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Psycho-oncology (UK) Information & Help Resources for organizations, health professionals, patients and families relating to psychological aspects of cancer care |
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Emotion Thermometers Tool © A rapid modular screening tool for detection and monitoring of emotional disorders in clinical practice
In 1998 the Distress Thermometer (DT) was developed and validated for evaluation of distress (and anxiety and depression) in cancer [Roth et al, 1998]. It was adopted into recommendations by the US National Comprehensive Cancer Network. The DT is a simple, self-report, pencil and paper measure consisting of a line with a 0-10 scale anchored at the zero point with ‘No Distress’ and at scale point ten with ‘Extreme Distress’. Patients are given the instruction “How distressed have you been during the past week on a scale of 0 to 10?” The recommended cut-off was 4v5, but in 2007 was revised to 3v4. In a comprehensive review of the accuracy of the DT, it was found to have a sensitivity of 80.9% and a specificity of 60.2%, (positive predictive value (PPV) of 32.8 and negative predictive value (NPV) of 92.9%) for depression, a sensitivity of 77.3% and specificity 56.6% (PPV of 55.2% and NPV of 80.25%) for anxiety it and a sensitivity of 77.1% and specificity 66.1% (PPV 55.6% and NPV 84.0%) for broadly defined distress [Mitchell, 2007].
In 2007 we piloted and validated an extension of the DT called the Emotion Thermometers Tool. This is a new five dimensional tool retaining the convenience of the innovative DT but with superior accuracy. It comprises five visual analogue scales in the form of four predictor domains (distress, anxiety, depression, anger) and one outcome domain (need for help). Each domain is rated on an 11 point (0 to 10) Likert scale in a visual thermometer, namely the Distress Thermometer (DT), Depression Thermometer (DepT), Anxiety Thermometer (AnxT) and Anger Thermometer (AngT). In a pilot evaluation in the Leicester Cancer Centre (UK), we found that the tool takes about 45 seconds (compared to about 20 seconds for the DT) for most patients for complete and is no less acceptable than the DT alone.
The 2007 original version (ET5) comprised four emotion domains and a help thermometer The 2009 ET7 added duration of illness and burden to the core thermometers above We currently have pilot versions adding domains of function (work, social, family), pain, and QoL We have pilot versions including descriptive text anchors for the thermometers of help and pain.
Tool Download (Original version)
Download Word Version (by request only)
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in checklist format
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Version in Spanish
Download PDF Version in Portuguese
Download PDF Version in Dutch
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Version in German
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Version in French
Validation Papers (full papers published in Psycho-oncology 2010 Feb;19(2):125-33 and 2010 Feb;19(2):134-140) In our study in the Leicester Cancer Centre, 11.5% of people scored three or below on all ET domains and 69.3% scored four or above on at least one domain. Of low scorers on the DT about 50% recorded emotional difficulties on the new Emotion Thermometers (ET) tool, suggesting added value beyond the Distress thermometer (DT) alone. Using a cut-off of 3v4 on all thermometers against the total HADS score (cut-off 14v15), the optimal thermometer was the AngT (sensitivity 89% specificity 46%). Against HADS Anxiety scale (cut-off 7v8), and judging by the Predictive Summary Index, the optimal thermometer was AnxT (sensitivity 92% specificity 61%). Against the HADS depression scale, the optimal thermometer was the depression thermometer (sensitivity 60% specificity 78%). Finally, against the DSM-IV diagnosis of major depression the optimal thermometer was the depression thermometer sensitivity 80% specificity 79%) but no single method had good positive predictive value (PPV). Further improvements can be made by adjusting the cut-offs particularly for detection of anxiety (AnxT ROC = 0.867 at a cut-off of 5v6) and detection of depression (DepT ROC = 0.751 at a cut-off 4v5).
Validation Posters We have published a series of posters on the ET at the IPOS and APOS conferences 2010-2012.
IPOS2010 Poster 130 (defining ET thresholds)
The tool is subject to copyright (c) Alex J Mitchell but freely available (royalty free) for non-commercial and clinical use. If this (or related) tools are useful please consider donating to help with our research
We welcome collaborations with other groups who are interested in using the ET for research. The following groups have sought permission to study the ET in various settings
The ET7 has been validated in a neurological setting
(epilepsy) see this poster
The ET5 has been validated in cardiovascular settings (link)
Roth AJ, Kornblith AB, Batel-Copel L, et al. Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer 82:1904 –1908, 1998 NCCN Clinical Practice Guidelines in Oncology™ Distress Management V.1.2007 http://www.nccn.org/professionals/physician_gls/PDF/distress.pdf (accessed 25 March 2007) Mitchell AJ. Pooled results from 38 analyses of the accuracy of distress thermometer and other ultra-short methods of detecting cancer-related mood disorder. J Clin Oncol 2007; 25:4670-4681.
Q. Has the ET been validated? A. Yes in cancer (incl small palliative subsample), neurology (epilepsy) and misc cardiovascular disease Q. Can the ET be used clinically without permission? A. Yes, it is royalty free for clinical use at the current time Q. Can the ET be used for research without permission? A. No, please write to me with the title and duration of your proposed project. It is likely I will grant permission. Q. Is the ET available with addition thermometer domains? A. Yes there is a modular ET (ET_mod) which optionally adds customised assessments of QoL, function, pain. Q. Is the ET sensitive to change? A. Usually VAS are sensitive to change, but this requires formal study Q. What is the best cut off on the ET? A. Please refer to the validation papers, but be aware fixed cut-offs are somewhat arbitrary, and may require study in your setting Q. How long does the ET take to administer A. Usually about 1 minute Q. Has the ET been translated into.....my language? A. Probably not, please consider doing this and sending us your version Q. Can the ET be read out for those with visual (or other) impairment? A. Yes but this really requires separate validation Q. What should happen when someone scores above threshold? A. We recommend a further assessment is made along with clarification of unmet needs, but this is a local decision Q. How does the ET compare to the HADS A. Please see above poster on ET vs HADS in 660 cancer subjects. Q. How easy is it to adopt the ET into a screening programme delivered by cancer clinicians? A. Please feel free to use our screening programme form and see our new paper on this (submitted) Q. Can the ET be computerised to automated screening? A. Certainly, but no one has done this yet
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