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Mental Health Screening Tools

Updated July 2013

Screening Tools for Completing Mental Health Assessments in HIV Primary Care Settings
Abbreviation (Full Name) Screens for: Administered by: Items/Minutes Notes
BAI
(Beck Anxiety Inventory)
Anxiety Patient 21 items,
5 minutes
BDI-II
(Beck Depression Inventory-II)
a
Depression Patient 21 items,
10 minutes
The most widely accepted measure of depressive distress. Originally developed for use as a measure of symptom severity in psychiatric patients, it has also been used in numerous studies of depression in medically ill patients.1
BSI 18
(Brief Symptom Inventory 18)
Depression, anxiety, somatization Patient 18 items,
4 minutes
For pts >18 years
CDQ
(Client Diagnostic Questionnaire)
Depression, anxiety, post-traumatic stress disorder, psychosis, alcohol and substance use, and general health worries Trained assistant 15-20 minutes
CESD-R
(Center for Epidemiologic Studies Depression
Scale Revised)
a
Depression Patient 20 items Originally designed for use in nonpsychiatric community samples. It may be the most widely used screening instrument in North America. It has also been used extensively in medically ill samples, with evidence of good psychometric properties. Studies support the value of CES in the medically ill, although the positive predictive value has been relatively low in some studies, and a lack of consensus remains about the optimal cutoff score.1
DRS-2
(Dementia Rating Scale-2)
Measure cognitive status in adults with cognitive impairment Patient 5 subscales
(36 items total)
DUKE-AD
(Duke Anxiety-Depression Scale)
Depression, anxiety Patient 7 items
HADS
(Hospital Anxiety and Depression Scale)
a
Depression, anxiety Patient 14 items Specifically designed for use in the medically ill. A lack of consensus exists about the utility of the HADS and about the optimal cutoff scores to screen for major and minor depression.1
HAM-D/HDI
(Hamilton Rating Scale for Depression)
Depression, anxiety, suicidal ideation, insomnia, diminished appetite, weight loss, obsessive compulsive behavior Clinician 21 items Widely used in psychiatric research. Has high reliability and validity for diagnosing and monitoring clinical depression.
HANDS
(Harvard Dept. of Psychiatry, NDSD Scale)
Depression (other tools available) Patient or assistant 10 items
HDS
(HIV Dementia Scale)
HIV-associated dementia Clinician 4 areas
(16 points)
Timed written alphabet, recall, cube copy time, antisaccadic error task; most users choose the shortened version (MHDS; described below), deleting the antisaccadic error task, which is difficult to administer and score.
IHDS
(International HIV Dementia Scale)
HIV-associated dementia Clinician 3 areas
(12 points)
Can be administered by non-neurologists and may detect early motor and cognitive slowing.2
Mental Alternation Test HIV-associated dementia Clinician Patients with early dementia usually will show impairments in timed trials, such as this test.1
MHDS
(Modified HIV Dementia Scale)
HIV-associated dementia Clinician 4 areas
(12 points),
5-7 minutes
Memory-registration, psychomotor speed, memory-recall, constructional; omits the antisaccadic item in the HDS (described above).
MMSE
(Mini-Mental State Exam)
Cognitive status/ability Interviewer 11 items This is the most widely used and tested brief battery for cortical impairment, but has lower sensitivity with signs of subcortical impairment, such as slowing and motor abnormalities.
PHQ-2
(Patient Health Questionnaire-2)
Depression Patient or assistant 2 items A PHQ-2 score of 3 or greater was found to have a sensitivity of 83% and specificity of 92% for major depression in a sample of primary care and OB-GYN clinic patients.1
PHQ-9
(Patient Health Questionnaire-9)
a
Depression Patient or assistant 9 items Specifically designed for the primary care setting, it has been studied in thousands of primary care and medical specialty outpatients. Spanish version has also been validated.1
PHQ-15
(Patient Health Questionnaire-15)
Somatic Symptom Severity Scale Patient or assistant 15 items Details symptoms that account for 90% of somatic symptoms encountered in the primary care setting.1
PRIME-MD
(Primary Care Evaluation of Mental Disorders)
Depression, anxiety, alcohol, eating disorders Patient or assistant 3 pages,
5 minutes
SAMISS
(Substance Abuse and Mental Illness Symptoms Screener)
b
Co-occurring substance and mental health disorders Trained assistant 13 items Designed to detect symptoms of co-occurring substance use and mental health disorders.3
ZUNG
(Zung Self-Rating Depression Scale)
Depression, insomnia, diminished appetite, weight loss, diminished self-esteem, suicidal ideation, anhedonia Patient 20 items
a Any of these instruments (CESD-R, HADS, PHQ-9, BDI-II) may be acceptable to screen for depression in the medically ill, although the evidence for the utility of the HADS is less strong than for the CES and BDI-II. The PHQ has better sensitivity and specificity than the HADS. The cutoff score used on any of these instruments should depend on the purpose of screening and resources for follow up.1
b For other alcohol- and substance use-related screening tools, see the substance use clinical guidelines Screening and Ongoing Assessment for Substance Use.

References
1. Levenson JL, ed. Textbook of Psychosomatic Medicine. American Psychiatric Publishing, Inc.; 2005.
2. Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry 2001;58:721-728. [PubMed]
3. Whetten K, Reif S, Swartz M, et al. A brief mental health and substance abuse screener for persons with HIV. AIDS Patient Care STDS 2005;19:89-99. [PubMed]




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