Sleep problems in cancer patients: prevalence and association with distress and pain.

BACKGROUND: Although it is increasingly recognized that cancer patients often have sleep problems, we lack data on their prevalence and associations in representative clinical populations. We aimed to determine (i) the prevalence of sleep problems amongst outpatients of a cancer centre and (ii) the association with medical variables, emotional distress and pain. METHODS: Secondary analysis of self-report and medical data on 2862 cancer centre outpatients. Sleep problems were identified using the sleep item from the Patient Health Questionnaire-9: 'Over the last two weeks, how often have you been bothered by trouble falling or staying asleep or sleeping too much?' scored on a four-point frequency scale. Emotional distress was measured using the Hospital Anxiety and Depression Scale and pain using the subscale of the European Organisation for Research and Treatment of Cancer Quality of Life Core 30 questionnaire. Medical data were obtained from the cancer centre clinical database. RESULTS: Sleep problems (bothered more than half the days during the previous 2 weeks) were reported by 30.2% (865/2862, 95% CI = 28.5 to 31.9) of the patients. They were common in both patients with active cancer (34.5%) and in cancer survivors (28.0%). There was only a modest association with cancer site and treatment status, but there was a strong association with pain (odds ratio = 2.7, 95% CI = 2.2 to 3.4) and emotional distress (odds ratio = 4.5, 95% CI = 3.7 to 5.6). CONCLUSIONS: Sleep problems are common in cancer outpatients and are strongly associated with pain and emotional distress. A combined approach to the management of sleep, pain and emotional distress is indicated. Copyright © 2011 John Wiley & Sons, Ltd.

Pain in patients attending a specialist cancer service: prevalence and association with emotional distress.

CONTEXT: We know little about how many outpatients of a modern cancer center suffer from clinically significant unrelieved pain and the characteristics of these patients to guide better care. OBJECTIVES: To determine the prevalence of clinically significant pain (CSP) in the outpatients of a regional cancer center and the association with distress and other variables. METHODS: A secondary analysis of cross-sectional, self-reported and clinical data from 2768 patients reattending selected clinics of a regional National Health Service cancer center in the U.K. Pain was measured using the pain severity scale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, emotional distress was measured by the Hospital Anxiety and Depression Scale, and demographic and clinical data were taken from medical records. RESULTS: Fifty-four percent (95% confidence interval [CI] 52-56) of patients reported pain at least "a little" in the previous week and 18% (95% CI 17-20) at least "quite a bit" (CSP). The strongest independent associations of CSP were active disease (odds ratio [OR] 1.95, 95% CI 1.5-2.5) and emotional distress (OR 4.8, 95% CI 4-6). CONCLUSION: CSP is surprisingly common in outpatients of specialist cancer services, and it is strongly and independently associated with emotional distress. Better symptom management should consider pain and distress together.

Thoughts of death and suicide reported by cancer patients who endorsed the "suicidal thoughts" item of the PHQ-9 during routine screening for depression.

BACKGROUND: Patients with serious medical illnesses, such as cancer, are at increased risk of suicide but are also often facing death. The Patient Health Questionnaire-9 (PHQ-9) is widely used to screen patients for depression. It includes an item that asks about thoughts of death and hurting yourself (Item-9). OBJECTIVE: To describe the nature of thoughts of death and suicide reported in clinical interviews carried out to further assess suicidal ideation of cancer outpatients who had endorsed the "suicidal thoughts item" (Item-9) of the PHQ-9 during routine depression screening. METHOD: Secondary analysis of anonymized service data (with ethical approval) derived from the routine clinical administration of self-report questionnaires and telephone interviews to outpatients attending a Cancer Centre in the UK. RESULTS: Complete data were available on 330/463 (71%) of patients who had endorsed Item-9. In a subsequent structured telephone interview, approximately one-third of these patients denied any thoughts that they would be better off dead, another third acknowledged having thoughts that they would be better off dead, but not of suicide, and the remaining third reported clear thoughts of committing suicide. CONCLUSION: Only one-third of cancer outpatients who endorse the "suicidal thoughts item" of the PHQ-9 report suicidal thoughts at a subsequent interview. Services planning to set up depression screening with the PHQ-9 need to carefully consider the relative benefits and burden to their service and patients of including Item-9 and interviewing all those who endorse it.

What do physicians think of somatoform disorders?

OBJECTIVE: Although somatoform presentations are common, there is considerable confusion regarding the diagnostic terminology and a reluctance to use these diagnostic labels. The aim of this study was to elicit the views of physicians who see these patients. METHODS: Four small group discussions were held in San Diego and Edinburgh. Psychiatrists from very different practice settings attended these groups (child psychiatrists, forensic psychiatrists, psychopharmacologists, consultation psychiatrists, psychotherapists). Non-psychiatrist attendees included neurologists, pediatricians, internists, and gastroenterologists. Using themes identified from the groups, an anonymous internet poll was designed and physicians from a variety of professional organizations were invited to respond to an anonymous poll. RESULTS: Three hundred thirty-two physicians responded to the poll. Two-thirds were psychiatrists; two-thirds were from the United States. While, in general, physicians reported that somatoform patients were relatively rare in their practices (i.e., 0-2%), some physicians reported high prevalence of these patients (i.e., >20%). Over 30% of the physicians considered the diagnostic guidelines for pain disorder and somatoform disorder not otherwise specified as "unclear." Similar numbers of doctors regarded these particular diagnoses as "not useful." Physicians were uniform in their opinion that patients disapproved of such diagnostic labels. Over 90% of respondents felt that there was an overlap between somatization disorder, pain disorder, hypochondriasis, and somatoform disorder not otherwise specified. CONCLUSION: These observations imply a need for considerable restructuring of these diagnoses in DSM-5.

Measuring improvement in depression in cancer patients: a 50% drop on the self-rated SCL-20 compared with a diagnostic interview.

OBJECTIVE: To determine the validity of a 50% drop in the 20-item Symptom Checklist Depression Scale (SCL-20) score against the "gold standard" of no longer meeting criteria for major depression as assessed using a diagnostic interview in an outpatient cancer population and also to examine the validity of other potential cut-offs (i.e., percentage drops). MATERIALS AND METHODS: Secondary analysis of data from a randomized trial which compared collaborative care with usual care for cancer patients with major depression. A total of 194 trial participants who had both SCL-20 scores and depression diagnoses on the Structured Clinical Interview for DSM-IV at both baseline and at 12-week outcome formed the analyzed sample. RESULTS: A 50% reduction in the SCL-20 score from baseline to 12 weeks correctly identified the patients who no longer met criteria for major depression in 153 (78.9%) of 194 (95% CI 73.1% to 84.6%) cases. Most of those misclassified had not achieved a 50% reduction in SCL-20 score despite no longer meeting criteria for major depression. Examination of the performance of percentage drops other than 50% on the SCL-20 using a receiver operating characteristics (ROC) curve and histogram of misclassification suggested that the 50% drop was best if both a low overall misclassification rate and the minimizing of false positives of improvement were required. CONCLUSIONS: A 50% reduction in the SCL-20 score performs well as a conservative measure of change in depression status in cancer patients.

Screening for suicidality in cancer patients using Item 9 of the nine-item patient health questionnaire; does the item score predict who requires further assessment?

OBJECTIVE: To determine whether a higher score on Item 9 of the Patient Health Questionnaire-9 (range zero to three) was more likely to indicate suicidality as determined at subsequent clinical interview in cancer outpatients. METHOD: Analysis of anonymized data (with ethical approval) obtained from the routine clinical administration of self-report questionnaires and telephone interviews to patients attending a cancer centre in the UK. RESULTS: Complete data were available on 330 patients. Those with higher scores on the item were more likely to be suicidal at interview. However, a substantial number of those (54/235; 23%) who scored only one on the item were also found to be suicidal. CONCLUSIONS: A higher score on Item 9 of the PHQ-9 indicates a greater likelihood that the patient is suicidal. However, even patients who score only 1 may be suicidal and consequently also require further assessment.

What should we call pseudoseizures? The patient's perspective.

BACKGROUND: There are numerous terms to describe seizure-like episodes not explained by disease-for example pseudoseizures, psychogenic seizures and non-epileptic attack disorder. Debates about which is best to use tend to centre around theoretical arguments and not scientific evaluation. In this study we examine the meanings of these labels for patients, which have the least potential to offend, and consequently to provide a more positive basis for further management. METHODS AND RESULTS: We interviewed 102 consecutive general neurology outpatients who were asked to consider a scenario that they were being given a diagnosis by a doctor after experiencing a blackout with normal tests. We investigated 10 different diagnoses for blackouts with six different connotations. Three of these connotations--'putting it on', 'mad' and 'imagining symptoms'--were used to derive an overall 'offence score'. Using this score some labels were highly offensive, e.g. 'symptoms all in the mind' (89%) and 'hysterical seizures' (48%). There were no significant differences between the labels 'pseudoseizures', 'psychogenic seizures' and 'non-epileptic attack disorder'. 'Stress-related seizures' and 'functional seizures' were significantly less offensive than these three diagnoses and were equivalent to 'tonic-clonic' and 'grand mal'. CONCLUSIONS: Many labels for seizures unexplained by disease are potentially offensive to patients. The search for labels that accurately describe the phenomenon, can be used by patients, doctors and researchers and enhance trust and recovery is worthwhile and amenable to scientific study.