Validating the Distress Thermometer as a tool to screen

for psychological distress in the UK

Dr Joe Low (1), Dr Sue Gessler (2), Emma Daniells (1), Rachael Williams (1), Veronica Brough (1), Dr Adrian Tookman (1) , Dr Louise Jones (1)
(1)
Marie Curie Palliative Care Research Unit, Royal Free & University College Medical School and (2)UCLH Gynaecological Cancer Centre, London.

Introduction • Sensitivity and specificity of the Distress Thermometer were examined against
each concurrent variable using Receiver ROC analysis, for Distress Thermometer
scores against the diagnostic cut-off score for ‘caseness’.
• Psychological distress is common in people with cancer, with 40% of all UK
patients experiencing anxiety or depression during their cancer journey.
Results
• Recommendation 5.10 of the NICE
guidelines on Supportive and Palliative • From our initial sample of 399 patients, 150 were excluded for the following
Care emphasises the need for health reasons: new to clinic (n=71), doctor judged not appropriate (n=54) and poor
care professionals to be able to screen English (n=25). Of the remaining 249 eligible patients, 171 returned completed
for psychological distress. questionnaires, giving a response rate of 69%.

• Current research tools are long and • Our sample was predominantly white (145, 86%), with a mean age of 60 years
cumbersome for patients to complete. (s.d. = 14) and a slightly higher proportion of females (91, 53%). Most people
They are difficult for clinicians to score have been educated to 18 years or over (102, 60%) and were home owners (121,
for distress in a busy clinical setting. 71%). Most came from managerial, professional or intermediate occupations (108,
Hence, there is a clinical need for a 63%), but only 33% (n=29) were currently in employment.
short tool, which is easy for patients
to complete. ‘Frequency distribution of Distress Thermometer scores at baseline’

• The Distress Thermometer, a single item

scale with a symptom checklist, potentially
fits the criteria. Initially developed by the
National Comprehensive Cancer Network
(NCCN) and validated in the USA,
Australia, Japan and southern Europe,
but not the UK.

Aims
First UK study to assess the concurrent validity of the Distress Thermometer in
a UK population with supportive and palliative care needs, against four criterion
measures of psychological caseness widely used in the UK.

Methods
Sample
• Our sample had a median Distress Thermometer of three with an inter-quartile
• Out-patients attending oncology clinics in University College Hospital range of five (1-6). Over half our sample had a score of between zero and three
(Gynaecological Oncology and Gastro-intestinal) and Royal Free Hospital (see figure above).
(Melanoma-Renal, and two Gastro-intestinal clinics)
• Using a cut-off of four for the Distress Thermometer, we maximised sensitivity,
• Patients at the day therapy unit, Marie Curie Hospice Hampstead. specificity, positive and negative predictive values against all four of the
established criterion measures (see table below).
Exclusion criteria
Sensitivity, specificity, positive predictive values and negative predictive
values at the optimum cut-off point of four on the Distress Thermometer
• Under 18 years, have organic brain disease or psychotic illness, considered to
in relation to each of the criterion measures at baseline
be too ill by the health professional, or if they are unable to read or understand
written English.
Sensitivity Specificity Positive Negative
Predictive Predictive
Measures
Value Value
• NCCN Distress Thermometer. HADS 83 76 57 92
• Hospital Anxiety and Depression Scale (HADS).
• General Health Questionnaire 12 (GHQ-12). GHQ-12 68 78 68 78
• Brief Symptom Inventory 18 (BSI-18).
• Two screening questions on depression (Arroll et al, BMJ 2003): BSI-18 92 69 35 98

1. ‘During the past month have you often been bothered by feeling down, Arroll questions 71 79 68 82
depressed, or hopeless?’ on depressed
mood
2. ‘During the last month have you often been bothered by little interest or pleasure
in doing things?’

97% sensitivity, 67% specificity reported in a primary care setting for these Summary
screening questions.
• The Distress Thermometer is a valid measure for screening for psychological
Data analyses distress in British cancer patients

• All data was inputted into STATA (v9.1).
• Concurrent validity was assessed by constructing receiver operating characteristic
(ROC) curves, in which sensitivity versus (1-specificity) was plotted for a range
of possible scores on the Distress Thermometer compared with the established
measures (HADS, GHQ-12, BSI-18, depression screening questions) cut-off
scores for clinically significant psychological distress.
• A cut-off of four offers best-fit sensitivity and specificity across all measures,
which agrees with other studies internationally.
• As a one item tool, the Distress Thermometer fits well with the criteria set for a
patient self-assessment tool as specified by the National Overview Specification
Framework for Assessment, a national process initiated to assess patients’ needs
in a routine fashion.