Screening for mental health problems and memory impairment for people with long term physical health

conditions

Louise Ross September 2010

The North East Mental Health Development Unit is hosted by NHS County Durham

Executive Summary

At present there are 15.4 million people in England with a Long-Term Condition (LTC) and due to the increasingly ageing population by 2025 this is predicted to reach 18 million (DH, 2010). The costs associated with the treatment and care for those with a LTC account for a significant proportion of health and social care resources and are forecast to rise to 26.4 billion (DH, 2010). This can be explained by the greater use of GP and outpatient appointments and use of inpatient bed days by people with a LTC (DH, 2010). There are high incidences of people with LTCs and co morbid common mental health problems (Stafford et al 2007; Anderson et al, 2001; Barry et al, 2008). Evidence shows that this can negatively impact upon their ability to manage and cope with their LTC (Whiting et al, 2006). The Operating Framework for the NHS in England 2009/10 recognises how important it is to ensure that people with LTCs receive an optimum level of care, stating that “Over the next two years, to ensure that those living with long term conditions receive a high quality service and help to manage their condition, everyone with a long term condition should be offered a personalised care plan.” (DH, 2008, p15) The DH strategy for LTCs pioneers personalised care planning, which ensures a person’s full range of needs are accounted for and puts people with LTCs at the centre of decision making about their own care (DH, 2009). These principles are reflected by those set out in Our Vision, Our Future (NHS NE, 2008) and New Horizons (DH, 2009) whereby early detection and intervention are central to patient outcomes and QIPP savings. This paper will focus on two problems often associated with LTCs, which would limit abilities to manage a LTC and are high on the agenda on current policy drivers: mental health and memory. This will inform a pilot study, in which screening of common mental health (MH) problems and memory impairment will be incorporated into the annual health check for people living with a LTC, within 12 general practices in the North East (NE) of England. This paper will appraise the screening tool options and their applicability to a LTCs client group. The structure will be parallel in both mental health and memory, providing recommendations for a self-administered questionnaire to be completed prior to meeting with the GP, and in cases where this screens as positive, a follow up screening instrument to inform the referral process. The tools that are recommended in this paper for mental health screening for people with LTCs are the PHQ-2 and GAD-2 and the PHQ-9 and GAD-7 as pre-screening and further screening respectively. The TYM test is the recommended tool for memory screening in the LTC pilot.

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...11 3...........14 Final Thoughts ....8 2................ ...7 2......3.................22 3 .....................6 2.................3...................5 2.......1 Patient Health Questionnaire (PHQ)...............................................................................................14 References ...........................8 Introduction: Screening for Memory Problems in Primary Care ...............3 GAD-2 and GAD-7.......3 The Referral Pathway ..........Comparative Table: Common MH Screening Tools…………….............1..................2 PHQ-9 ..............Comments received from Draft 1………………………………….2 Recommendations for Long Term Conditions (LTCs) pilot..11 4.........5 2......................1............7 2........5 Beck Depression Inventory ® Second Edition (BDI-II) .......................................Table of Memory Screening Tools evaluated against BPS Criteria…………………………………………………..................................Table of Common MH Screening Tools evaluated against BPS Criteria…………………………………………………...1..................................1 PHQ-2 .............2 Recommendations for Long Term Conditions (LTC) Pilot ...4 1.11 Review of Screening Tools ...........1 The Test Your Memory (TYM).......................1 NICE guidance & NHS drivers...............21 Appendix 5.......................Comparative Table: Memory Screening Tools………………….............6 2..3 Referral Pathway ...............................20 Appendix 3............15 3 4 5 6 7 Figure 1: IAPT Stepped Care Model for Common Mental Health Problems ...13 4...........................................19 Appendix 2..........21 Appendix 4.....................................5 2........................................Contents 1 2 Introduction: Screening for Depression & Anxiety in Primary Care...............................4 Hospital and Anxiety Depression Scale (HADS) ...........13 Overview of Recommendations for Long Term Conditions (LTCs) pilot ....................................12 4........1..1 NICE guidance & NHS drivers...............1 IAPT & the Stepped Care Model for Common Mental Health Problems .......................................................1...............................................4 Review of Screening Tools .................................................................................................................13 4............................1 The Stepped Care Model for Memory Impairments.9 Appendices Appendix 1..................................................7 2...............1........

as this is likely to lead to financial savings (Michie et al. 2009.’. In particular. Productivity and Prevention (QIPP) potential. The Guideline Development Group (GDG).1 Introduction: Screening for Depression & Anxiety in Primary Care It is widely reported that the detection of mental health problems is essential for responsive delivery of appropriate interventions. There is now strong evidence that the level of symptom severity can be inferred from the implementation of both self-assessment and clinician delivered questionnaires (BMA. advocate that a two stage process of identification and diagnosis would be best practice in primary care and that evidence supported the continued use of the Whooley questions (see Box 1) as part of this initial process. 2004). Depression is associated with a 50% increase in costs of long term medical care (Katon. Innovation. 2003). have you often been bothered by feeling down. depressed or hopeless? • During the last month. 2005) may improve the specificity of this initial screening phase. 2005) and increase the Quality. It has been suggested that using an additional question: “is this something with which you would like help?” (Arroll et al. improvements need to be made in the identification and treatment of depression and anxiety. NICE. Furthermore. This makes investment in improving the mental health of people with long-term conditions valuable. 1.1 NICE guidance & NHS drivers NICE guidelines on the management of depression in primary and secondary care advocate the use of the International Classification of Diseases (ICD-10) criteria for diagnosing and assessing severity of depression. Box 1 • During the last month. However. which makes NICE recommendations when evidence is uncertain. in terms of a particular MH screening tool for the rest of this process NICE do not make recommendations but suggest a second step of a ‘more detailed instrument possessing better overall psychometric properties’ if either of the Whooley screening questions was marked as ‘yes. this invites a collaborative discussion with the patient about the relevant treatment interventions and options available to them. thus driving the quality of care provided (NICE. 2004). 2009). have you often been bothered by having little interest or pleasure in doing things? Whooley et al (1997) 4 . as guided by the stepped care model endorsed by NICE (NICE. Although NICE has identified ICD-10 as the recommended diagnostic tool for depression they acknowledge that ‘it is doubtful whether severity can realistically be captured in a single symptom count’ (NICE. 2008).

1. which are validated for use in primary care settings. PHQ-2 (Kroenke et al. second edition (BDI-II) See Appendix 1 for an overview of these tools 2. Although the PHQ-2 and the ‘Whooley questions’ use the same items the difference is that the PHQ-2 follows the Likert scale format of the PHQ-9 whereas the ‘Whooley’ version dichotomises the questions (yes/no). Wales. 2007). These are endorsed by NICE guidelines in the process of identifying depression cases. The ‘Whooley questions’ and the PHQ-2 have a cut-off points of 1 and 3 respectively. taking between 2 and 5 minutes to complete) are not routine in primary or secondary care (Gilbody et al. Practices are advised to choose one of the three measures listed below. Mitchell & Coyne (2007) propose that the PHQ2 is the most well known example of this (see Box 1). and Scotland was introduced in 2004 as part of the General Medical Services Contract. • • • The Patient Health Questionnaire (PHQ-2 and PHQ-9) The Hospital Anxiety and Depression Scale (HADS) Beck Depression Inventory. two or three question tests 5 . This replaced other fee arrangements and financially rewarded GPs for implementing best practice. these tools are reviewed and evaluated in the context of use with people with LTCs. 1999). two or even one single-detection question.1 Patient Health Questionnaire (PHQ) The PHQ was developed from the more detailed PRIME-MD tool (Spitzer et al. Subsequently there have been three main tools developed from this scale. Evidence suggests that a one-question test only identifies three out of every ten patients with depression in primary care and therefore is likely to be an unacceptable screening tool if solely relied upon (Mitchell & Coyne. 2 Review of Screening Tools In this section. a NICE-led performance management and payment system for general practitioners (GPs) in the National Health Service (NHS) in England.The Quality and Outcomes Framework (QOF) (BMA. in support of the use of the PHQ-2. the PHQ-9 (Spitzer et al. 2003) and the ‘Whooley questions’ (Whooley et al. 2008). 1997) see Box 1. However. It was widely adopted by GPs throughout the UK.1 PHQ-2 Increasingly there has been a demand for ‘ultra-short’ questionnaires. Incentives included assessing for depression and/or anxiety. to encourage discussions with the patient with regard to their treatment options. 1994). as evidence suggests that even ‘short questionnaires’ (defined as those with 514 items. This has directly led to the development of ‘ultra-short’ questionnaires comprising of three. 2002). 2.

2007). known as the GAD-2. This consists of the first 2 items on the GAD-7 and representing the core anxiety symptoms. The PHQ-9 has been validated against a diagnostic gold standard of depression in the UK (Gilbody et al.perform better. 2005) and should only be used in a screening process whereby there are sufficient resources to administer a second-stage assessment for those who screen positive (Mitchell & Coyne et al. Caution should be taken when interpreting the PHQ-2. and is reported to be of equal value to a GP’s ability to eliminate depression (Arroll et al. Both have been shown to be effective in detecting generalised anxiety. These form part of the minimum data set for all IAPT sites to collect. The PHQ-9 and GAD-7 form the main body of the questionnaires as part of the Improving Access to Psychological Therapies (DH. 2009). There are currently over 100 Primary Care Trusts (PCTs) which have joined the IAPT programme and all PCTs are committed to provide a service by 2011 (DH. 2008) data set.3%) for depression. well-validated measures for monitoring depression and anxiety respectively. the GAD-7 has an abbreviated two-item version. 2007).1. 2008). identifying eight out of every ten people with depression in primary care. However. rather than having diagnostic capabilities (Mitchell & Coyne.7%) and specificity (78. as 2 and 3 item questionnaires can often result in false positives (Mitchell & Coyne. It can be completed in less than two minutes and provides evidence of good levels of sensitivity (91. 2006) the levels of sensitivity for this tool are not yet definitive (Kroenke et al. 2001). 2010). Hansson et al. The IAPT programme reports that the IAPT data set was compiled 6 . evidencing an improvement in the diagnostic specificity from 78% (two questions alone) to 89% (either screening question plus ‘help question’) for depression.2 PHQ-9 The PHQ-9 is a self-administered nine item depression questionnaire developed in the US (Kroenke et al. social anxiety and post-traumatic stress disorder (Kroenke et al.1. a recent article published by Kroenke et al (2010) benchmarks the PHQ-9 and GAD-7 as brief. 2010. Arroll et al (2005) extended the two question format by adding the additional question: “Is this something with which you would like help?”.3 GAD-2 and GAD-7 Similar to the PHQ-9. panic. 2007). Scores on this GAD-2 subscale ranged from 0 to 6. 2007). 2007). 2. This makes the brief PHQ-9 questionnaire comparable to the screening abilities of more lengthy clinician-administered instruments in detecting depression (Gilbody et al. There is a wealth of evidence that supports the validity of the PHQ-9 for use in screening for depressive symptoms in primary care (Kroenke et al. although there are promising findings for the GAD-2 and GAD-7’s validity in screening for Generalised Anxiety Disorder (GAD) (Spitzer et al. 2. 2010). Although the PHQ-9 does not detect for anxiety. The PHQ-2 is proposed to be an effective method for ruling out a diagnosis of depression.

2. which has arranged translations into many languages which are available at request. 1961) and was updated a number of times (Beck et al. The PHQ-9 would be filled in by the patient in the presence of the GP who could aid administration and support its delivery. their use is recommended within this pilot. Beck et al. a shortened version of the full scale which was been developed for use in primary care (Beck et al. they have shown to be an effective and accurate 7 . The HADS consists of 14 items with the response format of four options of symptom severity per item in relation to the respondent’s experiences over the last week. Many studies have supported the validity of HADS (Snaith et al. 1996) subsequently.1. The GAD-2 and GAD-7 are the equivalent of these measures for the identification of anxiety disorders and.report instrument that uses the DSM-IV criteria to categorise the symptom severity of depression. free to access tools that were available in other languages and most widely used in practice (DH. It is a self. These are also widely used nationally and although they have not received as much attention as the PHQ-9. their depression counterpart. which has both an anxiety and depression scale enabling a clinician to establish severity of both anxiety and depression simultaneously. 2002). 2. It can be used alongside the BDI-fast screen. The HADS can be purchased from a reliable publisher of psychometric scales. as with PHQ-2 and PHQ-9. 2008). 1979. 1997).2 Recommendations for Long Term Conditions (LTC) Pilot As a result of this paper the recommendations for the LTC Pilot are.using the most suitable.4 Hospital and Anxiety Depression Scale (HADS) The HADS is a self administered questionnaire. the use of the PHQ-2 as a tool for the patient to self administer prior to meeting with the GP followed by the PHQ-9 if the patient scores 3 or more. The BDI-II takes around five minutes to complete and can be purchased from the supplier’s website.1. 2. primary care patients and the general population (Bjelland et al. psychiatric. internally consistent and valid scores in primary care medical settings suggesting that it may improve the detection and support the treatment of people with depression (Arnau et al. 2002). The BDI-II has demonstrated reliable. The BDI-II consists of 21 items that will assess the severity of depression in clinical and normal patient samples. 2003). Each item has four statements attached to it that are arranged in increasing severity in relation to a symptom of depression.5 Beck Depression Inventory ® Second Edition (BDI-II) The BDI was originally developed in the 1960’s (Beck et al. for the identification of depression. This scale has been widely used as a tool to identify depression severity (Sharp & Lipsky. 2001). whilst providing separate scores for each of the independent subscales as independent measures. A review of 747 studies in which the HADS was administered concluded that it was shown to ‘perform well’ in the assessment of both anxiety and depression for somatic.

The stepped care model has two main principles: • • Treatment should always have the best chance of delivering positive outcomes while burdening the patient as little as possible. and • there are no charges associated with their use.3. • they are both part of the IAPT minimum data-set and thus scores link directly to the stepped care model providing clear care pathways. Only in cases where anxiety is the primary diagnosis should this be treated first (NICE. p10). • the PHQ is endorsed by the QOF as a tool that benchmarks effective depression screening. The stepped care model provides a system of care in line with the levels of severity associated with mental health problems. Figure 1 outlines the IAPT stepped care model.uk NICE guidelines advocate the treatment of depression if the patient presents with depression as the primary diagnosis.org. stepping down where a less intensive treatment becomes appropriate and stepping out when an alternative treatment or no treatment become appropriate. such as depression and anxiety.iapt. The IAPT service functions to support the delivery of the stepped care model in relation to common mental health problems. The scores of the PHQ-9 and GAD-7 would then be used to inform the referral pathway (see Table 1 and Table 2. 2004).screening tool. The PHQ and GAD scales were deemed as the tool of choice for a number of reasons: • they are widely used in the NHS in primary care nationally and in other healthcare systems internationally. A system of scheduled reviews to detect and act on non-improvement must be in place to enable stepping up to more intensive treatments. NICE. 2.1 IAPT & the Stepped Care Model for Common Mental Health Problems NICE recommends a range of psychological therapies to treat people who are experiencing depression and/or anxiety. 8 . Derived from the IAPT website www. 2009.3 The Referral Pathway 2.

This has resulted in the development of clear referral pathways to ensure smooth and effective delivery of psychological services.Figure 1: IAPT Stepped Care Model for Common Mental Health Problems NICE promotes the stepped care framework in the MH guidelines in the delivery of effective services. diabetes and COPD. which in this case would correspond with severe and complex depression where there may also be a risk to life and/ or severe self-neglect. IAPT recommends that people are referred to the IAPT service if they screen positive on the two questions recommended by the QOF (also known as the ‘Whooley questions’) The PHQ-2 would ideally be administered before meeting with the GP and 9 . This also includes a Step 4. such as CHD. The majority of psychological therapies provided by the IAPT programme are Cognitive Behavioural Therapy (CBT) based interventions. Mental Health has been prominent in policy drivers for some time due to the overt health and cost implications attached to it. This is not incorporated into the IAPT stepped care model as this level of mental ill health would not constitute input at a primary care level. CBT has been shown to improve mental health problems in people who have long term physical conditions.

and moderate (PHQ-9=15-19) and severe depression (PHQ-9=20-27) Developed in line with NICE. Table 2 GAD-7 Score Step 1: All known and suspected presentations of GAD Step 2: Diagnosed GAD that has not improved after education and active monitoring in step 1 Step 3: GAD with marked functional impairment or that has not improved after step 2 Step in Stepped Care Model Step 1 Step 2 Step 3 Developed in line with NICE. The tables below outline the range of scores mapped onto the IAPT stepped care model (see IAPT Stepped Care Model for Common Mental Health Problems (Figure 1)).could be sent out prior to the meeting. Table 1 PHQ-9 Score Step in Stepped Care Model Recognition. The IAPT service provides a smooth care pathway. If a patient was referred to the IAPT service they would continue to complete the PHQ-9 as part of the IAPT Data Set and this continuity would make worthwhile links between primary care services. as there is the flexibility to move up or down the stepped care model in accordance with progress made at any given level. assessment and Initial Step 1 management Persistent sub threshold depressive symptoms (PHQ-9= 1-4). 2011 (Still in development) The IAPT service would use the information provided by a referrer and the PHQ-9/GAD-7 questionnaires to allocate an individual to a low or high intensity practitioner who would initially offer an appointment to the patient. 2009. The further PHQ-9 questionnaire can then be administered in primary care and the score from this can be used to inform the referral process within the Stepped Care Model. 10 . mild (PHQ9= 5-9) or moderate depression (PHQ-9= 10-14) Step 2 Persistent sub threshold depressive Step 3 symptoms (PHQ-9= 1-4) or mild (PHQ-9= 5-9) to moderate depression (PHQ-9= 10-14) with inadequate response to initial interventions.

General Practitioner Assessment of Cognition (GP COG) and the 6-Item Cognitive Impairment Test (6CIT) and a number of tools. The Strategy has set out the development of specialist services. 2009). 2009) places primary care at the heart of this initial identification process. This stresses the importance of early diagnosis. For this reason cognitive testing is often deemed as too time consuming by primary care teams (Brooke & Bullock.5 minutes. some which have not been outlined by NICE but which have been specifically validated for use in primary care with a good evidence base. This includes the Mini-Cog and Memory Impairment Screen (MIS). 4 Review of Screening Tools This paper will define and critically appraise a number of cognitive screening tests in line with their appropriateness for use in GP consultations with people with long term conditions (LTCs). and one that is becoming increasingly costly for the NHS. 2006): MMSE. 2007). Research shows that early intervention in cases of dementia is cost effective and can improve quality of life for people with dementia and their families…. there has been a surge of development of alternative brief tests in response to this need. with the increased pressure to manage the growing number of people with cognitive impairments as our population ages (Brodaty et al. This is reflected in the Department of Health Operating Framework for 2008/2009 (DoH. 2006). This will include tools highlighted in NICE guidance (NICE. 2009). brief.3 Introduction: Screening for Memory Problems in Primary Care The average consultation time in UK primary care is 7. which summarised the situation as: “…providing people with dementia and their carers the best life possible is a growing challenge.” The National Dementia Strategy (DH.1 NICE guidance & NHS drivers The importance of early detection is emphasised in the National Dementia Strategy (DH. such as memory clinics. Traditionally the Mini-Mental State Exam (MMSE) has been labelled as the ‘gold standard’ cognitive test. self-administered test for dementia known as the ‘Test Your Memory’ (TYM) assessment is discussed. However more recently. Finally. Sperlinger et al (2004) utilised work by The British Psychological Society (BPS) on outcome measures to produce a set of criteria which clinical 11 . More recently. 1999). 3. assessment of a patient’s cognition has moved towards being deemed as a crucial component of medical consultation (Brown et al. which would support primary care by providing explicit referral pathways. as late detection limits the extent a person has over their treatment choices. a new NHS recognised.

Feasibility (acceptability to patients and clinicians. time taken to complete). The TYM shows equivalent screening abilities to the original and revised Addenbrooke’s examinations in the diagnosis of dementia (Mioshi et al. Milne et al (2008) further adapted these in line with the target population of people with cognitive impairments. Despite the above three tools being advocated as best practice. The four key domains have been used in this paper to evaluate the Memory Screening Tools available at present. as they provide a parallel system for ensuring the screening tools for the LTC pilot meet BPS standards of best practice (See Appendices 3 and 4). which was still in development at the time the study was underway). Milne et al (2008) reviewed eight instruments that met the inclusion criteria. It has been referred to as the ”simple test that can spot Alzheimer’s in five minutes” and this has been publicised by NHS choices. sensitivity to education level. Using the cut off point of ≥42 to indicate a possible diagnosis of Alzheimer’s in a group of people where 10% had Alzheimer’s gave a negative predictive value of 99% and a positive predictive value of 42% (Brown et al. This means that it is unlikely that the patient or scorer will have an influence on the score thus securing the TYM as a valid and robust memory tool. Brown et al (2009) stress that these do not fully meet three essential requirements for widespread use by non-specialists: that it takes minimal operator time to administer tests. 2006. The TYM has the advantage over the Addenbrooke’s examinations and other substantial instruments. Psychometric Properties (validity. covering similar cognitive domains in its testing and also being sensitive to mild dementia. The three screening measures that were rated as best overall for implementation in primary care using this point system were the GP COG. 2009).1. that is covers a reasonable range of cognitive functions and that it is sensitive to mild Alzheimer’s disease. Mathuranath et al. cost and availability of tool). They propose that the TYM test fulfils these three essential requirements.measures could be scored against.1 The Test Your Memory (TYM) The TYM is quick to use. specificity and sensitivity). 2009). the TYM is completed by the patient and scored using a rigid scoring sheet. and detects 93% of cases of Alzheimer’s disease in comparison to 53% by the MMSE (Brown et al. the Mini-Cog and the MIS (see Appendix 2 for an overview of these tools). 4. ease of administration and scoring. These criteria have also been utilised to evaluate the MH screening tools (see section 2). language and culture). including those presented as options in the opening section of this paper (with the exception of the TYM. examines 10 cognitive skills. such as the 12 . The Sixteen criteria were grouped into four key domains • • • • Practicality (Time implications for clinician. reliability. 2000). Furthermore. Range of applicability (applicability to wide age range and different dementia types.

both now and increasingly in the future” (DH. a five-year strategy which is funding the development of services that are fit for the 21st century for people with dementia and their carers. the tool he had used with this client group. 4. 2009. Memory complaints at a primary care level. 13 . A three step model is used in this paper to structure the care pathway process. The TYM test has shown good sensitivity to mild dementia (Brown et al 2009) and is likely to fit well in place of the MMSE in Palmer’s (2003) referral framework. This gap is identified in the National Dementia Strategy (DH. Specific cognitive testing in a specialised setting.2 Recommendations for Long Term Conditions (LTCs) pilot. This has a strong advantage over current cognitive tests in that it has a brief but rigorous scoring system and as a result of this a strong interrater agreement that is described as a level of excellence (Brown et al. 2. In the future it is likely that through the development of memory services there will be a clearer framework for GPs to follow in response to detection of memory impairment. This consists of: 1. a combination of ten minutes and presence of the scoring sheet enabled a nurse to score the TYM sheets as accurately as a specialist.3. 3. 2009). For example. Assessment of global functioning by a GP. The simplicity of the implementation of this tool aligns with the need for people to be trained quickly in response to what is described as a “huge challenge to society. Palmer (2003) showed that this three-step framework resulted in a high positive predictive value for Alzheimer’s disease (85-100%). One drawback of Palmer’s (2003) three step procedure was that it was not very good at identifying people with mild dementia due to the low sensitivity of the MMSE.MMSE due to its simplicity in delivery and accessibility and ease for training implementation. This provides assurance that the TYM test will avoid the pitfalls of other cognitive screening tools regarding to confusing scoring and interpretation systems. 4. As a result of this paper the recommendations for the LTC pilot are the use of the TYM test. 2009).1 The Stepped Care Model for Memory Impairments There is no clear nationwide referral process or ‘stepped care model’ at present for memory impairment.3 Referral Pathway 4. p9).

Although this is an area that is still in development it is suggested that lowering the cut off scores substantially improves the sensitivity of mental health screening tools due to the presence of physical complaints as a result of the presence of a LTC (Stafford et al. 2007). The PHQ-2 and GAD-2 provide a pre-screening process. The TYM test was recommended as the memory screening tool of choice for the LTC pilot. The added value of detecting and managing co-morbidity for people with LTCs reflects the importance of screening for mental health and memory problems in this client group. have promising findings for detection and are already in use on a national scale in projects or as part of NHS policy drivers.5 Overview of Recommendations for Long Term Conditions (LTCs) pilot For a more detailed overview of the rationale for the recommended mental health and memory screening tools see 2.2 and 4. 6 Final Thoughts This paper was intended to be comprehensive but not exhaustive in providing an overview of the evidence for mental health and memory screening tools and the associated referral pathways in line with NHS policy. whereby they could be completed prior to meeting with the GP to inform whether further screening using the PHQ-9 and GAD-7 was required. 14 . All tools recommended. The PHQ-2 and the PHQ-9 (screening for depression) and the GAD-2 and GAD-7 (screening for anxiety) were recommended as the mental health screening tools for the LTC pilot.2 respectively. for both mental health and memory screening. 2007). One area that requires further research is the validity of the recommended cut off points with a LTCs client group (Stafford et al. have a good evidence base for use in primary care.

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Not free to use -Not based on DSM-IV criteria BDI-II Assesses severity of depression 5m .Not as much evidence for different client groups HADS Designed to assess both anxiety and depression 5m . 1-4 (minimal) 5-9 (mild) 10-14 (moderate) 15-19 (moderate/severe) 20-27 (severe) First two items on GAD-7 representing core anxiety symptoms. 0-4 (normal) 5-9 (mild) 10-14 (moderate) 15-21 (severe) 7-item questionnaire with a maximum score of 21. Scores on this subscale ranges from 0-6 to inform further use of GAD-7 7 item questionnaire with the maximum score of 21.Beneficial to add the ‘help’ question.Not free to use .Comparative Table: Common MH Screening Tools Tool PHQ-2 Description Ultra-short questionnaire consisting of two items to screen for depression Scoring System . 0-13 (minimal) 14-19 (mild 20-28 (moderate) 29-36 (severe) 3m GAD-2 GAD-7 Ultra-short questionnaire consisting of two items to screen for anxiety Aids diagnosis of generalised anxiety and measures symptom severity 1m -Relatively new screening tool -Redundant without a follow up questionnaire .established tool .Only of use when there are sufficient resources to administer a second stage assessment .Assesses both anxiety and depression -Validated for use in primary care -Likely to require little training due to being a well.Appendix 1. Shown to improve specificity from 78% to 89% -Based directly on diagnostic criteria for major depressive disorder in the DSM-IV . Nine-item questionnaire with a maximum score of 27.Free -Part of IAPT minimum data-set -Scores directly map onto stepped-care model and referral pathways -Validated for use in primary care -Greater sensitivity in the detection of depression in comparison to HADS. . Delivery Time 1m Advantages . 0-7 (normal) 8-10 (mild) 11-14 (moderate) 15-21 (severe) 21-item questionnaire with a maximum score of 36.Equal value to GPs ability in elimination of depression .Good reliability . a well known and endorsed screening tool for the IAPT service.Effective method to rule out a diagnosis of depression .Score of 3 or more indicates further screening is required.Part of the GAD-7. .Training practitioners to use the tool would be time consuming 19 .Has an abbreviated fast-screen for use in screening for primary care .Relatively new screening tool PHQ-9 Aids diagnosis of depression and measures symptom severity.Can often result in false positives .Based on DSM-IV criteria .Based on DSM-IV criteria Disadvantages .

or recall one or two of the three words an abnormal clock is suggestive.Regarded as ‘gold standard. naming. Scoring System Scores out of 30 25/30 (normal range) 10/20 (moderate) <10 /9 (severe) Scores >8 or <5 on CA indicate cognitively intact or impaired (CI) respectively. Assess the test as suggestive of dementia if the total score is 8 or more. -Test requires further validation in primary care. verbal fluency. -Further validation in larger populations required . A score of >3 on this indicates CI. Score of 5-8 (inclusive) requires the further IQ. urging caution when interpreting scores. recall of copied sentence and ability to do the test.NICE endorsed -Two stage method has good sensitivity and specificity in detecting dementia -Evidence suggests it is reliable and may be superior to MMSE -Misclassification rate less than MMSE -Free -Correlates well with MMSE and outperforms MMSE in detecting milder dementia -Free to use -Used as part of a large European tool (Easycare©) -Computerised versions in use -Misclassification rate less than MMSE -Simple scoring system -Scores not influenced by education level or language abilities. similarities. -Misclassification rate less than MMSE -Can be self-administered -More sensitive in detection of Alzheimer’s disease than MMSE (93% versus 52% respectively) -Accurately detects mild cognitive impairments . registration (immediate memory). recent event report and word recall.Complex scoring system GP COG Two components: cognitive assessment (CA) and informant questionnaire (IQ). -No current evidence of its validity in primary care. The cut-off point for Alzheimer’s is 42 or less 2-4m >5m . Measures orientation. IQ asks about changes over last few years. short term (ST) memory and language functioning. clock drawing.’ Disadvantages -Does not detect subtle memory loss particularly in well-educated patients -Not free ($1 Per use) -at least 1 of the instruments from which the GPCOG was derived (the CAMCOG [39]) is significantly biased by sociodemographic factors. MIS TYM Recall of none of the three words. 4-6m Mini-Cog Mini-Cog measures only two areas of cognition: shortdrawing. ST memory and attention. CA includes time orientation. semantic knowledge.Appendix 2: Comparative Table: Memory Screening Tools Tool MMSE Description Measures Orientation. Delivery Time 10m Advantages -NICE endorsed -Validated in number of populations . CA:4m IQ: 2m 6CIT All items verbally based. visuospatial abilities. The MIS score is calculated as [2X (free recall)]+[cued recall] Each component is allocated a number of points giving a possible total of 50 points. calculation. Verbal memory task with specific encoding procedure Series of 10 tasks including scoring on: orientation. -Scoring of clock drawing is open to bias. ability to complete a sentence.Brief but vigorous scoring system -10 m required to train nurse as specialist scorer -Free -Only measures two areas of cognition. 20 .

Table of Memory Screening tools evaluated against criteria adapted from BPS Guidelines Practicality MMSE GP COG 6CIT Mini-Cog MIS TYM Feasibility Range of Psychometric applicability Properties X ? ? X ? ? ? ? ? ? Screening Tools shaded in Grey highlight common MH and memory screening tools recommended by this paper for implementation in the LTC pilot 21 .Table of Common MH Screening Tools evaluated against criteria adapted from BPS Guidelines Practicality Feasibility MEASURE A. Anxiety GAD-7 HADS-A Range of Psychometric applicability Properties X X X ? ? Appendix 4. Depression PHQ-9 BDI-II HADS-D B.Appendix 3.

He recommended the additional use of the WHO-5 wellbeing questionnaire. which is something the paper outlined in the Overview of Recommendations for Long Term Conditions (LTCs) pilot section. He highlighted how importance it was to build in additional checks into the system for a LTCs client group.’ A lead Consultant Psychiatrist & Psychotherapist in the region. He also confirmed that the MMSE is the routine measure at present although it ‘tends to miss mild problems’. The comments below therefore serve to show the suggestions made in the papers development. Memory screening tool comments: The TYM test was recommended by a Consultant Clinical Psychologist Older Adults specialist working for NTW. as WHO recommends it as a measure of positive mental health. He suggested it has added value in that it is beginning to be used more widely in the region. She also commented how she was ‘really interested to see how the TYM performs in primary care as it looks very promising’.Appendix 4. A Regional GP Advisor for IAPT reported how the paper had made ‘some really sensible suggestions’ endorsing the use of PHQ-9 due to it's established use in Primary Care. specialising in CBT. as in evaluation of some projects in County Durham they have found that service users preferred this shorter scale as they found it less invasive than the longer version. He stated how the paper ‘ties up some of the activities already being developed and cements the way forward in line with them.Comments received from Draft 1 The first draft of this paper was circulated to a number of health professionals working in a variety of settings in both primary and secondary care. 22 . General comments: An IAPT Lead for the region commented positively on the links the paper makes with IAPT and the commonality of the tools used within primary care. as ’Probably the best self report memory test’ stressing how it is relatively new and not used in the north east at present. The shortened version of this scale was highlighted as being the preferred version. The completed paper was developed in line with the comments but could not incorporate all suggestions of additional tools in its content. Mental Health screening tool comments: A Public Health Lead for the region recommended the inclusion of the WEMWBS scale (Warwick Edinburgh Mental Wellbeing Scale). commented upon the value of the scales being cost free and having data for use in primary care. The comments received were very useful in shaping the document and provided the paper with valuable input from clinicians and mental health leads in the region.

nemhdu.org.uk 23 .Supporting better mental health The North East Mental Health Development Unit Hosted by NHS County Durham The Greenhouse Greencroft Industrial Park Stanley County Durham DH9 7XN Tel: 01207 523655 www.