Patients are asked, "How would you rate your distress today, on a scale of 0 to 10?" Accompanying the thermometer is a problem list that helps to identify which potential sources of stress are relevant. The patient is asked to check those problems of most relevance. Categories of problems include the following:
- Practical (e.g., housing, insurance, transportation).
- Physical (e.g., pain, nausea, fatigue).
- Family or support (e.g., partner, children, friends).
- Emotional (e.g., worry, sadness, depression, anger).
- Spiritual/religious (e.g., relating to God, loss of faith).
The primary oncology team (oncologist, nurse, palliative care specialist, social worker) is responsible for administering and evaluating a patient's response to this brief screening and arranging for referral, when necessary. Preliminary testing of this procedure used a cutoff score of 5 or higher as requiring further evaluation. Initial needs assessments have shown that 20% to 35% of patients report significant levels of distress.
At Johns Hopkins Cancer Center, all new patients are given an 18-item version of the Brief Symptom Inventory (BSI), which lists 18 problems people sometimes experience (e.g., faintness or dizziness, no interest in things, loneliness, nausea or upset stomach). They are asked, "How much were you distressed by" each of the 18 problems "during the past 7 days including today?" The procedure is automated and utilizes existing clerical and support staff to distribute and retrieve the inventory during the first or second visit. After computerized scoring is completed, professional staff is involved when offers for services are being provided. Those screened as having high distress are referred to a social worker for immediate follow-up, while those screened as having low distress are referred to the psychosocial orientation program. This is a structured educational program designed to enhance the adaptation of patients by providing information about a range of psychosocial programs (e.g., disease-specific support groups, psychoeducational presentations).
The Oncology Symptom Control Research group at Community Cancer Care typically screens all incoming patients with the Zung Self-Rating Depression Scale (ZSDS).[21,22] The ZSDS is a 20-item self-report depression screen that has been used to detect depression and more general distress; single items are also used to screen for conditions such as fatigue. Staff typically administer the screen while patients are in the waiting room. Scores are analyzed immediately after completion so that the medical oncologists can be briefed on any pertinent issues. In addition, patients scoring in the moderate range or higher are identified for further follow-up and more extensive interviews and assessment by the staff psychiatrist or psychologist. Also, patients who trigger single items of interest such as fatigue are interviewed and followed for possible inclusion in a number of symptom-control research trials.
Self-report screening instruments