Behavioral Health

There are many screening tools available that enable providers to identify and intervene with patients facing crisis. Using a suicide assessment tool can help providers differentiate acuity of crisis and risk of harm. Three evidence-based screening tools that assess for suicide risk are listed below:

• The Columbia-Suicide Severity Rating Scale (C-SSRS) is a widely used tool for assessing suicidal ideation and behavior. It helps healthcare providers determine the severity of suicidal thoughts and behaviors, enabling them to initiate appropriate interventions. The C-SSRS has multiple versions available depending on the service setting, e.g. healthcare, school, first response, military, etc. The Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) risk assessment tool is also available, developed by SAMHSA with C-SRRS questions embedded.\
• While primarily used for depression screening, the Patient Health Questionnaire-9 (PHQ-9) also includes questions related to suicidal ideation. It is a widely accepted tool for assessing depressive symptoms in primary care and can flag patients needing more close assessment of their thoughts and feelings.
• The Suicidal Behaviors Questionnaire-Revised (SBQ-R) is a self-report questionnaire designed to assess suicidal behaviors and ideation. It is a tool commonly used in research and clinical settings to evaluate the presence and severity of suicidal thoughts and behaviors.

De-escalation strategies in healthcare settings promote a safe environment, particularly when dealing with patients experiencing heightened emotional distress. De-escalation emphasizes active listening, empathy, and non-confrontational language, and techniques such as maintaining a calm demeanor, using open-ended questions, and offering reassurance. Creating environments where patients feel heard and understood contributes to defusing potential crises and helps providers address challenging situations without resorting to punitive measures. These strategies not only enhance the quality of care but also contribute to a more compassionate and patient-centered approach in healthcare settings.

Mental Health First Aid was designed to serve like CPR for behavioral health crises, training non-clinicians and clinicians alike in the basic skills of safety assessment, de-escalation and mental health referral. The complete training is 8 hours and delivered by trained facilitators.

If a behavioral health crisis is able to be de-escalated and the patient achieves a level of stabilization where they do not pose a danger to themselves or others, then providers can utilize a safety plan to support the individual once they return to their community.

Basic elements of a safety plan include identifying and writing down:

• Warning signs for a behavioral health crisis
• Internal coping strategies
• Ways to distract oneself
• People within one’s support system to call
• Professionals or agencies to contact
• Making the environment safer

There are many online examples of safety plans, apps for safety planning, or your agency can develop its own.

Knowing 24/7 crisis response resources is essential for behavioral health crisis management and contacts should be shared with any individual whose history includes crisis or self-harm. Information for crisis resources should also be widely shared throughout the care setting, for example in high traffic areas like waiting rooms and patient care hallways. Providers can play an important role in normalizing crisis and the presence of overwhelming or distressing thoughts, to reduce stigma and support timely care.

Community Behavioral Health Crisis Resources:

• Child & Adolescent Mobile Psychiatric Service (202-481-1440): Emergency response service for children & adolescents aged 6-17 who are having a suicidal or mental health crisis
• DBH Access Helpline (888-793-4357): A 24/7 local helpline staffed by clinicians who can refer a caller to immediate help or ongoing care\
• DBH Community Response Teams (202-673-6495): A 24/7 multidisciplinary direct service team that provides assessment and support in the community
• National Suicide Lifeline (988): A 24/7 call or text suicide and mental health crisis support line
• Medical First Responders & Police (911) 

In certain situations individuals may pose a significant risk to themselves or others, in which case they may need to be hospitalized.  Ideally in such cases individuals would elect to go to the hospital voluntarily or with the support of a loved one.  However, some mental health conditions and crises warrant involuntary hospitalization, which is when a person is taken to the hospital against their will. Involuntary hospitalization is typically implemented when a person exhibits imminent danger, such as expressing explicit suicidal thoughts, demonstrating a high risk of self-harm, or presenting a threat to the safety of others. The goal is to ensure the safety and well-being of the individual and those around them, with the ultimate aim of stabilizing the immediate crisis and initiating appropriate mental health care.

In Washington, DC, the “Application for Emergency Hospitalization" or FD-12 allows trained mental health providers, medical providers and emergency responders such as police officers to initiate the hospitalization process. The FD-12 form is required to be completed as the first step for involuntary admission. It guarantees only that the individual can be brought for assessment, and does not mean they will be ultimately admitted.

• Attention Deficit Hyperactivity Disorder (Children & Teens): NICQH Vanderbilt Assessment Scales

• Alcohol: Alcohol Use Disorders Identification Test (AUDIT)

• Anxiety: Generalized Anxiety Disorder - 7 (GAD-7)

• Behavior & Mood (Children & Teens): Strengths & Difficulties Questionnaire (SDQ)

• Depression: Patient Health Questionnaire - 9 (PHQ-9)

• Other Drugs: Drug Abuse Screening Test - 10 (DAST-10) or Tobacco, Alcohol, Prescription Medication or other Substances Tool (TAPS)

• Postpartum Depression: Edinburgh Postnatal Depression Scale (EPDS)

Anxiety disorders are prevalent mental health conditions that affect a significant portion of the adult population. Estimates suggest that nearly 20% of adults in the United States have some anxiety disorder, which can include generalized anxiety disorder, panic disorder, and social anxiety disorder, each characterized by excessive worry, fear, or apprehension. Treatment options for anxiety in adults often involve a combination of psychotherapy, medication, and lifestyle modifications. Psychoeducation, stress management techniques, and support groups can also be integral components of comprehensive treatment plans. The goal is to alleviate symptoms, improve coping mechanisms, and enhance overall mental well-being, promoting a more balanced and fulfilling life for individuals grappling with anxiety.

Screening Tools:

• General Anxiety Disorder-7 (GAD-7)

Clinical Guidelines:

• Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition that often persists into adulthood. While commonly associated with childhood, a significant number of individuals continue to experience symptoms throughout their adult years. It is estimated that up to 5% of American adults suffer from ADHD. ADHD is characterized by persistent difficulties in sustaining attention, impulse control, and hyperactivity. The impact of these symptoms can extend beyond work or academic settings, affecting relationships and daily functioning. Diagnosis can be challenging due to the diversity of symptoms and their overlap with other mental health conditions, including trauma. Treatment options typically include a combination of behavioral interventions, psychoeducation, and in some cases, medication. A tailored, multi-modal approach is recommended to address the unique challenges faced by adults with ADHD and to enhance overall functioning and quality of life.

Screening Tools:

• Wender Utah Rating Scale

Clinical Guidelines:

• Treatment and Management of ADHD in Adults

• Overview of Treatment Recommendations for Adult ADHD

• Attention deficit hyperactivity disorder: diagnosis and management

Bipolar disorder (formerly called manic depression) is a lifelong illness characterized by distinct shifts in mood, energy level, and activity. The two mood states associated with bipolar disorder are mania (symptoms can include high energy, euphoria, impulsivity, irritability, decreased need for sleep, pressured speech, racing thoughts or increased risk-taking behavior) and depression (symptoms can include low mood, feeling sad, low motivation or energy, sleep disturbances, withdrawal from others, feeling hopeless or having thoughts of suicide). There are several different subtypes of bipolar disorder, but all are defined by the shifts between mania and depression, which can last for weeks at a time. Identifying bipolar disorder requires thorough assessment by a mental health professional, as it can sometimes be hard to diagnose due to comorbidities with other mental health conditions like anxiety, trauma, and ADHD. Treatment for bipolar disorder includes medication to manage symptoms and psychotherapy to manage emotions and mood states, as well as adopt healthy behaviors.

Recommended Screening Tools:

• Mood Disorder Questionnaire (MDQ)

Clinical Guidelines:

• Practice Guidelines for the Treatment of Patients with Bipolar Disorder
• Bipolar Disorder Algorithms

Depression in adults is a prevalent and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities. It is estimated that approximately 18% of adults in the United States suffer from depression. Treatment options for depression often involve a combination of psychotherapy and medication, as well as making lifestyle changes, increasing exercise, and strengthening social supports. Early detection and a comprehensive, individualized treatment plan are essential for effectively addressing depressive symptoms and promoting mental well-being in adults.

Screening Tools:

• Patient Health Questionnaire (PHQ-9)

Clinical Guidelines:

• Identification and Management of Clinical Depression in Adults

• Major Depressive Disorder Algorithms Procedural Manual

Trauma is a broad term referring to a wide range of experiences that can be distressing or shocking and have lasting physical or psychological impacts. Anyone can experience trauma, however both the severity of and response to a traumatic event can vary greatly and is usually dependent upon an individual’s past experiences, coping skills, and resilience factors. Traumatic experiences can include those that are acute or short-lived like natural disasters. singular incidents of abuse or violence, or losing a loved one OR those that are chronic or complex like ongoing violence in relationships, exposure to community violence or war, or persistent financial or familial instability. One does not have to achieve a diagnosis of Post-Traumatic Stress Disorder in order to be struggling with the symptoms or after-effects of trauma. Symptoms of PTSD and other trauma-related disorders include unwanted and intrusive memories, mood changes including depression and irritability, anxiety or hypervigilance, sleep disturbances, and avoidance of people, places or things associated with the traumatic event. Although there are no medications to treat trauma specifically, various forms of psychotherapy have been proven effective in helping individuals recover from trauma and medications can be used to treat correlating symptoms of depression, anxiety, and sleep issues.

Recommended Screening Tools:

• Brief Trauma Questionnaire (BTQ)
• PTSD Checklist for DSM-5 (PCL-5)

Clinical Guidelines:

• Clinical Practice Guideline for the Treatment of PTSD

Psychosis refers to difficulties with thoughts or perceptions that contribute to a disconnection from common reality. People who struggle with psychosis have difficulty recognizing what’s real and what’s not, usually in the form of delusions (false beliefs), hallucinations (seeing or hearing things that others do not experience), and incoherent speech. Psychotic episodes or breaks can happen at any age in life, but are typically experienced in late adolescence and early 20’s. Signs of a psychotic episode include suspiciousness or paranoia, difficulty thinking or communicating clearly, social withdrawal, decline in self-care and hygiene, and sleep disturbances. There is no one cause of psychosis, rather it is the result of a complex combination of genetic risk, differences in brain development, and exposure to stressors or trauma. The most commonly known diagnosis is Schizophrenia, however there are a wide range of psychotic and psychosis-related disorders including substance-induced psychosis and severe depression with psychosis. Diagnosis and treatment of psychotic disorders should be conducted by an experienced mental health professional and will typically include antipsychotic medication along with other familial, coordinated care, or community-based supports. Early detection of psychosis symptoms is critical to providing appropriate interventions to ensure long-term health and recovery.

Clinical Guidelines:

• Practice Guideline for the Treatment of Patients with Schizophrenia
• Schizophrenia Treatment Algorithms

Anxiety disorders in children and teens are common and can significantly impact their emotional well-being and daily functioning. It is estimated that nearly 10% of children ages 3-17 are diagnosed with an anxiety disorder, which can include generalized anxiety disorder, separation anxiety disorder, and social anxiety disorder. Symptoms include excessive worry, fearfulness, restlessness, and often physical complaints such as headaches or stomachaches. Early identification and intervention are crucial, with treatment including a combined approach of psychotherapy, behavioral interventions, parent and family support, and in some cases, medication. Creating a supportive environment, teaching coping skills, and fostering open communication are key components of effective anxiety management in children.

Screening Tools:

• Screen for Child Anxiety Related Disorders (SCARED)
• General Anxiety Disorder-7 (GAD-7; ages 12+)

Clinical Guidelines:

• Pediatric Anxiety Disorders Assessment and Treatment

Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition that frequently emerges in childhood and can persist into adulthood. It is estimated that up to 10% of children ages 3-17 have been diagnosed with ADHD. The disorder is characterized by persistent patterns of inattention, hyperactivity, and impulsivity, which can significantly impact a child's academic performance, social interactions, and overall well-being. Diagnosis involves a comprehensive evaluation of behavior, developmental history, and educational performance. Treatment options often include behavioral interventions, parent training, and school accommodations to address specific challenges. In some cases, healthcare professionals may also prescribe medications to manage symptoms. Early identification and a multidisciplinary approach involving parents, teachers, and healthcare providers are crucial in effectively managing ADHD in children and promoting optimal development.

Screening Tools:

• NICHQ Vanderbilt Assessment Scales

Clinical Guidelines:

• Management of Pediatric ADHD

• Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder

Although bipolar disorder is often diagnosed in adolescence or adulthood, symptoms can arise in childhood and therefore it’s important to be aware of early warning signs. Bipolar disorder (formerly called manic depression) is a lifelong illness characterized by distinct shifts in mood, energy level, and activity. When children experience more extreme changes in mood, sleep, energy, and cognitions, they may be exhibiting symptoms of mania (high energy, more active or irritable than is typical) and/or depression (very sad or much lower energy than is typical), which are the two mood states that characterize bipolar disorder.  Diagnosing bipolar disorder in children and teens can be complicated, as symptoms often overlap with other conditions like ADHD, anxiety, or PTSD, and therefore assessment must be completed by a trained, experienced mental health professional. Treatment for bipolar disorder includes medication to manage symptoms, psychotherapy to manage emotions and adopt healthy behaviors. Family education and involvement for children and teens with bi-polar disorder is key to achieving stabilization and a successful recovery.

Clinical Guidelines:

• Practice Parameter for the Assessment and Treatment of Children and Adolescents with Bi-Polar Disorder

Depression in children and teens is a serious mental health concern characterized by persistent feelings of sadness, irritability, and a loss of interest in activities. The prevalence of depression in youth has been on the rise, with various factors such as genetics, trauma, and environmental stressors contributing to its development.  Family history is a big risk factor of depression, as mothers who struggle with depression impact the development of childhood depression 50% of the time. It is estimated that nearly 4% of children and teens have diagnosed depression, with nearly 15% of teens reporting a major depressive episode in the last year. Identifying depression in children and teens can be challenging, as symptoms may manifest differently than in adults, often appearing as behavioral problems or academic decline. Early identification and intervention are crucial, with treatment including a combined approach of psychotherapy, behavioral interventions, parent and family support, and in some cases, medication. Family support and open communication play pivotal roles in the successful management of depression in children and teens, emphasizing the importance of a holistic approach to address both biological and environmental factors influencing a child's mental health.

Screening Tools:

• Strengths & Difficulties Questionnaire (SDQ)

• Patient Health Questionnaire (PHQ-9; ages 12+)

Clinical Guidelines:

• Pediatric Depressive Disorders Assessment and Treatment

Trauma is a broad term referring to a wide range of experiences that can be distressing or shocking and have lasting physical or psychological impacts. Addressing trauma with children and adolescents is key due to the impact trauma can have on development, brain functioning, and social-emotional interactions. The types of trauma often experienced by children and adolescents include (but are not limited to) physical, sexual, or emotional abuse, bullying, community or school violence, neglect, familial or financial instability, and exploitation. Signs and symptoms that a child has experienced something traumatic include sleep disturbances, difficulty at school, trouble getting along with family or friends, withdrawal from activities previously enjoyed, irritability, behavioral issues, anxiety or depression. A child or teen does not have to meet the full criteria for Post-Traumatic Stress Disorder to need support following a traumatic event. When addressing trauma with children, it is important to ensure an environment of safety and trust, as they may be wary of sharing about what happened. Individual, group, and/or family therapy is the treatment recommendation for children and teens struggling with symptoms of trauma. Although there are no medications to treat trauma itself, medications can be used to treat correlated symptoms of depression or anxiety.

Recommended Screening Tools:

• Child Trauma Screen (CTS)

Clinical Guidelines:

• Psychotherapies for Child and Adolescents Affected by Trauma or Violence

There are no specific, standardized screening tools exclusively for grief, as it is a highly individual experience. Assessing grief requires the provider to consider the individual’s unique context and, crucially, their culture. However, healthcare providers may use broader instruments that assess symptoms associated with grief and related emotional distress. It is important to remember a positive screen does not equate to a diagnosis of complicated grief or specific mental health disorder.

• Although primarily a depression screening tool, the Patient Health Questionnaire-9 (PHQ-9) includes items related to feelings of sadness, loss of interest or pleasure, and changes in appetite or sleep. These symptoms can be indicative of grief-related distress.
• The Generalized Anxiety Disorder 7 (GAD-7) assesses symptoms of anxiety, which can be heightened during the grieving process. Persistent worry, restlessness, and irritability are common manifestations of grief-related distress.
• The Brief Grief Questionnaire (BGQ) is a brief self-report questionnaire that assesses complicated grief symptoms, including sadness, preoccupation with thoughts of the deceased, and difficulty accepting the reality of the loss.

Primary care doctors should be aware that grief is a complex experience that can be influenced by cultural factors. Understanding the intersection of grief and culture is essential for providing culturally competent and patient-centered care.

Key considerations for understanding the intersection of grief and culture include:

• Grief is expressed differently across cultures. Different cultural groups may have unique rituals, mourning practices, and ways of coping with loss.
• Cultural norms play a significant role in shaping how individuals express and share their emotions, including grief. Some cultures may encourage open expression, while others may value stoicism.
• Many cultures integrate spiritual or religious beliefs into their grief processes. Understanding a patient's spiritual or religious background can provide insight into their coping mechanisms, beliefs and rituals.
• For some, grieving is a communal experience involving extended family and community members. Providers may consider involving family or community resources in the patient's care plan.
• Individuals within the same cultural group may have unique ways of grieving. Providers should approach each patient as an individual.
• Cultural stigmas related to mental health or expressing grief may exist. Providers should be aware of these potential barriers and work to create non-judgmental environments that encourage help seeking.

• Wendt Center for Loss & Healing
• Grief Support Groups
• DHS Burial Assistance Program
  
   

• The MedStar Social Needs Resource Page is a one-stop shop to find local, free or low-cost resources to support patients like food banks, utilities assistance, transportation services and more.
• The PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences) is a tool that includes questions related to housing, financial stress, education, employment, and other social determinants. It assists in identifying both risks and protective factors. 

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) includes codes that allow healthcare providers to document social determinants of health in patient records. These codes fall under the "Z" series, and each code corresponds to a different social determinant or a set of related factors that is known to affect health and health-related outcomes. Utilizing Z codes can help support data collection and understanding of how social determinants of health affect a patient’s health outcomes.

• Improving the Collection of Social Determinants of Health Data with ICD-10-CM Z Codes

• Utilization of Z Codes for Social Determinants of Health among Medicare Fee-for-Service Beneficiaries