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  • Behavioral Health Services > Behavioral Health Screening Tools

    Behavioral Health Screenings for Patients

    The role of health care professionals has evolved to include discussing and addressing mental health and substance use disorders with patients. In fact, the relationships that patients have with their doctors and other health care professionals have proven to be one of the most important factors in ensuring individuals receive appropriate behavioral health care.

    Recognizing the signs of a behavioral health condition is not always easy. We are providing you with the following behavioral health screening tools to help you diagnose and refer individuals for further care.


    Measure

    Tool

    About the Tool

    Scoring and Action Steps

    Depression

    PHQ-21

    Depression Screen - 2 Questions

    Score of 0-2 = Negative screen
    Action: None
    Score of 3+ = Positive screen
    Action: Administer the PHQ-91.

    PHQ-91

    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. Possible referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
    Score of 10-14 = Moderate depression
    Action: Develop treatment plan, consider pharmacotherapy and/or
    referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
    Score of 15-19 = Moderately severe depression
    Action: Active treatment with pharmacotherapy and/or referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
    Score of 20-27 = Severe depression
    Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.
    Positive score on Item 9.
    Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.

    PHQ-9 - Modified for Teens2

    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. Possible referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
    Score of 10-14 = Moderate depression
    Action: Develop treatment plan, consider pharmacotherapy and/or
    referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
    Score of 15-19 = Moderately severe depression
    Action: Active treatment with pharmacotherapy and/or referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
    Score of 20-27 = Severe depression
    Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.
    Positive score on Item 9.
    Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.

    Edinburgh Postnatal Depression Scale3

    Depression Screen - 10 Questions

    Score of 0-9 = Low probability of depression
    Action: Watchful waiting; repeat Edinburgh Postnatal Depression Scale at follow-up visit.
    Score of 10-30 = High probability of moderate to severe depression
    Action: Develop treatment plan, possible active treatment with pharmacotherapy and/or referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
    If a patient scores a 1, 2, or 3 on question 10, please address suicidal thoughts immediately.
    Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.

    Geriatric Depression Scale (GDS)4

    Depression Screen - 15 Questions

    Score of 1-4 = Minimal depression
    Action: Watchful waiting; repeat GDS at follow-up visit.
    Score of 5-15 = Mild to severe depression
    Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.

    Anxiety

    GAD-21

    Anxiety Screen -
    2 Questions

    Score of 0-2 = Negative Screen 
    Action: None 
    Score of 3+ = Positive screen 
    Action: Administer the GAD-7.1 

    GAD-71

    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 care professional. 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 behavioral health care professional for psychotherapy and/or collaborative management.

    Substance
    Abuse/ Dependence

    NIDA-
    Quick Screen
    5

    Alcohol/Drug and Tobacco Screen -
    4 Questions (Single Question Screener Included)

    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. Provide brief counseling (5-15 minutes) to help the patient develop a plan to reduce drinking, identify high-risk situations, and learn coping strategies. Consider referral to behavioral health care professional within 60 days of positive screen.

    AUDIT-C6

    Alcohol Screen - 3 Questions

    Score of 0-3 in Men / Score of 0-2 in Women = Minimal to moderate use. Low probability of abuse or dependence.
    Action: Reinforce abstinence. Watchful waiting; repeat AUDIT-C at follow-up visit.
    Score of 4-12 in Men / Score of 3-12 in Women =Moderate to severe use. High probability of abuse or dependence.
    Action: Review current list of medications to ensure medications prescribed are not at risk for abuse. Provide brief counseling (5-15 minutes) to help the patient develop a plan to reduce drinking, identify high-risk situations, and learn coping strategies. Consider referral to behavioral health care professional within 60 days of positive screen.

    Substance Use

    AUDIT7

    Alcohol Screen - 10 Questions

    Score of 1-7 = Minimal to moderate use. Low probability of abuse or dependence.
    Action: Reinforce abstinence. Watchful waiting; repeat AUDIT at follow-up visit.
    Score of 8-15 = Moderate to severe use. Moderate probability of abuse or dependence.
    Score of 16-19 = Moderate to severe use. Moderate to high probability of abuse or dependence.
    Score of 20-40 = Severe use. High probability of abuse or dependence.
    Action steps for scores of 8 or higher:
    Review current list of medications to ensure medications prescribed are not at risk for abuse. Provide brief counseling (5-15 minutes) to help the patient develop a plan to reduce drinking, identify high-risk situations, and learn coping strategies. Consider referral to behavioral health care professional within 60 days of positive screen.

    Suicidality

    CSSRS - Clinical Screener8

    Suicide Severity Screen, Clinical Practice Screener - Recent - 6 Questions

    1 or more “Yes” responses are a positive screen.
    Action:
    Refer to behavioral health care professional 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 care professional 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.

    Please also consult the Beacon Health Options PCP Toolkit for additional resources.

    1Spitzer, R.; Williams, J. B.W.; Kroenke, K. and colleagues, with an educational grant from Pfizer. No permission required to reproduce, translate, display, or distribute. 2Johnson J.G., Harris E.S., Spitzer R.L., Williams, J.B.W.: The Patient Health Questionnaire for Adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolescent Health 30:196–204, 2002. 3Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786. and K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199. 4Yes average: The Use of Rating Depression Series in the Elderly, in Poon (ed.): Clinical Memory Assessment of Older Adults, American Psychological Association, 1986. 5National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. 6Bradley, K. A., Bush, K. R., Epler, A. J., et al (2003). Two brief alcohol-screening tests from the Alcohol Use Disorders Identification Test (AUDIT): Validation in a female Veterans Affairs patient population. Arch Intern Med. 163:821-9 and Bush, K., Kivlahan, D.R., McDonell, M.B., et al (1998). The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Arch Intern Med. 158:1789-95. 7Babor, T.F.; de la Fuente, J.R.; Saunders, J.; and Grant, M. AUDIT. The Alcohol Use Disorders Identification Test. Guidelines for use in primary health care. Geneva, Switzerland: World Health Organization, 1992. 8Developed 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

    CES-D

    Depression Screen - 20 Questions

    See instructions for more information.

    Depression

    MFQ

    Depression Screen - Several Versions

    See instructions for more information.

    Substance Use

    ORT

    Opioid Use Screen - 5 Questions

    See instructions for more information.

    Substance Use

    CAGE-AID

    Alcohol Screen - 4 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

    C-SSRS - Pediatric Lifetime /Recent

    Suicide Severity Screen, Initial Visit - 5 Questions

    See instructions for more information.

    Suicidality

    C-SSRS - Pediatric Since Last Visit

    Suicide Severity Screen, Since Last Visit - 5 Questions

    See instructions for more information.

    Suicidality

    C-SSRS - Risk Assessment Page

    Protective and Risk Factors Checklist for Suicidality

    See instructions for more information.

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