Clinical Review

Which behavioral health screening tool should you use—and when?

OBG Manag. 2021 February;33(2) | doi: 10.12788/jfp.0089.

Rebecca Sewell, PsyD

Elizabeth Cottrell, PsyD

Karina Gutman, MA, BCB

Mary Katherine Clemons, PsyD

Daniel Friedman, PsyD

Elise Kotin, PsyD

Emma Smith, PsyD

Joseph Whitehouse, PsyD

Courtney Pratt, MD, MPH

This review focuses on screens to assess everything from mood and substance use to pain and cognition. It also offers an algorithm to aid with clinical decision making.

Adapted from J Family Pract . 2020;69(9):608–616.

References

Robinson RL, Grabner M, Palli SR, et al. Covariates of depression and high utilizers of healthcare: impact on resource use and costs. J Psychosom Res. 2016,85:35-43.
Fogarty CT, Sharma S, Chetty VK, et al. Mental health conditions are associated with increased health care utilization among urban family medicine patients. J Am Board Fam Med. 2008,21:398-407.
Weissman JD, Russell D, Beasley J, et al. Relationships between adult emotional states and indicators of health care utilization: findings from the National Health Interview Survey 2006–2014. J Psychosom Res. 2016,91:75-81.
Haddad M, Walters P. Mood disorders in primary care. Psychiatry. 2009,8:71-75.
Mitchell AJ, Yadegarfar M, Gill J, et al. Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic metaanalysis of 40 studies. BJPsych Open. 2016,2:127-138.
Siu AL and US Preventive Services Task Force. Screening for depression in adults. JAMA. 2016;315:380-387.
Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873-1875.
Hirschfeld RM, Cass AR, Holt DC, et al. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. J Am Board Fam Med. 2005;18:233-239.
Das AK, Olfson M, Gameroff MJ, et al. Screening for bipolar disorder in a primary care practice. JAMA. 2005;293:956-963.
CDC. Suicide mortality in the United States, 1999-2017. www.cdc.gov/nchs/products/databriefs/db330.htm. Accessed October 23, 2020.
Viguera AC, Milano N, Ralston L, et al. Comparison of electronic screening for suicidal risk with Patient Health Questionnaire Item 9 and the Columbia Suicide Severity Rating Scale in an outpatient psychiatric clinic. Psychosomatics. 2015;56:460-469.
Spitzer RL, Kroenke K, Williams JBW, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-1097.
Birmaher B, Khetarpal S, Brent D, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Chil Adolesc Psychiatry. 1997;36:545-553.
DeSousa DA, Salum GA, Isolan LR, et al. Sensitivity and specificity of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a community-based study. Child Psychiatry Hum Dev. 2013;44:391-399.
Ford ES, Cunningham TJ, Giles WH, et al. Trends in insomnia and excessive daytime sleepiness among U.S. adults from 2002 to 2012. Sleep Med. 2015;16:372-378.
Morin CM, LeBlanc M, Daley M, et al. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Med. 2006;7:123-130.
Buysse DJ, Ancoli-Israel S, Edinger JD, et al. Recommendations for a standard research assessment of insomnia. Sleep. 2006;29:1155-1173.
Martin JL, Hakim AD. Wrist actigraphy. Chest. 2011;139:1514-1527.
Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017;26:675-700.
Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2:297-307.
Wong ML, Lau KNT, Espie CA, et al. Psychometric properties of the Sleep Condition Indicator and Insomnia Severity Index in the evaluation of insomnia disorder. Sleep Med. 2017;33:76-81.
Gagnon C, Bélanger L, Ivers H, et al. Validation of the Insomnia Severity Index in primary care. J Am Board Fam Med. 2013;26:701-710.
Saunders JB, Aasland OG, Babor TF, et al. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption. Addiction. 1993;88:791-804.
Selin KH. Test-retest reliability of the Alcohol Use Disorder Identification Test in a general population sample. Alcohol Clin Exp Res. 2003;27:1428-1435.
Bohn MJ, Babor TF, Kranzler HR. The Alcohol Use Disorders Identification Test (AUDIT): validation of a screening instrument for use in medical settings. J Stud Alcohol. 1995;56:423-432.
Conigrave KM, Hall WD, Saunders JB. The AUDIT questionnaire: choosing a cut-off score. Addiction. 1995;90:1349-1356.
Gomez A, Conde A, Santana JM, et al. Diagnostic usefulness of brief versions of Alcohol Use Identification Test (AUDIT) for detecting hazardous drinkers in primary care settings. J Stud Alcohol. 2005;66:305-308.
Butler SF, Fernandez K, Benoit C, et al. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPPR). J Pain. 2008;9:360-372.
Knight JR, Sherritt L, Shrier LA, et al. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156:607-614.
DHHS. Post-traumatic stress disorder (PTSD). https://archives.nih.gov/asites/report/09-09-2019/report.nih.gov/nihfactsheets/ViewFactSheetfdf8.html?csid=58&key=P#P. Accessed October 23,2020.
Blevins CA, Weathers FW, Davis MT, et al. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress. 2015;28:489-498.
Verhey R, Chilbanda D, Gibson L, et al. Validation of the Posttraumatic Stress Disorder Checklist- 5 (PCL-5) in a primary care population with high HIV prevalence in Zimbabwe. BMC Psychiatry. 2018;18:109.
Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695-699.
Stewart S, O’Riley A, Edelstein B, et al. A preliminary comparison of three cognitive screening instruments in long term care: the MMSE, SLUMS, and MoCA. Clin Gerontol. 2012;35:57-75.
Godefroy O, Fickl A, Roussel M, et al. Is the Montreal Cognitive Assessment superior to the Mini-Mental State Examination to detect poststroke cognitive impairment? A study with neuropsychological evaluation. Stroke. 2011;42:1712-1716.

Many screening tools are available in the public domain to assess a variety of symptoms related to impaired mental health. These tools can be used to quickly evaluate for mood, suicidal ideation or behavior, anxiety, sleep, substance use, pain, trauma, memory, and cognition (TABLE). Individuals with poor mental health incur high health care costs. Those suffering from anxiety and posttraumatic stress have more outpatient and emergency department visits and hospitalizations than patients without these disorders,^1,2 although use of mental health care services has been related to a decrease in the overutilization of health care services in general.³

Here we review several screening tools that can help you to identify symptoms of mental illnesses and thus, provide prompt early intervention, including referrals to psychological and psychiatric services.

Mood disorders

Most patients with mood disorders are treated in primary care settings.⁴ Quickly measuring patients’ mood symptoms can expedite treatment for those who need it. Many primary care clinics use the 9-item Patient Health Questionnaire (PHQ-9) to screen for depression.⁵ The US Preventive Services Task Force (USPSTF) has recommended screening for depression with adequate systems to ensure accurate diagnoses, effective treatment, and follow-up. Although the USPSTF did not specially endorse screening for bipolar disorder, it followed that recommendation with the qualifying statement, “positive screening results [for depression] should lead to additional assessment that considers severity of depression and comorbid psychological problems, alternate diagnoses, and medical conditions.”⁶ Thus, following a positive screen result for depression, consider using a screening tool for mood disorders to provide diagnostic clarification.

The Mood Disorder Questionnaire (MDQ) is a validated 15-item, self-administered questionnaire that takes only 5 minutes to use in screening adult patients for bipolar I disorder.⁷ The MDQ assesses specific behaviors related to bipolar disorder, symptom co-occurrence, and functional impairment. The MDQ has low sensitivity (58%) but good specificity (93%) in a primary care setting.⁸ However, the MDQ is not a diagnostic instrument. A positive screen result should prompt a more thorough clinical evaluation, if necessary, by a professional trained in psychiatric disorders.

We recommend completing the MDQ prior to prescribing antidepressants. You can also monitor a patient’s response to treatment with serial MDQ testing. The MDQ is useful, too, when a patient has unclear mood symptoms that may have features overlapping with bipolar disorder. Furthermore, we recommend screening for bipolar disorder with every patient who reports symptoms of depression, given that some pharmacologic treatments (predominately selective serotonin reuptake inhibitors) can induce mania in patients who actually have unrecognized bipolar disorder.⁹

Continue to: Suicide...

References

Robinson RL, Grabner M, Palli SR, et al. Covariates of depression and high utilizers of healthcare: impact on resource use and costs. J Psychosom Res. 2016,85:35-43.
Fogarty CT, Sharma S, Chetty VK, et al. Mental health conditions are associated with increased health care utilization among urban family medicine patients. J Am Board Fam Med. 2008,21:398-407.
Weissman JD, Russell D, Beasley J, et al. Relationships between adult emotional states and indicators of health care utilization: findings from the National Health Interview Survey 2006–2014. J Psychosom Res. 2016,91:75-81.
Haddad M, Walters P. Mood disorders in primary care. Psychiatry. 2009,8:71-75.
Mitchell AJ, Yadegarfar M, Gill J, et al. Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic metaanalysis of 40 studies. BJPsych Open. 2016,2:127-138.
Siu AL and US Preventive Services Task Force. Screening for depression in adults. JAMA. 2016;315:380-387.
Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873-1875.
Hirschfeld RM, Cass AR, Holt DC, et al. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. J Am Board Fam Med. 2005;18:233-239.
Das AK, Olfson M, Gameroff MJ, et al. Screening for bipolar disorder in a primary care practice. JAMA. 2005;293:956-963.
CDC. Suicide mortality in the United States, 1999-2017. www.cdc.gov/nchs/products/databriefs/db330.htm. Accessed October 23, 2020.
Viguera AC, Milano N, Ralston L, et al. Comparison of electronic screening for suicidal risk with Patient Health Questionnaire Item 9 and the Columbia Suicide Severity Rating Scale in an outpatient psychiatric clinic. Psychosomatics. 2015;56:460-469.
Spitzer RL, Kroenke K, Williams JBW, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-1097.
Birmaher B, Khetarpal S, Brent D, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Chil Adolesc Psychiatry. 1997;36:545-553.
DeSousa DA, Salum GA, Isolan LR, et al. Sensitivity and specificity of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a community-based study. Child Psychiatry Hum Dev. 2013;44:391-399.
Ford ES, Cunningham TJ, Giles WH, et al. Trends in insomnia and excessive daytime sleepiness among U.S. adults from 2002 to 2012. Sleep Med. 2015;16:372-378.
Morin CM, LeBlanc M, Daley M, et al. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Med. 2006;7:123-130.
Buysse DJ, Ancoli-Israel S, Edinger JD, et al. Recommendations for a standard research assessment of insomnia. Sleep. 2006;29:1155-1173.
Martin JL, Hakim AD. Wrist actigraphy. Chest. 2011;139:1514-1527.
Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017;26:675-700.
Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2:297-307.
Wong ML, Lau KNT, Espie CA, et al. Psychometric properties of the Sleep Condition Indicator and Insomnia Severity Index in the evaluation of insomnia disorder. Sleep Med. 2017;33:76-81.
Gagnon C, Bélanger L, Ivers H, et al. Validation of the Insomnia Severity Index in primary care. J Am Board Fam Med. 2013;26:701-710.
Saunders JB, Aasland OG, Babor TF, et al. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption. Addiction. 1993;88:791-804.
Selin KH. Test-retest reliability of the Alcohol Use Disorder Identification Test in a general population sample. Alcohol Clin Exp Res. 2003;27:1428-1435.
Bohn MJ, Babor TF, Kranzler HR. The Alcohol Use Disorders Identification Test (AUDIT): validation of a screening instrument for use in medical settings. J Stud Alcohol. 1995;56:423-432.
Conigrave KM, Hall WD, Saunders JB. The AUDIT questionnaire: choosing a cut-off score. Addiction. 1995;90:1349-1356.
Gomez A, Conde A, Santana JM, et al. Diagnostic usefulness of brief versions of Alcohol Use Identification Test (AUDIT) for detecting hazardous drinkers in primary care settings. J Stud Alcohol. 2005;66:305-308.
Butler SF, Fernandez K, Benoit C, et al. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPPR). J Pain. 2008;9:360-372.
Knight JR, Sherritt L, Shrier LA, et al. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156:607-614.
DHHS. Post-traumatic stress disorder (PTSD). https://archives.nih.gov/asites/report/09-09-2019/report.nih.gov/nihfactsheets/ViewFactSheetfdf8.html?csid=58&key=P#P. Accessed October 23,2020.
Blevins CA, Weathers FW, Davis MT, et al. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress. 2015;28:489-498.
Verhey R, Chilbanda D, Gibson L, et al. Validation of the Posttraumatic Stress Disorder Checklist- 5 (PCL-5) in a primary care population with high HIV prevalence in Zimbabwe. BMC Psychiatry. 2018;18:109.
Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695-699.
Stewart S, O’Riley A, Edelstein B, et al. A preliminary comparison of three cognitive screening instruments in long term care: the MMSE, SLUMS, and MoCA. Clin Gerontol. 2012;35:57-75.
Godefroy O, Fickl A, Roussel M, et al. Is the Montreal Cognitive Assessment superior to the Mini-Mental State Examination to detect poststroke cognitive impairment? A study with neuropsychological evaluation. Stroke. 2011;42:1712-1716.

Women increasingly turn to CBD, with or without doc’s blessing

Which behavioral health screening tool should you use—and when?

References

Mood disorders

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