Vol. 29 No. 1 January 2005 Journal of Pain and Symptom Management 91 Original Article Development of an Impact Thermometer for Use in Combination with the Distress Thermometer as a Brief Screening Tool for Adjustment Disorders and/or Major Depression in Cancer Patients Nobuya Akizuki, MD, Shigeto Yamawaki, MD, PhD, Tatsuo Akechi, MD, PhD, Tomohito Nakano, MD, and Yosuke Uchitomi, MD, PhD Psychiatry Division (N.A., T.N.), National Cancer Center Hospital, Tokyo Department of Psychiatry and Neurosciences (S.Y.), Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima Psycho-Oncology Division (T.A., Y.U.), National Cancer Center Research Institute East, Chiba and Psychiatry Division (T.A., Y.U.), National Cancer Center Hospital East, Chiba, Japan. Abstract Screening cancer patients for adjustment disorders and major depression is important, because both are prevalent and often underrecognized. The purpose of this study was to validate the Distress and Impact Thermometer, a 2-item questionnaire, which we newly developed as a brief screening tool for detection of adjustment disorders and/or major depression. Two hundred ninety-five cancer patients completed the Distress and Impact Thermometer and the Hospital Anxiety and Depression Scale (HADS), and were examined by psychiatrists based on DSM-IV criteria. Using cutoff points for detection of adjustment disorders and major depression of ���3/4��� on ���distress��� score and ���2/3��� on ���impact,��� the sensitivity and specificity were 0.82 and 0.82, respectively. Screening performance of the Distress and Impact Thermometer was comparable to that of the Hospital Anxiety and Depression Scale. Its brevity and good performance suggest that the Distress and Impact Thermometer is an effective tool for routine screening in clinical oncology settings. J Pain Symptom Manage 2005 29:91���99. 2005 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Screening, cancer, adjustment disorders, major depression, suicidal ideation Address reprint requests to: Yosuke Uchitomi, MD, PhD, Psycho-Oncology Division, National Cancer Center Research Institute East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan. Accepted for publication: April 27, 2004. 2005 U.S. Cancer Pain Relief Committee 0885-3924/05/$���see front matter Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jpainsymman.2004.04.016 Introduction Derogatis et al. reported that about half of all cancer patients have psychiatric disorders, with the most common being adjustment disor- ders and major depression.1 Subsequent re- search on the prevalence of psychiatric disorders in cancer patients confirmed that adjustment disorders and major depression are often the

92 Vol. 29 No. 1 January 2005 Akizuki et al. most prevalent psychiatric disorders among cancer patients.2,3 Although their prevalence varies with patient characteristics (i.e., type of cancer and staging), and the tools used to mea- sure them, the prevalence of adjustment disor- ders in cancer patients has been reported to be 4���35%, and the prevalence of major depression has been reported to be 3���26%.1���8 Adjustment disorders are relatively brief mal- adaptive reactions to stress and are often associ- ated with depressed mood and/or anxiety.2 Major depression is a psychiatric syndrome characterized by two core symptoms, depressed mood and loss of interest or pleasure that per- sist for at least two weeks and interfere with normal functioning.9 Although adjustment dis- orders and major depression are different disor- ders, they are often associated with significant psychological distress, mainly anxiety and de- pressed mood.10 Both disorders are known to have various adverse effects for example, de- pressed mood often leads to impaired quality of life (QOL)11 and is related to desire to die.12 Major depression affects patients��� decision making about cancer treatment,13 and psycho- logical distress affects caregiver���s QOL.14 Both psychotherapy and pharmacotherapy are effective against these disorders, and early diagnosis and treatment are considered to be important.15 However, they are often underrec- ognized by the medical staff in clinical oncology settings.16,17 Both clinicians��� and patients��� belief that depressive mood or anxiety is an appro- priate reaction to cancer, the lack of physician training in the treatment of depression, and the stigma attached to the words ���psychiatric��� and ���psychological��� are possible reasons for reluc- tance to talk about emotional issues.15,18 Screening is useful for detecting diseases that are prevalent in the population, are not evi- dent, and are treatable screening may be partic- ularly important if there is an advantage to early treatment.19 Several screening tools for adjust- ment disorders and major depression in cancer patients have been developed, and they have been reported to be valid,10,20���26 but they are not brief enough for use in cancer patients in clini- cal oncology settings. Important points that need to be borne in mind when devising tools to screen cancer patients for adjustment disorders and major depression are that the screening items should not include somatic symptoms that are difficult to interpret 15 the screening should be brief enough to use in cancer pa- tients, because many of them have physical symptoms and excessive questioning can cause distress 2 the screening should not be so stigma- tizing that it cannot be easily used by the medi- cal staff or is unacceptable to patients 18 and it should be easy to score and evaluate, because screening tests are mainly used by non-mental health professionals.27 Several screening tools have been used to detect psychological distress in cancer patients, and they have a mean sensitivity of 0.78 and mean specificity of 0.71.2 For the sake of brevity and ease, screening tests for adjustment disor- ders and major depression that ask only one question have been developed for cancer pa- tients, and the Single-item Interview Screen- ing,23 the Visual Analog Scale (VAS),23 the Distress Thermometer,24,26 and the One Ques- tion Interview26 have been used in patients with advanced cancer. However, the Single-item In- terview Screening requires some training for use by non-mental-health professionals, be- cause it is part of a structured diagnostic inter- view, and poor performance of the VAS has been shown as a screening tool for major and minor depression in cancer patients (sensitivity 0.72, specificity 0.50). Our previous study showed sensitivity of 0.84 for the Distress Ther- mometer and 0.80 for the One Question In- terview, which require no training. Sensitivity levels are comparable to that of the Hospital Anxiety and Depression Scale (HADS), but their specificities (Distress Thermometer, 0.61 One Question Interview, 0.61) are poorer.26 In view of the cost and resources required for as- sessment and treatment after screening, speci- ficity is as important for screening as sensitivity, however, no sufficiently brief screening tests with both high sensitivity and high specificity for detecting psychiatric problems in cancer patients currently exist. Most screening tools for psychiatric disorders incancerpatientstargetadjustmentdisordersor major depression because of their high preva- lence. Some studies of the HADS have reported different cutoffs for screening for adjustment disorders or major depression and for screen- ing for major depression alone.10,25 However, no studies have reported differences in performance in regard to brief screening for different target problems.