Mood Disorders

Major Depressive Disorder

PHQ-9 (Patient Health Questionnaire – 9)
Assessing: Major Depressive Episode in General Population
Cutoff > 10 draw attention to likely clinically significant condition
Edinburgh Postnatal Depression ScaleAssessing: Post-partum depression
Cutoff > 13 indicates likely depression

Bipolar Disorder

MDQ (Mood Disorder Questionnaire)Screen for Bipolar 1 Disorder (NOT Bipolar 2 Disorder) in Outpatients
Young Mania Rating ScaleAssess Intensity of Mania / Hypomania in Patients (Time Frame – Last 48 hours); < 13 indicates remission
Anxiety Disorders

GAD-7 (Generalized Anxiety Disorder -7)scope: screen for generalized anxiety disorder; also validated screener for social anxiety, panic disorder, PTSD.
Cutoff > 10 draw attention to likely clinically significant condition
Liebowitz Social Anxiety Scale scope: screen for social anxiety disorder;
cut-off: if < 30, SAD is unlikely; if > 60 SAD probable
Panic Disorder Severity Scale – Self Reportscope: screening for panic disorder
cut-off: score > 9 suggest need for diagnostic assessment
Trauma Related Disorders

PC-PTSD-5 (Primary Care PTSD Screen for DSM-V ) scope: very brief screen for post traumatic stress disorder (PTSD) for primary care physicians . Cutoff > 4 (max 5) for men and 3 > for females. (if positive do PCL-5)
PCL-5 (PTSD Checklist for DSM-5)scope: provisional diagnosis for PTSD. Cutoff > 33-35 (max 80). Serial measurement of severity of symptoms. Need: Qualifying trauma, and at least one score of 2 in each of questions 1-5, 6-7, 8-14, 15-20.
Attention-Deficit / Hyperactivity Disorder

Adult ADHD

Wender Utah Rating Scale (Long Form) scope: to help validate history of childhood ADHD symptoms in adults. There are 60 questions, but only 25 relate to ADHD symptoms. Cutoff of > 46; sensitivity of 86%, specificity of 99% (in population without psychiatric co-moribidity)

Wender Utah Rating Scale (Short Form)
scope: same as above. This includes only the ADHD related questions. Same cutoffs as above.
Adult ADHD Self Report Scale (ASRS-v1.1) scope: screener for symptoms of adult ADHD. Cutoff: 4 or more responses in shaded areas of part A indicative of ADHD symptoms in adults and warrant further investigation.
Psychotic Disorders
BPSD (Brief Psychiatric Rating Scale)scope: Most helpful in assessing treatment efficacy in psychosis. Based on clinician interview (+/- collateral) and observation of patient over 2-3 days. Measures 18 symptom constructs (each rated from 1 to 7). scoring: mildly ill > 31, mod ill >41, markedly ill > 53
Cognition

SLUMS (Saint Louis University Mental Status Exam)scope: alternative to MMSE (now copyrighted) to detect mild cognitive impairment (MCI) and dementia. Takes 7-10min. Better than MMSE at detecting MCI. Validated in older adults.
sensitivity: 80-90% Specificity: 75-85%
Mini-Cogscope: 3 min test to screen for cognitive impairment in older adults; normal > 3. Administration instructions. Scoring instructions.
No Longer Easily Accessible or FREE
MOCA ( Montreal Cognitive Assessment)
scope: developed for assessment




scope: developed for assessment of mild cognitive impairment; normal > 26/30
* training required for valid assessment although free for students/faculty.
Note that the MOCA Is no longer freely available on the internet as a PDF (systemically taken down off of websites). Training required and MOCA is accessed through the official website only now.
MMSE (Mini-Mental State Examination)The Mini-Mental State Examination (MMSE) became copyrighted in 2000 when its rights were acquired by Psychological Assessment Resources, Inc. (PAR). Prior to this, the MMSE, originally developed in 1975 by Marshal Folstein, Susan Folstein, and Paul McHugh, was freely available for use in clinical and research settings.
Substance Use

Clinical Institute Withdrawal Assessment – Alcohol Revised (CIWA – Ar) scope: measures severity of alcohol withdrawal syndrome.
Cutoff: less than 8-10 minimal to mild (no intervention usually required);
between 11-15, moderate withdrawal; >15, severe withdrawal
(Example treatment protocol)