Psychosocial Distress Screening
Nina Miller, MSSW, OSW-C
Psychosocial Distress Screening
Commission on Cancer Standard
Standard 3.2
The cancer committee develops and
implements a process to integrate and
monitor on-site psychosocial distress
screening and referral for the provision of
psychosocial care.
Distress in Cancer
NCCN defines distress as a multifactorial
unpleasant emotional experience of a
psychological, social, and/or spiritual nature that
may interfere with the ability to effectively cope
with cancer, its physical symptoms and its
treatment. Distress extends along a continuum
ranging from common normal feelings of
vulnerability, sadness, and fears to problems
that can become disabling, such as depression,
anxiety, panic, social isolation and existential
and spiritual crisis.
Psychosocial Distress Screening
CoC Process Requirements:
Timing of Screening - Patients with cancer
are offered screening for distress a
minimum of one time per patient at a pivotal
medical visit to be determined by the
program.
Methods - The mode of administration
(such as patient questionnaire, clinicianadministered questionnaire) is determined
by the program.
CoC Process Requirements, cont.
Tools - Facilities select the tool to be
administered to screen for current distress.
Preference is given to standardized, validated
instruments with established clinical cutoffs.
Assessment and Referral – The oncologist,
nurse and social worker are to identify and
examine the psychological, behavioral and
social problems of patients that interfere with
their ability to participate fully in their health
care and manage their illness and its
consequences.
• The oncology team (oncologist, nurse, social
worker) reviews the distress screening results
to determine the need for referrals to
interventions e.g. educational programs,
support groups, counseling, exercise,
relaxation, meditation for expected distress
symptoms e.g. sadness, worry, anger,
preoccupation with thoughts of illness.
• If the distress screening reveals a higher
score, the oncology team should complete a
clinical assessment with referral to mental
health, social work/counseling or chaplaincy.
MENTAL HEALTH EVALUATION
DIAGNOSIS
DISTRESS
DEMENTIA
BEHAVIORAL PROBLEMS
DELIRIUM
PSYCHIATRIC HISTORY/MEDS
MOOD DISORDER
PAIN/SYMPTOM CONTROL
SCHIZOPHRENIA/PSYCHOTIC
DISORDER
BODY IMAGE/SEXUALITY
ADJUSTMENT DISORDER
IMPAIRED CAPACITY
ANXIETY DISORDER
SAFETY
SUBSTANCE-RELATED DISORDER
OR ABUSE
PSYCHIATRIC DISORDER
PERSONALITY DISORDER
Documentation for Survey
• Screening, referral or provision of care and
follow-up are documented in the patient’s
medical record to facilitate integrated, highquality care.
• The program completes the Survey Application
Record.
• The program provides cancer committee
minutes along with other sources to document
the development and implementation of a
process to integrate and monitor distress
screening and referral for the provision of
psychosocial care.
29-43% distress among sample of 4,500
adults with seven common types of
cancer.
Zabora et al. Psych-Onc 2001
Consequences of Distress
•
•
•
•
•
•
Decreased employment functioning
Decreased medical adherence
Increased medical costs
Increased health risk behaviors
Decreased health protection behaviors
May interfere with cancer outcomes
• Physicians substantially underestimate
oncology patients’ psychosocial distress.
• Patients are willing to discuss distress but
are not likely to initiate the conversation
with the physician.
• Physician’s often defer to the patients to
raise any concerns about distress-related
topics.
Fallowfield et al. 2001; Keller et al. 2004;
Merckaert et al. 2005; Detmar et al JCO 2000
Screening Methods
Method
Pros
Cons
Clinicianadministered
questions
-Immediate interpretation
and triage
-Time intensive
-Patient may not
disclose sensitive
personal information
Patient
questionnaire:
Paper based
-Can be completed at
patient convenience, e.g.
while waiting for appt.
-Provides more privacy
than face-to-face
questions
-Requires real-time
review of responses for
completeness of
responses, elevated
distress
-Requires patient
literacy skills
Patient
questionnaire:
Electronic
assessment
-Integration with electronic
health record possible
-Automated scoring and
interpretation
-Automated triage
possible
-Requires patient to
have Internet access or
in-clinic access
-Programming for EHR
integration costly
Distress Screening Tools
•
•
•
•
•
•
NCCN Distress Thermometer
PHQ-9
PHQ-2
Hospital Anxiety and Depression Scale
Brief Symptom Inventory – 18
Beck Depression Inventory
Single Item Distress Thermometer
Screening Cut-off = 5
Sensitivity
Specificity
Anxiety
.85
.78
Depression
.63
.69
Butt et al. JPSM 2007; 35:20-30
• Patient Reported Outcomes Measurement
Information System (PROMIS)
• NIH-funded network
• www.nihPROMIS.org
• Brief, precise measures of cancer-related
symptoms through computer adaptive testing
• Assessment Center provides platform for online
administration of PROMIS measures
PROMIS Computer Adaptive
Testing assesses these domains:
•
•
•
•
•
Depression
Anxiety
Fatigue
Pain
Physical function
TOTAL LENGTH: 40 items
Sample Depression Question
Assessment and Messaging at the Robert H. Lurie
Comprehensive Cancer Center
• New patients receive instructions to activate
EHR patient communication portal (Epic
MyChart)
• Patients access Epic MyChart
• MyChart links seamlessly with Assessment
Center within organization firewall
• Patient completes assessment through
Assessment Center (at home or in-clinic)
• Provider messages and triage managed
through Epic health record integration
Social Work Needs Assessment
In-Clinic Assessment Provided via iPad
Screening Triage Algorithm
Depression,
Anxiety
1) MD, RN message when
symptoms are
moderate/severe (70th %ile)
2) Psychology, Social work
copied to initiate consult
Practical,
financial
concerns
Social worker sent
message with list of
needs expressed by
patient to initiate consult
RHLCCC Screening: Patient Feedback
• Median age = 61.5 (range 34-73)
• Administration 10.7 minutes (range 6-22 minutes)
• All patients reported assessment was “easy” or
“very easy”
• Questions too personal? 100% “Not at all”
Did the survey ask questions about
aspects of your health and wellbeing that are important to you?
8
7
6
4
2
1
0
Not at all
A little bit
2
Somewhat
Very much
Do you think it's important for
your medical team to know your
results from these surveys?
7
6
5
4
3
2
1
0
6
4
Not at all
A little bit
Somewhat
Very much
Implementing Distress Screening
Standard at Your Institution
• Determine timing for screening e.g. new patients, at
certain points of transition
• Determine methods e.g. clinician administered, selfadministered
• Tools: Select tool and cut-off based on resources for
administration
• Determine how you will refer patient for assessment
• Establish community, state and national referral
sources
• Identify psychosocial staff at your institution and/or
establish referral agreements with providers external
to your organization
Thank you