Autori: Yuri Battaglia (1), Elena Martino (2), Giulia Piazza (2), Elena Cojocaru (1), Sara Massarenti (2), Luana Peron (3), Alda Storari (1), Luigi Grassi (2,3)
Affiliazioni: (1) Nephrology Unit, St. Anna University Hospital, Ferrara; (2) Institute of Psychiatry, S. Anna University, Ferrara; (3) University Hospital Psychiatry Unit, S. Anna University, Ferrara
Background: Kidney transplant recipients (KTRs) have a high risk (20-75%) of psychiatric comorbidity, although improvements have been observed in long term survival of KTRs over the last two decades.
Edmonton Symptom Assessment System(ESAS) is widely used as screening tool of physical and psychological symptoms in medically ill patients.
Aims:To test the screening capabilities of the ESAS for ICD-10 psychiatric diagnoses evaluated with MINI International Neuropsychiatric Interview 6.0(M.I.N.I. 6.0)and investigate optimal cut-off points for ESAS single and global items for detecting ICD-10 psychiatric diagnoses in KTRs.
Methods:This study was carried out in KTRs who were followed up in the Nephrology Unit.
Inclusion criteria were:Karnofsky Performance Status Scale ≥ 50 and absence of cognitive disorders (Mini Mental State Examination≥24).
Study population were approached during one of their routine follow up nephrological visit and were met by same psychiatrist. Each patient was individually administered MINI 6.0. ESAS was given as self-report instruments to be filled in.
M.I.N.I. 6.0 is a short,structured diagnostic interview that has been validated against both the Structured Clinical Interview for DSM diagnoses and the Composite International Diagnostic Interview for ICD-0 diagnoses.
ESAS was used to examine the severity of physical(i.e. pain,tiredness,nausea,drowsiness,lack of appetite,shortness of breath)and psychological symptoms(i.e. depression,anxiety,feeling of not well-being)on a 0(no symptom)to 10(the worst symptom)scale.
Emotional distress item, which corresponds to Distress Thermometer(DT)was added as optional tenth psychological symptom.
Physical distress sub-score(ESAS-PHYS)is the sum of scores for the six physical symptoms.Psychological distress sub-score(ESAS-PSY)is the sum of the scores of the four psychological symptoms.Global Distress score(ESAS-TOT)is given by summing up all the scores on the single ESAS symptoms.
Socio-demographic and routine biochemistry were collected.
ROC analysis was used to examine the ability of all ESAS single items,ESAS-TOT,ESAS-PSY and ESAS PHYS,to detect psychiatric cases defined by using MINI(caseness).
Results:Data pertaining to 134 out of 143 consecutive outpatients were collected. Socio-demographic and clinical characteristics of the sample are shown in Table 1.
Mean and standard deviations on ESAS for the different groups of patients, according to ICD diagnoses are presented in Table 2.Higher scores on the ESAS symptoms(except shortness of breath),ESAS-TOT,ESAS PHYS and PSY sub-scores were found among ICD-10 cases than ICD-10 no-cases(p<0.01).
Area under the ROC curves for DT item,ESAS-TOT,ESAS-PHYS and ESAS-PSY,were 0,77, 0.89, 0.73 and 0.85, respectively(Figure 1).ROC curves showed relatively moderate accuracies of DT item, ESAS-TOT and ESAS-PSY to detect caseness.
DT cut-off point ≥ 3 provides the most acceptable balance between sensitivity 0.74 and specificity 0.73 for caseness.Similarly,ESAS-TOT and ESAS-PSY optimal cut-off points were 20(sensibility 0.85, specificity 0.74)and 12(sensibility 0.85, specificity 0.80),respectively.
A specificity of 0.7 combined with a sensitivity of 0.7 or higher was not reached by any ESAS-PHYS cut-off. Only 4 patients with a formal ICD diagnosis did exceed neither ESAS-TOT nor ESAS-PSY cut-off.
Conclusions:The study reported, for the first time, the optimal screening capabilities(80%)of the ESAS to identify ICD-10-cases evaluated with MINI and ESAS-PSY, ESAS-TOT, DT item cut-off points to detect ICD-10 psychiatric diagnoses in KTRs.
ESAS could be a comprehensive and feasible instrument for physical and psychological symptoms assessment in routine clinical practice among KTRs, easy to use by“non-specialists”in the topic under investigation.
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