The 15 Minute The 15 Minute Psychiatric Screening Psychiatric Screening

AssessmentAssessment

Jose Silveira MD FRCPCAssistant Professor, Department of Psychiatry, University of TorontoClinical Director, Portuguese Mental Health and Addiction ServicesUniversity Health Network

Patricia Rockman MD, CCFP, FCFPAssistant ProfessorUniversity of TorontoDepartment of Family and CommunityMedicineChair, OCFP Collaborative Mental Health Care Network

ObjectivesObjectives

►►Participants will obtain the knowledge and Participants will obtain the knowledge and skills to quickly assess patients and answer skills to quickly assess patients and answer the following questions:the following questions:

Is this patient suffering from a mental disorder?Is this patient suffering from a mental disorder?Is this patient a risk to themselves or others?Is this patient a risk to themselves or others?What do I need to do today?What do I need to do today?

Questions to answerQuestions to answer

►►Is this patient suffering from a mental Is this patient suffering from a mental disorder?disorder?

►►Is the patient a risk to themselves or Is the patient a risk to themselves or others?others?

►►What do I need to do today?What do I need to do today?

Mental Disorder?Mental Disorder?

Exercise #1Exercise #1

►►What are your 2 favorite questions to What are your 2 favorite questions to screen for:screen for:

MDEMDEAlcohol MisuseAlcohol MisusePanic DisorderPanic DisorderGADGADADHDADHDBulimia NervosaBulimia NervosaPsychosisPsychosis

Index of SuspicionIndex of Suspicion

►► MDEMDE►► Alcohol MisuseAlcohol Misuse►► Panic DisorderPanic Disorder►► GADGAD►► ADHDADHD►► Bulimia NervosaBulimia Nervosa►► PsychosisPsychosis

►► Why these Conditions?Why these Conditions?CommonCommonRisk Risk Hard to find specifically worded screening questions with clinicHard to find specifically worded screening questions with clinical validity in al validity in primary care settingprimary care setting

RisksRisks

►►SuicideSuicide►►HomicideHomicide►►Unintended harmUnintended harm

ApproachApproach

►►Screening instrumentsScreening instruments►►Past Psychiatric HistoryPast Psychiatric History►►Family Psychiatric HistoryFamily Psychiatric History►►Risk AssessmentRisk Assessment

Screening InstrumentsScreening Instruments

CMDQCMDQ

►► Common Mental Disorder Questionnaire Common Mental Disorder Questionnaire ►► Disorders screened forDisorders screened for

►► somatoform disorders somatoform disorders ►►anxiety anxiety ►►depression and depression and ►►alcohol abusealcohol abuse

►► How is it usedHow is it used►►Patient completes Patient completes ►►patient takes 2patient takes 2––5 minutes, the rating by the GP less than one 5 minutes, the rating by the GP less than one

minute.minute.

►► LimitsLimits►► Ignores psychosisIgnores psychosis►► Ignores riskIgnores risk►►Developed for researchDeveloped for research

CMDQCMDQ

►►Sensitivity/SpecificitySensitivity/SpecificityDepressive disorder: 78/86 (SCLDepressive disorder: 78/86 (SCL--DEP6)DEP6)Alcohol abuse or dependence: 78/97 (CAGE); Alcohol abuse or dependence: 78/97 (CAGE); Severe anxiety disorder: 77/85 (SCLSevere anxiety disorder: 77/85 (SCL--ANX4); ANX4); Somatisation disorder: 83/56 (SCLSomatisation disorder: 83/56 (SCL--SOM); and SOM); and 75/52 (Whiteley75/52 (Whiteley--7); 7); any mental disorder above: 72/72 (SCLany mental disorder above: 72/72 (SCL--8)8)

►►Improved diagnostic accuracy over typical Improved diagnostic accuracy over typical practicepractice

PRIME MDPRIME MD

►► Disorders screened forDisorders screened for►►mood mood ►►anxietyanxiety►► somatoformsomatoform►►alcohol misusealcohol misuse►►eating disorders eating disorders

►► 11--page of 26 yespage of 26 yes--no questions no questions ►►Patient completedPatient completed

►► 1212--page Clinician Evaluation Guide page Clinician Evaluation Guide MD selects modules from 12 guide according to YES MD selects modules from 12 guide according to YES responsesresponses

►► 88% accurate 88% accurate ►►agreement with comprehensive psychiatric assessmentagreement with comprehensive psychiatric assessment

PRIME MDPRIME MD

►►How much time will this take?How much time will this take?11.4 minutes 11.4 minutes ►►for patients who received a PRIMEfor patients who received a PRIME--MD diagnosisMD diagnosis

5.6 minutes 5.6 minutes ►►for patients without a PRIMEfor patients without a PRIME-- MD diagnosisMD diagnosis

►►Developed with research in mindDeveloped with research in mind

32 Questions32 Questions

►►NamelessNameless►►Adapted from multiple sourcesAdapted from multiple sources

PRIME MDPRIME MDWHO CIDI (Composite International Diagnostic WHO CIDI (Composite International Diagnostic Interview)Interview)

►►Patient self report or MDPatient self report or MD►►Developed for clinical applicationDeveloped for clinical application

32 Questions32 Questions

►►ConditionsConditions►►MDEMDE►►Alcohol MisuseAlcohol Misuse►►Panic DisorderPanic Disorder►►GADGAD►►ADHDADHD►►Bulimia NervosaBulimia Nervosa►►PsychosisPsychosis

►►10 minutes for entire questionnaire10 minutes for entire questionnaire

MDE (3)MDE (3)

►►During the past month have you often been During the past month have you often been bothered by feeling down, depressed or bothered by feeling down, depressed or hopeless? hopeless? Yes Yes nono

►►During the past month have you often been During the past month have you often been bothered by little interest or pleasure in bothered by little interest or pleasure in doing things? doing things? Yes Yes nono

►► (sensitivity 96%, Specificity 78%) (sensitivity 96%, Specificity 78%)

MDEMDE

►►Add one question to improve specificity Add one question to improve specificity (89%)(89%)

►►Is this something with which you would like Is this something with which you would like help?help?

NoNoYesYesYes but not todayYes but not today

►►Add psychosis questions if positive screen.Add psychosis questions if positive screen.

MDE AlternativeMDE Alternative

►►The single question screenThe single question screen►►Have you felt sad or depressed much of the Have you felt sad or depressed much of the

time in the past year? time in the past year? yes yes nono

►► had sensitivity comparable to the Center for had sensitivity comparable to the Center for Epidemiological Studies Depression Screen (CESEpidemiological Studies Depression Screen (CES--D) (85% D) (85% vs 88%) but was slightly less specific (66% vs 75%).18vs 88%) but was slightly less specific (66% vs 75%).18

►► 18. Williams JW, 18. Williams JW, MulrowMulrow CD, Kroenke K, et al. CaseCD, Kroenke K, et al. Case--finding for depression in primary finding for depression in primary care: A randomized trial. care: A randomized trial. Am J Med. Am J Med. 1999;106:361999;106:36--43.43.

Alcohol (5)Alcohol (5)

►► Have any of the following happened to Have any of the following happened to you you in the last 6 monthsin the last 6 months??

You drank alcohol even though a doctor You drank alcohol even though a doctor suggested that you stop drinking because of a suggested that you stop drinking because of a problem with your health? problem with your health? yes yes nonoYou drank alcohol, were high from alcohol, or You drank alcohol, were high from alcohol, or hung over while you were working, going to hung over while you were working, going to school, or taking care of children or other school, or taking care of children or other responsibilities? responsibilities? yes yes nono

AlcoholAlcohol

You missed or were late for work, school, or You missed or were late for work, school, or other activities because you were drinking or other activities because you were drinking or hung over? hung over? yes yes nonoYou had a problem getting along with other You had a problem getting along with other people while you were drinking? people while you were drinking? yes yes nonoYou drove a car after having several drinks or You drove a car after having several drinks or after drinking too much? after drinking too much? yes yes nono

►► YES to any question suggests Alcohol YES to any question suggests Alcohol MisuseMisuse

Adapted From PRIME MDAdapted From PRIME MD

Panic Disorder (5)Panic Disorder (5)

►►Autonomic Nervous System questionnaireAutonomic Nervous System questionnaire►►Sensitivity 94%Sensitivity 94%►►Specificity 25%Specificity 25%

M. B. STEIN et al. 364 Psychosomatic Medicine M. B. STEIN et al. 364 Psychosomatic Medicine 61:35961:359––364 (1999)364 (1999)

ANSQ (5)ANSQ (5)

1. In the past 6 months, did you ever have a spell or 1. In the past 6 months, did you ever have a spell or an attack when all of a sudden you felt frightened, an attack when all of a sudden you felt frightened, anxious or very uneasy? anxious or very uneasy? yes yes nono

2. In the past 6 months, did you ever have a spell or 2. In the past 6 months, did you ever have a spell or attack when for no reason your heart suddenly attack when for no reason your heart suddenly began to race, you felt faint, or you couldnbegan to race, you felt faint, or you couldn’’t catch t catch your breath? your breath? yesyes nono

►► IF YOU ANSWERED YES TO QUESTION #1 OR TO IF YOU ANSWERED YES TO QUESTION #1 OR TO QUESTION #2, THEN CONTINUE WITH THE QUESTION #2, THEN CONTINUE WITH THE ANSQANSQ, , OTHERWISE, STOP.OTHERWISE, STOP.

ANSQANSQ

3. Did any of these spells or attacks ever 3. Did any of these spells or attacks ever happen in a situation when you were the happen in a situation when you were the center of attention? center of attention? yes yes NoNo

•• (YES = consider Social Phobia)(YES = consider Social Phobia)

ANSQANSQ

4. How many times have you had a spell or 4. How many times have you had a spell or attacks in the past month? (Check one.)attacks in the past month? (Check one.)00Once Once 2 to 3 times 2 to 3 times 4 to 10 times 4 to 10 times More than 10 timesMore than 10 times

ANSQANSQ

5. In the past month, how worried have you 5. In the past month, how worried have you been that spells or attacks might happen been that spells or attacks might happen again?again?Not at all worried Not at all worried Somewhat worried Somewhat worried Very worriedVery worried

ADHD (6)ADHD (6)

►►66--item version of the ASRSitem version of the ASRSsensitivity (68.7%) sensitivity (68.7%) specificity (99.5%)specificity (99.5%)

►►agreed with the clinical diagnosis in 96.2% agreed with the clinical diagnosis in 96.2% of participants.of participants.

►►the 18the 18--item ASRS had aitem ASRS had asensitivity of 56.3%sensitivity of 56.3%specificity of 98.3%,specificity of 98.3%,

GAD (2)GAD (2)

Not being able to stop or control Not being able to stop or control worryingworrying

Feeling nervous, anxious or on edgeFeeling nervous, anxious or on edge

33221100Over the last 2weeks, how often have you been Over the last 2weeks, how often have you been bothered by any of the following problems?bothered by any of the following problems?(combined score of (combined score of ≥≥ 3 = high probability)3 = high probability)

not at all 0several days 1more than half the days 2nearly everyday 3

From PRIME MD GAD-2

Bulimia Nervosa (3)Bulimia Nervosa (3)

►► Do you often feel that you canDo you often feel that you can’’t control t control whatwhat or or how muchhow much you eat? you eat? yes yes nono

►► Do you often eat, Do you often eat, within any 2within any 2--hour hour periodperiod, what most people would regard as , what most people would regard as an unusually an unusually largelarge amount of food? amount of food?

yes yes nono►► If you checked If you checked ‘‘YESYES’’ to either aboveto either above, , Has Has

this been as often, on average, as twice a this been as often, on average, as twice a week for the last 3 months? week for the last 3 months? yes yes nono

2 positive responses = high probability2 positive responses = high probability

Bulimia NervosaBulimia Nervosa

►►Likelihood ratios for positive diagnosis and Likelihood ratios for positive diagnosis and chancechance-- corrected agreement (kappa) 73.0 corrected agreement (kappa) 73.0 and 0.73 and 0.73

PsychosisPsychosis

►►Use alone or if positive for depressionUse alone or if positive for depression

Psychosis Screening (8)Psychosis Screening (8)

►►The next questions are about unusual The next questions are about unusual things, like seeing visions or hearing voices things, like seeing visions or hearing voices that some people may not believe in. In fact that some people may not believe in. In fact these things may be quite common in these things may be quite common in certain situations.certain situations.

Adapted from WHO CIDIAdapted from WHO CIDI

PsychosisPsychosis

►►Have you ever heard voices that other Have you ever heard voices that other people could not hear. I don't mean having people could not hear. I don't mean having good hearing, but rather hearing things that good hearing, but rather hearing things that other people said did not exist, like voices other people said did not exist, like voices coming from inside your head talking to you coming from inside your head talking to you or about you, or voices coming out of the or about you, or voices coming out of the air when there was no one around. Did you air when there was no one around. Did you ever hear voices in this way? ever hear voices in this way?

PsychosisPsychosis

►►Have you ever felt that some mysterious Have you ever felt that some mysterious force was inserting thoughts force was inserting thoughts ---- that were that were definitely not your own thoughts definitely not your own thoughts –– directly directly into your head? into your head?

►►Have you ever felt that your thoughts were Have you ever felt that your thoughts were being read by other people or were being being read by other people or were being stolen out of your mind. stolen out of your mind.

PsychosisPsychosis

►►Did you ever have a time when you felt that Did you ever have a time when you felt that your mind was being taken over by others?your mind was being taken over by others?

►►Have you ever felt that someone or Have you ever felt that someone or something was trying to communicate something was trying to communicate directly with you by sending special signs or directly with you by sending special signs or signals. Some people experience this signals. Some people experience this through the radio or television. through the radio or television.

PsychosisPsychosis

►►Have you ever felt that there was a plot Have you ever felt that there was a plot going on to harm you or to have people going on to harm you or to have people follow you that your family and friends did follow you that your family and friends did not believe was true?not believe was true?

PsychosisPsychosis

►►Do you have any special powers that most Do you have any special powers that most people lack?people lack?

►►Has a doctor ever told you that you have Has a doctor ever told you that you have schizophrenia ?schizophrenia ?

Exercise #2Exercise #2

►►Working in PairsWorking in PairsUse 32 questions to diagnose Cases A & BUse 32 questions to diagnose Cases A & BEach member of pair takes turn being MDEach member of pair takes turn being MD

Case ACase A

►►The 15 Minute Psychiatric Screening The 15 Minute Psychiatric Screening Assessment case Assessment case A.docA.doc

Case BCase B

►►The 15 Minute Psychiatric Screening The 15 Minute Psychiatric Screening Assessment case Assessment case B.docB.doc

Augmenting QuestionsAugmenting Questions

Past Psychiatric HistoryPast Psychiatric History

►►Any mental disorderAny mental disorder►►LongLong--term use of benzodiazepinesterm use of benzodiazepines

Family Psychiatric HistoryFamily Psychiatric History

►►Patient says Patient says ““NONO”” means nothing (false means nothing (false negative rate is huge)negative rate is huge)

►►Positive finding for known condition and/or Positive finding for known condition and/or treatment is highly importanttreatment is highly important

►►Include family history of suicide or homicideInclude family history of suicide or homicide

RiskRisk

Understanding RiskUnderstanding Risk

►►Risk is about what is possible. Risk is about what is possible. Possibility is based on the Possibility is based on the ddxddx

►►Probability is based on individual factorsProbability is based on individual factors►►You need to know what is possible in order You need to know what is possible in order

to assess what is probable. to assess what is probable.

Risk Assessment Risk Assessment –– Suicide/HomicideSuicide/Homicide

Protective/Inhibiting Protective/Inhibiting FactorsFactors

•Hope of improving

•Subjective unwanted negative impact on others

•Religious beliefs - strong

Worrisome FactorsWorrisome Factors

•MDE

•Psychosis

•Specific targets

•Hopelessness

•Method Considered

•Preparation

Suicide QuestionsSuicide Questions

►►Do you think you will ever get better?Do you think you will ever get better?►►Do you have any hope for the future?Do you have any hope for the future?►►Do you have thoughts that life is not worth Do you have thoughts that life is not worth

living?living?►►Have you had thoughts of ending your life? Have you had thoughts of ending your life?

(have you thought it would be better to (have you thought it would be better to take your children with you?)take your children with you?)

Suicide QuestionsSuicide Questions

►► Do the thoughts of killing yourself feel as if they Do the thoughts of killing yourself feel as if they are coming from outside of you?are coming from outside of you?

►► Do the thoughts ever feel like or sound like a voice Do the thoughts ever feel like or sound like a voice telling or prompting you to end your life?telling or prompting you to end your life?

►► Protective factorsProtective factors►► Who do you have in your life that makes life worth Who do you have in your life that makes life worth

living?living?►► What has held you back from killing yourself thus What has held you back from killing yourself thus

far?far?

Homicide QuestionsHomicide Questions

►►Do you feel that any one is to blame for Do you feel that any one is to blame for your current suffering?your current suffering?

►►Have you had thoughts of revenge?Have you had thoughts of revenge?►►Have you had thoughts of ending the Have you had thoughts of ending the

personperson’’s life or their lives?s life or their lives?►►What has held you back thus far?What has held you back thus far?►►Are you concerned about the consequences Are you concerned about the consequences

to yourself or others?to yourself or others?

Homicide QuestionsHomicide Questions

►►Have you had thoughts that someone you Have you had thoughts that someone you care about is suffering and that they would care about is suffering and that they would be better off dead?be better off dead?

►►Have you had thoughts of ending a personHave you had thoughts of ending a person’’s s life?life?

Unintended harmUnintended harm

►►Motor vehicle accidentsMotor vehicle accidents►►Child welfareChild welfare►►Method of suicideMethod of suicide

What do I need to do today?What do I need to do today?

What do I need to do todayWhat do I need to do today

►►Assess RisksAssess RisksConsider emergency admissionConsider emergency admissionInform othersInform others

►►Start a medication?Start a medication?►►Book the next appointment?Book the next appointment?

MDEMDE

►►Review risksReview risksSuicideSuicideHomicideHomicideChild welfareChild welfareDrivingDriving

►►Start antidepressant if warrantedStart antidepressant if warranted

MDE MDE –– Next VisitNext Visit

►►MDE MDE –– Diagnostic ConsiderationDiagnostic Consideration

MDE MDE –– Next VisitNext Visit

►►The Bipolar Spectrum Diagnostic ScaleThe Bipolar Spectrum Diagnostic ScaleDeveloped by Ronald PiesDeveloped by Ronald Pies

C:C:\\Documents and SettingsDocuments and Settings\\JoseJose\\My DocumentsMy Documents\\PSYCHIATRYPSYCHIATRY\\Family PhysiciansFamily Physicians\\15 minute psychiatric screener15 minute psychiatric screener\\The Bipolar Spectrum The Bipolar Spectrum Diagnostic Scale with modified instructions for the 15 minute psDiagnostic Scale with modified instructions for the 15 minute psych interview ych interview augmentation.docaugmentation.doc

MDEBIPOLAR UNIPOLAR

Suicide/Homicide RiskSuicide/Homicide Risk

►►If high If high –– admitadmitVoluntarily or involuntarilyVoluntarily or involuntarily

PsychosisPsychosis

►►Review RisksReview RisksSuicideSuicideHomicideHomicideChild welfareChild welfare

►►Start AntipsychoticStart Antipsychotic

AlcoholAlcohol

►► Do I need to do something today?Do I need to do something today?Assess RisksAssess Risks►►Driving Driving

Advise against drivingAdvise against drivingInform MOTInform MOT

►►Child WelfareChild WelfareInform CASInform CAS

►►Both (Driving with Children)Both (Driving with Children)Inform CASInform CASInform MOTInform MOT

Order Blood workOrder Blood work►►CBC, GGTCBC, GGT

AlcoholAlcohol

►►At next visit (1At next visit (1--4 weeks)4 weeks)Review Review BloodworkBloodworkFurther physical examFurther physical examDrivingDriving

Forms and toolsForms and tools

►►Family physicians see patients for many Family physicians see patients for many years and are perpetually dealing with years and are perpetually dealing with undefined problemsundefined problems

►►Risk does not lend itself to Risk does not lend itself to spontaneous/creative solutionsspontaneous/creative solutions

►►We are at increased risk of poor judgment We are at increased risk of poor judgment in infrequent anxiety inducing situationsin infrequent anxiety inducing situations

►►Have a protocol and stick to it so you donHave a protocol and stick to it so you don’’t t get into messy situationsget into messy situations

Forms and toolsForms and tools

►►Documentation is your friendDocumentation is your friend►►Form 1Form 1►►MOT MOT –– have a standard letterhave a standard letter►►CAS CAS –– have a standard protocolhave a standard protocol►►Use your secretaryUse your secretary

Discussion and ReviewDiscussion and Review