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Specific Mental Health Screening Measures

Traumatic Life Events Inventory and Posttraumatic Stress Disorder Checklist

Listed below are a number of difficult or stressful things that sometimes happen to people. For each event, circle one or more of the numbers to the right to indicate that: (a) it happened to you personally, (b) you witnessed it

happen to someone else, (c) you learned about it happening to someone close to you, (d) you’re not sure if it fits, or (e) it doesn’t apply to you.

Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events.

Event Happened to me Witnessed it about it Leaned Not sure Doesn’t apply

1. Natural disaster (for example, flood, hurricane, tornado,

earthquake) 0 1 2 3 4

2. Fire or explosion 0 1 2 3 4

3. Transportation accident (for example, car accident, boat

accident, train wreck, plane crash) 0 1 2 3 4

4. Serious accident at work, home, or during recreational activity 0 1 2 3 4

5. Exposure to toxic substance (for example, dangerous chemicals,

radiation) 0 1 2 3 4

6. Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)

0 1 2 3 4

7.

Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb)

0 1 2 3 4

8.

Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)

(continued)

Event Happened to me Witnessed it Leaned about it sure Not Doesn’t apply

10. Combat or exposure to a war-zone (in the military or as a

civilian) 0 1 2 3 4

11. Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war)

0 1 2 3 4

12. Life-threatening illness or injury 0 1 2 3 4

13. Severe human suffering 0 1 2 3 4

14. Sudden, violent death (for

example, homicide, suicide) 0 1 2 3 4

15. Sudden unexpected death of

someone close to you 0 1 2 3 4

16. Serious injury, harm, or death you

caused to someone else 0 1 2 3 4

17. Any other very stressful event or

(continued)

If an event listed on the previous page happened to you, or you witnessed it, please complete the items below. If more than one event happened, please choose the one that is most troublesome to you now.

The event you experienced was:

__________________________________________________ on __________________

(Event) (Date)

Instructions

Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully, then circle one of the numbers to the right to indicate how much you have been

bothered by the problem in the past month.

Bothered by Not at all A little bit Moderately Quite a bit Extremely

1. Repeated disturbing

memories, thoughts or images

of the stressful experience? 1 2 3 4 5

2. Repeated, disturbing dreams

of the stressful experience? 1 2 3 4 5

3. Suddenly acting or feeling as if the stressful experience were happening again? (As if you were reliving it?)

1 2 3 4 5

4. Feeling very upset when something reminded you of the stressful experience?

1 2 3 4 5

5. Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the stressful experience?

1 2 3 4 5

6. Avoiding thinking about or talking about the stressful experience or avoiding having feelings related to it.

1 2 3 4 5

7. Avoiding activities or

(continued)

Bothered by Not at all A little bit Moderately Quite a bit Extremely

8. Trouble remembering important parts of the

stressful experience? 1 2 3 4 5

9. Loss of interest in activities

that you used to enjoy? 1 2 3 4 5

10. Feeling distant or cut off from

other people? 1 2 3 4 5

11. Feeling emotionally numb or being unable to have loving feelings for those close to you?

1 2 3 4 5

12. Feeling as if your future will

somehow be cut short? 1 2 3 4 5

13. Trouble falling or staying

asleep? 1 2 3 4 5

14. Feeling irritable or having

angry outbursts? 1 2 3 4 5

15. Having difficulty

concentrating? 1 2 3 4 5

16. Being “super-alert” or

watchful or on guard? 1 2 3 4 5

17. Feeling jumpy or easily

startled? 1 2 3 4 5

Scoring

1) Was the person exposed to at least one event that involved actual or threatened death or serious injury, or threat to physical integrity of self or others? _____ YES

_____ NO

2) Did the person respond with intense fear, helplessness, or horror?

_____ YES _____ NO

3) Score of 44 or more? (add up all 17 items on the second page)

_____ YES _____ NO

If YES to all, PTSD:

_____ YES _____ NO Total Score: ____________________

Social Interaction Anxiety Scale

Instructions

In this section, for each item, please circle the number to indicate the degree to which you feel the statement is characteristic or true for you. The rating scale is as follows:

0 = Not at all characteristic or true of me. 1 = Slightly characteristic or true of me. 2 = Moderately characteristic or true of me. 3 = Very characteristic or true of me. 4 = Extremely characteristic or true of me

Characteristic Not at all Slightly Moderately Very Extremely

01. I get nervous if I have to speak with someone in authority (teacher, boss).

0 1 2 3 4

02. I have difficulty making eye

contact with others. 0 1 2 3 4

03. I become tense if I have to talk about myself or my feelings.

0 1 2 3 4

04. I find it difficult to mix comfortably with the people

I work with. 0 1 2 3 4

05. I find it easy to make friends

my own age. 0 1 2 3 4

06. I tense up if I meet an

acquaintance in the street. 0 1 2 3 4

07. When mixing socially, I am

uncomfortable. 0 1 2 3 4

08. I feel tense when I am alone

with just one person. 0 1 2 3 4

09. I am at ease meeting people

at parties, etc. 0 1 2 3 4

10. I have difficulty talking with

other people. 0 1 2 3 4

11. I find it easy to think of

(continued)

Characteristic Not at all Slightly Moderately Very Extremely

14. I have difficulty talking to attractive persons of the

opposite sex. 0 1 2 3 4

15. I find myself worrying that I won’t know what to say in

social situations. 0 1 2 3 4

16. I am nervous mixing with

people I don’t know well. 0 1 2 3 4

17. I feel I’ll say something

embarrassing when talking. 0 1 2 3 4

18. When mixing in a group, I find myself worrying I will

be ignored. 0 1 2 3 4

19. I am tense mixing in a

group. 0 1 2 3 4

20. I am unsure whether to greet someone I know only slightly.

0 1 2 3 4

Scoring

Total Score: Reserve Items: 5, 9, 11

Interpretation: 34+ Social Phobia is probable.

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

NAME: ______________________ DATE: ______________________

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use a check mark to indicate your answer)

Not at all Several days More than half the days Nearly every day

1. Little interest or pleasure in doing things 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 0 1 2 3 6. Feeling bad about yourself – or that you are a

failure or have let yourself or your family down

0 1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television

0 1 2 3

8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual.

0 1 2 3

9. Thought that you would be better off dead, or of hurting yourself

0 1 2 3

add columns + + (Healthcare professional: For interpretation of TOTAL,

please refer to accompanying scoring card). TOTAL:

10. If you checked off any problems, how difficult have these problems 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 ___

PHQ-9 Patient Depression Questionnaire For initial diagnosis:

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 check marks by column. For every check mark:  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 check mark:

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

Patient Health Questionnaire (PHQ-2)

Over the past 2 weeks, have you often been bothered by: 1. Little interest or pleasure in doing things? [Yes] [No] 2. Feeling down, depressed, or hopeless? [Yes] [No]

If the patient responded “yes” to either question, follow up using the PHQ-9, a nine-item, self-administered questionnaire.

Primary Care PTSD Screen (PC-PTSD) Prins, Ouimette, & Kimerling, 2003

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. In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:

Have had nightmares about it or thought about it when you did not want to? YES / NO

Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES / NO

Were constantly on guard, watchful, or easily startled? YES / NO

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.

References

Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2003). (PDF) The primary care PTSD screen (PC-PTSD): development and operating characteristics. Primary Care Psychiatry, 9, 9-14.

Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2004). The primary care PTSD screen (PC-PTSD): Corrigendum. Primary Care Psychiatry, 9, 151.

Center for Epidemiologic Studies Depression Scale (CES-D), NIMH

Below is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way during the past week.

During the Past Week

Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days) Occasionally or a moderate amount of time (3-4 days) Most or all of the time (5-7 days)

1. I was bothered by things that usually don’t bother me.

2. I did not feel like eating; my appetite was poor.

3. I felt that I could not shake off the blues even with help from my family or friends.

4. I felt I was just as good as other people. 5. I had trouble keeping my mind on what I

was doing. 6. I felt depressed.

7. I felt that everything I did was an effort. 8. I felt hopeful about the future.

9. I thought my life had been a failure. 10. I felt fearful.

11. My sleep was restless. 12. I was happy.

13. I talked less than usual. 14. I felt lonely.

15. People were unfriendly. 16. I enjoyed life.

17. I had crying spells. 18. I felt sad.

19. I felt that people dislike me. 20. I could not get “going.”

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