Perhaps the most important development in psychooncology in the past 10 years has been the development and testing of short, user-friendly screening tools for distress. Attempts to validate these tools have helped crystallize the concept of distress, which had previously received little attention compared with depression.1 Distress is a very common complication of cancer at any stage and often occurs when multiple needs are unmet.2,3 The presence of distress is also linked with reduced health-related quality of life,4 poor satisfaction with medical care,5 and possibly reduced survival.6 Early psychometric research focused on diagnostic accuracy (performance against another scale) and diagnostic validity (performance against a true criterion standard) of longer tools involving 10 items or more that typically took at least 5 minutes to administer.7,8 It is now known that fewer than 15% of cancer professionals are prepared to use these questionnaires in clinical practice, with most relying on their own clinical judgement.9,10 It is also known that self-assessed judgement is inaccurate, just as accuracy in vignette studies overestimates clinical performance.11,12 Direct observation of clinicians' habits suggests modest clinical accuracy with a high proportion of both false-negative and -positive errors.13 These errors are seen in several professional groups and in all settings, leading to the interpretation that distress can be difficult to detect in busy clinical settings.
Patient-reported information such as distress and quality of life can be evaluated through interview (verbally), pencil and paper, or computer. Most questionnaires use a multiple-choice format with a Likert scale (e.g., mild, moderate, severe), but some use a visual analog format. This review and brief meta-analysis examines the merits of short tools with 5 to 14 items taking 2 to 5 minutes to complete, and ultra-short screening tools of 1 to 4 items taking less than 2 minutes to complete.14
The first application of a visual analog scale (VAS) was in 1921,15 although it was not used to measure mood until 1969. In 1969, Zealley and Aitken16 compared patient and nurse twice-daily VAS ratings. A high correlation was found between the patients' self-rated VAS score and their Hamilton score, although interestingly nurses' VAS ratings tended to cluster centrally and lag behind patient-reported change.
In the 1970s, several independent groups experimented with VAS ratings for mood, suicidal thoughts, pain, and quality of life.17 The development of simple but structured verbal methods has been a more recent development, given that verbal enquiry may be more acceptable than even a single self-report item (e.g., “are you depressed?” or “how distressed have you been in the previous week?”).18 In cancer settings, use of the VAS for emotional difficulties has followed from its use in pain measurement (e.g., in the Memorial Pain Assessment Card).19 In 1997, Chochinov et al.20 examined a VAS from “worst possible mood” to “best possible mood.” However, the best known example and most adequately studied is the Distress Thermometer (DT),21 which was developed by a panel of 23 health professionals along with a patient representative working in collaboration with the NCCN.22 The DT is a simple pencil and paper measure consisting of a line with a 0-to-10 scale, indicating “No Distress” at 0, and at 10, indicating “Extreme Distress.” The words no distress, moderate distress, and severe distress are present as anchors along the scale in some versions. Patients are asked to answer the question “How distressed have you been during the past week on a scale of 0 to 10?” A cutoff of 4 or above is recommended to be significant, with 4 or 5 indicating mild distress, 6 or 7 denoting moderate distress, and 8 or higher indicating severe distress. An important addition is a problem checklist that highlights potential areas of difficulty for a patient that may be linked with perceived distress.
Recently, several other methods of measuring distress have been proposed. The Psychological Distress Inventory (PDI) is a 13-item scale first proposed to measure distress in patients with breast cancer. It was tested against a structured clinical interview as the criterion, with a cut-off of 28 or 29 considered clinically significant.23,24 Several variants on the thermometer format have also been developed. Lees and Lloyd-Williams25 tested a VAS anchored with a sad face and happy face. They reported a high correlated with the Hospital Anxiety and Depression Scale total score (HADS-T) but did not report sensitivity or specificity. García et al.26 tested a VAS for anxiety and depression but did not use a robust outcome standard.
In a multicenter study in Europe, Gil et al.27 assessed the value of both the DT and a Mood Thermometer (MT), although the comparator was the HADS. Interestingly, the DT was more highly associated with HADS anxiety scores than depression scores, whereas the MT was related to both HADS anxiety and depression scores. Recently, Mitchell et al.28 developed a 5-item Emotion Thermometer designed to measure multidomain emotional complications of cancer. It had good validity against Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)-defined depression and HADS total scores in early cancer, but studies are awaited regarding interview-defined distress.28
In addition to these custom scales, abbreviated versions of every major mood scale have been published using factor analysis or Rasch analysis. A good example is the adaptation of 10-item Edinburgh Postnatal Depression Scale (EPDS) into an 8-item version.29 An important caveat is that often the abbreviated version is untested in an independent sample, making interpretation difficult.
The purpose of the following data synthesis is to examine which short scales have been adequately validated against defined distress in cancer or palliative settings and to compare the accuracy of single and multiple applications of the scale.
The author has disclosed that he has no financial interests, arrangements, or affiliations with the manufacturers of any products discussed in the article or their competitors.
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