The PHQ-9, a nine-item self-report depression scale, is often used both for client screening and for tracking progress through treatment, using the initial score as a baseline. Based on the DSM-IV diagnostic criteria for major depression, it has been extensively field-tested and is available in multiple languages. Some clinicians prefer to use only the first two items (asking how often in the past two weeks the respondent has had “little interest or pleasure in doing things” and has been “feeling down, depressed or hopeless”), then following up with the remaining seven items if an affirmative response is given. [The abbreviated version is known as the PHQ-2.]
While the PHQ-9 appears to be the most widely used instrument to detect depression among primary care clients, others include the Geriatric Depression Scale, the Center for Epidemiologic Studies Depression Scale, theHopkins Symptom Checklist, the Beck Scale for Suicidal Ideation and the Beck Depression Inventory. The MacArthur Foundation has developed a tool kit for treating depression as part of their Depression in Primary Care Initiative.
Mood, Anxiety and PDST
The Beck Anxiety Inventory was developed to quickly assess the severity of patient anxiety. It was designed to discriminate anxiety from depression by focusing on anxiety symptoms minimally associated with those of depression. On the 21-item scale, covering both the physiological and cognitive components of anxiety, respondents rate the degree to which they’ve been bothered by described symptoms. Several other tools used as screening devices, like the Clark-Beck Obsessive-Compulsive Inventory, the Penn State Worry Questionnaire, and thePDST Checklist can also serve as progress monitors. The Mood Disorder Questionnaire, developed by Robert Hirschfeld MD, is primarily used to identify clients who may have a bipolar disorder. Other measures of anxiety include the GAS-7, a seven-item self-administered questionnaire which gauges generalized anxiety, and the DASS-21, measuring anxiety along with depression and stress.
Most substance abuse instruments are screening tools rather than outcome measures, given that treatment results can be easily ascertained by asking clients whether they are currently using drugs or drinking and, if so, how much. A popular 6-question tool to determine drug and alcohol use by adolescents is the CRAFFT, developed and copyrighted by Children’s Hospital of Boston. Both the TWEAK and the Alcohol Dependence Data Questionnaire measure alcohol usage and the simple four-question survey CAGE gives an indication of when the possibility of alcoholism should be investigated further.
A version of the GAS (above) has been adapted for children (the Children’s Global Assessment Form or C-Gas). A psychosocial screening tool, the Pediatric Symptom Checklist (PSC) can, like other such measures, also chart emotional, behavioral and cognitive progress through the course of treatment. Completed by clinicians, the PSC consists of 35 descriptive statements rated on frequency of occurrence. The Child Depression Inventory(CDI), a symptom-oriented instrument for assessing depression in children between the ages of seven and 17 years, consists of 27 items, but a 10-item short form is also available as a screener.
The startling fact that persons with serious mental disorders are dying, on average, 25 years earlier than the general population has generated a call to action by both clinicians and researchers. The National Association of State Mental Health Program Directors commissioned a report to guide them in assessing the physical health of this population. The 2008 report, Measurement of Health Status of People with Severe Mental Illness, was written by Barbara Mauer and edited by Joe Parks MD.
To assist mental health and primary care collaboration in identifying and treating cardiovascular disease among persons with serious mental health disorders, CalMEND in California proposed measurement strategies for assessing both clinical outcomes and adherence to program objectives. Data-gathering guidelines for measures such as statin use, blood pressure control, risk behavior screening and smoking cessation counseling are also included.For more information, go to the System-wide Collaboration section of this website.
Assessing Systems Integration
To assist the collaboration between public mental health services and primary care, Barbara Demming Lurie of IBHP developed a synthesis of process and outcome measures, both physical and mental health, which can be used as a menu of possible options in evaluating the success of collaborative relationships between the two systems. For a broader discussion of measurements and data systems that support integrated health care delivery, see Integrated Policy Initiative: Behavioral Health Measurement Project (2011), prepared by Karen Linkins et al., for IBHP.