Alex Mitchell University of Leicester #ipos2013 Screening for Distress Debate

…What are the sources of disagreement?

Areas of Disagreement: 1. How to screen (which tool) 2. When to screen 3. How often to screen 4. Which screening population 5. Who should screen 6. Does screening work

……in short Should we screen at all?

But what are the alternatives to screening?

1. Diagnosis as usual (do nothing) 2. Enhanced diagnosis (clinician = screen) 3. Screen everyone 4. Screen high risk (targeted screening)

Comment: Slide illustrates diagnostic accuracy according to score on DT

Lessons from primary care….

Results disappointing Acceptability overlooked Most are not depressed Many do not want help Some are already Rx

Screening in Cancer

Missed diagnosis GP = CNS = Oncologists

Screening tools (validity)

Depression Distress Brief / ultra-short Multi-domain

Implementation evidence Randomized Non-Randomized

Q. What type of studies? Q. How many +ve studies? Q. What are the beneficial outcomes? Q. What is the size of the effect?

Implementation Reviews

Implementation Studies 9 studies Distress => Referral 6 studies => Communication

….this is getting complex……. ………………..what is the overall effect?

Overall Effect of screening Baseline CARE x% with screening +10% (0-20%)

Overall Effect of screening Baseline CARE x% with screening +10% + follow-up +10% +treatment +10%

What is holding back screening success?

BOTH. How Many Receive Ps Help? (n=2557)

% Receiving Any treatment for Mental Health Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical Oncology, Vol 20, Issue 23 (December), 2002: mo Service Use (NIH, 2002)

Overall Effect of screening Baseline CARE x = 35% with screening +10% (0-20%) + follow-up +10% (0-20%) +treatment +10% (0-20%)

……..So is screening successful or not? …….It depends

Analogy : How do we reduce speeding drivers? US deaths 10,000

Aim is to reduce speed (and hence deaths) Not simply to detect speeding! Analogy

Aim is to reduce distress (improving QoL) Not simply to detect distress!

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0. Summary Screening can be ineffective or effective Screening may be optional or mandated