ltcs screening tool for mental health problems memory loss

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Screening for mental health problems and memory impairmentfor people with long term physical health conditions

Louise RossSeptember 2010

The North East Mental Health Development Unit is hosted by NHS County Durham


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Executive Summary

At present there are 15.4 million people in England with a Long-TermCondition (LTC) and due to the increasingly ageing population by 2025 this ispredicted to reach 18 million (DH, 2010). The costs associated with the

treatment and care for those with a LTC account for a significant proportion ofhealth and social care resources and are forecast to rise to 26.4 billion (DH,2010). This can be explained by the greater use of GP and outpatientappointments and use of inpatient bed days by people with a LTC (DH, 2010).

There are high incidences of people with LTCs and co morbid commonmental health problems (Stafford et al 2007; Anderson et al, 2001; Barry et al,2008). Evidence shows that this can negatively impact upon their ability tomanage and cope with their LTC (Whiting et al, 2006). The OperatingFramework for the NHS in England 2009/10 recognises how important it is toensure that people with LTCs receive an optimum level of care, stating that

Over the next two years, to ensure that those living with long term conditionsreceive a high quality service and help to manage their condition, everyonewith a long term condition should be offered a personalised care plan. (DH,2008, p15)

The DH strategy for LTCs pioneers personalised care planning, whichensures a persons full range of needs are accounted for and puts people withLTCs at the centre of decision making about their own care (DH, 2009).These principles are reflected by those set out in Our Vision, Our Future (NHSNE, 2008) and New Horizons (DH, 2009) whereby early detection and

intervention are central to patient outcomes and QIPP savings.

This paper will focus on two problems often associated with LTCs, whichwould limit abilities to manage a LTC and are high on the agenda on currentpolicy drivers: mental health and memory. This will inform a pilot study, inwhich screening of common mental health (MH) problems and memoryimpairment will be incorporated into the annual health check for people livingwith a LTC, within 12 general practices in the North East (NE) of England.

This paper will appraise the screening tool options and their applicability to a

LTCs client group. The structure will be parallel in both mental health andmemory, providing recommendations for a self-administered questionnaire tobe completed prior to meeting with the GP, and in cases where this screensas positive, a follow up screening instrument to inform the referral process.

The tools that are recommended in this paper for mental health screening forpeople with LTCs are the PHQ-2 and GAD-2 and the PHQ-9 and GAD-7 aspre-screening and further screening respectively. The TYM test is therecommended tool for memory screening in the LTC pilot.


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Contents

1 Introduction: Screening for Depression & Anxiety in Primary Care...........41.1 NICE guidance & NHS drivers...........................................................4

2 Review of Screening Tools .......................................................................52.1 Patient Health Questionnaire (PHQ)..................................................5

2.1.1 PHQ-2 ........................................................................................52.1.2 PHQ-9 ........................................................................................62.1.3 GAD-2 and GAD-7......................................................................62.1.4 Hospital and Anxiety Depression Scale (HADS) ........................72.1.5 Beck Depression Inventory Second Edition (BDI-II) ............... 7

2.2 Recommendations for Long Term Conditions (LTC) Pilot .................72.3 The Referral Pathway........................................................................8

2.3.1 IAPT & the Stepped Care Model for Common Mental HealthProblems ..................................................................................................8

3 Introduction: Screening for Memory Problems in Primary Care.............. 113.1 NICE guidance & NHS drivers.........................................................11

4 Review of Screening Tools .....................................................................114.1.1 The Test Your Memory (TYM)..................................................12

4.2 Recommendations for Long Term Conditions (LTCs) pilot. ............. 134.3 Referral Pathway .............................................................................13

4.3.1 The Stepped Care Model for Memory Impairments.................. 135 Overview of Recommendations for Long Term Conditions (LTCs) pilot .146 Final Thoughts........................................................................................147 References .............................................................................................15

Figure 1: IAPT Stepped Care Model for Common Mental Health Problems ....9

Appendices

Appendix 1- Comparative Table: Common MH Screening Tools.19Appendix 2- Comparative Table: Memory Screening Tools..20Appendix 3- Table of Common MH Screening Toolsevaluated against BPS Criteria...21Appendix 4- Table of Memory Screening Toolsevaluated against BPS Criteria...21Appendix 5- Comments received from Draft 1.22


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1 Introduction: Screening for Depression & Anxietyin Primary Care

It is widely reported that the detection of mental health problems is essentialfor responsive delivery of appropriate interventions, thus driving the quality ofcare provided (NICE, 2009; NICE, 2004). There is now strong evidence thatthe level of symptom severity can be inferred from the implementation of bothself-assessment and clinician delivered questionnaires (BMA, 2008).Furthermore, this invites a collaborative discussion with the patient about therelevant treatment interventions and options available to them, as guided bythe stepped care model endorsed by NICE (NICE, 2009).

Depression is associated with a 50% increase in costs of long term medicalcare (Katon, 2003). This makes investment in improving the mental health of

people with long-term conditions valuable. In particular, improvements need tobe made in the identification and treatment of depression and anxiety, as thisis likely to lead to financial savings (Michie et al, 2005) and increase theQuality, Innovation, Productivity and Prevention (QIPP) potential.

1.1 NICE guidance & NHS drivers

NICE guidelines on the management of depression in primary and secondarycare advocate the use of the International Classification of Diseases (ICD-10)criteria for diagnosing and assessing severity of depression. Although NICEhas identified ICD-10 as the recommended diagnostic tool for depression they

acknowledge that it is doubtful whether severity can realistically be capturedin a single symptom count (NICE, 2004). The Guideline Development Group(GDG), which makes NICE recommendations when evidence is uncertain,advocate that a two stage process of identification and diagnosis would bebest practice in primary care and that evidence supported the continued useof the Whooley questions (see Box 1) as part of this initial process. It hasbeen suggested that using an additional question: is this something withwhich you would like help? (Arroll et al, 2005) may improve the specificity ofthis initial screening phase. However, in terms of a particular MH screeningtool for the rest of this process NICE do not make recommendations butsuggest a second step of a more detailed instrument possessing betteroverall psychometric properties if either of the Whooley screening questionswas marked as yes..

Box 1

During the last month, have you often been bothered by feeling down,depressed or hopeless?

During the last month, have you often been bothered by having little interestor pleasure in doing things?

Whooley et al (1997)


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The Quality and Outcomes Framework (QOF) (BMA, 2008), a NICE-ledperformance management and payment system for general practitioners(GPs) in the National Health Service (NHS) in England, Wales, and Scotlandwas introduced in 2004 as part of the General Medical Services Contract. This

replaced other fee arrangements and financially rewarded GPs forimplementing best practice. It was widely adopted by GPs throughout the UK.Incentives included assessing for depression and/or anxiety, to encouragediscussions with the patient with regard to their treatment options. Practicesare advised to choose one of the three measures listed below, which arevalidated for use in primary care settings.

2 Review of Screening Tools

In this section, these tools are reviewed and evaluated in the context of usewith people with LTCs.

The Patient Health Questionnaire (PHQ-2 and PHQ-9) The Hospital Anxiety and Depression Scale (HADS) Beck Depression Inventory, second edition (BDI-II)

See Appendix 1 for an overview of these tools

2.1 Patient Health Questionnaire (PHQ)

The PHQ was developed from the more detailed PRIME-MD tool (Spitzeretal, 1994). Subsequently there have been three main tools developed from thisscale; the PHQ-9 (Spitzeret al, 1999), PHQ-2 (Kroenke et al, 2003) and theWhooley questions (Whooley et al, 1997) see Box 1. Although the PHQ-2and the Whooley questions use the same items the difference is that thePHQ-2 follows the Likert scale format of the PHQ-9 whereas the Whooleyversion dichotomises the questions (yes/no). The Whooley questions and thePHQ-2 have a cut-off points of 1 and 3 respectively.

2.1.1 PHQ-2

Increasingly there has been a demand for ultra-short questionnaires, asevidence suggests that even short questionnaires (defined as those with 5-14 items, taking between 2 and 5 minutes to complete) are not routine inprimary or secondary care (Gilbody et al, 2002). This has directly led to thedevelopment of ultra-short questionnaires comprising of three, two or evenone single-detection question. Mitchell & Coyne (2007) propose that the PHQ-2 is the most well known example of this (see Box 1). These are endorsed byNICE guidelines in the process of identifying depression cases.

Evidence suggests that a one-question test only identifies three out of everyten patients with depression in primary care and therefore is likely to be an

unacceptable screening tool if solely relied upon (Mitchell & Coyne, 2007).However, in support of the use of the PHQ-2, two or three question tests


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perform better, identifying eight out of every ten people with depression inprimary care. Caution should be taken when interpreting the PHQ-2, as 2 and3 item questionnaires can often result in false positives (Mitchell & Coyne,2007). Arroll et al (2005) extended the two question format by adding theadditional question: Is this something with which you would like help?,evidencing an improvement in the diagnostic specificity from 78% (two

questions alone) to 89% (either screening question plus help question) fordepression.

The PHQ-2 is proposed to be an effective method for ruling out a diagnosis ofdepression, rather than having diagnostic capabilities (Mitchell & Coyne,2007), and is reported to be of equal value to a GPs ability to eliminatedepression (Arroll et al, 2005) and should only be used in a screening processwhereby there are sufficient resources to administer a second-stageassessment for those who screen positive (Mitchell & Coyne et al, 2007).

2.1.2 PHQ-9The PHQ-9 is a self-administered nine item depression questionnairedeveloped in the US (Kroenke et al, 2001). There is a wealth of evidence thatsupports the validity of the PHQ-9 for use in screening for depressivesymptoms in primary care (Kroenke et al, 2010; Hansson et al, 2009). ThePHQ-9 has been validated against a diagnostic gold standard of depression inthe UK (Gilbody et al, 2007). It can be completed in less than two minutes andprovides evidence of good levels of sensitivity (91.7%) and specificity (78.3%)for depression. This makes the brief PHQ-9 questionnaire comparable to thescreening abilities of more lengthy clinician-administered instruments indetecting depression (Gilbody et al, 2007). Although the PHQ-9 does not

detect for anxiety, a recent article published by Kroenke et al (2010)benchmarks the PHQ-9 and GAD-7 as brief, well-validated measures formonitoring depression and anxiety respectively.

2.1.3 GAD-2 and GAD-7

Similar to the PHQ-9, the GAD-7 has an abbreviated two-item version, knownas the GAD-2. This consists of the first 2 items on the GAD-7 andrepresenting the core anxiety symptoms. Scores on this GAD-2 subscaleranged from 0 to 6. Both have been shown to be effective in detecting

generalised anxiety, panic, social anxiety and post-traumatic stress disorder(Kroenke et al, 2010). However, although there are promising findings for theGAD-2 and GAD-7s validity in screening for Generalised Anxiety Disorder(GAD) (Spitzeret al, 2006) the levels of sensitivity for this tool are not yetdefinitive (Kroenke et al, 2010).

The PHQ-9 and GAD-7 form the main body of the questionnaires as part ofthe Improving Access to Psychological Therapies (DH, 2008) data set. Theseform part of the minimum data set for all IAPT sites to collect. There arecurrently over 100 Primary Care Trusts (PCTs) which have joined the IAPTprogramme and all PCTs are committed to provide a service by 2011 (DH,

2008). The IAPT programme reports that the IAPT data set was compiled


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using the most suitable, free to access tools that were available in otherlanguages and most widely used in practice (DH, 2008).

2.1.4 Hospi tal and Anxiety Depression Scale (HADS)

The HADS is a self administered questionnaire, which has both an anxiety

and depression scale enabling a clinician to establish severity of both anxietyand depression simultaneously, whilst providing separate scores for each ofthe independent subscales as independent measures. The HADS consists of14 items with the response format of four options of symptom severity peritem in relation to the respondents experiences over the last week.

Many studies have supported the validity of HADS (Snaith et al, 2003). Areview of 747 studies in which the HADS was administered concluded that itwas shown to perform well in the assessment of both anxiety and depressionfor somatic, psychiatric, primary care patients and the general population(Bjelland et al, 2002). The HADS can be purchased from a reliable publisher

of psychometric scales, which has arranged translations into many languageswhich are available at request.

2.1.5 Beck Depression Inventory Second Edition (BDI-II)

The BDI was originally developed in the 1960s (Beck et al, 1961) and wasupdated a number of times (Beck et al, 1979; Beck et al, 1996) subsequently.It is a self- report instrument that uses the DSM-IV criteria to categorise thesymptom severity of depression. The BDI-II consists of 21 items that willassess the severity of depression in clinical and normal patient samples. Eachitem has four statements attached to it that are arranged in increasing severityin relation to a symptom of depression. The BDI-II takes around five minutesto complete and can be purchased from the suppliers website.

This scale has been widely used as a tool to identify depression severity(Sharp & Lipsky, 2002). The BDI-II has demonstrated reliable, internallyconsistent and valid scores in primary care medical settings suggesting that itmay improve the detection and support the treatment of people withdepression (Arnau et al, 2001). It can be used alongside the BDI-fast screen,a shortened version of the full scale which was been developed for use inprimary care (Beck et al, 1997).

2.2 Recommendations for Long Term Conditions (LTC) Pilot

As a result of this paper the recommendations for the LTC Pilot are, for theidentification of depression, the use of the PHQ-2 as a tool for the patient toself administer prior to meeting with the GP followed by the PHQ-9 if thepatient scores 3 or more. The PHQ-9 would be filled in by the patient in thepresence of the GP who could aid administration and support its delivery. TheGAD-2 and GAD-7 are the equivalent of these measures for the identificationof anxiety disorders and, as with PHQ-2 and PHQ-9, their use isrecommended within this pilot. These are also widely used nationally and

although they have not received as much attention as the PHQ-9, theirdepression counterpart, they have shown to be an effective and accurate


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screening tool. The scores of the PHQ-9 and GAD-7 would then be used toinform the referral pathway (see Table 1 and Table 2, p10).

The PHQ and GAD scales were deemed as the tool of choice for a number ofreasons:

they are widely used in the NHS in primary care nationally and in other

healthcare systems internationally; the PHQ is endorsed by the QOF as a tool that benchmarks effective

depression screening; they are both part of the IAPT minimum data-set and thus scores link

directly to the stepped care model providing clear care pathways; and there are no charges associated with their use.

2.3 The Referral Pathway

2.3.1 IAPT & the Stepped Care Model for Common Mental HealthProblems

NICE recommends a range of psychological therapies to treat people who areexperiencing depression and/or anxiety. The stepped care model provides asystem of care in line with the levels of severity associated with mental healthproblems. The IAPT service functions to support the delivery of the steppedcare model in relation to common mental health problems, such asdepression and anxiety. Figure 1 outlines the IAPT stepped care model. Thestepped care model has two main principles:

Treatment should always have the best chance of delivering positiveoutcomes while burdening the patient as little as possible.

A system of scheduled reviews to detect and act on non-improvementmust be in place to enable stepping up to more intensive treatments,stepping down where a less intensive treatment becomes appropriateand stepping out when an alternative treatment or no treatmentbecome appropriate.

Derived from the IAPT website www.iapt.org.uk

NICE guidelines advocate the treatment of depression if the patient presentswith depression as the primary diagnosis. Only in cases where anxiety is theprimary diagnosis should this be treated first (NICE, 2009; NICE, 2004).


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Figure 1: IAPT Stepped Care Model for Common Mental Health Problems

NICE promotes the stepped care framework in the MH guidelines in thedelivery of effective services. This also includes a Step 4, which in this casewould correspond with severe and complex depression where there may alsobe a risk to life and/ or severe self-neglect. This is not incorporated into theIAPT stepped care model as this level of mental ill health would not constituteinput at a primary care level.

Mental Health has been prominent in policy drivers for some time due to theovert health and cost implications attached to it. This has resulted in thedevelopment of clear referral pathways to ensure smooth and effectivedelivery of psychological services.

The majority of psychological therapies provided by the IAPT programme areCognitive Behavioural Therapy (CBT) based interventions. CBT has beenshown to improve mental health problems in people who have long termphysical conditions, such as CHD, diabetes and COPD. IAPT recommendsthat people are referred to the IAPT service if they screen positive on the twoquestions recommended by the QOF (also known as the Whooley questions)The PHQ-2 would ideally be administered before meeting with the GP and


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could be sent out prior to the meeting. The further PHQ-9 questionnaire canthen be administered in primary care and the score from this can be used toinform the referral process within the Stepped Care Model. If a patient wasreferred to the IAPT service they would continue to complete the PHQ-9 aspart of the IAPT Data Set and this continuity would make worthwhile linksbetween primary care services.

The tables below outline the range of scores mapped onto the IAPT steppedcare model (see IAPT Stepped Care Model for Common Mental HealthProblems (Figure 1)).Table 1PHQ-9 Score Step in Stepped Care ModelRecognition, assessment and Initialmanagement

Step 1

Persistent sub threshold depressivesymptoms (PHQ-9= 1-4), mild (PHQ-

9= 5-9) or moderate depression(PHQ-9= 10-14)

Step 2

Persistent sub threshold depressivesymptoms (PHQ-9= 1-4) or mild(PHQ-9= 5-9) to moderate depression(PHQ-9= 10-14) with inadequateresponse to initial interventions, andmoderate (PHQ-9=15-19) and severedepression (PHQ-9=20-27)

Step 3

Developed in line with NICE, 2009.

Table 2GAD-7 Score Step in Stepped Care ModelStep 1: All known and suspectedpresentations of GAD

Step 1

Step 2: Diagnosed GAD that has notimproved after education and activemonitoring in step 1

Step 2

Step 3: GAD with marked functionalimpairment or that has not improvedafter step 2

Step 3

Developed in line with NICE, 2011 (Still in development)

The IAPT service would use the information provided by a referrer and thePHQ-9/GAD-7 questionnaires to allocate an individual to a low or highintensity practitioner who would initially offer an appointment to the patient.The IAPT service provides a smooth care pathway, as there is the flexibility to

move up or down the stepped care model in accordance with progress madeat any given level.


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3 Introduction: Screening for Memory Problems inPrimary Care

The average consultation time in UK primary care is 7.5 minutes. For thisreason cognitive testing is often deemed as too time consuming by primary

care teams (Brooke & Bullock, 1999). Traditionally the Mini-Mental StateExam (MMSE) has been labelled as the gold standard cognitive test.However more recently, with the increased pressure to manage the growingnumber of people with cognitive impairments as our population ages (Brodatyet al, 2006), there has been a surge of development of alternative brief testsin response to this need.

3.1 NICE guidance & NHS drivers

The importance of early detection is emphasised in the National Dementia

Strategy (DH, 2009). This stresses the importance of early diagnosis, as latedetection limits the extent a person has over their treatment choices. Morerecently, assessment of a patients cognition has moved towards beingdeemed as a crucial component of medical consultation (Brown et al, 2009).This is reflected in the Department of Health Operating Framework for2008/2009 (DoH, 2007), which summarised the situation as:

providing people with dementia and their carers the best life possible is agrowing challenge, and one that is becoming increasingly costly for the NHS.Research shows that early intervention in cases of dementia is cost effectiveand can improve quality of life for people with dementia and their families.

The National Dementia Strategy (DH, 2009) places primary care at the heartof this initial identification process. The Strategy has set out the developmentof specialist services, such as memory clinics, which would support primarycare by providing explicit referral pathways.

4 Review of Screening Tools

This paper will define and critically appraise a number of cognitive screening

tests in line with their appropriateness for use in GP consultations with peoplewith long term conditions (LTCs). This will include tools highlighted in NICEguidance (NICE, 2006): MMSE, General Practitioner Assessment of Cognition(GP COG) and the 6-Item Cognitive Impairment Test (6CIT) and a number oftools, some which have not been outlined by NICE but which have beenspecifically validated for use in primary care with a good evidence base. Thisincludes the Mini-Cog and Memory Impairment Screen (MIS). Finally, a newNHS recognised, brief, self-administered test for dementia known as the TestYour Memory (TYM) assessment is discussed.

Sperlingeret al (2004) utilised work by The British Psychological Society

(BPS) on outcome measures to produce a set of criteria which clinical


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measures could be scored against. Milne et al (2008) further adapted these inline with the target population of people with cognitive impairments.

The Sixteen criteria were grouped into four key domains

Practicality (Time implications for clinician, cost and availability of tool).

Feasibility (acceptability to patients and clinicians, ease ofadministration and scoring, time taken to complete). Range of applicability (applicability to wide age range and different

dementia types, sensitivity to education level, language and culture). Psychometric Properties (validity, reliability, specificity and sensitivity).

The four key domains have been used in this paper to evaluate the MemoryScreening Tools available at present. These criteria have also been utilised toevaluate the MH screening tools (see section 2), as they provide a parallelsystem for ensuring the screening tools for the LTC pilot meet BPS standardsof best practice (See Appendices 3 and 4).

Milne et al (2008) reviewed eight instruments that met the inclusion criteria,including those presented as options in the opening section of this paper (withthe exception of the TYM, which was still in development at the time the studywas underway). The three screening measures that were rated as best overallfor implementation in primary care using this point system were the GP COG,the Mini-Cog and the MIS (see Appendix 2 for an overview of these tools).

Despite the above three tools being advocated as best practice, Brown et al(2009) stress that these do not fully meet three essential requirements forwidespread use by non-specialists: that it takes minimal operator time toadminister tests, that is covers a reasonable range of cognitive functions andthat it is sensitive to mild Alzheimers disease. They propose that the TYM testfulfils these three essential requirements.

4.1.1 The Test Your Memory (TYM)

The TYM is quick to use, examines 10 cognitive skills, and detects 93% ofcases of Alzheimers disease in comparison to 53% by the MMSE (Brown etal, 2009). It has been referred to as the simple test that can spot Alzheimersin five minutes and this has been publicised by NHS choices. Using the cut

off point of42 to indicate a possible diagnosis of Alzheimers in a group ofpeople where 10% had Alzheimers gave a negative predictive value of 99%and a positive predictive value of 42% (Brown et al, 2009). Furthermore, theTYM is completed by the patient and scored using a rigid scoring sheet. Thismeans that it is unlikely that the patient or scorer will have an influence on thescore thus securing the TYM as a valid and robust memory tool.

The TYM shows equivalent screening abilities to the original and revisedAddenbrookes examinations in the diagnosis of dementia (Mioshi et al, 2006;Mathuranath et al, 2000), covering similar cognitive domains in its testing andalso being sensitive to mild dementia. The TYM has the advantage over the

Addenbrookes examinations and other substantial instruments, such as the


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MMSE due to its simplicity in delivery and accessibility and ease for trainingimplementation.

4.2 Recommendations for Long Term Conditions (LTCs)pilot.

As a result of this paper the recommendations for the LTC pilot are the use ofthe TYM test. This has a strong advantage over current cognitive tests in thatit has a brief but rigorous scoring system and as a result of this a strong inter-rater agreement that is described as a level of excellence (Brown et al, 2009).For example, a combination of ten minutes and presence of the scoring sheetenabled a nurse to score the TYM sheets as accurately as a specialist. Thisprovides assurance that the TYM test will avoid the pitfalls of other cognitivescreening tools regarding to confusing scoring and interpretation systems.The simplicity of the implementation of this tool aligns with the need for peopleto be trained quickly in response to what is described as a huge challenge tosociety, both now and increasingly in the future (DH, 2009, p9).

4.3 Referral Pathway

4.3.1 The Stepped Care Model for Memory Impairments

There is no clear nationwide referral process or stepped care model atpresent for memory impairment. This gap is identified in the NationalDementia Strategy (DH, 2009), a five-year strategy which is funding thedevelopment of services that are fit for the 21st century for people with

dementia and their carers. In the future it is likely that through thedevelopment of memory services there will be a clearer framework for GPs tofollow in response to detection of memory impairment. A three step model isused in this paper to structure the care pathway process. This consists of:

1. Memory complaints at a primary care level.2. Assessment of global functioning by a GP.3. Specific cognitive testing in a specialised setting.

Palmer (2003) showed that this three-step framework resulted in a highpositive predictive value for Alzheimers disease (85-100%). One drawback of

Palmers (2003) three step procedure was that it was not very good atidentifying people with mild dementia due to the low sensitivity of the MMSE,the tool he had used with this client group. The TYM test has shown goodsensitivity to mild dementia (Brown et al 2009) and is likely to fit well in placeof the MMSE in Palmers (2003) referral framework.


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5 Overview of Recommendations for Long TermCondit ions (LTCs) pilot

For a more detailed overview of the rationale for the recommended mentalhealth and memory screening tools see 2.2 and 4.2 respectively. The PHQ-2

and the PHQ-9 (screening for depression) and the GAD-2 and GAD-7(screening for anxiety) were recommended as the mental health screeningtools for the LTC pilot. The PHQ-2 and GAD-2 provide a pre-screeningprocess, whereby they could be completed prior to meeting with the GP toinform whether further screening using the PHQ-9 and GAD-7 was required.

The TYM test was recommended as the memory screening tool of choice forthe LTC pilot. One area that requires further research is the validity of therecommended cut off points with a LTCs client group (Stafford et al, 2007).Although this is an area that is still in development it is suggested thatlowering the cut off scores substantially improves the sensitivity of mental

health screening tools due to the presence of physical complaints as a resultof the presence of a LTC (Stafford et al, 2007). All tools recommended, forboth mental health and memory screening, have a good evidence base foruse in primary care, have promising findings for detection and are already inuse on a national scale in projects or as part of NHS policy drivers.

6 Final ThoughtsThis paper was intended to be comprehensive but not exhaustive in providingan overview of the evidence for mental health and memory screening toolsand the associated referral pathways in line with NHS policy. The added valueof detecting and managing co-morbidity for people with LTCs reflects theimportance of screening for mental health and memory problems in this clientgroup.


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Appendix 1- Comparative Table: Common MH Screening Tools

Tool Description Scoring System DeliveryTime

Advantages

PHQ-2 Ultra-short questionnaireconsisting of two items to screenfor depression

- Score of 3 or more indicates furtherscreening is required.

1m - Effective method to rule oudepression- Equal value to GPs ability depression- Beneficial to add the help qu

improve specificity from 78% toPHQ-9 Aids diagnosis of depression and

measures symptom severity.Nine-item questionnaire with a maximum scoreof 27.1-4 (minimal)5-9 (mild)10-14 (moderate)15-19 (moderate/severe)20-27 (severe)

3m -Based directly on diagnostic depressive disorder in the DSM- Free-Part of IAPT minimum data-se-Scores directly map onto steand referral pathways-Validated for use in primary ca-Greater sensitivity in thedepression in comparison to HA

GAD-2 Ultra-short questionnaireconsisting of two items to screenfor anxiety

First two items on GAD-7 representing coreanxiety symptoms. Scores on this subscaleranges from 0-6 to inform further use of GAD-7

1m - Part of the GAD-7, a well knoscreening tool for the IAPT serv

GAD-7 Aids diagnosis of generalised

anxiety and measures symptomseverity

7 item questionnaire with the maximum score

of 21.0-4 (normal)5-9 (mild)10-14 (moderate)15-21 (severe)

- Good reliability

- Based on DSM-IV criteria

HADS Designed to assess both anxietyand depression

7-item questionnaire with a maximum score of21.0-7 (normal)8-10 (mild)11-14 (moderate)15-21 (severe)

5m - Assesses both anxiety and de-Validated for use in primary ca-Likely to require little trainingwell- established tool

BDI-II Assesses severity of depression 21-item questionnaire with a maximum scoreof 36.0-13 (minimal)

14-19 (mild20-28 (moderate)29-36 (severe)

5m - Based on DSM-IV criteria- Has an abbreviated fast-scscreening for primary care


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Appendix 3- Table of Common MH Screening Tools evaluated against criteria adapted from BPSGuidelines

Practicality Feasibility Range ofapplicability

PsychometricProperties

MEASUREA. DepressionPHQ-9

BDI-II X ? HADS-D XB. Anxiety

GAD-7 ?HADS-A

X

Appendix 4- Table of Memory Screening tools evaluated against criteria adapted from BPSGuidelines

Screening Tools shaded in Grey highlight common MH and memory screening tools recommendedby this paper for implementation in the LTC pilot

Practicality Feasibility Range ofapplicability

PsychometricProperties

MMSE X ? X ?

GP COG ?6CIT ? ?Mini-Cog ?MIS ?TYM ?


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Appendix 4- Comments received from Draft 1

The first draft of this paper was circulated to a number of health professionals working in a variety ofsettings in both primary and secondary care. The comments received were very useful in shaping

the document and provided the paper with valuable input from clinicians and mental health leads inthe region. The completed paper was developed in line with the comments but could not incorporateall suggestions of additional tools in its content. The comments below therefore serve to show thesuggestions made in the papers development.

General comments:

An IAPT Lead for the region commented positively on the links the paper makes with IAPT and thecommonality of the tools used within primary care. He stated how the paperties up some of theactivities already being developed and cements the way forward in line with them.

A lead Consultant Psychiatrist & Psychotherapist in the region, specialising in CBT, commentedupon the value of the scales being cost free and having data for use in primary care. Herecommended the additional use of the WHO-5 wellbeing questionnaire, as WHO recommends it asa measure of positive mental health.

Mental Health screening tool comments:

A Public Health Lead for the region recommended the inclusion of the WEMWBS scale (WarwickEdinburgh Mental Wellbeing Scale). He suggested it has added value in that it is beginning to beused more widely in the region. The shortened version of this scale was highlighted as being thepreferred version, as in evaluation of some projects in County Durham they have found that serviceusers preferred this shorter scale as they found it less invasive than the longer version.

Memory screening tool comments:

The TYM test was recommended by a Consultant Clinical Psychologist Older Adults specialistworking for NTW, as Probably the best self report memory test stressing how it is relatively newand not used in the north east at present. He also confirmed that the MMSE is the routine measureat present although it tends to miss mild problems. He highlighted how importance it was to build inadditional checks into the system for a LTCs client group, which is something the paper outlined inthe Overview of Recommendations for Long Term Conditions (LTCs) pilot section.

A Regional GP Advisor for IAPT reported how the paper had made some really sensiblesuggestions endorsing the use of PHQ-9 due to it's established use in Primary Care. She alsocommented how she was really interested to see how the TYM performs in primary care as it looksvery promising.


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