Clinical Review

Behavioral Health: Using Rating Scales in a Clinical Setting

Clinician Reviews. 2017 September;27(9):28-31,33

References

1. McDowell I. Measuring Health: A Guide to Rating Scales and Questionnaires. 3rd ed. New York, NY: Oxford University Press; 2006.
2. Kennedy Forum. Fixing behavioral health care in America: a national call for integrating and coordinating specialty behavioral health care with the medical system. http://thekennedyforum-dot-org.s3.amazonaws.com/documents/KennedyForum-BehavioralHealth_FINAL_3.pdf. Accessed August 14, 2017.
3. The Office of the National Coordinator for Health Information Technology. Behavioral health (BH) Clinical Quality Measures (CQMs) Program initiatives. www.healthit.gov/sites/default/files/pdf/2012-09-27-behavioral-health-clinical-quality-measures-program-initiatives-public-forum.pdf. Accessed August 14, 2017.
4. Unutzer J, Harbin H, Schoenbaum M. The collaborative care model: an approach for integrating physical and mental health care in Medicaid health homes. www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/HH-IRC-Collaborative-5-13.pdf. Accessed August 14, 2017.
5. World Group On Psychiatric Evaluation; American Psychiatric Association Steering Committee On Practice Guidelines. Practice guideline for the psychiatric evaluation of adults. 2nd ed. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/psychevaladults.pdf. Accessed August 14, 2017.
6. Melek S, Norris D, Paulus J. Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry. Denver, CO: Milliman, Inc; 2014.
7. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012;10:CD006525.
8. Kennedy Forum. Fixing behavioral health care in America: a national call for measurement-based care. www.thekennedyforum.org/a-national-call-for-measurement-based-care/. Accessed August 14, 2017.
9. Zimmerman M, McGlinchey JB. Why don't psychiatrists use scales to measure outcome when treating depressed patients? J Clin Psychiatry. 2008;69(12):1916-1919.
10. Hatfield D, McCullough L, Frantz SH, et al. Do we know when our clients get worse? An investigation of therapists' ability to detect negative client change. Clin Psychol Psychother. 2010;17(1):25-32.
11. SAMHSA-HRSA Center for Integrated Solutions. Screening tools. www.integration.samhsa.gov/clinical-practice/screening-tools. Accessed August 14, 2017.
12. Moller HJ. Standardised rating scales in psychiatry: methodological basis, their possibilities and limitations and descriptions of important rating scales. World J Biol Psychiatry. 2009;10(1):6-26.
13. Sajatovic M, Ramirez LF. Rating Scales in Mental Health. 2nd ed. Hudson, OH: Lexi-Comp; 2003.
14. Patient Health Questionnaire-9 (PHQ-9). www.agencymeddirectors.wa.gov/files/AssessmentTools/14-PHQ-9%20overview.pdf. Accessed August 14, 2017.
15. Patient Health Questionnaire-9 (PHQ-9). Rehab Measures Web site. www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=954. Accessed August 14, 2017.
16. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.
17. Löwe B, Unützer J, Callahan CM, et al. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 2004;42(12):1194-1201.
18. Ketter TA. Strategies for monitoring outcomes in patients with bipolar disorder. Prim Care Companion J Clin Psychiatry. 2010;12(suppl 1):10-16.
19. The Mood Disorder Questionnaire. University of Texas Medical Branch. www.dbsalliance.org/pdfs/MDQ.pdf. Accessed August 14, 2017.
20. Hirschfeld RM, Holzer C, Calabrese JR, et al. Validity of the Mood Disorder Questionnaire: a general population study. Am J Psychiatry. 2003;160(1):178-180.
21. Boschloo L, Nolen WA, Spijker AT, et al. The Mood Disorder Questionnaire (MDQ) for detecting (hypo) manic episodes: its validity and impact of recall bias. J Affect Disord. 2013;151(1):203-208.
22. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097.
23. Lowe B, Decker O, Müller S, et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care. 2008;46(3):266-274.
24. Kroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317-325.
25. Ewing JA. Detecting alcoholism. The CAGE Questionnaire. JAMA. 1984;252(14):1905-1907.
26. CAGE substance abuse screening tool. Johns Hopkins Medicine. www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/cage%20substance%20screening%20tool.pdf. Accessed August 14, 2017.
27. O'Brien CP. The CAGE questionnaire for detection of alcoholism: a remarkably useful but simple tool. JAMA. 2008;300(17):2054-2056.
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29. Columbia Suicide-Severity Rating Scale (CS-SRS). http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare/#filter=.general-use.english. Accessed August 14, 2017.
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32. Esposito L. Suicide checklist spots people at highest risk. USA Today. http://usatoday30.usatoday.com/news/health/story/health/story/2011-11-09/Suicide-checklist-spots-peo ple-at-highest-risk/51135944/1. Accessed August 14, 2017.

However, reliability may be a concern, as some patients may lack insight or exaggerate or mask symptoms when completing such scales.¹³ Both observer- and self-rated scales can be used together to minimize bias, identify symptoms that might have been missed/not addressed in the clinical interview, and drive clinical decision-making. Both can also help patients communicate with their providers and make them feel more involved in clinical decision-making.⁸

ENDORSED RATING SCALES

The following scales have met many of the quality criteria described here and are endorsed by the government payer system. They can easily be incorporated into clinical practice and will provide useful clinical information that can assist in diagnosis and monitoring patient outcomes.

Patient Health Questionnaire

PHQ-9 is a nine-item self-report questionnaire that can help to detect depression and supplement a thorough mental health interview. It scores the nine DSM-IV criteria for depression on a scale of 0 (not at all) to 3 (nearly every day). It is a public resource that is easy to find online, available without cost in several languages, and takes just a few minutes to complete.¹⁴

PHQ-9 has shown excellent test-retest reliability in screening for depression, and normative data on the instrument's use are available in various clinical populations.¹⁵ Research has shown that as PHQ-9 depression scores increase, functional status decreases, while depressive symptoms, sick days, and health care utilization increase.¹⁵ In one study, a PHQ-9 score of ≥ 10 had 88% sensitivity and specificity for detecting depression, with scores of 5, 10, 15, and 20 indicating mild, moderate, moderately severe, and severe depression, respectively.¹⁶ In addition to its use as a screening tool, PHQ-9 is a responsive and reliable measure of depression treatment outcomes.¹⁷

Mood Disorder Questionnaire

MDQ is another brief, self-report questionnaire that is available online. It is designed to identify and monitor patients who are likely to meet diagnostic criteria for bipolar disorder.^18,19

The first question on the MDQ asks if the patient has experienced any of 13 common mood and behavior symptoms. The second question asks if these symptoms have ever occurred at the same time, and the third asks the degree to which the patient finds the symptoms to be problematic. The remaining two questions provide additional clinical information, addressing family history of manic-depressive illness or bipolar disorder and whether a diagnosis of either disorder has been made.

The MDQ has shown validity in assessing bipolar disorder symptoms in a general population, although recent research suggests that imprecise recall bias may limit its reliability in detecting hypomanic episodes earlier in life.^20,21 Nonetheless, its specificity of > 97% means that it will effectively screen out just about all true negatives.¹⁸

Generalized Anxiety Disorder 7-item scale

The GAD-7 scale is a brief, self-administered questionnaire for screening and measuring severity of GAD.²² It asks patients to rate seven items that represent problems with general anxiety and scores each item on a scale of 0 (not at all) to 3 (nearly every day). Similar to the other measures, it is easily accessible online.

Research evidence supports the reliability and validity of GAD-7 as a measure of anxiety in the general population. Sensitivity and specificity are 89% and 82%, respectively. Normative data for age- and sex-specific subgroups support its use across age groups and in both males and females.²³ The GAD-7 performs well for detecting and monitoring not only GAD but also panic disorder, social anxiety disorder, and posttraumatic stress disorder.²⁴

CAGE questionnaire for detection of substance use

The CAGE questionnaire is a widely used screening tool that was originally developed to detect alcohol abuse but has been adapted to assess other substance abuse.^25,26 The omission of substance abuse from diagnostic consideration can have a major effect on quality of care, because substance abuse can be the underlying cause of other diseases. Therefore, routine administration of this instrument in clinical practice can lead to better understanding and monitoring of patient health.²⁷

Similar to other instruments, CAGE is free and available online.²⁷ It contains four simple questions, with 1 point assigned to each positive answer (see Table); the simple mnemonic makes the questions easy to remember and to administer in a clinical setting.

CAGE has demonstrated validity, with one study determining that scores ≥ 2 had a specificity and sensitivity of 76% and 93%, respectively, for identifying excessive drinking, and a specificity and sensitivity of 77% and 91%, respectively, for identifying alcohol abuse.²⁸

Behavioral Health: Using Rating Scales in a Clinical Setting

References

ENDORSED RATING SCALES

Patient Health Questionnaire

Mood Disorder Questionnaire

Generalized Anxiety Disorder 7-item scale

CAGE questionnaire for detection of substance use

Pages

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