Top 3 Mental Health Assessment Forms for Measurement-Based Care

March 18, 2024

If you ever played the Mystery Box party game as a child, you’ll remember how challenging it was to guess the objects in the box by relying on your sense of touch. 

Assessing and monitoring your clients’ mental health can feel a bit like a game of Mystery Box. Each individual client’s experience is unique, and the nuances aren’t always clearly visible. The process is further complicated by the subjective nature of mental health experiences, which makes them difficult to quantify.  

Measurement-Based Care (MBC) offers structure and clarity to mental health assessment, monitoring, and treatment. It’s an evidence-based approach that relies on standardized measurement tools—like mental health assessment forms—to guide practitioners in making more informed care decisions. By providing a numerical measurement of their progress, the assessment tools also help engage patients more deeply in their care. 

In this article, we’ll take a closer look at three common mental health assessment forms you can incorporate into your own measurement-based care plans. But first, let’s dig into the goals and benefits of measurement-based care tools.

A quick overview of measurement-based care

The goal of measurement-based care in mental health is to enhance the quality and effectiveness of the care you’re delivering. 

According to the American Psychological Association (APA), there are three essential components to measurement-based care: 

  1. Routinely collecting patient-reported outcomes throughout the course of treatment. 
  1. Sharing timely feedback with patients about their reported progress scores and trends over time.
  1. Using these data, combined with the provider’s clinical judgment and the patient’s experiences, to shape treatment plans.

Standardized mental health assessment forms offer a tool to establish a baseline assessment that you can revisit throughout the care journey. You then use the data to observe trends, measure progress, and modify treatment. 

Advances in electronic health records (EHR) make it easy to collect, analyze, and securely share mental health assessment insights. For example, Practice Better helps you collect information directly from your clients using forms.  

Let’s take a look at three common mental health assessment forms that you might want to add to your intake process: PHQ-9, GAD-7, and the PTSD Checklist for DSM-5 (PCL-5). 

Form #1: Patient Health Questionnaire (PHQ-9) 

The Patient Health Questionnaire (PHQ-9) is a standardized tool widely used in diagnosing and determining the severity of a client’s depression. It consists of nine questions that a patient self-rates on a scale of 0 (not at all) to 3 (nearly every day).

A sample of the Patient Health Questionnaire 9 or PHQ-9, mental health assessment forms. 

The prescribed PHQ-9 scoring interpretation of a client’s overall score is as follows:

  • 1-4 = minimal depression
  • 5-9 = mild depression
  • 10-14 = moderate depression
  • 15-19 = moderately severe depression
  • 20-27 = severe depression

Having a patient complete the PHQ-9 questionnaire as part of your intake process and during treatment helps you monitor the impact of your plan. 

A sample of the PHQ-9 questionnaire in Practice Better
A sample of the PHQ-9 questionnaire in Practice Better.

There are many benefits to using the PHQ-9 as an assessment tool:

  • It’s quick to administer, with only nine questions to answer, plus a check for how much the problems are interfering with everyday functioning.
  • It provides a structured and standardized view of depression across intervals and individuals. 
  • Sharing the ongoing results of your assessments with patients can help improve self-awareness around their mental health and their progress. 
  • The PHQ-9 has been extensively validated across many studies to be a reliable measure of depression severity.

There are also some limitations to be aware of when using the PHQ-9: 

  • The questionnaire relies heavily on a patient’s self-analysis, which can be subject to availability bias or recall bias.
  • While the PHQ-9 is effective for screening, it’s not a diagnostic tool. It only serves to add information to your overall clinical assessment. 

Form #2: Generalized Anxiety Disorder 7 (GAD-7)

The PHQ-9 and GAD-7 screening tools were both developed by a research team made up of Spitzer, Williams, Kroenke, and colleagues. GAD-7 is a short, self-report questionnaire designed to identify and assess severity of generalized anxiety disorder.

GAD-7 consists of – you guessed it – seven questions related to anxious thoughts and behaviors patients might be experiencing. It asks the patient to rate how often each situation has affected them over a two-week period. Each item is scored on a scale from 0 (not at all) to 3 (nearly every day). 

A sample of the  Generalized Anxiety Disorder 7, or GAD-7, mental health assessment forms.

The GAD-7 scoring interpretation of a client’s overall score is as follows:

  • 0 – 4 = minimal anxiety
  • 5-9 = mild anxiety
  • 10 – 14 = moderate anxiety
  • 15 – 21 = severe anxiety
An sample of the GAD-7 questionnaire in Practice Better
A sample of the GAD-7 questionnaire in Practice Better.

The PHQ-9 and GAD-7 mental health assessment forms share similar benefits and limitations. 

GAD-7 is quick to complete, extensively validated, and supports better patient collaboration. It also relies on self-reporting, lacks insight into the context of anxiety symptoms, and has limited diagnostic power. 

Form #3: PTSD Checklist for DSM-5 (PCL-5)

Post-traumatic stress disorder (PTSD) can be tricky to diagnose. Often, other mental health issues, like anxiety, panic attacks, or difficulty concentrating sometimes obscure it. Measurement-based care tools help the clinician uncover PTSD so treatment can be targeted to what’s really going on. 

The PCL-5 is a 20-item self-report tool that assesses the symptoms of PTSD. If responses suggest a likelihood of PTSD, it prompts further evaluation – most often a structured clinical interview, such as the CAPS-5, or Clinician-Administered PTSD Scale. 

PTSD was classified as an anxiety disorder in DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition). It has since moved to a new category of “Trauma and Stressor-Related Disorders” in DSM-5. 

  • The wording of the PCL-5 reflects changes to existing symptoms and the addition of new symptoms in the DSM-5. 
  • The PTSD Checklist increased from 17 items to 20 questions with the migration to PCL-5. 
  • The PCL-5 serves several purposes, including screening for PTSD, making a preliminary diagnosis, and monitoring symptom change through treatment.

Clients completing the PCL-5 answer 20 questions about how much they were affected by specific symptoms in the past month. 

The rating scale ranges from 0 (Not at all) to 4 (extremely). Initial research suggests that a PCL-5 cutoff score between 31-33 is indicative of probable PTSD across samples. 

A sample of the PCL-5 mental health assessment forms 

The PCL-5 shares similar benefits to the PHQ-9 and GAD-7 for PTSD screening and assessment. It also provides a trauma-specific focus. This questionnaire has a nuanced assessment of the most up-to-date symptoms associated with PTSD within re-experiencing, avoidance, and hyperarousal.

A sample of the PCL-5 form in Practice Better.
A sample of the PCL-5 form in Practice Better.

As with any assessment tool, it should be used within the broader context of a thorough clinical evaluation, considering individual differences and potential limitations.

Best practices for implementing measurement-based care forms

Integrating standardized mental health assessment forms into your treatment programs helps you track client progress. Here are some tips for ensuring they fit seamlessly into your practice:

  • Ensure training is up to date. You need proper administration of assessment tools, interpretation of results, and a thorough understanding of the clinical implications of those results. For those needing training or support, many professional associations provide resources and guidance around delivering measurement-based care. 

You can also find resources online. For example, Stanford Medicine offers guidance on interpreting test results.

  • Keep your clients in the loop. Ensure you clearly communicate the purpose of mental health assessment forms and how you will use the results. Let patients know how this questionnaire benefits their mental health progress. 
  • Be mindful of relevance. patient differences. Review your assessment tools to ensure they are well-matched to your patients and aligned with current best practices. 

For example, if you work with clients under the age of 18, then you might want to consider an assessment tool specifically for that younger population, like the Children’s Depression Inventory (CDI). 

Many assessment tools are also available in multiple languages, which can help maintain the accuracy and relevance of your data if you work with clients who are more comfortable answering questions in a language other than English.

Incorporating measurement-based care into your practice

Finding ways to embed measurement-based care tools seamlessly into the routine workflows of your practice can save precious time and resources. 

The added ability to convert completed assessment forms into notes that you can use during a session is also a huge timesaver. 

Screen shot of the Practice Better interface showing a list of completed forms and a drop down with Create Notes selected.
Turning you completed forms into notes in Practice Better is easy.
  • Charting is essential in order to implement measurement-based care. Having access to reusable templates and easy sharing makes organizing, documenting, and communicating smoother. 
  • It’s also handy to have a single repository where you can monitor a client’s progress and easily pull information related to assessment results, treatment plans, and more. This will help you organize your notes and find information for insurance companies.
  • If you counsel clients by telehealth, using a built-in AI note-taking tool frees you to channel 100% of your focus on what the patient is saying, rather than scrambling to take accurate notes while actively listening.

Of course, any technology you choose must be HIPAA compliant to safeguard patient privacy. They should also provide secure communication channels for sharing results or conducting telehealth sessions. 

The future of mental health practices features measurement-based care 

When it comes to optimizing mental health, each client’s journey is unique. Trying to assess symptoms and understand outcomes can quickly land you back in Mystery Box territory. 

It’s not surprising that measurement-based care in mental health is rapidly growing in popularity. It gives practitioners a proven, data-driven approach to enhance clinical expertise, measure success, and detect changes sooner, so they can make timely adjustments and provide more individualized care. 

Standardized screening questionnaires – like PHQ-9 and GAD-7 – are important measurement-based care tools when it comes to the objective assessment of your clients’ mental health. Having these forms built into your practice management software can go a long way toward streamlining care and providing a holistic, accurate view of every client.  

The PHQ-9, GAD-7, and the PTSD Checklist for DSM-5 forms are already pre-populated in the Practice Better platform – you can easily access them right from your account. If you’re not a Practice Better customer yet, you can still check them out. Try the platform free for 14 days.

Practice Better is the complete practice management platform for health and wellness professionals. Streamline your practice and begin your 14-day free trial today.

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