MENTAL HEALTH ASSESSMENT TOOL

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The Mental Health Assessment Tool was developed to bring awareness to behaviors that may potentially disrupt the
TB treatment regimen. Substance abuse and mental illness may complicate case management. Knowledge of these
issues can help TB program staff anticipate problems.
This tool includes a series of questionnaires and observations that can be documented during the patient's medical
evaluation. This information may highlight significant issues which should be addressed by TB program staff or
require referral to a mental health professional.
The design of the Mental Health Assessment Tool encourages TB program staff to learn as much as possible about
the patient and involve them in creating a treatment plan that will increase treatment success. This may involve the
recognition and management of mental health diagnosis and substance abuse problems.
CAUTIONS
Please keep in mind the following cautions:
Use of the screening tools and ratings does not produce a diagnosis. Rather, the tools and scales can point toward
significant behaviors that may require further assessment by a professional. In addition, the tool can identify
behaviors that may need to be addressed to ensure successful patient adherence or that require referral to a mental
health professional.
A particular "score" does not mean that the individual has a specific condition. These screening tools and rating
scales are only one component of an evaluation.
Programs may benefit from a protocol that clearly identifies which behaviors, scores, or responses require referral to
a mental health provider. For further assistance see the attached Mental Health Resource Guide.
Symptoms suggestive of suicidal or harmful behaviors warrant immediate attention by a trained mental health
clinician.
Please see Considerations for a Successful Interview at the end of this booklet.
DISCLAIMER
THIS DOCUMENT CONTAINS A SCREENING TOOL.
IT IS NOT INTENDED TO BE USED AS A MENTAL HEALTH DIAGNOSTIC TOOL.

MENTAL HEALTH ASSESSMENT TOOL
DEPRESSION DISORDER
Patient Health Questionnaire (PHQ-2)
Yes No
1. Do you often feel down, depressed, or hopeless?
2. Do you lack interest in activities, hobbies, and what is happening around you?
Interpretation: If patient answers "yes" to either of these questions, it may be an indicator that further assessment is needed.
SUICIDE – SELF HARM
Suicide Assessment
Yes No
1. Do you feel hopeless about the present or future? If yes move to question 2. If no, go to question 4.
2. Have you had thoughts about taking your life? If yes move onto question 3.
3. When did you have these thoughts and do you have a plan to take your life?
4. Have you ever attempted to harm yourself or attempted suicide?
Interpretation: If the patient answered "yes" to any of the questions, seek immediate attention from a trained clinician.
BIPOLAR DISORDER
Black Dog Institute's Self-Test
Yes No
1. Have you been too depressed to work, or only able to work with difficulty?
2. Do you experience 'ups' as well as 'downs' with your mood?
3. Are your ups 'wired' or 'hyper' – more than when you are just happy?
Interpretation: If patient answered "yes" to all 3 questions, seek referral. If all three answers were not "yes", then the patient may have
another condition such as depression or Attention Deficit Hyperactivity Disorder (ADHD). Adjustment of the care plan may be needed. If in
question, it is always best to seek referral to a trained clinician.
SUBSTANCE ABUSE AND DRUG ABUSE
CAGE-AID (CAGE questions adapted to Include drugs)*
Yes No
1. Have you ever felt you should 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?
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?
Interpretation: Yes = 1 pt, No = 0 pts A higher score is a stronger indication of an alcohol or drug problem. A total score of 1 or greater is
considered significant and suggests a referral to a professional addiction counselor.
Miscellaneous Drug and Alcohol Questions
1. What do you think it looks like if someone has an alcohol or drug problem?
2. What are your reasons for drinking or using drugs?
3. What do you think would happen if you decreased or stopped your alcohol or drug use?
Interpretation: The previous questions may be effective as they allow a means for patient to be more open in discussing their substance
use.
PROVIDER OBSERVATION OF PATIENT
This section is completed through observations made by the TB program staff.
The following observations represent behaviors and/or thoughts that identify the need for further assessment and referral to a mental health
professional:
The patient gives inappropriate responses to normal questions
The patient does not exhibit a grasp of reality
The patient indicates that they are a person of authority or power
The patient exhibits an inappropriate or unusual facial expression
The patient exhibits unusual behavior
Observations noted:
INTRODUCING THE MENTAL HEALTH SCREENING TOOL TO YOUR PATIENT
Prior to beginning questionnaire, introduce the purpose of the tool.
? Caution the patient that the following questions may be personal. A patient-centered case management approach is most
successful when tailored to each person's individual clinical and social circumstances.
? Advise the patient that TB treatment is more often successful when underlying psychological issues, and or substance
abuse are identified and addressed.
REFERENCES
1. Black Dog Institute. (2011). Self-test for bipolar disorder. Retrieved from
http://www.blackdoginstitute.org.au/public/bipolardisorder/self-test.cfm
2. Ewing, J.A. (1984). Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the American Medical Association,
252, 1905–1907.
3. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2005). The patient health questionnaire-2: Validity of a two-item depression
screener. Medical Care 41(11), 208-213.
4. United States Department of Veterans Affairs. (2011). Mental health: Suicide prevention. Retrieved from
http://www.mentalhealth.va.gov/suicide_prevention/index.asp
*'CAGE' is an acronym formed from the italicized letters in the questionnaire (Cut-Annoyed-Guilty-Eye). For more information
see JA Ewing (1984) 'Detecting Alcoholism: The CAGE Questionaire', Journal of the American Medical Association 252:
1905-1907.

 

NON SPECIFIC MENTAL HEALTH ASSESSMENT CHECKLIST

BEHAVIOR

Normal

Abnormal

Comments

Alertness - Hypervigilant Sleepy Confused
Posture - Slumped Rigid Jerky
Walking Movement - Abnormal
Facial Expression -Immobile Sad Worried Angry Happy Confused
Eye Contact - Poor
Attention Span - Poor Highly Distractible
Motor Level - Hypoactive Hyperactive
Mannerisms - Posturing Spontaneous Movements
Physiological - Tearful Crying Blushing Sweating Tremulous Drooling
Response to Staff - Seductive Indifferent Cold
Cooperativeness - Uncooperative Sarcastic Hostile Evasive Demanding Unfriendly

APPEARANCE

Normal

Abnormal

Comments

Actual Age, Appears Older, Appears Younger.

Build - Malnourished Obese
Hygienic State - Disheveled Unshaven Odorous

SPEECH

Normal

Abnormal

Comments

Quantity - Mute, Answers' questions only, Talkative

Speed - Slow, Rapid, Pressured

MOOD AND AFFECT

Emotions - Lack of emotion, Overly relaxed, Anxious, Tearful, Scared, Angry, Depressed.

Mood Intensity - Moderate, Extreme

Affection - Uninterested, Inappropriate

SENSORIUM

Normal

Abnormal

Comments

Perception of Person

Perception of Place

Perception of Time

INSTRUCTIONS
Indicate whether normal or abnormal. If abnormal circle the appropriate response, or add a comment (e.g., patient wearing shorts in
very cold weather). If you have not been able to assess a specific item, come back to it at a later time.
INTERPRETATION
If numerous responses are identified as abnormal, it may indicate issues that should be addressed during TB treatment, and/or issues
to be addressed by a mental health professional.

MENTAL HEALTH RESOURCE GUIDE
General
2-1-1: Free and confidential community information and referral service: http://www.211.org/
Centers for Disease Control and Prevention: http://cdc.gov
United Way: http://liveunited.org/
US Department of Health and Human Services: http://www.hhs.gov/
US Department of Veterans Affairs: http://www.va.gov/landing2_vetsrv.htm
Mental Illness
NAMI: Support Organizations:
http://www.nami.org/Template.cfm?section=Find_Support
National Alliance on Mental Illness: http://www.nami.org/
Veteran's Administration Mental Health:
http://www.va.gov/healtheligibility/
Substance Abuse
12 Step Program: http://www.12step.org/
Addiction Technology Transfer Center (ATTC): http://www.nattc.org/index.asp
Alcoholics Anonymous: http://aa.org/?Media=PlayFlash
Alcohol and Drug Abuse Council: http://www.adacdet.org/
Assistance for Persons Who Use Drugs; Find services near you for:
Buprenorphine Physicians & Treatment Program: http://buprenorphine.samhsa.gov/bwns_locator/
Drug and Alcohol Treatment Facilities: http://dasis3.samhsa.gov/
Mental Health Services: http://mentalhealth.samhsa.gov/databases/
Opioid Treatment: http://dpt2.samhsa.gov/treatment
CDC: Substance Abuse Treatment (for HIV Infected Persons):
http://www.cdc.gov/pwud/substance-treatment.html
Centers for Disease Control and Prevention, Persons Who Use Drugs:
http://www.cdc.gov/pwud/Default.html
National Substance Abuse Index: http://nationalsubstanceabuseindex.org
Substance Abuse and Mental Health Services Administration (SAMHSA):
http://www.samhsa.gov/
Substance Abuse and Mental Health Services Administration (SAMHSA): Substance Abuse Treatment Facility Locator:
http://dasis3.samhsa.gov/
Alcohol & Drug, Treatment Centers & Programs: http://www.theagapecenter.com/Treatment-Centers/
CONSIDERATIONS FOR A SUCCESSFUL INTERVIEW
Before using this questionnaire, it is important to make the patient comfortable and establish rapport. Good rapport can build trust
which may contribute to honest disclosure. Establish rapport by:
Offering a glass of water, a chair, and a private setting
Exhibiting a demeanor that is calm, respectful, and genuine
Encouraging open communication
Acknowledging and validating the patient's distress and concerns
Avoiding interruptions while interviewing the patient
Modifying language to use a communication style appropriate to the patient's cultural background.
This assessment should be completed by the TB program staff; not the patient.
The mental health assessment can be started during the medical evaluation. TB staff should ask questions about substance abuse and
mental health symptoms, preferably in the context of other lifestyle questions so that these potentially sensitive topics seem less threatening.
This tool can also be used throughout the treatment phase as better patient rapport is established.
If the patient declines to answer a question, skip the question and try to address the question at a later time.
The assessment can be used to record patient responses as well as observations of the patients' verbal and nonverbal behavior.
MENTAL HEALTH REFERRAL
Healthcare professionals can refer patients to appropriate treatment programs or counselors. The likelihood of a successful
referral is increased by:
Telephoning for a specific appointment while the patient is present.
Following up with an encouraging note or phone call to the patient.
Arranging for the patient to be seen without delay.