for cancer-related fatigue . J Pain Sympt Manage. 2001; 22: 931–937 .
57.
Block S . Assessing and managing depression in the terminally ill . Ann Intern Med. 2000; 132: 209–218 .
58.
Fallowfield LV , Baum M , Maguire GP . Do psychological studies upset patients? [Letter]. J R Soc Med. 1987; 80: 59-59 .
59.
Ly KL , Chidgey J , Addington-Hall J , Hotopf M . Depression in palliative care: a systematic review. Part 2. Treatment . Palliat Med. 2002; 16: 279–284 .
60.
Sullivan MD . Treatment of depression at the end of life: clinical and ethical issues . Sem Clin Neuropsychiatry. 1998; 3: 151–156 .
