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  • Behavioral Health Services > Behavioral Health Screening Tools

    Behavioral Health Screenings for Patients in the Primary Care Setting

    The role of the primary care physician has evolved to include discussing and addressing mental health and substance use disorders with patients. The relationships that the primary care physician creates with their patients have proven to be one of the most important factors in ensuring individuals receive appropriate care for behavioral health needs.

    Recognizing the signs of a mental health disorder is not always easy. We are providing you with the following behavioral health screening tools to assist in diagnosing and referring individuals for further care.


    Measures Tool About the Tool Scoring and Action Steps
    Depression PHQ-2* Depression Screen
    - 2 Questions
    Score of 0-2 = Negative screen
    Action: None
    Score of 3+ = Positive screen
    Action: Administer the PHQ-9.
    PHQ-9* Depression Screen
    - 9 Questions
    Score of 1-4 = Minimal depression
    Action: Watchful waiting; repeat PHQ-9 at follow-up visit.
    Score of 5-9 = Mild depression
    Action: Watchful waiting; repeat PHQ-9 at follow-up visit.
    Score of 10-14 = Moderate depression
    Action: Develop treatment plan, consider pharmacotherapy and/or
    referral to behavioral health treatment provider for psychotherapy.
    Score of 15-19 = Moderately severe depression
    Action: Active treatment with pharmacotherapy and/or referral to behavioral health treatment provider for psychotherapy.
    Score of 20-27 = Severe depression. 
    Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to a behavioral health treatment provider for psychotherapy and/or collaborative management.
    Anxiety GAD-2* Anxiety Screen
    - 2 Questions
    Score of 0-2 = Negative Screen 
    Action: None 
    Score of 3+ = Positive screen 
    Action: Administer the GAD-7. 
    GAD-7* Anxiety Screen
    - 7 Questions
    Score of 1-4 = Minimal anxiety
    Action: Watchful waiting; repeat GAD-7 at follow-up visit.
    Score of 5-9 = Mild anxiety
    Action: Watchful waiting; repeat GAD-7 at follow-up visit.
    Score of 10-14 = Moderate anxiety
    Action: Further diagnostic assessment by PCP or behavioral health treatment provider. Consider pharmacotherapy and/or psychotherapy. 
    Score of 15-21 = Severe anxiety
    Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to a behavioral health treatment provider for psychotherapy and/or collaborative management.
    Substance
    Abuse
    NIDA-
    Quick Screen
    **
    Alcohol/Drug and Tobacco Screen
    - 4 Questions
    If respondent indicates "No" for all drugs in prescreen.
    Action: Reinforce abstinence.
    If respondent indicates "Yes" to any of the drugs listed.
    Action: Review current list of medications to ensure medications prescribed are not at risk for abuse. Consider referral to behavioral health treatment provider.
    CAGE-AID*** Alcohol/Drug Screen
    - 4 Questions
    1 or more "Yes" responses are a positive screen.
    Action: Consider further assessment and/or referral to behavioral health treatment provider.
    Suicidality
    CSSRS - Clinical Screener**** Suicide Severity Screen, Clinical Practice Screen
    - 6 Questions
    1 or more "Yes" responses are a positive screen.
    Action: Refer to behavioral health treatment provider to evaluate risk factors and determine appropriate treatment setting.
    A "Yes" response to question #4 or #5 in the past month or any behavior in question #6 is an indication of severe risk.
    Action: Refer to behavioral health treatment provider to evaluate for hospitalization.

    Our Physician Pocket Reference, a comprehensive booklet that incorporates all of these screening tools, is available for your use. We hope you find it useful in your practice.

    * Spitzer, R.; Williams, J.B.W.; Kroenke, K. and colleagues, with an educational grant from Pfizer. No permission required to reproduce, translate, display or distribute.
    ** National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.
    *** Used / reprinted with permission from Brown, R.L., and Rounds, L.A.
    **** Developed by Drs. Posner, K.; Brent, D.; Lucas, C.; Gould, M.; Stanley, B.; Brown, G.; Fisher, P.; Zelazny, J.; Burke, A.; Oquendo, M.; Mann, J.

    Additional Behavioral Health Screening Resources

    Measures

    Tool

    About the Tool

    Scoring and Action Steps

    Depression

    PHQ-A

    Depression Screen
    - 9 Questions
    (Adolescents)

    See instructions for more information.

    Depression

    EPDS

    Postnatal Depression Screen
    - 10 Questions

    See instructions for more information.

    Substance Use

    ORT

    Opioid Use Screen
    - 5 Questions

    See instructions for more information.

    Substance Use

    ASSIST

    Substance Use Screen
    - 8 Questions

    See instructions for more information.

    Substance Use

    AUDIT-C

    Alcohol Screen
    - 3 Questions

    See instructions for more information.

    Substance Use

    AUDIT

    Alcohol Screen
    - 10 Questions

    See instructions for more information.

    Substance Use

    MSSI-SA

    Alcohol/Drug Screen
    - 16 Questions

    See instructions for more information.

    Substance Use

    NIAAA

    Alcohol Screen
    - 3 Questions

    See instructions for more information.

    Substance Use

    SOAPP

    Opioid Screen
    - 14 Questions

    See instructions for more information.

    Suicidality

    CSSRS- Pediatric Lifetime /Recent

    Suicide Severity Screen, Initial Visit
    - 5 Questions

    See instructions for more information.

    Suicidality

    CSSRS-Pediatric Since Last Visit

    Suicide Severity Screen, Since Last Visit
    - 5 Questions

    See instructions for more information.

    Suicidality

    CSSRS- Risk Assessment Page

    Protective and Risk Factors Checklist for Suicidality

    See instructions for more information.

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