Measurement-based Care Mental Health Patient Rating Scales

As mental health professionals, we need reliable tools to accurately assess and track the severity of our patients' symptoms. That's where rating scales come in. These standardized tools exist for most psychiatric conditions.

Osmind maintains a library of not only patient reported scales, but clinically administered measures as well. New surveys are regularly added to the library.

What's covered in this guide to mental health rating scales:

1) Popular mental health rating scales included in Osmind and when to use them.

2) Scoring Criteria for each mental health rating scale.

2) CPT or HCPCS codes can be used for the surveys.

3) Recommended sending frequency and other background information for each survey.

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What type of mental health patient rating scales are there?

Osmind has two types of surveys:

1) Patient-reported surveys - In Osmind a clinical user can request a patient-reported survey from their patients. When a survey is requested from a clinical user the patient will get a notification to complete the survey. When a patient opens the notification or patient app they'll be prompted to complete the survey. Once completed, the survey results are automatically transmitted back into Osmind. Patient surveys can be configured to be sent to patients at regular intervals.

2) Clinically administered surveys** - Some surveys are not available to send to patients because they are designed to be completed by a clinician. (Denoted by ** in the table below.)

Note: Clinical users can complete patient-reported surveys on behalf of their patients. This may be the case if a patient does not have access to a phone or computer, or if a patient filled out the survey with a physical pen and paper and the survey needs to be transcribed into Osmind.

Below is a list of surveys that are currently available in the Osmind EHR.
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ACE: Adverse Childhood Experiences

This is a widely used 10-item self-report scale used to identify childhood experiences of abuse, neglect and household dysfunction.

• Higher ACE Scores have been associated with increased levels of multiple health risks later in life.

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Score Ranges for the ACE:

• 0-3 without associated health conditions: Low Risk
• 1-3 with associated health conditions: Intermediate risk
• 4+ with or without associated health conditions: High Risk

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• Reference: Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258.

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ASRS v1.1: Adult ADHD Self-Report Scale Symptom Checklist

The 18 questions on the ASRS v1.1 are consistent with DSM-IV criteria and address the manifestations of ADHD symptoms in adults.

• If Part A (questions 0-6) is greater than or equal to 4, the patient has symptoms highly consistent with ADHD in adults and further investigation may be warranted.

• Age Range: 18 and up

• Reference: Schweitzer JB, et al. The Adult ADHD Self-Report Scale (ASRSv1.1). Med Clin North Am. 2001; 85(3): 757-777

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BDI-II: Beck Depression Inventory-2

A widely used 21-item self-report instrument for measuring the severity of depression in adults and adolescents.

• Age Range: 13-80 years

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Score ranges for the BDI-II:

• 0–13: minimal depression
• 4–19: mild depression
• 20–28: moderate depression
• 29–63: severe depression

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• Reference: Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck Depression Inventory–II [Database record]. PsycTESTS.

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BPRS: Brief Psychiatric Rating Scale - 18 item version

The Brief Psychiatric Rating Scale is an 18-item, provider-administered measure designed to assess positive, negative, and affective symptoms of individuals who have psychotic disorders.

• It assesses symptoms over the past 2-3 days.

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Score Ranges for the BPRS:

• 18-30: Not ill
• 31-40: Mildly ill
• 41-52: Moderately ill
• 53 and up: Markedly ill

Recommended notification threshold: 53 or above

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• Reference: Overall, JE, Gorham DR: The Brief Psychiatric Rating Scale (BPRS): recent developments in ascertainment and scaling. Psychopharmacology Bulletin 24:97-99, 1988.

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C-SSRS: Columbia-Suicide Severity Rating Scale: Screener-Recent-Self-Report

Screening tool that patients can complete for review of suicidal ideation and behavior over recent months

• The Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS), supports suicide risk assessment through a series of simple, plain-language questions that anyone can ask.

• Age range: 12 and up

• More information, including other versions of the scale, can be found here

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CAGE Alcohol Abuse Screening

The CAGE is a 4 question screening tool that is used to identify potential problems with alcohol and takes < 1 minute to administer.

• A total score of 2 or greater is considered clinically significant.

• Recommended notification threshold: 2

• Reference: Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984 Oct 12;252(14):1905-7.

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CADSS: Clinician-Administered Dissociative States Scale

The CADSS is a 27-item instrument for the measurement of present-state dissociative symptoms, and is administered by a clinician to assess treatment emergent dissociative symptoms.

• The CADSS was originally developed for use in PTSD and other dissociative disorders.

• It can be used as a repeated measure to assess symptomatology at specific time points.

• The total CADSS score ranges from 0 to 92, with a higher score representing a more severe condition and scores between 0 and 4 are considered to be in the normal range.

• Recommended notification threshold: 5

• Reference: Bremner JD, Krystal JH, Putnam FW, Southwick SM, Marmar C, Charney DS, Mazure CM. Measurement of dissociative states with the Clinician-Administered Dissociative States Scale (CADSS). J Trauma Stress. 1998 Jan;11(1):125-36.

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CADSS-6: Clinician Administered Dissociative States Scale - 6 question version

The CADSS-6 is a simplified 6-Item clinician administered dissociative symptom scale for monitoring dissociative effects of administration of ketamine or esketamine.

• The CADSS-6 was developed from questions 1, 2, 6, 7, 15, and 22 from the full length CADSS.

• Reference: Rodrigues NB, McIntyre RS, Lipsitz O, Lee Y, Cha DS, Shekotikhina M, Vinberg M, Gill H, Subramaniapillai M, Kratiuk K, Lin K, Ho R, Mansur RB, Rosenblat JD. A simplified 6-Item clinician administered dissociative symptom scale (CADSS-6) for monitoring dissociative effects of sub-anesthetic ketamine infusions. J Affect Disord. 2021 Mar 1;282:160-164. doi: 10.1016/j.jad.2020.12.119. Epub 2020 Dec 29. PMID: 33418362.

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CGI: Clinical Global Impression

The CGI provides an overall clinician-determined summary measure that takes into account all available information, including a knowledge of the patient's history, psychosocial circumstances, symptoms, behavior, and the impact of the symptoms on the patient's ability to function.

• Question one is CGI-Severity and Question Two is CGI-Improvement. Scores on each should be looked at separately rather than focusing on an overall score.
• Age range: All ages
• Given its simplicity (just two questions) and wide usage in research settings, consider using the CGI for most psychiatric visits.

Score Ranges for CGI-S:

• 0: Not assessed
• 1:  Normal, not at all il
• 2: Borderline mentally ill
• 3: Mildly ill
• 4: Moderately ill
• 5: Markedly ill
• 6: Severely ill
• 7: Among the most extremely ill patients

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Score Ranges for CGI-I:

• 0: Not assessed
• 1: Very much improved
• 2: Much improved
• 3: Minimally improved
• 4: No change
• 5: Minimally worse
• 6: Much worse
• 7: Very much worse

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• Reference: Guy, William (1976). "Clinical Global Impressions". ECDEU Assessment Manual for Psychopharmacology—Revised. Rockville, MD: U.S. Department of Health, Education, and Welfare; Public Health Service, Alcohol; Drug Abuse, and Mental Health Administration; National Institute of Mental Health; Psychopharmacology Research Branch; Division of Extramural Research Programs. pp. 218-222. OCLC 2344751. DHEW Publ No ADM 76–338

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DAST-10: Drug Abuse Screening Tool

The DAST-10, or the Drug Abuse Screening Test, is a widely-used screening tool used to identify individuals who may be at risk for drug abuse or addiction. It is a 10-item self-report questionnaire that asks individuals to rate how often they have experienced certain problems related to drug use in the past year.

• The questionnaire is designed to be quick and easy to administer, and can be used in a variety of settings, including clinical, research, and educational settings.

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Score Ranges for the DAST-10:

• 0: No problems reported

• 1–2: Low level

• 3–5: Moderate level

• 6–8:Substantial level

• 9–10: Severe level

• Recommended send frequency: At intake and then annually

• Recommended notification threshold: 6

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CPT codes that can be used for the DAST-10:

• If self-administered: 96127

• If administered by the clinician: 96160

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• Reference: Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behavior, 7(4),363–371

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EPDS: Edinburgh Perinatal/Postnatal Depression Scale

The EPDS is a set of 10 screening questions that can indicate whether a parent has symptoms that are common in women with depression and anxiety during pregnancy and in the year following the birth of a child.

• The survey asks about the past 7 days.

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Score Ranges for the EPDS:

• Less than 8: Depression not likely

• 9-11: Depression possible

• 12-13: Fairly high possibility of depression

• 14 and higher: Probably depression

• A score of 1, 2, or 3 on Question 10 suggests a risk of harm to self or to the baby

• Recommended frequency: weekly

• Recommended notification threshold: 14 or above

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• Reference: Cox, J.L., Holden, J.M. and Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.

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ESS: Epworth Sleepiness Scale

The Epworth Sleepiness Scale (ESS) is an 8 item self-administered questionnaire that is used to assess a person's level of daytime sleepiness. It is commonly used to evaluate the severity of sleep disorders, such as obstructive sleep apnea, narcolepsy, and insomnia.

• The ESS asks the respondent to rate the likelihood of dozing off or falling asleep in various situations, such as while sitting and reading, watching television, or sitting in traffic.

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Score Ranges for the ESS:

• 0-7: It is unlikely that you are abnormally sleepy.

• 8-9: You have an average amount of daytime sleepiness.

• 10-15: You may be excessively sleepy depending on the situation. You may want to consider seeking medical attention.

• 16-24: You are excessively sleepy and should consider seeking medical attention.

• Recommended Frequency: every 60 days

• Suggested Notification Threshold: 16

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• CPT code that can be used: 96127

• Reference: Johns MW. A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 1991; 14(6):540-5.

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GAD-7: General Anxiety Disorder-7

Rapid screening for the presence of a clinically significant anxiety disorder (Generalized Anxiety Disorder, Panic Disorder, Social Phobia, PTSD), especially in outpatient settings

• Higher GAD-7 scores correlate with disability and functional impairment (in measures such as work productivity and health care utilization)

• Age range: 12 and up

• Asks about symptoms over the past 2 weeks

• Recommended notification threshold: 15 (0-21 score, with 0-3 points for each of seven questions)

• Here is a list of the questions and information about the scoring scheme.

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Score ranges for the GAD-7

• 0–4: minimal anxiety

• 5–9: mild anxiety

• 10–14: moderate anxiety

• 15–21: severe anxiety

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• Reference: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Intern Med. 2006;166:1092-1097.

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HAM-A: Hamilton Anxiety Scale

The HAM-A is a clinician-administered scale that consists of 14 items, each defined by a series of symptoms, and measures both psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety).

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Score ranges for the HAM-A:

• ≤17: mild anxiety severity.

• 18-24: mild to moderate anxiety severity

• 25-30: moderate to severe anxiety severity

• >30 indicate severe anxiety

• Recommended notification threshold: 30

• Suggested frequency: No more than every 14 days, typically done during a visit

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• CPT code that can be used: 96127
• Reference: Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;32(1):50-5. doi: 10.1111/j.2044-8341.1959.tb00467.x. PMID: 13638508.

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HDRS: Hamilton Depression Rating Scale (HAM-D)

The most widely used clinician-administered depression assessment scale, it contains 17 items pertaining to symptoms of depression experienced over the past week and is designed to track severity over time and response to treatment.

• It was originally developed for hospital inpatients so emphasizes melancholic and physical symptoms of depression. Atypical symptoms of depression such as hypersomnia and hyperphagia are not addressed.

• It should not be used to diagnose depression.

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Score ranges for the HDRS:

• 0-7: Normal

• 8-13: Mild Depression

• 14-18: Moderate Depression

• 19-22: Severe Depression

• 23 and up: Very Severe Depression

• Recommended notification threshold: 19

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• Reference: Hamilton, M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960 Feb;23(1):56-62. doi: 10.1136/jnnp.23.1.56. PMID: 14399272; PMCID: PMC495331.

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Katz ADL: Katz Index of Independence in Activities of Daily Living

The Katz ADL is a widely used graded instrument that assesses six primary and psychosocial functions: bathing, dressing, going to toilet, transferring, feeding, and continence.

• A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe functional impairment.

• The instrument is most effectively used among older adults in a variety of care settings, when baseline measurements, taken when the client is well, are compared to periodic or subsequent measures

• Reference: Katz S, Ford AB, Moskowitz RW. et al. Study of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963;185(12):914-919

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ISEL: Interpersonal Support Evaluation List, General Population

The ISEL consists of a list of 40 statements concerning the perceived availability of potential social resources. The ISEL was designed to assess the perceived availability of four separate functions of social support as well as providing an overall support measure.

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ISEL Scoring

The four 10 item subscales are as follows:

• "Tangible": perceived availability of material aid (2, 9, 14, 16, 18, 23, 29, 33, 35, 39)

• "Appraisal": perceived availability of someone to talk to about one's problems (1, 6, 11, 17, 19, 22, 26, 30, 36, 38)

• "Self-esteem": perceived availability of a positive comparison when comparing one's self to others (3, 4, 8, 13, 20, 24, 28, 32, 37, 40)

• "Belonging": perceived availability of people one can do things with (5, 7, 10, 12, 15, 21, 25, 27, 31, 34)

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• Suggested send interval: 90 days

• CPT code that can be used 96127

• Reference: Cohen, S., & Hoberman, H. (1983). Positive events and social supports as buffers of life change stress. Journal of Applied Social Psychology, 13, 99-125

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Katz ADL: Katz Index of Independence in Activities of Daily Living

The Katz ADL is a widely used graded instrument that assesses six primary and psychosocial functions: bathing, dressing, going to toilet, transferring, feeding, and continence.

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Katz ADL Scoring:

• A score of 6 indicates full function
• 4 indicates moderate impairment
• 2 or less indicates severe functional impairment

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• The instrument is most effectively used among older adults in a variety of care settings, when baseline measurements, taken when the client is well, are compared to periodic or subsequent measures

• CPT code that can be used: 96127

• Reference: Katz S, Ford AB, Moskowitz RW. et al. Study of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963;185(12):914-919

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MADRS: Montgomery-Asberg Depression Rating Scale

A 10 item clinician-rated questionnaire with high interrater reliability, making it useful in both clinical and research settings. It can be used to stratify severity of depressive symptoms and for trending severity of a patient’s depressive episode.

• Not diagnostic for major depressive disorder; rather, can help stratify severity of depressive symptoms and the response to treatment over time.

• Unlike the HAM-D, it does not assess sexual function, hypochondriasis, diurnal variation, or depersonalization, among others but the two scales are highly correlated.

• Age Range: 18 and up

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Score Ranges for the MADRS:

• 0-8: Depressive Symptoms absent

• 9-17: Mild Depression

• 18-34: Moderate Depression

• 35-60: Severe Depression

• Recommended notification threshold: 35

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• Reference: Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979 Apr;134:382-9. doi: 10.1192/bjp.134.4.382. PMID: 444788.

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MSI-BPD: McLean Screening Instrument for BPD

The MSI-BPD is a 10-item self-report screening measure with a cutoff of seven or higher indicating good sensitivity (.81) and specificity (.85) for the borderline diagnosis.

• A score of 7 or more is suggestive of a possible diagnosis of Borderline Personality Disorder.

• Recommended notification threshold: 7 or above

• Reference: Zanarini, MC, Vujanovic, AA, Parachini, EA, Boulanger, JL, Frankenburg, FR, & Hennen, J. (2003). A screening measure for BPD: The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). Journal of Personality Disorders, 17(6), 568-573.

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MOAA/S: Modified Observer’s Assessment of Alertness/Sedation Scale

The Modified Observer's Assessment of Alertness and Sedation (MOAA/S) scale is a validated 6-point scale assessing responsiveness of patients coinciding with the American Society of Anesthesiologists (ASA) continuum of sedation.

• This scale is often used in studies involving esketamine.

• Recommended notification threshold: 2 or less

• Reference: Chernik DA, Gillings D, Laine H, Hendler J, Silver JM, Davidson AB, Schwam EM, Siegel JL. Validity and reliability of the Observer's Assessment of Alertness/Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol. 1990 Aug;10(4):244-51

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Mood Score

Mood (1-10 rating scale, 10 is the best, 1 is the worst)

• We also allow the user to input a journal entry to provide some context around why they may have felt that way on a given day.

• Recommended notification threshold: 1 or 2

• If you already have the other questionnaires set to one week intervals, you might not even need notifications for mood.

• Age range: All Ages

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MEQ30: Mystical Experiences Questionnaire- 30 Item Version

The 30-item revised Mystical Experience Questionnaire (MEQ30) was previously developed within an online survey of mystical-type experiences caused by psilocybin-containing mushrooms and can be administered after psychedelic experiences.

• Scores on the MEQ30 during a psychedelic experience are important because a series of studies have shown that higher scores on the MEQ30 during the ‘trip’ are one of the strongest predictors of beneficial outcomes weeks and months later for both distressed & healthy participants.

• Typically, a ‘complete mystical experience’ is defined as scoring 60% or more on all four MEQ30 subscales although some subsequent research has suggested that simply assessing the total MEQ30 score may be sufficient.

• Reference: Barrett, F. S., et al. (2015). "Validation of the revised Mystical Experience Questionnaire in experimental sessions with psilocybin." Journal of Psychopharmacology 29(11): 1182-1190.

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MLQ: Meaning in Life Questionnaire

A 10-item questionnaire designed to measure two dimensions of meaning in life: (1) Presence of Meaning (how much respondents feel their lives have meaning), and (2) Search for Meaning (how much respondents strive to find meaning and understanding in their lives.

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MLQ Scoring:

• The MLQ does not have cut scores like measures of psychological disorders might have. It is intended to measure meaning in life across the complete range of human functioning.

• Although there is no manual available for the MLQ, a brief guide to scoring and interpreting MLQ results is available.

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• CPT code that can be used: 96127

• Reference: Steger, M. F., Frazier, P., Oishi, S., & Kaler, M. (2006). The meaning in life questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53 (1), 80–93. https://doi.org/10.1037/0022-0167.53.1.80

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NDI: Neck Disability Index

The Neck Disability Index (NDI) is an instrument to measure patient-reported disability secondary to neck pain.

• The instrument has 10 items and patients rate their pain from 0 (no pain) to 5 (worst imaginable pain). Individual item responses are summed to a total score, where 0 points indicate no activity limitations and 50 points indicate complete activity limitation.

• This instrument may be useful in patients with chronic or acute onset neck pain and in patients with musculoskeletal complaints or with cervical radiculopathy.

• It is recommended that the NDI be used at baseline and for every 2 weeks thereafter within the treatment program to measure progress. At least a 5-point change is required to be clinically meaningful.

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Score Ranges for the NDI:

• 0 - 4 = no disability

• 5 - 14 = mild

• 15 - 24 = moderate

• 25 - 34 = severe

• above 34 = complete

• Recommended notification threshold: 25

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• Reference: Vernon, Howard, and Silvano Mior. “The Neck Disability Index: a study of reliability and validity.” Journal of manipulative and physiological therapeutics 14.7 (1991): 409-415.

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NIH-HEALS: NIH Healing Experience of All Life Stressors

Healing Experience of All Life Stressors (NIH-HEALS) was developed by the NIH Clinical Center Pain and Palliative Care Service as a psycho-social-spiritual measure of healing that assesses positive transformation in response to challenging life events. It is a self-report, 35-item questionnaire.

• NIH-HEALS was developed by the observation that some patients with life-threatening and/or severe chronic illness report positive psychological, social, and spiritual change during the diagnosis or treatment of their illness, even in the face of unfavorable prognosis.

• Identifying the factors that contribute to or detract from the positive transformation known as "healing", it has far reaching implications for interventions aimed at improving quality of life, mind, body, and spiritual wellness in the face of life's challenges.

• It is scored on a five-point Likert scale from Strongly Disagree (1) to Strongly Agree (5). It provides scores for 3 factors: connection, reflection and introspection, and trust and acceptance

• For more information: https://clinicalcenter.nih.gov/palliativecare/heals.html

• Reference: Ameli, R., Sinaii, N., Luna, M. J., Cheringal, J., Gril, B., & Berger, A. (2018). The National Institutes of Health measure of Healing Experience of All Life Stressors (NIH-HEALS): Factor analysis and validation. PloS one, 13(12), e0207820.

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NSESS-PTSD: National Stressful Events Survey PTSD Short Scale

The NSESSS-PTSD is a 9-item measure that assesses the severity of posttraumatic stress disorder in individuals age 18 and older following an extremely stressful event or experience.

• It was designed to be completed by an individual upon receiving a diagnosis of posttraumatic stress disorder (or clinically significant posttraumatic stress disorder symptoms) and thereafter, prior to follow-up visits with the clinician.

• Each item asks the individual receiving care to rate the severity of his or her posttraumatic stress disorder during the past 7 days.

• Patients who score higher than 14 on the NSESSS for acute stress symptoms may need closer follow-up.

• Recommended notification thershold: 14

• Reference: LeBeau R, Mischel E, Resnick H, Kilpatrick D, Friedman M, Craske M. Dimensional assessment of posttraumatic stress disorder in DSM-5. Psychiatry Res. 2014 Aug 15;218(1-2):143-7. doi: 10.1016/j.psychres.2014.03.032. Epub 2014 Apr 5. PMID: 24746390.

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Pain score

Asks patients to rate their pain today on a likert scale (1-10, 10 is the worst pain, 1 is pain-free)

• There is an optional section for comments about the pain

• Recommended notification threshold: 9

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PCL-5: Posttraumatic Stress Disorder Checklist

The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including:

• Monitoring symptom change during and after treatment

• Screening individuals for PTSD

• Making a provisional PTSD diagnosis

• There are 20 questions with a 0-4 score for each question. 0-4 refer to, respectively, "not at all," "a little bit," "moderately," "quite a bit," and "extremely." Total score range is 0-80. Research suggests a cutoff score around 31-33 is indicative of probable PTSD.

• Recommend notification threshold: 31

• Here are some readings about the PCL-5

• List of the questions

• Using as a screening tool

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PEG: Pain, Enjoyment, General Activity Scale Assessing Pain Intensity and Interference

The PEG scale is a 3 question pain scale based on the Brief Pain Inventory scale. It is used for quickly, yet thoroughly, assessing and monitoring chronic pain in primary care settings.

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Score ranges for the PEG:

• Mild pain: Total: 0 to 11, Average of all 3: 0 to <4

• Moderate pain: Total: 12 to 20 , Average of all 3: 4 to < 7

• Severe pain: Total: 21 to 30, Average of all 3: 7 to 10

• Recommended notification threshold: 21 If using total score, 7 if using average score

• Recommended frequency: weekly

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• Reference: Krebs, E. E., Lorenz, K. A., Bair, M. J., Damush, T. M., Wu, J., Sutherland, J. M., Asch S, Kroenke, K. (2009). Development and Initial Validation of the PEG, a Three-item Scale Assessing Pain Intensity and Interference. Journal of General Internal Medicine, 24(6), 733–738.

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PHQ-4: Patient Health Questionnaire-4

The validated four-item Patient Health Questionnaire (PHQ-4) for anxiety and depression includes two items from the General Anxiety Disorder (GAD-7) score and two items from the Personal Health Questionnaire (PHQ-9) depression measure. Its purpose is to allow for very brief and accurate measurement of depression and anxiety.

• When PHQ-4 score is greater than 5, more detailed screeners are recommended. This allows for more precise targeting of mental health conditions and type of behavioral health specialty provider to refer to when necessary.

• We recommend you use the PHQ-4 with anyone who is not very severely ill, or for use in a short interval (e.g. every few days) because it is a shorter version than the PHQ-9 and GAD-7. It asks about symptoms over the past 2 week period.

• Scores are rated as normal (0-2), mild (3-5), moderate (6-8), and severe (9-12). Total score ≥3 for first 2 questions suggests anxiety. Total score ≥3 for last 2 questions suggests depression.

• Recommended notification threshold: 6

• Age range: 11 and up

• Reference: Kroenke, K., Spitzer, R. L., Williams, J. B. W., Löwe, B. (2009). An ultra-brief screening scale for anxiety and depression: the PHQ-4 Psychosomatics, 50, 613-621.

PHQ-8: Patient Healthcare Questionnaire-8

A self-assessment tool used to screen for depression in adults. It consists of eight questions based on the nine criteria for major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

The PHQ-8 asks about the frequency of symptoms such as:

• low mood, loss of interest in activities
• changes in appetite and sleep
• fatigue
• feelings of worthlessness or guilt
• difficulty concentrating
• thoughts of self-harm.

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Score ranges for the PHQ-8: 

Each question is scored on a scale of 0 to 3, with a total possible score of 24.

• 0 to 4: no significant depressive symptoms
• 5 to 9: mild symptoms; 10 to 14: moderate symptoms
• 15 to 19: moderately severe symptoms
• 20 to 24: severe symptoms
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PHQ-8 vs PHQ-9:

The PHQ-8 is a shorter version of the PHQ-9, which includes an additional question on suicidal ideation. So, it can be used in place of the PHQ-9 in situations where ongoing remote monitoring of suicide risk is not feasible.

The PHQ-8 has been shown to have comparable accuracy to the PHQ-9 in identifying depression, making it a useful tool for screening in clinical settings or research studies where time constraints may be a concern.

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PHQ-9: Patient Healthcare Questionnaire-9

Use as a screening tool:

• To assist the clinician in making the diagnosis of depression.

• To quantify depression symptoms and monitor severity.

• Age range: 12 and up.

• Higher PHQ-9 scores are associated with decreased functional status and increased symptom-related difficulties, sick days, and healthcare utilization.

• Asks about symptoms over the past 2 weeks

• Recommended notification threshold: 20 (0-27 score, with 0-3 points for each of the nine questions)

• Here is a list of the questions and information about the scoring scheme.

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Score ranges for the PHQ-9:

• 0 to 4 points: No depression

• 5 to 9 points: Mild depression

• 10 to 14 points: Moderate depression

• 15 to 19 points: Moderately severe depression

• 20 to 27 points: Severe depression

• The 9th question asks if someone had “Thoughts that you would be better off dead or of hurting yourself in some way.” If they answer "yes", you are notified.

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• Reference: Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 1737-1744.

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QIDS-SR: Quick Inventory of Depressive Symptomatology- Self Report

A 16 item self-report questionnaire for patients who identify as depressed or who may be suffering from depression to track trends in symptoms over time

• It is appropriate for use in clinical and research settings and is based on DSM-IV symptoms of depression.

• Age Range: 13 and up

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Score ranges for the QIDS-SR:

• 0-5: Normal

• 6-10: Mild

• 11-15: Moderate

• 16-20: Severe

• 21 or higher: Very Severe

• Recommended notification threshold: 16

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• Reference: Rush AJ, Trivedi MH, Ibrahim HM, Carmody TJ, Arnow B, Klein DN, Markowitz JC, Ninan PT, Kornstein S, Manber R, Thase ME, Kocsis JH, Keller MB. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003 Sep 1;54(5):573-83. doi: 10.1016/s0006-3223(02)01866-8. Erratum in: Biol Psychiatry. 2003 Sep 1;54(5):585. PMID: 12946886.

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Resilience

A group of early childhood service providers, pediatricians, psychologists and health advocates developed this “Resilience” questionnaire modeled on the ACE questionnaire to help with parenting education around protective factors for those with higher ACE scores.

• It is intended to prompt reflection and conversation on experiences that may have served as protective factors for those with an ACE score of four or more.

• The content of the questions was based on a number of research studies from the literature over the past 40 years including that of Emmy Werner and others.

• Its purpose is limited to parenting education. It was not developed for research or to offset a high ACE score.

• Reference: Rains, M & Mclinn, K (2013). Resilience Questionnaire. Southern Kennebec Healthy Start, Augusta, Maine

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SCARED-Child: Screen for Child Anxiety Related Disorders, Child Version

The SCARED is a child and parent self-report instrument used to screen for childhood anxiety disorders including general anxiety disorder, separation anxiety disorder, panic disorder and social phobia. In addition, it assesses symptoms related to school phobia.

• Age range: 8-18

• For children ages 8 to 11, it is recommended that the clinician explain all questions, or have the child answer the questionnaire sitting with an adult in case they have any questions

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Score ranged for the SCARED-Child:

• A total score of ≥ 25 may indicate the presence of an Anxiety Disorder. Scores higher that 30 are more specific.

• A score of 7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder or Significant Somatic Symptoms.

• A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder.

• A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder.

• A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder.

• A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance.

• Recommended notification threshold: 30

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• CPT code that can be used: 96127

• Developed by Boris Birmaher, MD, Suneeta Khetarpal, MD, Marlane Cully, MEd, David Brent, MD, and Sandra McKenzie, PhD. Western Psychiatric Institute and Clinic, University of Pgh.

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SDS: Sheehan Disability Scale

The SDS is a brief, 5-item self-report tool that assesses functional impairment in work/school, social life, and family life.

Score ranges for the SDS:

• A score of 5 or more on any of the three domains suggests significant functional impairment

• Score range is 0 (unimpaired) -30 (highly impaired)

• The scale also asks how many days in the past week did symptoms cause work or school to be missed or cause productivity to be reduced.

• Recommended notification threshold: 20

• Recommended frequency: weekly

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• CPT code that can be used: 96127
• Reference: Sheehan DV, Harnett-Sheehan K, Raj BA. The measurement of disability. Int Clin Psychopharmacol. 1996 Jun;11 Suppl 3:89-95. Review

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SNAP-IV 18: SNAP-IV Teacher and Parent 18 Item Rating Scale

The SNAP-IV is a rating scale that is used to assess the symptoms of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents ages 6-18.  It can be used to help diagnose the condition and monitor the effectiveness of treatment.

• It is completed by a parent or guardian, teacher, or other person who knows the child well. You can print out a copy for a teacher to fill out.

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SNAP-IV Scoring

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Overall Scoring Guideline for ADHD-Combined:

• Divide total score by 18 (or number of questions answered)

• Teacher 5% cutoff: 2.00

• Parent 5% cutoff: 1.67

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Scoring Guidelines for SNAP-IV Subscales:

• Questions 1 – 9: Inattention Subset

• < 13/27 = Symptoms not clinically significant

• 13 – 17 = Mild symptoms

• 18 – 22 = Moderate symptoms

• 23 – 27 = Severe symptoms

• Or divide total of questions 1-9 by 9

• Teacher 5% cutoff: 2.56

• Parent 5% cutoff: 1.78

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Questions 10 – 18: Hyperactivity/Impulsivity Subset:

• <13/27 = Symptoms not clinically significant

• 13 – 17 = Mild symptoms

• 18 – 22 = Moderate symptoms

• 23 – 27 = Severe symptoms

• Or divide total of questions 10-18 by 9

• Teacher 5% cutoff: 1.78

• Parent 5% cutoff: 1.44

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Suggested Thresholds:

• >12 for inattention

• >12 for hyperactivity/impulsivity

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• CPT code that can be used: 96127
• Reference: Swanson, J. M. (2003) SNAP-IV Teacher and Parent Ratings Scale. In: F. Aykr (Ed.), Therapist’s Guide to Learning and Attention Disorders (pp. 487-500). New York: Academic Press.

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WHODAS 2.0: World Health Organization Disability Assessment Schedule 2.0

The World Health Organization Disability Assessment Schedule (WHODAS) 2.0 is a 36-item, generic self-assessment instrument for assessing health status and disability across different cultures and settings.

• It includes 6 domains of functioning: Cognition, Mobility, Self-care, Getting along, Life activities (household and work), and participation.

• It asks about the last 30 days.

• Note that the life/activities section can be skipped if not in work or school.

• Recommended frequency: Monthly

• Reference: World Health Organization (2014, October 29). WHO Disability Assessment 2.0 (WHODAS 2.0).

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WSAS: Work and Social Adjustment Scale

The WSAS is a simple 5 question reliable scale that assesses the impact of a person’s mental health difficulties on their ability to function in terms of work, home management, social leisure, private leisure and personal or family relationships.

Score ranges for the WSAS:

• 0-9: Low Impairment

• 10-19: Moderate Impairment

• 20-40: Severe impairment

• Recommended frequency: monthly

• Reference: Mundt, J. C., I. M. Marks, et al. (2002). "The Work and Social Adjustment Scale: A simple measure of impairment in functioning." Br. J. Psychiatry 180: 461-4.

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Y-BOCS: Yale-Brown OCD Scale

The Y-BOCS is a 10-item, clinician-administered scale that has become the most widely used rating scale for OCD and is designed to rate symptom severity, not to establish a diagnosis.

• Age range: 18 and up

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Score ranges for the Y-BOCS:

• 0-7: Subclinical

• 8-15: Mild

• 16-23: Moderate

• 24-31: Severe

• 32-40: Extreme

• Recommended frequency: Weekly

• Recommended notification threshold: 24 or above

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• Reference: Goodman WK, Price LH, Rasmussen SA, et al.: The Yale-Brown Obsessive Compulsive Scale: Part I. Development, use, and reliability. Arch Gen Psychiatry (46:1006-1011, 1989). and Goodman WK, Price LH, Rasmussen SA, et al.: The Yale-Brown Obsessive Compulsive Scale): Part II. Validity. Arch Gen Psychiatry (46:1012-1016, 1989).

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YMRS: Young Mania Rating Scale

The Young Mania Rating Scale is a provider-administered, 11-item, multiple-choice diagnostic questionnaire which is used to measure the severity of manic episodes in patients over the past 48 hours.

Score Ranges for the YMRS:

• 0-12: remission of manic symptoms

• 13-19: minimal manic symptoms

• 20-25: mild manic symptoms

• 26-37: moderate manic symptoms

• 38-60: severe mania

• Suggested notification threshold: 26 or above

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• Reference: Young RC, Biggs JT, Ziegler VE Meyer DA. A rating scale for mania: reliability, validity, and sensitivity. BrJ Psychiatry. 1978; 133:429-435.

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