17.6 Mental Health Screening & Substance Use Disorders

Mental Health & Behavioral Health Screening

Major Depressive Disorder (MDD): PHQ-2 & PHQ-9 Algorithm

The USPSTF recommends universal depression screening in all adults in primary care.

1. Initial Screen (PHQ-2): Consists of two questions assessing frequency of depressed mood and anhedonia over the past 2 weeks (scored 0 to 6). A score ≥3 is considered positive and mandates immediate administration of the full PHQ-9.
2. PHQ-9 Severity Scoring (0 to 27):
   • 5 to 9: Mild depression (supportive counseling, lifestyle modification, re-evaluate in 4–8 weeks).
   • 10 to 14: Moderate depression (consider psychotherapy and/or first-line pharmacotherapy).
   • 15 to 19: Moderately severe depression (initiate pharmacotherapy and/or psychotherapy).
   • ≥ 20: Severe depression (immediate combination pharmacotherapy and psychiatric consultation).
3. PHQ-9 Question 9 Suicide Risk Protocol: Question 9 asks about "thoughts that you would be better off dead, or of hurting yourself in some way." Any non-zero response (1, 2, or 3) mandates an immediate, comprehensive clinical suicide risk assessment before the patient leaves the clinical setting:
   • Assess suicidal ideation, intent, specific plans, lethal means access (especially firearms and medications), previous suicide attempts, and active protective factors.
   • Complete a collaborative Stanley-Brown Safety Plan: identify personal warning signs, internal coping strategies, social distractions, emergency contacts, and the 988 Suicide & Crisis Lifeline.
   • If active suicidal intent with high lethality or inability to maintain safety is present, initiate emergency psychiatric evaluation (voluntary or involuntary evaluation per state statute).

Generalized Anxiety Disorder (GAD-7)

Screening using the validated GAD-7 tool evaluates excessive worry, restlessness, irritability, and muscle tension over the prior 2 weeks:

• Scores 5 to 9: Mild anxiety.
• Scores 10 to 14: Moderate anxiety (threshold indicating likely GAD; initiate treatment).
• Scores ≥ 15: Severe anxiety.

Evidence-Based Psychotherapy & Pharmacotherapy

• Psychotherapy: Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Stress Reduction (MBSR) are highly effective first-line non-pharmacologic modalities.
• First-Line Pharmacotherapy for Depression and Anxiety:
  • Selective Serotonin Reuptake Inhibitors (SSRIs): Escitalopram (10–20 mg daily), Sertraline (50–200 mg daily), Fluoxetine (20–60 mg daily).
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Venlafaxine XR (75–225 mg daily), Duloxetine (30–60 mg daily).
• Critical Patient Education Points:
  • Therapeutic Latency: Educate the patient that antidepressant and anxiolytic clinical effects require 2 to 4 weeks to emerge, with maximal therapeutic efficacy reached at 6 to 8 weeks.
  • Transient Initial Side Effects: Inform patient that mild nausea, headache, jitteriness, and insomnia commonly occur in the first 7 to 14 days and typically self-resolve.
  • Black Box Warning: FDA warning regarding a potential transient increase in suicidal thoughts and behaviors in children, adolescents, and young adults up to age 24 during initial dose titration; schedule close follow-up within 1 to 2 weeks of initiation.
  • Discontinuation Syndrome: Instruct patient to never abruptly stop taking SSRIs or SNRIs. Abrupt cessation can precipitate Antidepressant Discontinuation Syndrome (flu-like symptoms, nausea, insomnia, dizziness, sensory "brain zaps", and severe rebound anxiety); taper gradually over weeks to months.

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Substance Use Disorders: SBIRT, Alcohol, Tobacco & Opioids

The SBIRT Framework

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based public health approach integrated into primary care to identify, reduce, and prevent problematic substance use.

Alcohol Screening & Risky Drinking Thresholds

• AUDIT-C (Alcohol Use Disorders Identification Test-Concise): A 3-item validated screening questionnaire scored 0 to 12. In women, an AUDIT-C score ≥3 indicates hazardous / risky drinking or an active alcohol use disorder.
• NIAAA Drinking Thresholds for Non-Pregnant Women: Low-risk drinking is defined as no more than 3 standard drinks on any single day AND no more than 7 standard drinks per week. (One standard drink = 12 oz beer [5%], 5 oz wine [12%], or 1.5 oz distilled spirits [40%]). For pregnant individuals or individuals attempting conception, zero alcohol consumption is safe.

Tobacco Cessation: The "5 A's" Model & Pharmacotherapy

1. Ask: Identify and document tobacco use status at every clinical visit.
2. Advise: Strongly urge all tobacco users to quit in a clear, non-judgmental, personalized manner.
3. Assess: Determine willingness to make a quit attempt within the next 30 days.
4. Assist: Aid the patient with a quit plan, behavioral counseling, and pharmacotherapy.
5. Arrange: Schedule follow-up contact within 1 week of the designated quit date.

• First-Line Cessation Pharmacotherapy:
  • Nicotine Replacement Therapy (NRT): Combination therapy (long-acting transdermal nicotine patch combined with short-acting nicotine gum or lozenge for breakthrough cravings) achieves superior cessation rates compared to monotherapy.
  • Bupropion SR: Norepinephrine-dopamine reuptake inhibitor (150 mg daily x 3 days, then 150 mg BID). Contraindicated in patients with active or past seizure disorders or eating disorders (anorexia, bulimia).
  • Varenicline (Chantix): Alpha-4 beta-2 nicotinic receptor partial agonist (titrated to 1 mg PO BID). Demonstrates the highest single-agent smoking cessation efficacy.

Opioid Use Disorder (OUD) & Harm Reduction

• Harm Reduction Principles: Universal, non-stigmatizing, non-punitive care. Provide access to sterile injection supplies, fentanyl test strips, and hepatitis C / HIV screening.
• Universal Naloxone (Narcan) Co-Prescribing: Prescribe intranasal naloxone (4 mg nasal spray) to all individuals taking opioid analgesics who have risk factors for overdose (high daily dose ≥50 morphine milligram equivalents [MME], concurrent benzodiazepine or alcohol use, personal history of overdose, or substance use disorder) and to any individual with suspected illicit opioid exposure.
• Medication for Opioid Use Disorder (MOUD):
  • Buprenorphine: Partial mu-opioid receptor agonist with high receptor affinity and a clinical ceiling effect on respiratory depression (commonly co-formulated with naloxone as Suboxone). Prescribed autonomously by CNMs in outpatient office settings under federal guidelines eliminating the former DATA 2000 X-waiver requirement.
  • Methadone: Full mu-opioid receptor agonist; highly effective in pregnancy to prevent opioid withdrawal and improve perinatal outcomes; dispensed through federally licensed Opioid Treatment Programs (OTPs).
  • Naltrexone: Full opioid antagonist; requires a strict 7- to 14-day opioid-free washout period prior to administration to avoid precipitating severe acute withdrawal; less favorable in pregnancy.

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