Screening and detection of any disorder that requires further assessment is a complex process. Screening protocols assume that (a) detection will lead to early intervention, which can prevent a mental health or substance abuse disease process from advancing, and that (b) improved health outcomes and/or cost-effectiveness result from clearly defined screening guidelines, according to epidemiological studies and evidence-based research. Therefore, sufficient evidence is needed to support the use of behavioral health screening measures for a specific population in a primary care setting.

Screening is not a diagnostic litmus test, but an indicator that further assessment is needed. Screening for mental health conditions, consequently, is not a diagnosis of a mental health condition. And, clinical situations where a patient may require behavioral health expertise does not confirm or sufficiently describe which behavioral health intervention is needed. Clinical interviewing, judgment, and decision-­making processes of the provider are not replaced but augmented by standardized screening. Screening tools supplement the provider-patient relationship, with the understanding that unique patient needs, style, cultural and family backgrounds, and other factors may influence the validity of a screening tool. Choosing the appropriate tool among the many screening tools and assessment instruments is just one of the initial steps in implementation. The larger health care context plays a significant role in the effective use of screening.

Using screening tools goes beyond choosing a measurement and “sending patients off” and expecting something to change. Incorporating screening tools into clinical practice is a process that may begin with identifying the target population or condition, choosing reliable tool(s), and then implementing and nurturing a system of care to achieve expected benefits and outcomes. It requires the entire practice to adapt and embrace the incorporation of this process. These questions and tasks are described in Fig. 12.1, using the integrated care practice “lexicon” (See Chap. 2; Peek, 2011) as the framework.

In this chapter, valid and reliable screening tools for primary care will be described using the what, how, and supported by parameters of integrated care: (1) defining the team members’ level of training, roles and tasks, and communication between providers about the screening results; (2) identifying the patient population and rationale for screening—life stages and/or specific patient group with particular attention to the cultural, socioeconomic, and gender issues; (3) describing the clinical screening tools, including the primary purpose and function of the standardized screening tools along with its specificity and sensitivity, (4) outlining the office management process and financial systems for effectively using screening tools such as cost, time, and billing; and (5) using a data collection system to track individual and/or clinical population trends and identifying quality improvement methods. Since there are a host of resources, such as Health and Psychosocial Instruments (HaPI database) for mental health and behavioral health assessment instruments, the focus of this chapter is not to provide an exhaustive list of behavioral health screening tools, rather to focus on the most common standardized tools used in primary care settings and, more importantly, address the components within the health care setting that are needed to effectively embed these tools for patient-­centered care.

One of the first steps in effectively implementing screening tools is defining the roles and responsibilities of each team member—physicians, nurses, medical assistants, behavioral health providers, and support staff. The team has the responsibility of making a number of screening decisions, such as who gets screened and with what screening tools. The responsibility of administering, scoring, reporting results to the patient or family, and managing follow-up care needs to be discussed and delegated among team members. Without clearly defined tasks and communication pathways, information from screening tools are often not completed, reviewed or discussed with patients much less become part of the clinical monitoring system for follow-up care (Hayutin, Reed-Knight, Blount, Lewis, & McCormick, 2009; Herman-Staab, 1994; Pinto-Martin et al., 2005).

Like pediatric screening tools, screening tools for adults should be focused on identifying modifiable or treatable disorders or conditions and identifying adults who could benefit from behavioral health strategies. In addition to the recommendations of the USPSTF, other organizations, like the Veterans Administration of the Department of Defense, the American Psychology Association, and the American Psychiatric Association, are developing guidelines for screening (Cook, Freedman, Freedman, Arick, & Miller, 1996; Engel et al., 2008). In 2009, the National Network of Depression Centers was organized to address the need for consistency in assessing and evaluating behavioral health and specifically depression in health care settings. This multi-professional group has identified a common assessment package of nine tools to measure mental health “vital signs.” The purpose of this group has been to develop a standard core of assessment scales, to understand what they mean in the primary care setting, to use them regularly in clinical practice, and to use the information to facilitate communication about patient care within multidisciplinary teams (see Table 12.3 for examples).