Screening for Perinatal Mental Health Conditions
Browse our collection of screening forms to help providers assess potential behavioral health conditions in their perinatal patients. Providers may be able to bill insurance for completing mental health assessments. Click here to view our Billing Guide.
Mood and Anxiety Disorders
Patient Health Questionnaire (PHQ-9)- Screens for: Unipolar depression in the general population
- Ages: 18+ (The PHQ-Modified can be used for teens aged 11-17)
- Languages: English, Spanish, and 29 other languages
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The PHQ-9 assesses all diagnostic criteria for Major Depressive Disorder (MDD) as outlined in the DSM-5, including suicidal ideation. Providers who are short on time may start with the PHQ-2, which screens for the core symptoms of depression (anhedonia, feeling down or sad) and indicates whether further evaluation is needed.
Scoring the PHQ-2
- Response categories are scored 0 – 3 according to increased severity of the symptom. A score of 2 or more indicates a possible positive screen for depression and suggests that patients should subsequently complete the PHQ- 9.
Scoring the PHQ-9
- Response categories are scored 0 – 3 according to increased severity of the symptom with a maximum score of 27.
- PHQ-9 Score of:
- ≥ 5 indicates mild depression
- ≥ 10 indicates moderate depression
- ≥ 15 indicates moderately severe depression
- ≥ 20 indicates severe depression
- ≥ 0 on Q9 indicates the need for additional risk assessment
Access the form in your preferred language: PHQ Screeners
- Screens for: Generalized Anxiety Disorder for the general population
- Ages: 11+
- Languages: English, Spanish, and many other languages
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The GAD-7 is designed to screen for and assess the severity of generalized anxiety disorder (GAD). Providers who are short on time may start with the GAD-2, which consists of just two questions from the GAD-7 and indicates whether further evaluation is needed.
Scoring the GAD-2
- Response categories are scored 0 – 3 according to increased severity of the symptom with a maximum score of 6. A score of 3 indicates a possible positive screen for generalized anxiety disorder and suggests the patients should subsequently complete the GAD-7.
Scoring the GAD-7
- Response categories are scored 0 – 3 according to increased severity of the symptom with a maximum score of 21.
- GAD-7 Score of:
- ≥ 5 indicates mild anxiety
- ≥ 10 indicates moderate anxiety
- ≥ 15 indicates severe anxiety
Access the form in your preferred language: GAD Screeners
- Screens for: Anxiety symptoms specifically in the perinatal population
- Ages: 18+
- Languages: English
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The PASS screens for four main categories of anxiety as they are present in pregnant and postpartum individuals: 1) General worry and specific fears, 2) Perfectionism, control and trauma, 3) Social anxiety, and 4) Acute anxiety and adjustment.
Scoring the PASS
A total PASS score is obtained by adding all of the items. Scoring a 26 on the PASS can be considered the cut-off score for differentiating between high and low risk for presenting with an anxiety disorder. The maximum score on the PASS is 93.
PASS Score of:
- 0-20 indicates the patient is asymptomatic
- 21-41 indicates mild-moderate anxiety symptoms
- 42-93 indicates severe anxiety symptoms
Subscales
- Excessive worry and specific fears- Q1-Q10
- Perfectionism, control, trauma- Q11-Q18
- Social anxiety- Q19-Q23
- Acute anxiety and adjustment- Q24-Q31
Access the form in English: PASS Screener
- Screens for: Postpartum Depression (PPD)
- Ages: 16+
- Languages: English, Spanish, and many other languages
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The Edinburgh Postnatal Depression Scale (EPDS) was developed to assist primary care health professionals in detecting mothers suffering from postpartum depression (PPD). The EPDS may be used at six to eight weeks to screen postnatal women or during pregnancy. The child health clinic, postpartum check-up or a home visit may provide suitable opportunities for its completion.
Scoring the EPDS:
Scores on the EPDS range from 0 – 30. Response categories are scored on a scale of 0-3 according to increased severity of the symptom. Items 3 and 5-10 are reverse scored. The total score is calculated by adding together the individual scores for each of the ten items.
EPDS Score of:
- < 13 Depression likely not indicated
- ≥ 13 Positive screen for depression
- Responds “yes” to Q10 (self-harm): conduct further risk assessment
Access the form in English: EPDS
- Screens for: Bipolar Disorder
- Ages: 18+; MDQ-Adolescent 12+
- Languages: English, Spanish, and multiple other languages.
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The Mood Disorder Questionnaire (MDQ) assists in identifying bipolar disorder and distinguishing it from other mood disturbances in clinical populations. This includes bipolar I, bipolar II, and bipolar NOS.
Scoring The MDQ
Further medical assessment for bipolar disorder is clearly warranted if patient:
- Answers Yes to 7 or more of the items in Question #1 (symptom checklist), AND
- Answers Yes to Question #2 (have several symptoms ever happened during the same period), AND
- Answers “Moderate Problem” or “Serious problem” to Question #3
Access the form in English: MDQ Screener
- Screens for: Bipolar I Disorder in patients with depressive symptoms
- Ages: 18+
- Languages: English, Spanish, Chinese (Mandarin, Cantonese), French, Tagalog, and Vietnamese.
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The Rapid Mood Screener (RMS) is a screening tool that was developed to differentiate bipolar I disorder from major depressive disorder (MDD) in patients with depressive symptoms who have been diagnosed with MDD. The RMS consists of six questions that assess both depressive and manic symptoms. It can be completed in less than 2 minutes.
Scoring the RMS
“YES” responses to 4 or more of the 6 items is considered a positive screen providing high confidence for BP-I, with an estimated 88% sensitivity, 80% specificity, and 84% accuracy.
Access the form in English: RMS
Contact Mehul.Patel@Allergan.com for your preferred language
Substance Use
5Ps- Screens for: Substance use in pregnant women
- Ages: 15+
- Languages: English and Spanish
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The Modified 5P’s assesses patient’s use of alcohol or illicit drugs and risk of substance use based on parent, peer, partner, and past risk factors. This screening tool poses questions related to substance use by women’s parents, peers, partner, during her pregnancy and in her past.
Scoring The 5Ps:
Response categories are stratified into low risk, average risk, and high risk. Low risk is classified as patients who have never used alcohol or other drugs. Average risk is classified as patients who report using drugs and/or alcohol in the past, but not since learning of their pregnancy. High risk is classified as patients who used alcohol or drugs in the past month.
Access the form in English: 5Ps Screener
Safety
Ask Suicide-Screening Questions (ASQ)- Screens for: Suicide Risk
- Ages: 8+
- Languages: English, Spanish, and many other languages
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The Ask Suicide-Screening Questions (ASQ) tool is a set of four brief suicide screening questions that takes 20 seconds to administer. Patients who screen positive for suicide risk on the ASQ should receive a brief suicide safety assessment (BSSA) conducted by a trained clinician (e.g., social worker, nurse practitioner, physician assistant, physician, or other mental health clinicians) to determine if a more comprehensive mental health evaluation is needed.
Scoring the ASQ
If patient answers “No” to all questions 1 through 4, screening is complete (not necessary to ask question #5). No intervention is necessary
If patient answers “Yes” to any of questions 1 through 4, or refuses to answer, they are considered a positive screen. Ask question #5 to assess acuity:
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- “Yes” to question #5 = acute positive screen (imminent risk identified)
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- Patient requires a STAT safety/full mental health evaluation. Patient cannot leave until evaluated for safety.
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- Keep patient in sight. Remove all dangerous objects from the room. Alert physician or clinician responsible for patient’s care.
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- “No” to question #5 = non-acute positive screen (potential risk identified)
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- Patient requires a brief suicide safety assessment to determine if a full mental health evaluation is needed. If a patient (or parent/guardian) refuses the brief assessment, this should be treated as an “against medical advice” (AMA) discharge.
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- Alert physician or clinician responsible for patient’s care.
Access the form in your preferred language: ASQ Screeners
- Screens for: Suicide Risk
- Ages: 16+
- Languages: English and 15 other languages
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The P4 screener assesses suicide risk by asking about the “4 P’s”: past suicide attempts, a plan, probability of completing suicide, and preventive factors. The screener stratifies participants into one of three risk categories: ‘minimal’, ‘lower’, or ‘higher’
Scoring The P4
- Minimal: the first three items are negative AND the individual lists one or more preventive factor
- Lower: Either of the first 2 items are positive, BUT the third item indicates that self-harm is ‘Not at all likely’ AND the individual lists one or more preventive factor
- Higher: Either the third item suggests some likelihood of self-harm OR the individual indicates that there are no preventive factors
Access the form in English: P4
- Screens for: Interpersonal Violence (IPV)
- Ages: 17+
- Languages: English
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The HARK (Humiliation, Afraid, Rape, and Kick) was developed to assist primary care health professionals in identifying persons experiencing interpersonal violence (IPV), including emotional, sexual, and physical abuse. It has four questions that help identify individuals who have experienced IPV in the past year. The scale will not detect persons experiencing other mental health conditions like depression, anxiety, or post-traumatic stress disorder.
Scoring The HARK
Scores on the HARK range from 0 – 4. Response categories are scored on a scale of 0 – 1. A score of 1 or more is indicative of a positive screen.
Access the form in English: HARK