Mental Health Screening Tools

BAI (Beck Anxiety Inventory): Patient-administered; 21 items; 5 minutes

BDI-II (Beck Depression Inventory-II) [a]: Patient-administered; 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): Patient-administered; 18 items, 4 minutes

  • Screens for depression, anxiety, Somatization
  • For patients >18 years of age.

CDQ (Client Diagnostic Questionnaire): Trained assistant-administered; 15-20 minutes

  • Screens for: depression,  anxiety, PTSD, psychosis, alcohol and substance use, general health worries

CESD-R (Center for Epidemiologic Studies Depression Scale Revised) [a]: Patient-administered; 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): Patient-administered; 14 items

  • Screens for depression, anxiety
  • 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): Clinician-administered; 21 items

  • Screens for: Depression, anxiety, suicidal ideation, insomnia, diminished appetite, weight loss, obsessive compulsive behavior
  • Widely used in psychiatric research.
  • High reliability and validity for diagnosing and monitoring clinical depression.

HANDS (Harvard Dept. of Psychiatry, NDSD Scale): Patient or clinician-administered; 10 items

  • Screens for depression
  • Other tools available

HDS (HIV Dementia Scale): 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): Clinician-administered; 3 areas (12 points)

  • Can be administered by non-neurologists
  • May detect early motor and cognitive slowing [2].

Mental Alternation Test: Clinician-administered

  • Screens for HIV-associated dementia
  • Patients with early dementia usually will show impairments in timed trials, such as this test [1].

MHDS (Modified HIV Dementia Scale): Clinician-administered; 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): Interviewer-administered; 11 items

  • Screens for cognitive status/ability
  • 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): Patient- or assistant-administered; 2 items

  • Screens for depression
  • 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]: Patient- or assistant-administered; 9 items

  • Screens for depression
  • 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): Patient- or assistant-administered; 15 items

  •  Somatic symptom severity scale
  •  Details symptoms that account for 90% of somatic symptoms encountered in the primary care setting [1].

PRIME-MD (Primary Care Evaluation of Mental Disorders): Patient- or assistant-administered; 3 pages; 5 minutes

  • Screens for depression, anxiety, alcohol, eating disorders

SAMISS (Substance Abuse and Mental Illness Symptoms Screener) [b]: Administered by trained assistant; 13 items

  •  Designed to detect symptoms of co-occurring substance use and mental health disorders [3].

ZUNG (Zung Self-Rating Depression Scale): Patient-administered; 20 items

  • Screens for depression, insomnia, diminished appetite, weight loss, diminished self-esteem, suicidal ideation, anhedonia


  1. 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]
  2. For other alcohol- and substance use-related screening tools, see the substance use clinical Screening and Ongoing Assessment Guideline.
  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]