Mental Health Status and Signs of Alcohol Abuse Screening Tools

Depression Screening Tools

PHQ-2 and PHQ-9

What is the PHQ-2?

Asks 2 questions; over the past two weeks, how often have you been bothered by any of the following problems?

• Little interest or pleasure in doing things

• Feeling down, depressed, or hopeless

What is the PHQ-9?

Consists of 9 items, scored 0 (not at all), to 3 (nearly every day)

Scores 0-27

Alcohol Use Disorders Identification Test (AUDIT)

10-item screening tool used to assess alcohol consumption, drinking behaviors, and alcohol-related problems

• 3 questions on the amount and frequency of drinking

• 3 questions on alcohol dependence

• 4 questions on problems caused by alcohol

A score of 8+ is considered to indicate harmful alcohol use

Level of Consciousness

Alert, Lethargic, Obtunded, Stupor, and Coma

Alert Findings

Clients’ eyes are open, able to ask and answer questions, maintains eye contact

Lethargic Findings

Client opens eyes, answers questions, but falls back to sleep quickly

Obtunded Findings

Client opens eyes to loud voices, responds slowly to questions

Stupor Findings

Client awakens to painful stimuli but returns to sleep

Coma Findings

Unresponsive to painful/noxious stimuli

Glasgow Coma Scale

Neurological scale to record the conscious state of a person

Scored on:

• Eye opening

• Most appropriate verbal response

• Motor responses

The lowest possible score is 3 = deep coma

The highest possible score is 15 = fully awake

Primary Care Posttraumatic Stress Disorder (PTSD) Screen for DSM-5 (PC-PTSD-5)

Requires to inquire about any unusual or traumatic events

• If no, screen total = 0

• If yes, ask further questions (yes/no)

  • Nightmares

  • Avoid situations that remind you of the event

  • Been constantly on guard or easily started?

  • Felt numb or detached from people, activities, or surroundings

  • Felt guilty or unable to stop blaming yourself or others for the events?

• If yes to 3 of 5 questions → probable PTSD

Quick Inventory of Depressive Symptomatology

Provides a quick inventory of depressive symptomatology

Interpretation

• 0-5 no risk

• 6-10 mild

• 11-15 moderate

• 16-20 severe

• 21-27 very severe

Geriatric Depression Scale

30-item questionnaire in which participants are asked to respond yes or no in reference to how they felt over the past week

Screening instrument, and if + will need a more in-depth assessment

Scoring 0-10 within normal range

11+ possible depression

SAD Persons Suicide Risk Tool

Assessment guide used to asses the likelihood of a suicide attempt

Risk Factors:

• Sex

• Age

• Depression

• Previous attempt

• Sickness

• Organized plan

• No social support

Mini-Cog Test

3-minute test

Detects cognitive impairment

Clients’ will do the following:

• Remember three unrelated words

• Draw a clock with a specific time

• Repeat the three previously stated words

Score is based on:

• Ability to recall words (0-3)

• Clock drawing score (0-2)

• A total score of 0, 1, or 2 indicated higher likelihood of clinically important cognitive impairment

Saint Louis University Mental Status (SLUMS)

Brief oral/written exam given to people that are suspected to have dementia or Alzheimer’s Disease

Quick measure to evaluate cognitive function

Score depends on level of education

• 27-30 (high school education) and 20-30 (less than high school education) is considered normal

Confusion Assessment Method (CAM)

Delirium is usually under-recognized and underdiagnosed

Standardized form that is reliable and valid

The CAM includes four features to determine delirium

• 1 Acute onset fluctuating course

• 2 Inattention

• 3 Disorganized thinking

• 4 Altered LOC

Delirium = 1 + 2 + (3 or 4)

Clinical Institute Withdrawal Scale (CIWA)

10-item scale

• Nausea, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and orientation

Higher scores correlate to the severity of alcohol withdrawal