Identifying and treating behavioral and mental health disorders is not as straightforward as treating bodily illness or injury. Mental illness symptoms manifest in cognitive, emotional, behavioral and sometimes physical ways, making it challenging to grasp the full diagnosis at a glance. Mental health assessments are valuable tools for practitioners to help fill in these gaps and provide a better-rounded picture of a patient's status.
Table of Contents
- What Is a Behavioral Health Assessment?
- What Does a Mental Health Assessment Include?
- What Are Mental and Behavioral Assessment Tools?
- How Do You Assess Mental Health Status?
- What Is the Difference Between a Screening Tool and an Assessment Tool?
- 7 Types of Screening Tools for Behavioral Healthcare
- 6 Mental Health Assessment Examples for Behavioral Health Practitioners
- 75+ Rating Scales and Assessment Tools
What Is a Behavioral Health Assessment?
Behavioral and mental health assessments include a combination of tests, examinations and screenings that provide information about how a patient is functioning. These assessments help identify mental health problems, differentiate between mental and physical health problems and give insight into patients who received their referral due to issues at work, school or home.
Understanding the methods and practices associated with mental health assessments can help you take practical diagnostic and treatment approaches with each client.
What Does a Mental Health Assessment Include?
Each mental health assessment you administer will differ based on your patient and their symptoms. A typical mental health assessment may include the following elements.
- Interview: General interviews allow you to note your patient's mood and presentation. Asking questions about the patient's symptoms and concerns, as well as their life situation and thought patterns, can help reveal initial areas on which to focus.
- Physical exam: To help distinguish between symptoms resulting from a mental disorder and symptoms related to bodily illness, you may need to complete a physical exam. Ask about your patient's personal and family medical history, as well as any medications they may take.
- Lab tests: Some symptoms may prompt the need for lab tests or scans. Blood or urine samples and MRI, EEG or CT scans may be helpful when assessing a patient.
- Written or verbal tests: You may want to administer a test to help identify specific problems, test certain functions or further assess a patient's well-being.
Mental and behavioral assessment tools can help assist and guide your assessments by pinpointing symptoms and providing valuable data.
What Are Mental and Behavioral Assessment Tools?
Assessment tools are specific methods of gathering information to help understand a patient, their symptoms, their life situation and more. These tools may come in the form of tests or examinations and typically target certain disorders. When assessing a patient, you'll likely use multiple approaches and compile the data to create a comprehensive observation.
Assessing each patient's overall mental health status is key to providing quality, effective treatment.
How Do You Assess Mental Health Status?
Determining how you assess your patient's mental health status will depend on the types of assessment and screening tools you use. Consider the following factors when selecting a tool:
- Does the test have the reliability to produce consistent results?
- Does the test have the validity to differentiate between a patient with a problem and one without a problem?
- Does the test have the sensitivity to identify a problem accurately?
- Does the test have the specificity to identify individuals who do not have a problem?
Selecting a test that conforms to the above factors will help make your results as accurate and helpful as possible. Disorder-specific assessments are valuable tools when working with patients, but how can you know which areas to test for? Screening tools can be the starting point that illuminates these risk areas.
What Is the Difference Between a Screening Tool and an Assessment Tool?
At nearly 1,000 pages, the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5) contains hundreds of potential disorders you may see in your facility. Administering detailed assessments for all possible problems would be illogical and time-consuming, which is why clinicians use screening tools.
Here are some key differences between screening and assessment tools.
- Screening tools identify the possible presence of certain problems. Usually given in a checklist or questionnaire format, these tests may be broader in scope so they can narrow down essential areas. Clinicians typically use screening tools early on when working with a patient to help focus in on potential disorders.
- Assessment tools tend to focus on determining the presence of a specific disorder, as well as its nature and severity. Clinicians typically use assessment tools to dig deeper into screening results. Assessment tools are available for a range of topics and come in a wide variety of mediums.
The advantages of mental health screening and assessment tools are their help in diagnosing and treating your patients quickly and accurately. Understanding the different types of screening and assessment tools available allows you to make an informed decision for each patient.
7 Types of Screening Tools for Behavioral Healthcare
The screening tool you use will depend on your patient's level of self-awareness and evident symptoms. If mental illness is present in your patient's family medical history, you may also be inclined to screen for those disorders.
Here are seven common types of screening tools to consider using.
- General: In some situations, your patient may not recognize the symptoms and disorders they are experiencing. General mental health screenings like the Kessler 6, Kessler 10, Patient Stress Questionnaire or M3 Checklist check for early signs of mental health symptoms. Primary care doctors may also use these screenings during regular checkups to refer at-risk patients to behavioral and mental health specialists.
- Depression: If your patient is showing signs of depression or has a family history of depression, screenings like the Patient Health Questionnaire may help give a more definitive answer.
- Drug and alcohol use: Screenings for drug and alcohol use may help identify destructive habits or addictions in patients. For example, the World Health Organization's Alcohol Use Disorders Identification Test checks for hazardous or harmful alcohol use, and the National Institute on Drug Abuse's NIDAMED test identifies other drug abuse. Other common drug and alcohol screenings include the CAGE AID, AUDIT-C and the DAST-10.
- Bipolar disorder: To help identify symptoms of bipolar disorder, clinicians may use the STABLE Resources or the Mood Disorder Questionnaire. Because bipolar disorders exist on a spectrum, it may also be helpful to use the Bipolar Spectrum Diagnostic Scale to determine where or if your patient registers.
- Suicide risk: You can help determine if your patient is at risk for suicide by using the SAFE-T, C-SSRS or ASQ screenings. To promote your patient's safety and reduce risk, screening for suicide risk is an essential preventive measure.
- Anxiety disorders: Anxiety disorder screening can help determine if your patient exhibits symptoms of generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder or social phobia. Some relevant anxiety screenings include the GAD-7, PCL-5 and HAM-A.
- Trauma: To screen for potentially traumatic events in your patient's life, you may use the Life Event Checklist. This tool checks for 16 common sources of PTSD or extreme distress to help uncover potential mental health triggers.
Talk to your patient to determine which screenings may be necessary. After you have highlighted areas of concern, you can use assessment tools to understand the depth and scope of individual problems.
6 Mental Health Assessment Examples for Behavioral Health Practitioners
Mental and behavioral health assessments serve a variety of purposes when working with a patient. Assessments can help pinpoint symptoms, guide the diagnosis and treatment planning process, inform decision-making, set baselines and track patient progress. Unlike screenings, free mental health assessment tools come in a variety of forms and mediums. Regardless of the method, the goals of behavioral assessment are to understand, diagnose and treat your patient thoroughly.
Here are six common behavioral assessment methods to consider using.
- Observation: Patient observation can help uncover unspoken data to inform your diagnosis and treatment. Take note of your patient's attitudes, expressions, words and actions in various surroundings to develop an understanding of the patient's situation beyond what they communicate. To use this tool well, you will want to pay close attention to your patient and observe with a professional, neutral demeanor.
- Interview: Psychiatric interviews can help establish a relationship with your patients, as well as collect information about their symptoms and experiences. Allow your patients to speak without interruption, and guide their responses with open-ended questions. Keep diagnostic reasoning in mind while you ask clarifying questions. If you want to build trust with your patient, it is helpful to make sure they feel validated and understood. Allowing your patients to present their feelings and experiences can help reveal specific symptoms, life events and situations that may be causing those symptoms and which are the most bothersome.
- Family interview: In some scenarios — especially when working with younger children — it may be helpful to interview a patient's family members. Family interviews can provide additional insight into a patient's condition and help the family better understand what the patient is experiencing. However, you must be sure to observe HIPAA confidentiality regulations when involving family. In most cases, adult patients must allow clinicians to speak with or inform family members of their condition.
- Checklists: Like many screening tools, assessment tools feature checklists to provide insight into a patient's mental health status. A targeted list can be a quick and efficient way to supplement your knowledge. The DSM-5 contains several such ways to help identify and classify patient symptoms, but you should use these lists with caution. Checklists do not take into account all biological, psychological, sociological and cultural variables possible in a patient's life. Accordingly, checklists are appropriate tools when used in conjunction with other assessment methods.
- Rating scales: A strength of using rating scales as assessment tools is that they provide numerical data many other methods do not. Rating scales also help patients sort confusing feelings and emotions into simple responses. They can be valuable when working with patients who have difficulty communicating about their illness or as a general assessment to determine the severity of symptoms at a given point.
- Questionnaires/standardized tests: Assessment questionnaires function like screening questionnaires, except they often go into greater detail about a specific illness and its severity. If your patient screening identified the potential for particular disorders, it can be helpful to use a disorder-specific assessment to gather further data. One common standardized assessment includes the Global Mental Health Assessment Tool, which can screen and assess a variety of mental health issues.
It's important to note that behavior and mental health assessment tools for adults may not be effective for children. Optimize the tools you use for your patients to achieve meaningful and accurate results.
75+ Rating Scales and Assessment Tools
It's difficult to deny the impact of behavioral and mental health assessments when it comes to understanding patients. However, clinicians may be hesitant to incorporate specific measures, due to the possibility of accumulating excess papers and adding time-consuming tasks to their day. ICANotes' Behavioral Health EHR allows you to use more than 75 well-known rating scales and assessment tools electronically. This paperless solution integrates assessment results into your patients' health charts and treatment plans while keeping results accessible and secure.
The following are the behavior assessment tools for adults ICANotes integrates with.
- 1915(i) Independent Behavioral Health Assessment
- ACE: Adverse Childhood Experience Questionnaire
- ANSA: Adult Needs and Strengths Assessments
- ASI: Addiction Severity Index
- ASRS: Adult ADHD Self-Report Scale
- AUDIT-C: Alcohol Use Disorders Identification Test-Concise
- BSDS: Bipolar Spectrum Diagnostic Scale
- Brief Addiction Monitor
- CAGE: Substance Abuse Screening Tool
- CES: Center for Epidemiologic Studies Depression Scale
- CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol
- CIWA-b: Benzodiazepine Withdrawal Scale
- Columbia Depression Scale — Last 4 Weeks (Parent)
- Columbia Depression Scale (Year) — Parent
- Columbia Suicide Severity Rating Scale
- COWS: Clinical Opiate Withdrawal Scale
- C-SSRS: Inpatient Setting Discharge Screener
- C-SSRS: Lifetime/Recent
- DASS-21: Depression Anxiety Stress Scale
- DASS-42: Depression Anxiety Stress Scale
- DAST-10: Drug Abuse Screening Test
- DLA20 Daily Living Activities
- DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure
- Eating Disorder Diagnosis Scale
- Edmundson Fall Assessment
- FAD: McMaster Family Assessment Device (Subscales)
- FARS: Functional Assessment Rating Scale
- GAD-7: Generalized Anxiety Disorder Screener
- GAIN — Short Screener
- GDS: Geriatric Depression Scale
- HAM-A: Hamilton Anxiety Rating Scale
- HAM-D: Hamilton Depression Rating Scale
- Kessler Psychological Distress Scale
- LOCUS: Level of Care Utilization System
- MAST: Michigan Alcohol Screening Test
- MDI: Major Depression Inventory
- MDQ: Mood Disorder Questionnaire
- MFQ-Parent: Mood and Feelings Questionnaire
- MSI: Marital Status Inventory
- ORAS-CST: Ohio Risk Assessment — Community Supervision Tool
- Parental Stress Scale
- PCL-5: Post-Traumatic Stress Disorder Checklist
- PHQ-9: Patient Health Questionnaire
- PSWQ: Penn State Worry Questionnaire
- QIDS-C: Quick Inventory of Depressive Symptomatology
- SAFE-T Protocol with C-SSRS-Recent
- Satisfaction with Life Scale
- SOCRATES 8A: Personal Drinking Questionnaire
- South Oaks Gambling Screen Assessment
- SPANE: Scale of Positive and Negative Experience
- TCU Drug Screen V
- URICA: Change Assessment Scale — Alcohol
- URICA: Change Assessment Scale — Drug
- URICA: Change Assessment Scale — Psych
- Wahler Self-Description Inventory
- Wender Utah Rating Scale
- YMRS: Young Mania Rating Scale
- Zung Anxiety Scale
- Zung Self-Rating Depression Scale
ICANotes also offers the following assessment tools for children:
- 1915(c) Independent Behavioral Health Assessment
- CANS: Child and Adolescent Needs and Strengths
- CASII: Child and Adolescent Service Intensity Instrument
- CATS: Child and Adolescent Trauma Screen — Caregiver 3-6
- CATS: Child and Adolescent Trauma Screen — Caregiver 7-17
- CATS: Child and Adolescent Trauma Screen — Youth
- CFARS: Children's Functional Assessment Rating Scale
- Children's Uniform Mental Health Assessment
- Columbia Depression Scale (4 Weeks) — Youth
- Columbia Depression Scale (Year) — Youth
- CPSS: Child PTSD Symptom Scale
- CRAFFT Screening Test
- MFQ-Child: Mood and Feelings Questionnaire
- NICHQ Vanderbilt Parent Assessment
- NICHQ Vanderbilt Parent Follow-Up
- PHQ-A: Patient Health Questionnaire, Adolescent
- POSIT: Problem-Oriented Screening Instrument for Teenagers
- PSC: Pediatric Symptom Checklist
- RAPI: Rutgers Alcohol Problem Index
- RCADS-P: Revised Children's Anxiety and Depression Scale — Parent
- RCADS: Revised Children's Anxiety and Depression Scale
- SCARED: Screen for Child Anxiety Related Disorders — Parent
- TESI-C: Traumatic Events Screening Inventory for Children
Keeping your assessments electronic saves you time and paper, allowing you to spend your sessions connecting with patients and providing quality treatment. Behavioral and mental healthcare is already complex. Incorporating your screening and assessments into your EHR saves you from the hassle of paperwork and enables you to address your patients with the standard of care they deserve.
Does Your EHR Support Your Needs?
Behavioral and mental health screening and assessment options exist to help you make informed decisions as you work with patients. Using the right tools can help maximize your appointments and help you provide the best care possible.
When your screening and assessment tools integrate into your EHR, you'll be able to track your patients' data in one secure location. ICANotes can help keep your office organized with an intuitive EHR built with a behavioral and mental health professional in mind.