Addressing Behavioral and Mental Health Problems in Community Settings
Screening and Early Detection
Roberto is a 78-year-old man who emigrated from a small town in Mexico 4 years ago to live with his children. Two months ago he noticed blood in his urine; an urgent care center referred him to a urologist, who diagnosed Roberto with prostate cancer. A month ago, he underwent surgical removal of his prostate. Postoperatively, the urologist referred him to you for primary care.
Roberto arrives today, with his daughter, for his first primary care visit. Because both speak Spanish as their primary language, you ask for the assistance of an interpreter. While you await the arrival of the interpreter, Roberto takes the Spanish versions of the Patient Health Questionnaire 9-item depression scale (PHQ-9) and the Generalized Anxiety Disorder 7-Item Scale (GAD-7). His PHQ-9 total score is 4, but he has marked 2 (more than half the days) for the ninth item, “Thoughts that you would be better off dead or hurting yourself in some way.” His GAD-7 total score is 7, suggesting mild anxiety.
In mental health care, a screen is an initial testing instrument used either to identify a previously undiagnosed disorder or to measure the severity of symptoms of a previously diagnosed disorder. There are three steps to using a screen: administering, scoring, and interpreting (Blais and Baer 2010). We discuss each of these concepts briefly here, with further details about how to correctly administer, score, and interpret several particular screens in Chapter 11, “Selected DSM-5 Assessment Measures.” The instructions that accompany a mental health screen will usually explain if the screen is self-administered, caregiver administered, or practitioner administered. Scoring can be straightforward, such as when the practitioner adds up the numbers a patient has selected on the PHQ-9, or may require interpretation, such as when the practitioner determines whether the cube is drawn correctly on the Montreal Cognitive Assessment (MoCA).
An important part of mental health screening involves deciding which screens to use for which people. Something to keep in mind is that most screening instruments were validated with a particular group of people who may be quite different from the individual presenting to you. In today’s clinical practice, it is common to encounter a person for whom, because of language, cultural heritage, cognitive ability, or other factors, the use of most screening instruments requires an act of translation. Translated screens can be valuable for an ethnically diverse population; however, if a screen has not been validated in a specific language, it should be used cautiously in the context of a clinical interview. Practitioners can always use screens in populations for which they have not been validated, but they should do so with humility and care, aware of the limits of the screening tool. In mental health settings, a thorough clinical interview or, in some cases, multiple interviews are needed to arrive at an accurate understanding of a person’s mental distress.
Despite these caveats, we recommend screens both because they can save time in clinical interviews and because they allow you to communicate your findings to other practitioners. For example, if the result of a screening tool matches your findings from a brief interview and observation, both true positives and negatives, you can feel comfortable making a diagnosis based on the result. Then, when you record a diagnosis in your records, any consulting practitioners will have an objective sense of how you determined the diagnosis and its severity.
On the other hand, even well-validated screens like the PHQ-9 have limitations. Consider Roberto, who reported having frequent suicidal thoughts but responded mostly with 0 (not at all) or 1 (several days per week) to the other items on the PHQ-9. Roberto’s responses are clues that you need to extend your inquiry.
When the interpreter arrives and you ask Roberto about his thoughts of being dead, he explains that in the past month he has become incontinent and impotent from surgery for prostate cancer but cannot afford to return to the urologist. He marked most of his answers on the PHQ-9 with a 0 or 1 because he assumed that most of his mood and somatic symptoms, such as fatigue and insomnia, were normal effects of surgery. After your brief interview, you are concerned that he may be minimizing his depressive symptoms, so you dedicate 15 minutes to exploring symptoms of depression and thoughts of suicide.
During your 15-minute mental health interview, Roberto explains that sometimes he feels so overwhelmed by the complications of his surgery that he stares at his pill bottles and thinks of overdosing on his medications. You diagnose him with major depressive disorder, start an antidepressant with low potential for lethality in overdose, and arrange for him to visit a depression care manager as part of your clinic’s primary care mental health integration initiative. The depression care manager helps Roberto manage his depression and suicidal ideation. At your next visit, his PHQ-9 total score is 2, and he responds to the suicidal ideation question with 0. His GAD-7 total score has improved to 3.
Roberto’s story has two major lessons. First, although his initial PHQ-9 score was a false negative, he benefited from screening, careful interpretation of the screen, and a follow-up interview. Looking at the individual items on the screen that are high yield (e.g., the suicidality item), in addition to the overall score, can help in both detecting false negatives and making a correct diagnosis. Second, Roberto’s story illustrates how screening for mental health problems in primary care enables initiation of treatment before symptoms become severe. Early detection and treatment may prevent an adverse outcome, such as a suicide attempt due to an untreated severe major depressive episode or a driving accident due to undiagnosed neurocognitive disorder.
QUICK TIPS FOR SCREENING
Carefully follow the administration instructions for every screen, whether it is self-administered by the patient or administered by a caregiver or a practitioner.
Know the limitations of the screen, particularly regarding its validity for your patient population and the setting in which you work.
When a screen is consistent with a brief clinical interview, a mental health diagnosis can be made on the basis of its score.
If the screen, whether positive or negative, is inconsistent with a brief clinical interview or observation, a more detailed interview with the patient or an informant is necessary.
Assessment Tools for Use in a Brief Interview
To help a practitioner maximize his efficiency and effectiveness, Section III of DSM-5 (American Psychiatric Association 2013) includes assessment tools that a patient can fill out before a visit. The first form, the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult, is a psychiatric review of systems that correlates with DSM-5 criteria. For each major domain of mental illness, DSM-5 includes Level 2 Cross-Cutting Symptom Measures for a practitioner to administer. These tools can save time by allowing interviewers to structure their evaluations around the symptoms that concern a patient.
Diagnosis in Stages
In Chapter 9, we describe a stepwise approach to differential diagnosis from scratch. In this section, we describe how to clarify a diagnosis that you have identified using screening tools.
STAGE 1: CHARACTERIZATION OF A BEHAVIORAL OR MENTAL HEALTH PROBLEM IDENTIFIED BY A SCREENING TOOL
Vera is a 65-year-old woman with coronary artery disease and type 2 diabetes whom you have followed for the past 6 years in your clinic. At the end of her last visit, she reported feeling depressed about arguments with her children over money. You schedule an appointment for the following week to evaluate her depressive symptoms in detail. When she arrives for the visit, she completes the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult. She responds positively to questions about depressive and anxiety symptoms but negatively to the other questions, so you decide to focus your evaluation on determining whether Vera is experiencing a depressive or anxiety disorder and to administer the Level 2 tools for depression and anxiety.
As a practitioner reads through a patient’s responses to assessment questions, he should consider which broad categories—such as mood, anxiety, substance use, personality, and cognition—fit the symptoms experienced by a patient. It is common to hear a chief complaint such as “I’m feeling sad,” unconsciously decide that the most likely diagnosis is major depressive disorder, and immediately walk a patient through the DSM-5 criteria for major depressive disorder. Instead, you should listen to the patient’s story, determine whether he spontaneously mentions the symptoms, and then explore further, asking the necessary questions to arrive at the specific diagnosis. A brief psychiatric review of systems should be performed to ensure that other symptoms or diagnoses have not been missed. Even experienced practitioners have been surprised to discover, after further investigation, that a seemingly depressed patient is actually having a mixed episode with manic and depressed features; or a depressed patient also has psychotic symptoms; or a person’s depressed mood is caused by a medication, a substance of abuse, or another medical condition; or even that a depressed mood is a variant of normal behavior. Not every sad day is a depressed day.
After practitioners choose the potential diagnostic categories, they should differentiate among the mental disorders within those categories. For example, if a depressive disorder is the potential diagnosis, all the likely possibilities in that category, such as major depressive disorder, dysthymic disorder, and bipolar disorder, should be considered. This should be done systematically for each category, as modeled in Chapter 5, “The 15-Minute Older Adult Diagnostic Interview,” and Chapter 6, “The 30-Minute Older Adult Diagnostic Interview.”
STAGE 2: CONFIRMING A DIAGNOSIS USING DSM-5 CRITERIA
After using your assessment tools, you interview Vera. She shares with you that when she lived in East Berlin in the 1970s, she and her husband were wrongfully imprisoned for being spies. They were tortured, and Vera was raped in prison. When she reflected on those events over the years, she would experience intermittent sadness and anxiety. When her husband died 6 months ago, the sadness and anxiety became more frequent. At the end of your interview, your differential diagnosis, from most likely to least likely, includes major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), and adjustment disorder with mixed anxiety and depressed mood.