8.2 Mental Health & Substance Screening Tools

Domain II.D also names the mental-health and substance instruments: Patient Health Questionnaire (PHQ) any version, GAD-7, SCARED, Ask Suicide-Screening Questions, CRAFFT, and the Edinburgh Postnatal Depression Scale (EPDS). Depression, anxiety, suicide risk, and adolescent substance use are high-volume CPNP-PC clinical categories. This section is screening — how you detect and triage. Diagnosis and management of major depression, anxiety disorders, ADHD comorbidity, and suicide safety planning as treatment live in later clinical chapters. Do not mix those jobs.

Two naming traps sit on this outline. ASQ in Section 8.1 is the Ages & Stages Questionnaire. Ask Suicide-Screening Questions is also abbreviated ASQ in NIMH materials. If an item says "ASQ" in a toddler motor vignette, it is developmental. If it says Ask Suicide-Screening Questions, NIMH, or a 12-year-old in clinic who endorsed "wished you were dead," it is suicide screening. CRAFFT belongs here as a screen; substance anticipatory guidance even when the screen is negative belongs to Domain I.E (Chapter 5).

Screening versus diagnosis — the rule for every tool in this section

A screen is a short, standardized filter with a cutoff that says "look further." A diagnosis requires history, functional impairment, duration, differential (sleep, thyroid, bereavement, anemia, substance, trauma), and often a full symptom interview. You may start safety steps and referral on a screen. You may not tell a family, "Your PHQ-9 is 12, so you have major depressive disorder, here is an SSRI," without the rest of the assessment. Tools have version-specific cuts. You are not required to memorize every research cutoff. You are required to know the widely taught PHQ-9 ≥10 moderate range, that item-level suicide questions override a reassuring total, and that a positive CRAFFT is risk, not a substance-use-disorder code.

Patient Health Questionnaire (PHQ) — any version

Bright Futures and the USPSTF principle: screen adolescents for depression. In primary care that usually starts by age 12 and repeats annually or when surveillance is concerning. The named family is PHQ — PHQ-2, PHQ-9, PHQ-A, and PHQ-9 modified for adolescents. Any version on the outline counts.

PHQ-2 is the first two PHQ-9 items: anhedonia (little interest or pleasure) and depressed mood, over the past two weeks. A commonly used PHQ-2 cutoff of ≥3 means give the full PHQ-9/PHQ-A now, not at the next annual. A PHQ-2 of 0–1 in a teen who just described hopelessness does not forbid you from giving the full nine items — clinical concern overrides a negative two-item filter.

PHQ-9 / PHQ-A / PHQ-9 modified for adolescents map onto the nine DSM depression symptom groups. Totals are widely taught as:

PHQ-9 ≥10 is the number PNCB-style teaching treats as the moderate range and a typical threshold for further evaluation and a treatment discussion. It is not a diagnosis. Mild scores with impaired function still need a real interview. Item 9 (thoughts of being better off dead or of self-harm) is a safety item. Any positive item 9 triggers suicide-risk assessment the same visit, even if the total is 8.

PHQ-A and PHQ-9 modified for adolescents change wording (school, irritability) so a teen can answer. Do not insist on an adult-only PHQ-9 when the adolescent version is the form in the room. Confidential time matters: a parent hovering over a PHQ-A produces a falsely reassuring zero.

Clinic vignette. A 15-year-old's PHQ-9 is 11 with item 9 scored 0, slipping grades, and anhedonia for six weeks. You have a positive depression screen in the moderate range. Next is a diagnostic interview, safety assessment anyway, and a management plan — not "come back in six months because 11 is not 20."

Generalized Anxiety Disorder 7-item scale (GAD-7)

GAD-7 is a seven-item anxiety screen used widely in adolescents and adults. Items cover nervousness, uncontrollable worry, trouble relaxing, restlessness, irritability, and fear that something awful will happen. Commonly taught bands are 5 / 10 / 15 for mild / moderate / severe. Many clinics treat ≥10 as the point to look further. GAD-7 does not diagnose generalized anxiety disorder. It does not distinguish GAD from social anxiety, panic, PTSD, or ADHD-related restlessness. A high GAD-7 plus panic attacks still needs a panic history. A high GAD-7 plus school refusal still needs the school-refusal frame from health-promotion counseling.

Use GAD-7 when you need a short anxiety filter, especially in older adolescents. It is not a toddler tool and not a substitute for M-CHAT-R/F or ASQ:SE.

Screen for Child Anxiety Related Emotional Disorders (SCARED)

SCARED is a child-specific anxiety questionnaire with child and parent versions (commonly 41 items). It is built for school-age children and adolescents, often cited from about 8 years. A commonly taught total ≥25 suggests an anxiety disorder is worth a full evaluation. Subscales (panic/somatic, generalized anxiety, separation, social, school avoidance) are clues, not five separate diagnoses from a PDF.

SCARED is useful when GAD-7 feels too adult or too short, when separation or school avoidance is the story, or when parent and child reports disagree. A child SCARED that is sky-high and a parent SCARED that is zero is still a positive screen of the child — interview both. SCARED does not replace a suicide screen. Anxiety and depression overlap; a positive SCARED is a reason to look at mood and suicide risk, not a reason to skip them.

Ask Suicide-Screening Questions (NIMH ASQ)

Ask Suicide-Screening Questions is the NIMH 4-item yes/no screen used in medical settings, plus an acuity item if any of the four is yes. Teach the four constructs (use the current NIMH wording in clinic):

1. In the past few weeks, wished you were dead?
2. In the past few weeks, felt you or your family would be better off if you were dead?
3. In the past week, thoughts about killing yourself?
4. Have you ever tried to kill yourself?

Any yes = positive screen. Then ask the acuity item: are you having thoughts of killing yourself right now?

A positive suicide screen is a same-day safety assessment. It is not a routine follow-up slot in three weeks. It is not "denied a plan, so negative." It is not the Ages & Stages Questionnaire. Next steps in a medical setting follow a brief suicide safety assessment (current ideation, plan, intent, means, prior attempt, supports) and a disposition: stay and get help today, urgent specialty evaluation, or — only if the brief assessment is truly low-risk and supports are in place — a specific, timely outpatient plan with means counseling. Sending a positive screen home without that assessment is the exam-fail move.

If the acuity item is yes (active ideation right now), this is an emergency pathway: remain with the patient, remove means in the clinic, involve a parent unless doing so increases danger, and use emergency/crisis resources. PHQ item 9 can trigger the same pathway. Do not wait for a "full psychiatric diagnosis" to keep a child safe.

Clinic vignette. A 13-year-old answers yes to "wished you were dead" on Ask Suicide-Screening Questions and no to the acuity item. You do not book a 6-week counselor slot as the only act. You complete a same-day safety assessment, ask about means (firearms, medicines), involve a responsible adult, and arrange a level of care that matches risk.

CRAFFT Alcohol and Substance Screening Tool

CRAFFT is the named adolescent substance screen. The mnemonic is the content:

• Car — ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs?
• Relax — use to relax, feel better about yourself, or fit in?
• Alone — use while alone?
• Forget — forget things you did while using?
• Friends/Family — told you to cut down?
• Trouble — gotten into trouble while using?

Current CRAFFT versions (CRAFFT 2.1 and similar) start with opening frequency questions for alcohol, cannabis, and other substances in the past 12 months, and many practices add nicotine/vaping (CRAFFT+N). If the teen reports no use, you still ask the Car question. If there is any use, you ask the full CRAFFT.

A commonly used total of ≥2 is a positive screen that means further assessment (pattern, DSM SUD criteria, brief intervention, referral as needed). It is not a diagnosis of alcohol-use disorder, cannabis-use disorder, or "addiction." A score of 0–1 with a story of counterfeit pills or fentanyl exposure is still a safety visit. A negative CRAFFT does not cancel Domain I.E prevention talk about vaping, alcohol, cannabis, and illicit pills.

CRAFFT is not for toddlers. It is not a urine drug test. Confidential adolescent time improves honesty; explain the limits (suicide, homicide, abuse) before you ask.

Edinburgh Postnatal Depression Scale (EPDS)

EPDS is the named perinatal mood screen. Bright Futures includes maternal depression screening at the 1-, 2-, 4-, and 6-month infant visits. The caregiver — typically the postpartum parent — completes 10 items. Totals have version- and program-specific cuts; many pediatric primary-care settings treat ≥10 as a reason to look further, and some programs use 12 or 13. You do not need every paper's cutoff. You do need this: item 10 (thoughts of self-harm) is urgent even if the total is low. A positive EPDS is not a diagnosis of major depression or bipolar disorder. It is a reason to assess the caregiver's safety, infant safety, bonding, and access to adult mental-health care the same day if item 10 or function is collapsing.

The infant is your patient; the caregiver's depression is an infant-health finding. Do not discharge a 2-month well visit as "normal baby" with an EPDS of 18 sitting on the chart unread.

Putting the mental-health tools together

Universal adolescent depression screening is the principle. Positive suicide screens are today. Substance screens are not diagnoses. That is II.D for mental health and CRAFFT.