Symtoms and Risk Screening Tools

Description

• Contributes to the analysis of occupational performance.

• Brief standardized information about CLIENT FACTOR and safety conditions under which OT management may work.

• They tell us WHAT may be interfering, while occupation-based assessment tells us HOW it is interfering with performance/participation.

Screening

• Screening is deliberately brief and over-inclusive.

• These tools are built to favor sensitivity over specificity

  • A positive result is a flag, NOT a diagnosis

  • A negative result does NOT rule out a problem if performance impairment is observed.

Tool: Cognition

1. BPRS - Brief Psychiatric Rating Scale

BPRS (Cognition)

Brief Psychiatric Rating Scale

Assesses: Severity of a Broad Range of Psychiatric Symptoms

• Somatic concern, Anxiety, Emotional withdrawal, Conceptual disorganization, Guilt, Tension, Mannerisms/posturing, Grandiosity, Depressive mood, Hostility, Suspiciousness, Hallucinatory behavior, Motor retardation, Uncooperativeness, Unusual thought content, Blunted affect, Excitement, Disorientation

Score: 18 items (used to be 16 back in 1962)

Administration: 20-30 mins

• Clinician-rated

• Interview + observation

Scoring & Interpretation:

• 0 = not assessed

• 1 = bit present

• 7 = extremely severity

• Higher total = greater severity

Important: There is no specified cutoff. Interpret the symptoms profile and changes across repeated rating.

Tool: Mood, Anxiety, Trauma, and Sleep (MATS)

1. BDI-II - Beck Depression Inventory-II

2. GAD-7 - Generalized Anxiety Disorder

3. PHQ-9 - Patient Health Questionnaire-9

4. PCL-5 - PTSD Checklist for DSM-5

5. PSQ1 - Pittsburgh Sleep Quality Index

BDI-II (mats)

Beck Depression Inventory-II

Assesses: Severity of depressive symptoms

• Cognitive-Affective Symptoms

• Somatic-Vegetative Symptoms

Score: 21 items

Administration: 5-10 minutes

• Past 2 weeks

• Self-report

Scoring & Interpretation:

• Minimal = 0-13

• Mild = 14-19

• Moderate = 20-28

• Severe = 29-63

Important: Any endorsement of the suicidal-ideation item requires immediate risk screening using C-SSRS and escalation, regardless of the total score.

GAD-7 (mats)

General Anxiety Disorder-7

Assesses: Frequency of generalized anxiety symptoms.

• Nervousness, Uncontrollable worry, Worrying about different things, Difficulty relaxing, Restlessness, Irritability, Fear something awful might happen

Score: 7 items

Administration: 2-3 minutes

• Past 2 weeks

• Self-report

• Final item about functional difficult is not scored.

Scoring & Interpretation:

• Minimal = 0-4

• Mild = 5-9

• Moderate = 10-14

• Severe - 15-21

• ≥10 = cut-point for probable GAD

  • Reported sensitivity: 89%

  • Reported specificity: 82%

PHQ-9 (mats)

Patient Health Questionnaire-9

Assesses: The 9 DSM criteria for a major depressive episode, rated according to frequency.

• Also includes an unscored question about interference with":

  • Work, Home Life, and Relationships

Score: 9 items

• Item 9: Asks about thoughts of self-arm or being better off dead.

Administration: 2-3 minutes

• Past 2 weeks

• Self-report

Scoring & Interpretation:

• None to Minimal = 0-4

• Mild = 5-9

• Moderate = 10-14

• Moderately Severe = 15-19

• Severe = 20-27

• ≥10 = Sensitivity and Specificity for major depression were both reported as 88%

• Any endorsement → C-SSR + Escalation

PCL-5 (mats)

PTSD Checklist for DSM-5

Assesses: PTSD symptoms clusters

1. Intrusion (memories, dreams, flashbacks, reactivity)

2. Avoidance

3. Negative Alterations in Cognition & Mood

4. Alterations in Arousal and Reactivity (hypervigilance, startle, concentration, sleep, irritability, reckless behavior)

Score: 20 items

Administration: 5-10 minutes

• Past month

• Self-report

Scoring & Interpretation

• 0 = Not at all → 4 = Extremely

• Total: /80

• A provisional PTSD cutoff of approximately 31-33 is commonly used, but it is setting-dependent

• A 10-20 point change = clinically meaningful

PSQI (mats)

Pittsburgh Sleep Quality Index

Assesses: Sleep quality and disturbance

1. Subjective sleep quality

2. Sleep latency

3. Sleep duration

4. Habitual sleep efficiency

5. Sleep disturbances

6. Use of sleep medication

7. Daytime dysfunction

Score: 19 self-rated items + 5 bed-partner items

Administration: 5-10 minutes

• Past month

Scoring & Interpretation

• 0 = No difficulty → 3 = Severe difficulty

• Global Score: 0-21

• Higher score = worse sleep quality

• >5 = poor sleep quality

Note: Don't look only at the global score alone. Examine the component profile to determine where the sleep problem occurs.

Tool: Self-Harm and Safety

1. ISAS - Inventory of Statements About Self-Harm

2. C-SSRS - Columbia-Suicide Severity Rating Scale

ISAS (shs)

Inventory of Statement About Self-Harm

Assesses: Non-suicidal self injury (NSSI)

• Section 1

  • Lifetime frequency of 12 NSSI behaviors

  • Descriptive features

• Section 2

  • 39 items

  • Measures 13 functions of NSSI

Functions:

1. Intrapersonal

2. Interpersonal

Score: 2 sections

Administration: 10-15 minutes

• Self-report

• Sensitive administration

Scoring & Interpretation

• Each function = 0-6

• Higher-scoring functions describe why the self-injury occurs

• Positive ISAS ≠ suicide assessment (requires a separate suicide-risk screen)

C-SSRS (shs)

Columbia-Suicide Severity Rating Scale

Assesses Suicide Risk through:

1. Severity of Suicidal Ideation

2. Intensity of Ideation

3. Suicidal Behavior (NSSI is rated separately)

Administration: 2-5 minutes

• Lifetime/recent time frames

• Interview

Scoring & Interpretation

• NO SUMMED SCORE

• Risk is triaged using:

  • Highest ideation item endorsed

  • Suicidal behavior

  • Receny

• Global Score: 0-21

• Ideation items 3–5 OR any recent suicidal behavior → high risk requiring immediate escalation according to facility protocol.

Tool: Substance Use

1. DAST/DAST-10 - Drug Abuse Screening Test

2. MAST - Michigan Alcoholism Screening

3. FTDN - Fagerstrom Test for Nicotine Dependence

DAST/DAST-10 (su)

Drug Abuse Screening Test

Assesses: Problems and consequences related to drug use other than alcohol.

Score: 10 items

Administration: 2-5 minutes

• Past 12 months

• Self-report

Scoring & Interpretation

• No problems reported = 0

• Low = 1-2

• Moderate = 3-5

• Substantial = 6-8

• Severe = 9-10

• >3 = further assessment

• Cutoff of 6 is generally used across versions for a probable drug-use problem requiring full assessment

MAST (su)

Michigan Alcoholism Screening Test

Assesses: Lifetime alcohol-related problems

Score: 25 items

Administration: 10-15 minutes

• Lifetime

• Self-report

Scoring & Interpretation

• Non-alcoholic = 0-3

• Suggestive of Alcoholism = 4

• Alcoholism = ≥5

Note: Because the timeframe is lifetime, a high score does not establish that the problem is current.

FTND (su)

Fagerström Test for Nicotine Dependence

Assesses: Physical dependence on nicotine.

Score: 6 items

Administration: ~2 mins

• Self-report

Scoring & Interpretation

• Total: /10

  • Very Low = 0-2

  • Low = 3-4

  • Moderate = 5

  • High = 6-7

  • Very High = 8-10

• Higher scores predict greater withdrawal severity and need for more intensive cessation support.

Tool: Medication Adherence

1. MMS - Modified Morisky Scale

MMS (ma)

Modified Morisky Scale

Assesses: Medication-taking behavior through two dimensions.

1. Motivation

2. Knowledge

Score: 6 yes/no items

Administration: <2 mins

• Interview

Scoring & Interpretation

• Two separate sub scores:

  • Motivation = 0-3

  • Knowledge = 0-3

• For each:

  • Low = 0-1

  • High = 2-3