Title: Approved Behavioral Health Screening Tools for 3ai and 4aiii Date Created: 10/8/2015 Date Modified: 07/27/2017 Date Approved by Board of Directors: 11/10/2015 Clinical Guideline # CGC-CG-26
Purpose: The purpose of this guideline is to establish a menu of approved behavioral health screening tools for use in the 3ai Integration of Behavioral Health and Primary Care (Model 1) project and 4aiii Strengthening Mental Health and Substance Abuse Infrastructure Across Systems.
Participating practices may choose from the menu of approved screening tools below or use nationally-accepted best practice that are determined to be aged-appropriate:
Approved Screening Tools:
Depression: PHQ-9: Patient Health Questionnaire (9 questions) PHQ-2: Patient Health Questionnaire (2 questions)
Anxiety: GAD-7: General Anxiety Disorder (7 questions)
Substance CAGE-AID: Cut-down, Annoyed, Guilty, and Eye-Opener (4 questions) Abuse: CAGE: 4 questions AUDIT: Alcohol Use Disorder Identification Test (10 questions) DAST- 10: Drug-Abuse Screening Test (10 question; excludes alcohol) CRAFFT: Series of 6 questions to identify adolescents 14- 21 years of age for risky alcohol and other drug use disorders NIAAA: 3 question screen Trauma: PC-PTSD: Primary Care- Post Traumatic Stress Disorder (for veterans) PCL-C: Abbreviated PTSD Checklist, Civilian Version
Suicide or Nursing Assessment for Suicide/Violence (4 questions) Violence: If appropriate, followed by: Suicide Assessment (23 questions) Violence Assessment (23 questions)
BH Works: BH Works, a tablet-based screening IT solution has a “smart” assessment tool which covers 13 domains of behavioral health.
SBIRT: Screening, Brief Intervention and Referral to Treatment is an evidence based practice. Staff must be certified/ trained in SBIRT prior to administering SBIRT. Additional screenings such as AUDIT, DAST or CRAFFT may be warranted for further assessments.
Integrating Behavioral Health and Primary Care—Approved Behavioral Health Screening Tools Page 1 of 2
Pediatrics: Pediatric Symptom Checklist –(PSC) is a brief screening questionnaire used by pediatricians and other professionals to improve early detection and interventions of psychosocial problems in children.
Clinical Guideline Board Approval History: 11/10/2015
Clinical Guideline Revisions:
Date Revision Log Updated by 10/8/2015 Initial Draft E. Pape 09/09/2016 Incorporated 4aiii Strengthening B. Rosetti Mental Health and Substance Abuse. Project and CAGE screening. Added SBIRT, NIAAA, CRAFFT screening 10/19/2016 Added Pediatric Symptom B. Rosetti Checklist (PSC) 01/13/2017 To align with DOH’s minimum B. Rosetti standards: Added PHQ-2 and incorporated all behavioral health screenings that are nationally-accepted best practice that are determined to be aged- appropriate 07/06/2017 and 07/27/2017 Annual Review – No changes. B. Rosetti CGC members agreed that partners should be allowed to use nationally-accepted best practice screenings that are aged- appropriate.
This Clinical Guideline shall be reviewed periodically and updated consistent with the requirements established by the Board of Directors, Care Compass Network’s senior management, Federal and State law(s) and regulations, and applicable accrediting and review organizations.
Integrating Behavioral Health and Primary Care—Approved Behavioral Health Screening Tools Page 2 of 2 PHQ-9 Patient Depression Questionnaire
For initial diagnosis:
1. Patient completes PHQ-9 Quick Depression Assessment. 2. If there are at least 4 3s in the shaded section (including Questions #1 and #2), consider a depressive disorder. Add score to determine severity.
Consider Major Depressive Disorder
- if there are at least 5 3s in the shaded section (one of which corresponds to Question #1 or #2)
Consider Other Depressive Disorder
- if there are 2-4 3s in the shaded section (one of which corresponds to Question #1 or #2)
Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood the questionnaire, as well as other relevant information from the patient. Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social, occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms.
To monitor severity over time for newly diagnosed patients or patients in current treatment for depression:
1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home and bring them in at their next appointment for scoring or they may complete the questionnaire during each scheduled appointment.
2. Add up 3s by column. For every 3: Several days = 1 More than half the days = 2 Nearly every day = 3
3. Add together column scores to get a TOTAL score.
4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score.
5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree of response, as well as guiding treatment intervention.
Scoring: add up all checked boxes on PHQ-9
For every 3 Not at all = 0; Several days = 1; More than half the days = 2; Nearly every day = 3
Interpretation of Total Score
Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression
PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a trademark of Pfizer Inc.
A2662B 10-04-2005 PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
NAME: DATE:
Over the last 2 weeks, how often have you been bothered by any of the following problems? More than Several Nearly (use "ⁿ" to indicate your answer) Not at all half the days every day days
1. Little interest or pleasure in doing things 0 1 2 3
0 1 2 3 2. Feeling down, depressed, or hopeless
0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much
0 1 2 3 4. Feeling tired or having little energy
0 1 2 3 5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure or 0 1 2 3 have let yourself or your family down
7. Trouble concentrating on things, such as reading the 0 1 2 3 newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or 0 1 2 3 restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of 0 1 2 3 hurting yourself
add columns + +
(Healthcare professional: For interpretation of TOTAL, TOTAL: please refer to accompanying scoring card).
10. If you checked off any problems, how difficult Not difficult at all
have these problems made it for you to do Somewhat difficult your work, take care of things at home, or get Very difficult along with other people? Extremely difficult
Copyright © 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD© is a trademark of Pfizer Inc. A2663B 10-04-2005 Generalized Anxiety Disorder 7-item (GAD-7) scale Over the last 2 weeks, how often have you been Not at Several Over half Nearly bothered by the following problems? all sure days the days every day 1. Feeling nervous, anxious, or on edge 0 1 2 3
2. Not being able to stop or control worrying 0 1 2 3
3. Worrying too much about different things 0 1 2 3
4. Trouble relaxing 0 1 2 3
5. Being so restless that it's hard to sit still 0 1 2 3
6. Becoming easily annoyed or irritable 0 1 2 3
7. Feeling afraid as if something awful might 0 1 2 3 happen Add the score for each column + + +
Total Score (add your column scores) =
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all ______ Somewhat difficult ______ Very difficult ______ Extremely difficult ______ Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097. CAGE-AID Overview The Cage-AID is a conjoint questionnaire where the focus of each item of the CAGE questionnaire was expanded from alcohol alone to include alcohol and other drugs. Clinical Utility Potential advantage is to screen for alcohol and drug problems conjointly rather than separately. Scoring Regard one or more positive responses to the CAGE-AID as a positive screen.
CAGE-AID Questionnaire
Patient Name ______Date of Visit ______
When thinking about drug use, include illegal drug use, and the use of prescription drug use other than prescribed
Questions: YES NO
1. Have you ever felt that you ought to cut down on your drinking □ □ or drug use? 2. Have people annoyed you by criticizing your drinking or drug use? □ □ 3. Have you ever felt bad or guilty about your drinking or drug use? □ □ 4. Have you ever had a drink or used drugs first thing in the morning □ □ to steady your nerves or to get rid of a hangover? CAGE Questionnaire CAGE Questionnaire
• Have you ever felt you should Cut down on your drinking? • Have you ever felt you should Cut down on your drinking?
• Have people Annoyed you by criticizing your drinking? • Have people Annoyed you by criticizing your drinking?
• Have you ever felt bad or Guilty about your drinking? • Have you ever felt bad or Guilty about your drinking?
• Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? hangover (Eye opener)?
Scoring: Scoring:
Item responses on the CAGE are scored 0 or 1, with a higher score an indication of alcohol Item responses on the CAGE are scored 0 or 1, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant. problems. A total score of 2 or greater is considered clinically significant.
……………………………….. ………………………………..
Developed by Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, Developed by Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, University of North Carolina at Cahpel Hill, CAGE is an internationally used assessment instrument University of North Carolina at Cahpel Hill, CAGE is an internationally used assessment instrument for identifying alcoholics. It is particularly popular with primary care givers. CAGE has been for identifying alcoholics. It is particularly popular with primary care givers. CAGE has been translated into several languages. translated into several languages.
The CAGE questions can be used in the clinical setting using informal phrasing. It has been The CAGE questions can be used in the clinical setting using informal phrasing. It has been demonstrated that they are most effective when used as part of a general health history and should demonstrated that they are most effective when used as part of a general health history and should NOT be preceded by questions about how much or how frequently the patient drinks (see NOT be preceded by questions about how much or how frequently the patient drinks (see “Alcoholism: The Keys to the CAGE” by DL Steinweg and H Worth; American Journal of Medicine “Alcoholism: The Keys to the CAGE” by DL Steinweg and H Worth; American Journal of Medicine 94: 520-523, May 1993. 94: 520-523, May 1993.
The exact wording that can be used in research studies can be found in: JA Ewing “Detecting The exact wording that can be used in research studies can be found in: JA Ewing “Detecting Alcoholism: The CAGE Questionaire” JAMA 252: 1905-1907, 1984. Researchers and clinicians Alcoholism: The CAGE Questionaire” JAMA 252: 1905-1907, 1984. Researchers and clinicians who are publishing studies using the CAGE Questionaire should cite the above reference. No who are publishing studies using the CAGE Questionaire should cite the above reference. No other permission is necessary unless it is used in any profit-making endeavor in which case this other permission is necessary unless it is used in any profit-making endeavor in which case this Center would require to negotiate a payment. Center would require to negotiate a payment.
……………………………….. ………………………………..
Source: Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, University of North Source: Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill Carolina at Chapel Hill
012695 (02-2004) To reorder, call 1-877-638-7827 012695 (02-2004) To reorder, call 1-877-638-7827 The Alcohol Use Disorders Identification Test (AUDIT), developed in 1982 by the World Health Organization, is a simple way to screen and identify people at risk of alcohol problems.
1. How often do you have a drink containing alcohol?
(0) Never (Skip to Questions 9-10) (1) Monthly or less (2) 2 to 4 times a month (3) 2 to 3 times a week (4) 4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
(0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7, 8, or 9 (4) 10 or more
3. How often do you have six or more drinks on one occasion?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 6. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
7. How often during the last year have you needed an alcoholic drink first thing in the morning to get yourself going after a night of heavy drinking?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
8. How often during the last year have you had a feeling of guilt or remorse after drinking?
(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
(0) No (2) Yes, but not in the last year (4) Yes, during the last year
10. Has a relative, friend, doctor, or another health professional expressed concern about your drinking or suggested you cut down?
(0) No (2) Yes, but not in the last year (4) Yes, during the last year
Add up the points associated with answers. A total score of 8 or more indicates harmful drinking behavior.
DAST-10
Introduction
The Drug Abuse Screening Test (DAST-10) is a 10-item brief screening tool that can be administered by a clinician or self-administered. Each question requires a yes or no response, and the tool can be completed in less than 8 minutes. This tool assesses drug use, not including alcohol or tobacco use, in the past 12 months.
http://www.drugabuse.gov/nidamed-medical-health-professionals DAST‐10 Questionnaire
I’m going to read you a list of questions concerning information about your potential involvement with drugs, excluding alcohol and tobacco, during the past 12 months.
When the words “drug abuse” are used, they mean the use of prescribed or over‐the‐counter medications/drugs in excess of the directions and any non‐medical use of drugs. The various classes of drugs may include: cannabis (e.g., marijuana, hash), solvents, tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcohol or tobacco.
If you have difficulty with a statement, then choose the response that is mostly right. You may choose to answer or not answer any of the questions in this section.
These questions refer to the past 12 months. No Yes 1. Have you used drugs other than those required for medical reasons? 0 1 2. Do you abuse more than one drug at a time? 0 1 3. Are you always able to stop using drugs when you want to? (If never use 0 1 drugs, answer “Yes.” 4. Have you had "blackouts" or "flashbacks" as a result of drug use? 0 1 5. Do you ever feel bad or guilty about your drug use? If never use drugs, 0 1 choose “No.” 6. Does your spouse (or parents) ever complain about your involvement 0 1 with drugs? 7. Have you neglected your family because of your use of drugs? 0 1 8. Have you engaged in illegal activities in order to obtain drugs? 0 1 9. Have you ever experienced withdrawal symptoms (felt sick) when you 0 1 stopped taking drugs? 10. Have you had medical problems as a result of your drug use (e.g., 0 1 memory loss, hepatitis, convulsions, bleeding, etc.)? Interpreting the DAST 10
In these statements, the term "drug abuse" refers to the use of medications at a level that exceeds the instructions, and/or any non‐medical use of drugs. Patients receive 1 point for every "yes" answer with the exception of question #3, for which a "no" answer receives 1 point. DAST‐10 Score Degree of Problems Related to Drug Abuse Suggested Action.
Degree of Problems Related to DAST-10 Score Suggested Action Drug Abuse 0 No problems reported None at this time 1–2 Low level Monitor, re‐assess at a later date 3–5 Moderate level Further investigation 6–8 Substantial level Intensive assessment 9–10 Severe level Intensive assessment
Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behavior, 7(4),363–371. The CRAFFT Screening Interview
Begin: “I’m going to ask you a few questions that I ask all my patients. Please be honest. I will keep your answers confidential.”
Part A During the PAST 12 MONTHS, did you: No Yes 1. Drink any alcohol (more than a few sips)?
(Do not count sips of alcohol taken during family or religious events.) 2. Smoke any marijuana or hashish?
3. Use anything else to get high? (“anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff”)
For clinic use only: Did the patient answer “yes” to any questions in Part A? No Yes
Ask CAR question only, then stop Ask all 6 CRAFFT questions
Part B No Yes 1. Have you ever ridden in a CAR driven by someone (including yourself) who
was “high” or had been using alcohol or drugs? 2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit
in? 3. Do you ever use alcohol or drugs while you are by yourself, or ALONE? 4. Do you ever FORGET things you did while using alcohol or drugs? 5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your
drinking or drug use? 6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?
CONFIDENTIALITY NOTICE: The information recorded on this page may be protected by special federal confidentiality rules (42 CFR Part 2), which prohibit disclosure of this information unless authorized by specific written consent. A general authorization for release of medical information is NOT sufficient for this purpose. © CHILDREN’S HOSPITAL BOSTON, 2009. ALL RIGHTS RESERVED. Reproduced with permission from the Center for Adolescent Substance Abuse Research, CeASAR, Children’s Hospital Boston. (www.ceasar.org)
SCORING INSTRUCTIONS: FOR CLINIC STAFF USE ONLY
CRAFFT Scoring: Each “yes” response in Part B scores 1 point. A total score of 2 or higher is a positive screen, indicating a need for additional assessment.
1,2 Probability of Substance Abuse/Dependence Diagnosis Based on CRAFFT Score
10 0 % DX 80%
60%
endence 40%
20%
Probability of 0% 123456 Abuse/Dep CRAFFT Score
DSM-IV Diagnostic Criteria3 (Abbreviated) Substance Abuse (1 or more of the following): Use causes failure to fulfill obligations at work, school, or home Recurrent use in hazardous situations (e.g. driving) Recurrent legal problems Continued use despite recurrent problems Substance Dependence (3 or more of the following): Tolerance Withdrawal Substance taken in larger amount or over longer period of time than planned Unsuccessful efforts to cut down or quit Great deal of time spent to obtain substance or recover from effect Important activities given up because of substance Continued use despite harmful consequences
© Children’s Hospital Boston, 2009. This form may be reproduced in its exact form for use in clinical settings, courtesy of the Center for Adolescent Substance Abuse Research, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115, U.S.A., (617) 355-5433, www.ceasar.org.
References: 1. Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med 1999;153(6):591-6. 2. Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 2002;156(6):607-14. 3. American Psychiatric Association. Diagostic and Statistical Manual of Mental Disorders, fourth edition, text revision. Washington DC, American Psychiatric Association, 2000.
NIAAA
1. How many days per week do you drink alcohol?
2. On a typical day when you drink, how many drinks do you have?
3. What is the maximum number of drinks you had on any given day in the past month?
Maximum Drinking Limits For healthy men up to age 65—
• no more than 4 drinks in a day AND • no more than 14 drinks in a week For healthy women (and healthy men over age 65)—
• no more than 3 drinks in a day AND • no more than 7 drinks in a week
Updatedì A POCKET GUIDE FOR Alcohol Screening and Brief Intervention Updated 2005 Edition
This pocket guide is condensed from the 34-page NIAAA guide, Helping Patients Who Drink Too Much: A Clinician’s Guide. Visit www.niaaa.nih.gov/guide for related professional support resources, including: • patient education handouts • preformatted progress notes • animated slide show for training • materials in Spanish
Or contact: NIAAA Publications Distribution Center P.O. Box 10686, Rockville, MD 20849-0686 (301) 443–3860 www.niaaa.nih.gov HOW TO SCREEN FOR HEAVY DRINKING STEP 1 Ask About Alcohol Use
Ask: Do you sometimes drink beer, wine, or other alcoholic beverages?
NO YES
Screening complete. Ask the screening question about heavy drinking days: How many times in the past year have you had . . . 5 or more 4 or more drinks in a day? drinks in a day? (for men) (for women)
One standard drink is equivalent to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.
Is the answer 1 or more times?
NO YES
Advise staying within these Your patient is an at-risk limits: drinker. For a more complete Maximum Drinking Limits picture of the drinking men up to age 65— pattern, determine the For healthy weekly average: • no more than 4 drinks in a day AND • On average, how many days a week • no more than 14 drinks in a week do you have an X alcoholic drink? For healthy women (and healthy men over age 65)— • On a typical drinking day, how • no more than 3 drinks many drinks do in a day AND you have? • no more than 7 drinks in a week Weekly average Recommend lower limits or Record abstinence heavy drinking days as indicated: for in past year and weekly example, for patients who take average in chart. medications that interact with alcohol, have a health condition exacerbated by alcohol, or are pregnant (advise abstinence) GO TO Rescreen annually STEP 2 1 HOW TO ASSESS FOR ALCOHOL USE DISORDERS STEP 2 Assess For Alcohol Use Disorders Next, determine if there is a maladaptive pattern of alcohol use, causing clinically significant impairment or distress .
Determine whether, in the past 12 months, your patient’s drinking has repeatedly caused or contributed to
risk of bodily harm (drinking and driving, operating machinery, swimming) relationship trouble (family or friends) role failure (interference with home, work, or school obligations) run-ins with the law (arrests or other legal problems) If yes to one or more your patient has alcohol abuse. In either case, proceed to assess for dependence symptoms.
Determine whether, in the past 12 months, your patient has
not been able to stick to drinking limits (repeatedly gone over them) not been able to cut down or stop (repeated failed attempts) shown tolerance (needed to drink a lot more to get the same effect) shown signs of withdrawal (tremors, sweating, nausea, or insomnia when trying to quit or cut down) kept drinking despite problems (recurrent physical or psychological problems) spent a lot of time drinking (or anticipating or recovering from drinking) spent less time on other matters (activities that had been important or pleasurable) If yes to three or more your patient has alcohol dependence.
Does patient meet criteria for abuse or dependence?
NO YES
GO TO GO TO STEPS 3 & 4 STEPS 3 & 4 for for AT-RISK ALCOHOL USE DRINKING DISORDERS 2 HOW TO CONDUCT A BRIEF INTERVENTION FOR AT-RISK DRINKING (no abuse or dependence) STEP 3 Advise and Assist
State your conclusion and recommendation clearly and relate them to medical concerns or findings. Gauge readiness to change drinking habits.
Is patient ready to commit to change?
NO YES
Restate your concern. Help set a goal. Encourage reflection. Agree on a plan. Address barriers to change. Provide educational Reaffirm your willingness materials. (See www.niaaa. to help. nih.gov/guide.)
STEP 4 At Followup: Continue Support REMINDER: Document alcohol use and review goals at each visit.
Was patient able to meet and sustain drinking goal?
NO YES
Acknowledge that Reinforce and support change is difficult. continued adherence Support positive change to recommendations. and address barriers. Renegotiate drinking Renegotiate goal and goals as indicated (e.g., plan; consider a trial of if the medical condition abstinence. changes or if an abstain- ing patient wishes to Consider engaging resume drinking). significant others. Encourage to return Reassess diagnosis if if unable to maintain patient is unable to either adherence. cut down or abstain. Rescreen at least annually.
3 HOW TO CONDUCT A BRIEF INTERVENTION FOR ALCOHOL USE DISORDERS (abuse or dependence) STEP 3 Advise and Assist
State your conclusion and recommendation clearly and relate them to medical concerns or findings. Negotiate a drinking goal. Consider evaluation by an addiction specialist. Consider recommending a mutual help group. For patients who have dependence, consider • the need for medically managed withdrawal (detoxification) and treat accordingly. • prescribing a medication for alcohol dependence for patients who endorse abstinence as a goal. Arrange followup appointments, including medication management support if needed.
STEP 4 At Followup: Continue Support REMINDER: Document alcohol use and review goals at each visit. Was patient able to meet and sustain drinking goal?
NO YES
Acknowledge that change Reinforce and support is difficult. continued adherence. Support efforts to cut down Coordinate care with or abstain. specialists as appropriate. Relate drinking to ongoing Maintain medications problems as appropriate. for alcohol dependence Consider (if not yet done): for at least 3 months and as clinically indicated • consulting with an thereafter. addiction specialist. • recommending a mutual Treat coexisting nicotine help group. dependence. • engaging significant Address coexisting others. disorders —medical and psychiatric—as needed. • prescribing a medication for alcohol-dependent patients who endorse abstinence as a goal. Address coexisting disorders—medical and psychiatric—as needed.
4 WHAT’S A STANDARD DRINK? A standard drink in the United States is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons). Below are U.S. standard drink equivalents as well as the number of standard drinks in different container sizes for each beverage. These are approx- imate, since different brands and types of beverages vary in their actual alcohol content. STANDARD APPROXIMATE DRINK NUMBER OF EQUIVALENTS STANDARD DRINKS IN: BEER or COOLER 12 oz. • 12 oz. = 1 • 16 oz. = 1.3 • 22 oz. = 2 • 40 oz. = 3.3 ~5% alcohol MALT LIQUOR 8–9 oz. • 12 oz. = 1.5 • 16 oz. = 2 • 22 oz. = 2.5 • 40 oz. = 4.5 ~7% alcohol TABLE WINE 5 oz.
• a 750-mL (25-oz.) bottle = 5
~12% alcohol 80-proof DISTILLED SPIRITS 1.5 oz. • a mixed drink = 1 or more* • a pint (16 oz.) = 11 • a fifth (25 oz.) = 17 • 1.75 L (59 oz.) = 39
40% alcohol *Note: Depending on factors such as the type of spirits and the recipe, one mixed drink can contain from one to three or more standard drinks.
The percent of “pure” alcohol, expressed here as alcohol by volume (alc/vol), varies by beverage. Although the “standard” drink amounts are helpful for following health guidelines, they may not reflect customary serving sizes. In addition, while the alcohol concentrations listed are “typical,” there is considerable variability in alcohol content 5 within each type of beverage (e.g., beer, wine, distilled spirits). DRINKING PATTERNS
HOW COMMON HOW ARE ALCOHOL WHAT‘S YOUR COMMON DISORDERS IN DRINKING IS THIS DRINKERS WITH PATTERN? PATTERN? THIS PATTERN?
Based on the following limits— number of drinks: On any DAY—Never more Percentage Combined than 4 (men) or 3 (women) of prevalence U.S. adults of – and – aged 18 alcohol abuse In a typical WEEK—No more or older* and dependence than 14 (men) or 7 (women):
Never exceed the daily or weekly limits fewer than (2 out of 3 people in this group 1 in 100 abstain or drink fewer than 12 drinks a year) 72%
Exceed only the daily limit (More than 8 out of 10 in this 1 in 5 group exceed the daily limit less than once a week) 16%
Exceed both daily and weekly limits almost (8 out of 10 in this group 1 in 2 exceed the daily limit once a week or more) 10%
*Not included in the chart, for simplicity, are the 2 percent of U.S. adults who exceed only the weekly limits. The combined prevalence of alcohol use disorders in this group is 8 percent.
Source: 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationwide NIAAA survey of 43,093 U.S. adults aged 18 or older.
6 January 2007 an Note: substitute for the patient package inserts or other drug The chart below contains excerpts from page 16 of NIAAA’s Helping Patients Who Drink Too Much: A Clinician’s Guide . It does not provide complete information and is meant to be a reactions Usual adult dosage interactions Examples of drug Common side effects Serious adverse Precautions Contraindications Action individual circumstance and the NIH accepts no liability or responsibility for use of information with regard to particular patients. Whether or not a medication should be prescribed and in what amount is matter between individuals their health care providers. The prescribing information provided here
Laboratory followup: Monitor liver function. Evaluate liver function. reaction, a naloxone challenge test should be employed. there’s a risk of precipitating an opioid withdrawal minimum of 7 to 10 days before starting. If you feel that Before prescribing: Patients must be opioid-free for a Oral dose: 50 mg daily. Opioid medications (blocks action). dizziness; fatigue; somnolence; anxiety. Nausea; vomiting; decreased appetite; headache; appear to be a hepatotoxin at the recommended doses). dependent on opioids; hepatotoxicity (although does not Will precipitate severe withdrawal if the patient is information, see www.niaaa.nih.gov/guide . personnel in the event of an emergency. For wallet card C. Advise patients to carry a wallet card alert medical may be deeper and more prolonged. Pregnancy Category larger doses may be required, and respiratory depression attempts or depression. If opioid analgesia is needed, Other hepatic disease; renal impairment; history of suicide liver failure. anticipated need for opioid analgesics; acute hepatitis or Currently using opioids or in acute opioid withdrawal; reduced reward in response to drinking. Blocks opioid receptors, resulting in reduced craving and (Depade Naltrexone ® , ReVia references used by clinicians. For patient information, visit ® ) Laboratory followup: Monitor liver function. condition. the injection site for adequate muscle mass and skin Before prescribing: Same as oral naltrexone, plus examine injection, once monthly. IM dose: 380 mg given as a deep intramuscular gluteal Same as oral naltrexone. site; joint pain; muscle aches or cramps. Same as oral naltrexone, plus a reaction at the injection pneumonia and suicidal ideation behavior. site; depression; and rare events including allergic Same as oral naltrexone, plus infection at the injection bleeding problems. Same as oral naltrexone, plus hemophilia or other injection site. deep intramuscular injection; rash or infection at the Same as oral naltrexone, plus inadequate muscle mass for Same as oral naltrexone; 30-day duration. PRESCRIBING MEDICATIONS Extended-Release Injectable Naltrexone (Vivitrol ® )
abstinence. Before prescribing: Evaluate renal function. Establish times daily. 30 to 50 mL/min), reduce 333 mg (one tablet) three daily; Oral dose: 666 mg (two 333-mg tablets) three times No clinically relevant interactions known. Diarrhea; somnolence. and behavior. Rare events include suicidal ideation ideation and behavior. Pregnancy Category C. between 30 and 50 mL/min); depression or suicidal Moderate renal impairment (dose adjustment for CrCl Severe renal impairment (CrCl ≤ 30 mL/min). its Affects glutamate and GABA alcohol-related action is unclear. http://medlineplus.gov . or for patients with moderate renal impairment (CrCl Acamprosate (Campral neurotransmitter ®
)
systems, but Laboratory followup: Monitor liver function. (e.g., cologne, mouthwash). counter medications (e.g., cough syrups), and toiletries alcohol in the diet (e.g., sauces and vinegars), over-the- occur up to 2 weeks after the last dose and (2) avoid after drinking and that a disulfiram-alcohol reaction can patient (1) not to take disulfiram for at least 12 hours Before prescribing: Evaluate liver function. Warn the Oral dose: 250 mg daily (range 125 to 500 mg). phenytoin; any nonprescription drug containing alcohol. Anticoagulants such as warfarin; isoniazid; metronidazole; Metallic after-taste; dermatitis; transient mild drowsiness. peripheral neuropathy, psychotic reactions. Disulfiram-alcohol reaction, hepatotoxicity, optic neuritis, www.niaaa.nih.gov/guide . of an emergency. For wallet card information, see carry a wallet card to alert medical personnel in the event impairment. Pregnancy Category C. Advise patients to diabetes mellitus; epilepsy; hypothyroidism; renal or cerebral damage; psychoses (current history); Hepatic cirrhosis or insufficiency; cerebrovascular disease (thiuram) derivatives. severe myocardial disease; hypersensitivity to rubber preparations or metronidazole; coronary artery disease; Concomitant use of alcohol or alcohol-containing alcohol. sweating, nausea, and tachycardia if a patient drinks buildup of acetaldehyde and a reaction flushing, Inhibits intermediate metabolism of alcohol, causing a substitute for a provider’s judgment in Disulfiram (Antabuse ® )
7 Primary Care PTSD Screen (PC-PTSD)
Description The PC-PTSD is a 4-item screen that was designed for use in primary care and other medical settings and is currently used to screen for PTSD in veterans at the VA. The screen includes an introductory sentence to cue respondents to traumatic events. The authors suggest that in most circumstances the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any 3 items. Those screening positive should then be assessed with a structured interview for PTSD. The screen does not include a list of potentially traumatic events.
Scale Instructions: In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:
1. Have had nightmares about it or thought about it when you did not want to?
YES / NO
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
YES / NO
3. Were constantly on guard, watchful, or easily startled?
YES / NO
4. Felt numb or detached from others, activities, or your surroundings?
YES / NO
Current research suggests that the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items.
Prins, Ouimette, & Kimerling, 2003 Abbreviated PCL-C
This Abbreviated PCL-C is a shortened version of the PTSD Checklist – Civilian version (PCL-C). It was developed for use with in primary care or other similar general medical settings. Professional judgment should be used in generalizing it to other settings or if using the Military or Specific versions of the PCL. The initial development of the measure is presented in:
Lang, A.J., Stein, M.B. (2005) An abbreviated PTSD checklist for use as a screening instrument in primary care. Behaviour Research and Therapy, 43, 585-594
Additional psychometric information about this measure is available in:
Lang, A. J., Wilkins, K., Roy-Byrne, P. P., Golinelli, D., Chavira, D., Sherbourne, C., Rose, R. D., Bystritsky, A., Sullivan, G., Craske, M. G., & Stein, M. B. (2012). Abbreviated PTSD Checklist (PCL) as a Guide to Clinical Response. General Hospital Psychiatry, 34, 332-338.
You can generate 2 brief versions by extracting the instructions, items and response choices from the PCL-C (which is included in this document):
The 2-item version consists of items 1 and 4. An individual is considered to have screened positive if the sum of these items is 4 or greater.
The 6-item version consists of items 1, 4, 7, 10, 14 and 15. An individual is considered to have screened positive if the sum of these items is 14 or greater.
Appropriate citation of the Abbreviated PCL-C would include references to the above papers (Lang & Stein, 2005; Lang et al., 2012) as well as to the full PCL (Weathers, Litz, Herman, Huska, & Keane, 1993).
The complete reference for the PCL is:
Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (October 1993). The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX. PCL-C
The next questions are about problems and complaints that people sometimes have in response to stressful life experiences. Please indicate how much you have been bothered by each problem in the past month. For these questions, the response options are: “not at all”, “a little bit”, “moderately”, “quite a bit”, or “extremely”.
A little Quite Not at all bit Moderately A Bit Extremely PCL1 Repeated, disturbing memories, thoughts, or 1 2 3 4 5 images of a stressful experience from the past?
PCL2 Repeated, disturbing dreams of a stressful 1 2 3 4 5 experience from the past? PCL3 Suddenly acting or feeling as if a stressful experience from the past were happening again 1 2 3 4 5 (as if you were reliving it)? PCL4 Feeling very upset when something reminded you of a stressful experience from the past? 1 2 3 4 5
PCL5 Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something 1 2 3 4 5 reminded you of a stressful experience from the past? PCL6 Avoiding thinking or talking about a stressful experience from the past or avoiding having 1 2 3 4 5 feelings related to it? PCL7 Avoided activities or situations because they reminded you of a stressful experience from the 1 2 3 4 5 past? PCL8 Having trouble remembering important parts of a 1 2 3 4 5 stressful experience from the past? PCL9 Loss of interest in activities that you used to 1 2 3 4 5 enjoy? PCL10 Feeling distant or cut off from other people? 1 2 3 4 5 PCL11 Feeling emotionally numb or being unable to 1 2 3 4 5 have loving feelings for those close to you? PCL12 Feeling as if your future somehow will be cut 1 2 3 4 5 short? PCL13 Having trouble falling or staying asleep? 1 2 3 4 5 PCL14 Feeling irritable or having angry outbursts? 1 2 3 4 5 PCL15 Difficulty concentrating? 1 2 3 4 5 PCL16 Being “superalert” or watchful or on guard? 1 2 3 4 5 PCL17 Feeling jumpy or easily startled? 1 2 3 4 5 Assessment for Suicide Risk
1.) Do you feel as though your health problems have made you a burden to others? ______2.) Have you ever made plans to harm or kill yourself? ______3.) Have you ever attempted suicide? ______4.) Do you currently have any thoughts or desires to harm or kill yourself? ______Assessment for Suicide Risk Check one: □ Initial □ Re-assessment □ Change in condition □ Discharge Instructions: Evaluate the patient on each of the following factors. Make only one rating on each factor by checking the box that applies. Then add the total number of points across all risk factors. Ratings for each factor should be based on a combination of patient self-report, clinical observation, and collateral information RISK FACTOR Absent Low Moderate High (0 pts) (1 pt) (2 pts) (3 pts) Historical and Demographic (Items 1-4 are scored only on initial assessment; enter total of items from prior assessment: ______) 1. Age and Gender Not Applicable Age 13-19; Male 45+; Female 75+ □ □ 2. Prior History of Suicide None/Not Applicable Has had period of ideation, One or more gestures or One or more serious suicide but no history of attempts or attempts, without highly attempts (e.g., requiring medical gestures lethal means and with plans attention) with wish of success; or hope of being rescued history of suicide attempt in □ hospital □ □ □ 3. Marital Status Not Applicable Married with family; Separated, but living with Divorced, widowed, single, or experiencing moderate someone else; Married with separated and living alone martial or family difficulties relationship tension □ □ □ □ 4. Family History of Suicide Not Applicable History of completed suicide in first-degree relative (e.g., parent or sibling) □ □ ITEMS 5-23 ARE THE ONLY FACTORS EVALUATED ON FOLLOW-UP, RE-ASSESSMENT, OR DISCHARGE IN INPATIENT SETTING Clinical and Psychiatric 5. Hopelessness None/Not Applicable Feels down and pessimistic Pessimistic; hopeless; sees Complete despair, pessimism; no sometimes; views current only marginal possibility of possibility of a bright future situation as temporary things getting better □ □ □ □ 6. Anxiety and Agitation None/Not Applicable Mild anxiety or agitation Sporadic panic attacks of Severe, recurrent panic attacks; moderate severity; feels marked psychomotor agitation agitated or anxious (e.g., pacing, jittery) □ □ □ □ 7. Psychosis None/Not Applicable Over-valued ideas of guilt or Delusions of guilt or remorse; Command hallucinations with remorse command hallucinations of suicidal content that patient is suicide that patient can resist unable to resist □ □ □ □ 8. Impulsivity None/Not Applicable Sometimes acts impulsively Recurrent impulsive acts Frequent, unplanned, emotionally- or only when high or (e.g., gambling, risk-taking charged periods of self-mutilation; intoxicated; takes risks to feel behavior); planned episodes self-destructive reactions to better of self-mutilation disappointment □ □ □ □ 9. Cognitive Functioning None/Not Applicable Some rigidity or inflexibility Close-minded, somewhat Extreme “tunnel vision;” very inflexible in thinking or polarized thinking; major decision-making; loss of neurocognitive disorder with self- executive functioning destructive behavior □ □ □ □ 10. Mood Disorder None/Not Applicable Dysphoria; mild to moderate Depressed and/or labile Major mood disorder (e.g., depression mood; not well controlled; depression, bipolar, poor sleep and/or appetite schizoaffective) in the depressive phase; with anhedonia, melancholia; severe symptoms □ □ □ □ 11. Substance Abuse None/Not Applicable Occasional substance abuse; Impulsive use of alcohol or Drug and/or alcohol abuse AND social use of drugs or alcohol drugs; uses substance to major Axis I mood disorder; resulting in some difficulties medicate stress, anxiety, or polysubstance abuse or (e.g., DWI) depression dependence to cope with major stressor □ □ □ □ Current/Recent Suicidal Behavior 12. Suicidal Intent None/Not Applicable Vague thoughts of wanting to Frequent periods of intending Wants to die; would try to kill self be dead; very ambivalent to die; some ambivalence; if means available, as assessed about dying, can identify can identify few reasons for through self-report, collateral reasons for living living sources, or inferred from recent behavior (e.g., planning) □ □ □ □ 13. Suicidal Ideation None/Not Applicable Passive, sporadic, infrequent Frequent, intermittent, or Constant, persistent, intense thoughts of wanting to kill stress-induced tho0ugths of thoughts of wanting to kill self self wanting to kill self □ □ □ □ Assessment for Suicide Risk RISK FACTOR Absent Low Moderate High (0 pts) (1 pt) (2 pts) (3 pts) 14. Suicide Planning None/Not Applicable Thinking about the Recently gave away Suicide note recently written; has possibility of suicide, with possessions of value; has formulated a specific plan and vague ideas of means or given though to means, but has chosen a specific method plan, but undecided no specific plan formed □ □ □ □ 15. Means of Suicide None/Not Applicable Vague about specific Wants to use lethal means, Has ready access to highly lethal means; has thought about but has no ready access; means (e.g., firearms); has difficult to obtain means has access to moderately obtained sufficient means to kill lethal means (e.g., razors) self (e.g., stocked up medications) □ □ □ □ 16. Recent Attempt None/Not Applicable Superficial gestures or Recent gesture with low Recent suicide attempt with recent verbal threats with likelihood of death (e.g., lethal means (e.g., firearm, no overt action superficial cuts); recent hanging, asphyxiation, serious attempt with ambivalence overdose requiring medical attention) □ □ □ □ Psychosocial and Environmental Factors Number of Items 12-16 with 3-Point Ratings 17. Employment Status Not Applicable Mild job-related stressors Unemployed, but no Recent job loss; unemployment or difficulties pressing financial worries; with current financial problems employed but experiencing or drop in socioeconomic status financial worries □ □ □ □ 18. Social Supports Adequate social supports Some social supports; but Significant relationship Complete lack of social support; relationships strained; problems; estranged from alienated from friends and marginally connected to family, few close friends, or family; very isolated; severe family and friends family members. Family relationship problems (e.g., history of mental illness pending divorce) □ □ □ □ 19. Medical Problems None/Not Applicable General or vague medical Serious medical symptoms, Recent diagnosis of serious problems or illness with no hope for medical illness cure □ □ □ □ 20. Social Stressors None/Not Applicable Vague, general, or mild History of abuse Current abuse victim; high level psychosocial stressors victimization; poor or of perceived stress; recent inadequate housing; serious loss; recent incarceration lingering legal difficulties or serious legal charges pending □ □ □ □ Protective and Other Risk Management Factors 21. Treatment Accessibility No barriers to treatment Ambivalent about help, Wants no treatment, despite despite need; frequent no- obvious need; no established show or sporadic relationship with mental health involvement with provider in community; patient treatment mute or non-compliant when answering questions about suicide □ □ □ 22. Reasons for Living High religiosity; committed to Some trouble identifying Discouraged with life; feels Spouse and children no longer spouse and children; positive reasons for living; stressed family and/or children have any meaning; complete lack problem-solving skills, can over family responsibilities; would be better off of commitment or responsibility identify clear reasons for living general dissatisfaction with without; has minimal to leading a satisfying life; can life reasons to go on living identify no reasons for living □ □ □ □ 23. Feasibility of Life Plans Not Applicable Some resolution of Resolution of stressors, but Rapid resolution of serious stressors; plans difficult to plans are unrealistic stressors without clear or rational implement, but feasible explanation □ □ □ □ COLUMN SUBTOTALS 0 + + + + Total from Items 1-4 (for re-assessment only) ADD TOTALS TO OBTAIN FINAL SCORE _____ Low Risk (total score 0-22) _____ Moderate Risk (total score 23-33) _____ High Risk (total score 34 or above) or (Items 12-16 with 3-point ratings is 2 or more □ (check when completed): Physician notified of final score, classification, and individual risk factors.
______Signature Date/Time Assessment for Violence Risk Check one: □ Initial □ Re-assessment □ Change in condition □ Discharge Instructions: Evaluate the patient on each of the following factors. Make only one rating on each factor by checking the box that applies. Then add the total number of points across all risk factors. Ratings for each factor should be based on a combination of patient self-report, clinical observation, and collateral information RISK FACTOR Absent Low Moderate High (0 pts) (1 pt) (2 pts) (3 pts) Historical and Demographic (Items 1-4 are scored only on initial assessment; enter total of items from prior assessment: ______) 1. Age and Gender Not Applicable Male, age less than 15; Male Male, age 15-24 25+ □ □ □ 2. History of Early Violence None/Not Applicable Committed first act of serious Committed first act of serious violence between the ages of violence prior to the age of 20 20 and 40 □ □ □ 3. Early Maladjustment Not Applicable History of periodic family History of sporadic or History of serious criminal activity conflict, academic problems, periodic abuse/neglect; or delinquency before age 15; or behavioral difficulties moderate delinquency; victim of severe or prolonged history of long-term abuse or neglect academic problems □ □ □ □ 4. History of Violence None/Not Applicable History of generalized threats Remote history of one act of History of two or more acts of of harm to others; mild violence to another person; physical violence to another history of several acts of person; recent history of serious property damage verbal threats/intimidation or physical violence toward another serious property damage person □ □ □ □ ITEMS 5-23 ARE THE ONLY FACTORS EVALUATED ON FOLLOW-UP, RE-ASSESSMENT, OR DISCHARGE IN INPATIENT SETTING Clinical and Psychiatric 5. Negative Attitudes None/Not Applicable Feels pessimistic sometimes; Insensitive to the feelings of Completely lacking in empathy views self as misunderstood others; pessimistic most of toward others; cold or callous; has the time no hope for the future □ □ □ □ 6. Anger None/Not Applicable Mild anxiety or agitation Marked irritability or anger Intense feelings of rage or hostility □ □ □ □ 7. Psychosis None/Not Applicable Over-valued ideas of Schizophrenia, Command hallucinations with paranoid nature, but not schizophreniform, violent content that patient is schizoaffective disorder; unable to resist; threat-control delusional paranoid or grandiose over-ride symptoms (e.g., delusion delusions; command of thought insertion, control or hallucinations patient can influence resist □ □ □ □ 8. Impulsivity None/Not Applicable Sometimes acts impulsively Recurrent impulsive acts Frequent, unplanned, emotionally- or only when high or (e.g., gambling, risk-taking charged periods of impulsive intoxicated; takes risks to feel behavior) behavior; aggressive reactions to better disappointment □ □ □ □ 9. Psychopathic Traits None/Not Applicable Marginal level of antisocial or Narcissistic, cool and Long history of arrests for many psychopathic personality detached, manipulates different crimes; glib and shallow; traits others; moderate level of complete lack of empathy; long antisocial or psychopathic pattern of lying or deceit traits □ □ □ □ 10. Cognitive Functioning None/Not Applicable Some rigidity or inflexibility in Close-minded, somewhat Personality change due to head thinking inflexible in thinking or injury; loss of executive decision-making functioning, mental retardation; neurocognitive disorder with aggressive behavior □ □ □ □ 11. Substance Abuse None/Not Applicable Occasional substance abuse; Impulsive use of alcohol or Drug and/or alcohol abuse AND social use of drugs or alcohol drugs; uses substance major Axis I disorder; substance resulting in some difficulties recklessly in way that has led abuse or dependence resulting in (e.g., DWI) to legal or other behavioral aggression or violence problems □ □ □ □ Current/Recent Violent Behavior 12. Violent Ideation None/Not Applicable Sporadic thoughts of an Has intermittent ideas, or Has persistent and vivid fantasies aggressive nature, with no vague thoughts of wanting to or ideas about hurting or injuring clear detail hurt another person some other person □ □ □ □ 13. Violent Intent None/Not Applicable Vague thoughts of wanting to Frequent periods of wanting Wants to kill a specific person or is harm someone; ambivalent to kill or hurt someone, with definite about wanting to hurt about hurting others ambivalence or able to avoid someone; would act on such thoughts thoughts if given the chance □ □ □ □ Assessment for Violence Risk RISK FACTOR Absent Low Moderate High (0 pts) (1 pt) (2 pts) (3 pts) 14. Violent Ideation None/Not Applicable Passive, sporadic, Frequent, intermittent or Constant, persistent, intense infrequent thoughts of stress-induced thoughts of thoughts of wanting to harm or wanting to harm others; no homicide or violence kill others homicidal ideas □ □ □ □ 15. Violent Planning None/Not Applicable Vague thoughts of violence Has looked into getting Recently obtained weapon; made involving non-specific weapon (but did not explicit, credible threat to victim; means obtain); has given thought has developed clear plan to do to how violence might be harm to others carried out □ □ □ □ 16. Recent Violent Behavior None/Not Applicable Moderate behavioral Recent threats verbalized Recent act of aggression or gesturing or vague threats to others; recent act of violence resulting in injury to of violence violence resulting in serious others property damage □ □ □ □ Psychosocial and Environmental Factors Number of Items 12-16 with 3-Point Ratings 17. Employment Status Not Applicable Mild job-related stressors Unemployed, but no Recent job loss; unemployment or difficulties pressing financial worries; with current financial problems employed but experiencing or drop in socioeconomic status financial worries □ □ □ □ 18. Social Supports Adequate social supports Some social supports; but Significant relationship Complete lack of social support; relationships strained; problems; few close friends alienated from friends and marginally connected to or family members family; very isolated; severe others relationship problems (e.g., pending divorce) □ □ □ □ 19. Access to Weapons None/Not Applicable Does not own weapons, Owns weapons (i.e., guns, knives, but has idea or plan on how etc.) or has clear access to them to obtain for violence and has considered using for against others violence against others □ □ □ 20. Social Stressors None/Not Applicable Vague, general, or mild History of abuse Current abuse victim; high level psychosocial stressors victimization; poor or of perceived stress; recent inadequate housing; serious loss; recent incarceration lingering legal difficulties or serious legal charges pending □ □ □ □ Protective and Other Risk Management Factors 21. Treatment Accessibility No barriers to treatment; has Seems committed to Ambivalent about help, Long history of non-compliance an established relationship with treatment, but has not despite need; frequent no- with medications despite clear a mental health provider in the always followed through show or sporadic need; no established relationship community involvement with with mental health provider in treatment; marginal community; complete lack of compliance with insight medications □ □ □ □ 22. Legal Status Voluntary or informal Involuntary; court-ordered commitment □ □ 23. Feasibility of Life Plans Not Applicable Some resolution of Resolution of stressors, but Rapid resolution of serious stressors; plans difficult to plans are unrealistic stressors without clear or rational implement, but feasible explanation □ □ □ □ COLUMN SUBTOTALS 0 + + + + Total from Items 1-4 (for re-assessment only) ADD TOTALS TO OBTAIN FINAL SCORE _____ Low Risk (total score 0-22) _____ Moderate Risk (total score 23-33) _____ High Risk (total score 34 or above) or (Items 12-16 with 3-point ratings is 2 or more □ (check when completed): Physician no fied of final score, classifica on, and individual risk factors.
______Signature Date/Time
FACT SHEET
Office of National Drug Control Policy (ONDCP)
Substance Abuse and Mental Health http://www.samhsa.gov Services Administration (SAMHSA)
Screening, Brief Intervention, and
Referral to Treatment (SBIRT)
A Comprehensive Public Health Approach SBIRT at a Glance Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive public health approach for delivering early intervention and treatment services to people with, or at risk of developing, substance use disorders. Healthcare providers Step 1 using SBIRT ask patients about substance use during routine medical and dental visits, provide brief advice, and then, if appropriate, refer patients who are at risk of Screen Patients substance use problems Screening quickly assesses the to treatment. Release of severity of substance use and identifies the appropriate level of the Institute of Medicine treatment. Screenings take place in report Broadening the trauma centers, emergency rooms, Base of Treatment for community clinics, health centers, Alcohol Problems1 dental clinics, and school clinics. provided recognition that Screening can be done through one to five pre-screen questions based alcohol and drug abuse on evidence from NIDA and NIAAA. occur along a continuum of both level of Steps consumption and 2 and 3 consequences. This recognition is illustrated by a treatment pyramid (shown above) that has been developed to depict the role of SBIRT in addressing needs across the Conduct Brief Intervention continuum of use. and Brief Therapy Brief Intervention and Brief Studies show the need for a tool such as SBIRT: Therapy use motivational Results of the most recent National Survey on Drug Use and Health (NSDUH) interviewing techniques to show that an estimated 22.1 million people aged 12 or older have a increase a person’s awareness of 2 substance use and encourage diagnosable alcohol or illicit drug use disorder. changes in behavior. In 2010, according to NSDUH, 8.1 percent of the population aged 12 or older – about 20.5 million people – needed but did not receive substance use 3 Step 4 treatment at a specialty facility in the past year. 4 In 2006, excessive drinking cost the United States $223 billion. Factoring in public health, public safety, and lost productivity, illicit drug use cost the 5 Refer to Treatment Nation an estimated $193 billion in 2007. Referral to treatment offers access to specialty care for individuals who Elements of SBIRT are in need of treatment for Healthcare practitioners have the important responsibility of looking after their substance abuse. patients’ general health and welfare. In this role, they must be vigilant in identifying a host of potential health problems. It is critical, therefore, to focus resources and efforts on expanding the continuum of care health practitioners provide for their patients.
July 2012 With SBIRT, substance abuse screening is incorporated into mainstream healthcare settings, such as college health clinics, hospitals, trauma centers, and dental clinics, as well as into tribal and military healthcare settings. Practitioners screen patients to assess substance use, then, based on the screening results, provide the appropriate intervention.
SBIRT is a four-part process: Universal screening assesses substance use and identifies people with substance use problems. Brief intervention is provided when a screening indicates moderate risk. Brief intervention utilizes motivational interviewing techniques focused on raising patients’ awareness of substance use and its consequences and motivating them toward positive behavioral change. Brief therapy continues motivational discussion for persons needing more than a brief intervention. Brief therapy is more comprehensive and includes further assessment, education, problem solving, coping mechanisms, and building a supportive social environment. Referral to treatment provides a referral to specialty care for persons deemed to be at high risk. A key aspect of SBIRT is the integration and coordination of screening, early intervention, and treatment components into a system of care. This system links community health care and social service programs with specialty treatment programs. In each of the SBIRT grantee programs, healthcare professionals and clinical support staff conduct universal screening that targets risky to harmful use, thereby helping to reduce the number of people who move from substance use to addiction. History of the Federal SBIRT Program In 2003, the Federal Government established the SBIRT grantee program within the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance Abuse Treatment to implement SBIRT services in primary care and community health settings for adults with substance use disorders6 (see grantee map at right). To date, SAMHSA has fully or partially funded four portfolios for SBIRT grantees: (1) SBIRT Cooperative Agreements to Single State Authorities (SSAs) for Substance Abuse Services; (2) SBIRT implementation on college campuses; (3) a pilot project for SBIRT implementation within Federally Qualified Health Centers (FQHCs); and (4) SBIRT implementation within medical residency programs. These real- world implementations build on findings of more than 100 research studies conducted over the past 30 years that have supported development of reliable screening tools, empirically proven brief interventions, and implementation and technology transfer research. Effectiveness of SBIRT Research on SBIRT’s effectiveness for alcohol and drug problems indicates the approach clearly leads to short-term health improvements and, though not fully demonstrated, may also yield substantial long-term benefits.7,8 One study found that, in some instances, a brief motivational intervention appears to facilitate abstinence from heroin and cocaine use at a 6-month follow-up interview, even in the absence of specialty addiction treatment.9
July 2012 Data from SAMHSA grant programs10 help demonstrate the impact of SBIRT on patient health through documented:
Reduction in alcohol and drug use 6 months after receiving intervention (41 percent of respondents reported abstinence from drugs and/or alcohol at follow-up, compared to just 16 percent at baseline); Improvement in quality-of-life measures, including employment/education status, housing stability, and 30-day past arrest rates (95 percent of respondents reported no arrests in the past 30 days at follow-up, compared to 88 percent at baseline); and Reduction in risky behaviors, including fewer unprotected sexual encounters (injection drug use decreased from 3.2 percent at baseline to 1.5 percent at follow-up).
SBIRT also reduces the time and resources needed to treat conditions caused or worsened by substance use, making our health systems more cost-effective.11 For example, participants in the Washington State Screening, Brief Intervention, and Referral to Treatment (WASBIRT) program who received a brief intervention experienced a reduction in total Medicaid costs ranging from $185-$192 per month. Participants admitted as hospital inpatients after emergency department visits saw reductions in associated costs ranging from $238-$269 per month.12
Seeking Local Solutions
State and local level actions: Healthcare professionals can learn screening techniques to identify patients with, or at risk for, substance use problems and talk to them about consequences and behavioral change. To learn more about SBIRT, visit www.integration.samhsa.gov/clinical-practice/sbirt. More training can be made available to primary healthcare providers and staff to ensure fidelity to evidence- based practices such as SBIRT. Training and webinars on SBIRT are available at www.integration.samhsa.gov/clinical-practice/sbirt. Parents can talk to their children about the consequences of alcohol and illicit drug use. Advice and information about teen drug use is available online at http://www.theantidrug.com. Community anti-drug coalitions can apply for Federal grants through ONDCP’s Drug Free Communities Support Program (http://www.whitehouse.gov/ondcp/drug-free-communities-support-program). Codes for Reimbursable SBIRT Services The chart below lists codes approved by the American Medical Association (CPT Codes) and the Centers for Medicare and Medicaid Services (G and H Codes) to be used by healthcare practitioners for reimbursable SBIRT services.13
Payer Code Description Alcohol and/or substance abuse structured screening and brief CPT 99408 intervention services; 15 to 30 minutes Commercial Insurance Alcohol and/or substance abuse structured screening and brief CPT 99409 intervention services; greater than 30 minutes
Alcohol and/or substance abuse structured screening and brief G0396 intervention services; 15 to 30 minutes Medicare Alcohol and/or substance abuse structured screening and brief G0397 intervention services; greater than 30 minutes
H0049 Alcohol and/or drug screening Medicaid H0050 Alcohol and/or drug service, brief intervention, per 15 minutes
July 2012 Resources for Codes for Reimbursable SBIRT Services Private Insurance More information about Current Procedural Terminology (CPT) codes for private insurance is available from SAMHSA at http://www.samhsa.gov/prevention/SBIRT/index.aspx Medicare and Medicaid More information about Medicare and Medicaid G and H codes is available from SAMHSA at http://www.samhsa.gov/prevention/SBIRT/index.aspx and from the Centers for Medicare & Medicaid Services at http://www.cms.gov/. More information on Codes for Reimbursable SBIRT Services is available from the Medicare Learning Network at http://www.cms.gov/MLNgeninfo/. Physicians AMA Healthier Life Steps™: Coding for Routine Adult Lifestyle Screening, Early Intervention, and Motivational Interviewing, published in cpt Assistant: Your practical guide to current coding (2009), is available online from the American Medical Association at http://www.ama-assn.org/ama1/pub/upload/mm/433/cpt-assistant.pdf.
Other SBIRT Resources To learn more about substance use and SBIRT, visit the websites for SAMHSA (www.samhsa.gov) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) at www.niaaa.nih.gov. Screening for Drug Use in General Medical Settings: Quick Reference Guide, National Institute on Drug Abuse, 2009. Available online at http://m.drugabuse.gov/sites/default/files/files/screening_qr.pdf Screening for Drug Use in General Medical Settings: A Resource Guide for Providers, National Institute on Drug Abuse. Available online at www.nida.nih.gov/nidamed/resguide/resourceguide.pdf The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), developed by the World Health Organization (WHO), is designed to help healthcare providers detect and manage substance use and related problems in primary and general medical care settings. More information about this screening tool is available on WHO’s website at http://www.who.int/substance_abuse/activities/assist/en/ Wisconsin created a coding, billing, and reimbursement guide (http://www.wiphl.com/uploads/media/SBIRT_Manual.pdf)
Notes
1 Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems: Report of a Study by a Committee of the Institute of Medicine, Division of Mental Health and Behavioral Medicine. Washington, DC: National Academy Press. 2 Substance Abuse and Mental Health Services Administration, 2011. Results from the 2010 National Survey on Drug Use and Health: Volume 1. Summary of National Findings. DHHS Publication No. SMA 10-4856. 3 Substance Abuse and Mental Health Services Administration, 2011. Results from the 2010 National Survey on Drug Use and Health: Volume 1. Summary of National Findings. DHHS Publication No. SMA 10-4856. 4 Bouchery, E., Harwood, H., Sacks, J., Simon, C., Brewer, R. (2011). Economic Costs of Excessive Alcohol Consumption in the U.S., 2006. American Journal of Preventive Medicine, 41(5), 516-524. 5 National Drug Intelligence Center (2011). The Economic Impact of Illicit Drug Use on American Society. United States Department of Justice. Retrieved from http://www.justice.gov/ndic/ 6 SAMSHA FY 2011 Request for Applications (RFA), Cooperative Agreements for Screening, Brief Intervention and Referral to Treatment (Short Title: SBIRT), Initial Announcement, Request for Applications (RFA) No. TI-11-005. Posting on Grants.gov: March 30, 2011, http://www.samhsa.gov/grants/2011/ti_11_005.aspx 7 Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, brief intervention, and referral to treatment (SBIRT): Toward a public health approach to the management of substance abuse. Substance Abuse,2007. 28(3): 7-30. 8 Madras B., Compton W., Avula D., Stegbauer T., Stein J., & Clark H.W. (2009). Screening, brief intervention, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence, 99 (1-3), 280-295. doi: 10.1016/j.drugalcdep.2008.08.003. 9 Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, & S., Hingson, R. (2005). Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence, 77, 49-59. 10 Unpublished data from SAMHSA's Services Accountability Improvement System, July 2012. 11 Estee, S., He, L., Mancuso, D., & Felver, B.(2006).Medicaid cost outcomes.Department of Social and Health Services, Research and Data Analysis Division: Olympia, Washington. 12 Estee, S., Wickizer, T., He, L., Shah, M.F., Mancuso, D. (2010). Evaluation of the Washington State screening, brief intervention, and referral to treatment project: cost outcomes for Medicaid patients screened in hospital emergency departments. Medical Care, 48(1), 18-24. 13 Substance Abuse and Mental Health Services Administration, 2011. Retrieved from http://www.samhsa.gov/prevention/SBIRT/coding.aspx
July 2012
Office of National Drug Control Policy
www.WhiteHouse.gov/ONDCP
July 2012 BRIGHT FUTURES TOOL FOR PROFESSIONALS INSTRUCTIONS FOR USE Pediatric Symptom Checklist
The Pediatric Symptom Checklist is a psychosocial screen designed to facili- tate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible. Included here are two versions, the parent-completed version (PSC) and the youth self-report (Y-PSC). The Y-PSC can be administered to adolescents ages 11 and up. INSTRUCTIONS FOR The PSC consists of 35 items that are rated as “Never,” “Sometimes,” or SCORING “Often” present and scored 0, 1, and 2, respectively. The total score is calculat- ed by adding together the score for each of the 35 items. For children and adolescents ages 6 through 16, a cutoff score of 28 or higher indicates psycho- logical impairment. For children ages 4 and 5, the PSC cutoff score is 24 or higher (Little et al., 1994; Pagano et al., 1996). The cutoff score for the Y-PSC is 30 or higher. Items that are left blank are simply ignored (i.e., score equals 0). If four or more items are left blank, the questionnaire is considered invalid. HOW TO INTERPRET THE A positive score on the PSC or Y-PSC suggests the need for further evaluation PSC OR Y-PSC by a qualified health (e.g., M.D., R.N.) or mental health (e.g., Ph.D., L.I.C.S.W.) professional. Both false positives and false negatives occur, and only an experi- enced health professional should interpret a positive PSC or Y-PSC score as any- thing other than a suggestion that further evaluation may be helpful. Data from past studies using the PSC and Y-PSC indicate that two out of three chil- dren and adolescents who screen positive on the PSC or Y-PSC will be correctly identified as having moderate to serious impairment in psychosocial function- ing. The one child or adolescent “incorrectly” identified usually has at least mild impairment, although a small percentage of children and adolescents turn out to have very little or no impairment (e.g., an adequately functioning child or adolescent of an overly anxious parent). Data on PSC and Y-PSC negative screens indicate 95 percent accuracy, which, although statistically adequate, still means that 1 out of 20 children and adolescents rated as functioning ade- quately may actually be impaired. The inevitability of both false-positive and false-negative screens underscores the importance of experienced clinical judg- ment in interpreting PSC scores. Therefore, it is especially important for par- ents or other laypeople who administer the form to consult with a licensed professional if their child receives a PSC or Y-PSC positive score. For more information, visit the Web site: http://psc.partners.org.
REFERENCES Jellinek MS, Murphy JM, Little M, et al. 1999. Use of the Pediatric Symptom Checklist (PSC) to screen for psychosocial problems in pediatric primary care: A national feas- ability study. Archives of Pediatric and Adolescent Medicine 153(3):254–260. Jellinek MS, Murphy JM, Robinson J, et al. 1988. Pediatric Symptom Checklist: Screening school-age children for psychosocial dysfunction. Journal of Pediatrics 112(2):201–209. Web site: http://psc.partners.org. Little M, Murphy JM, Jellinek MS, et al. 1994. Screening 4- and 5-year-old children for psychosocial dysfunction: A preliminary study with the Pediatric Symptom Checklist. Journal of Developmental and Behavioral Pediatrics 15:191–197. Pagano M, Murphy JM, Pedersen M, et al. 1996. Screening for psychosocial problems in 4–5 year olds during routine EPSDT examinations: Validity and reliability in a Mexican-American sample. Clinical Pediatrics 35(3):139–146.
www.brightfutures.org
16 BRIGHT FUTURES TOOL FOR PROFESSIONALS Pediatric Symptom Checklist (PSC)
Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child’s behavior, emotions, or learning, you may help your child get the best care possible by answering these questions. Please indicate which statement best describes your child. Please mark under the heading that best describes your child: Never Sometimes Often
1. Complains of aches and pains 1 ______2. Spends more time alone 2 ______3. Tires easily, has little energy 3 ______4. Fidgety, unable to sit still 4 ______5. Has trouble with teacher 5 ______6. Less interested in school 6 ______7. Acts as if driven by a motor 7 ______8. Daydreams too much 8 ______9. Distracted easily 9 ______10. Is afraid of new situations 10 ______11. Feels sad, unhappy 11 ______12. Is irritable, angry 12 ______13. Feels hopeless 13 ______14. Has trouble concentrating 14 ______15. Less interested in friends 15 ______16. Fights with other children 16 ______17. Absent from school 17 ______18. School grades dropping 18 ______19. Is down on him or herself 19 ______20. Visits the doctor with doctor finding nothing wrong 20 ______21. Has trouble sleeping 21 ______22. Worries a lot 22 ______23. Wants to be with you more than before 23 ______24. Feels he or she is bad 24 ______25. Takes unnecessary risks 25 ______26. Gets hurt frequently 26 ______27. Seems to be having less fun 27 ______28. Acts younger than children his or her age 28 ______29. Does not listen to rules 29 ______30. Does not show feelings 30 ______31. Does not understand other people’s feelings 31 ______32. Teases others 32 ______33. Blames others for his or her troubles 33 ______34. Takes things that do not belong to him or her 34 ______35. Refuses to share 35 ______Total score ______
Does your child have any emotional or behavioral problems for which she or he needs help? ( ) N ( ) Y Are there any services that you would like your child to receive for these problems? ( ) N ( ) Y
If yes, what services?______www.brightfutures.org
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