Mental Health Toolkit

PHQ Screeners

This website allows selection of several different screening tools in multiple languages. 

• For Depression select the Patient Health Questionnaire 2 (PHQ –2) or Patient Health Questionnaire 9 (PHQ-9)
• For Anxiety select the Generalized Anxiety Disorder 2 (GAD 2) or Generalized Anxiety Disorder 7 (GAD 7)
• This link leads to the instructions for administering and scoring the PHQ-2 and 9 and GAD-2 and 7. 

Columbia-Suicide Severity Rating Scale (C-SSRS)

The C-SSRS is widely used and is much more selective in eliminating false positive screens for suicide.  Scroll down on this link to select the version of the screener desired.  The C-SSRS is available in several languages.  

• Quick access to a 24-minute video training for the C-SSRS is available.

Edinburgh Postnatal Depression Scale (Spanish/English)

The EPDS should be administered during the postpartum period.

Antenatal (Psychosocial) Risk Questionnaire (ANRQ)

FYI - this tool is to be used with permission of the author.  Use in an EMR would require a royalty.

• Questionnaire
• Scoring Guide

CAGE-AID is an easy-to-use screen for alcohol and drug use.

The Danger Assessment-5

The Danger Assessment-5 should be completed if the HITS screening is positive. This is a follow-up screening tool for a positive HITS screen.

Hurt, Insult, Threaten, Scream screening (HITS) - See PDF Link Below

Recommend screening all women of reproductive age. This is a first-line screening tool for intimate partner violence.