Guidelines for Using the Mental Health Screening Form-III

The Mental Health Screening Form-III was initially designed as a rough screening device for clients seeking admission to substance abuse treatment programs.

Each MHSF-III question is answered either “yes” or “no.” All questions reflect the respondent’s entire life history; therefore all questions begin with the phrase “Have you ever…”

The preferred mode of administration is for staff members to read each item to respondents and get their “yes” and “no” responses. Then, after completing all 18 questions (question 6 has two parts), the staff member should inquire about any “yes” response by asking “When did this problem first develop?”; “How long did it last?”; “Did the problem develop before, during, or after you started using substances?”; and, “What was happening in your life at that time?” This information can be written below each item in the space provided. There is additional space for staff member comments at the bottom of the form.

The MHSF-III can also be given directly to clients to complete, providing they have sufficient reading skills. If there is any doubt about someone’s reading ability, have the client read the MHSF-III instructions and question number one to the staff member monitoring this process. If the client cannot read and/or comprehend the questions, the questions must be read and/or explained to him or her.

Whether the MHSF-III is read to a client or he reads the questions and responds on his own, the completed MHSF-III should be carefully reviewed by a staff member to determine how best to use the information. It is strongly recommended that a qualified mental health specialist be consulted about any “yes” response to questions 3 through 17. The mental health specialist will determine if a follow-up, face-to-face interview is needed for a diagnosis and/or treatment recommendation.

The MHSF-III features a “Total Score” line to reflect the total number of “yes” responses. The maximum score on the MHSF-III is 18 (question 6 has two parts). This feature will permit programs to do research and program evaluation on the mental health-chemical dependence interface for their clients.^[1]

The first four questions on the MHSF-III are not unique to any particular diagnosis; however, questions 5 through 17 reflect symptoms associated with the following diagnoses/diagnostic categories: Q5, Schizophrenia; Q6, Depressive Disorders; Q7, Posttraumatic Stress Disorder; Q8, Phobias; Q9, Intermittent Explosive Disorder; Q10, Delusional Disorder; Q11, Sexual and Gender Identity Disorders; Q12, Eating Disorders (Anorexia, Bulimia); Q13, Manic Episode; Q14, Panic Disorder; Q15, Obsessive-Compulsive Disorder; Q16, Pathological Gambling; and Q17, Learning Disorder and Mental Retardation.

The relationship between the diagnoses/diagnostic categories and the above-cited questions was investigated by having four mental health specialists independently select the one MHSF-III question that best matched a list of diagnoses/diagnostic categories. All of the mental health specialists matched the questions and diagnoses/diagnostic categories in the same manner, that is, as noted in the preceding paragraph.

A “yes” response to any of questions 5 through 17 does not, by itself, ensure that a mental health problem exists at this time. A “yes” response raises only the possibility of a current problem, which is why a consult with a mental health specialist is strongly recommended.

Mental Health Screening Form-III

Instructions: In this program, we help people with all their problems, not just their addictions. This commitment includes helping people with emotional problems. Our staff is ready to help you to deal with any emotional problems you may have, but we can do this only if we are aware of the problems. Any information you provide to us on this form will be kept in strict confidence. It will not be released to any outside person or agency without your permission. If you do not know how to answer these questions, ask the staff member giving you this form for guidance. Please note, each item refers to your entire life history, not just your current situation, this is why each question begins -“Have you ever ….”
1.	Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor about an emotional problem?	YES	NO
2.	Have you ever felt you needed help with your emotional problems, or have you had people tell you that you should get help for your emotional problems?	YES	NO
3.	Have you ever been advised to take medication for anxiety, depression, hearing voices, or for any other emotional problem?	YES	NO
4	Have you ever been seen in a psychiatric emergency room or been hospitalized for psychiatric reasons?	YES	NO
5.	Have you ever heard voices no one else could hear or seen objects or things which others could not see?	YES	NO
6.	(a) Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had trouble concentrating and making decisions, or thought about killing yourself?	YES	NO
	(b) Did you ever attempt to kill yourself?	YES	NO
7.	Have you ever had nightmares or flashbacks as a result of being involved in some traumatic/terrible event? For example, warfare, gang fights, fire, domestic violence, rape, incest, car accident, being shot or stabbed?	YES	NO
8.	Have you ever experienced any strong fears? For example, of heights, insects, animals, dirt, attending social events, being in a crowd, being alone, being in places where it may be hard to escape or get help?	YES	NO
9.	Have you ever given in to an aggressive urge or impulse, on more than one occasion, that resulted in serious harm to others or led to the destruction of property?	YES	NO
10.	Have you ever felt that people had something against you, without them necessarily saying so, or that someone or some group may be trying to influence your thoughts or behavior?	YES	NO
11.	Have you ever experienced any emotional problems associated with your sexual interests, your sexual activities, or your choice of sexual partner?	YES	NO
12.	Was there ever a period in your life when you spent a lot of time thinking and worrying about gaining weight, becoming fat, or controlling your eating? For example, by repeatedly dieting or fasting, engaging in much exercise to compensate for binge eating, taking enemas, or forcing yourself to throw up?	YES	NO
13.	Have you ever had a period of time when you were so full of energy and your ideas came very rapidly, when you talked nearly non-stop, when you moved quickly from one activity to another, when you needed little sleep, and believed you could do almost anything?	YES	NO
14.	Have you ever had spells or attacks when you suddenly felt anxious, frightened, uneasy to the extent that you began sweating, your heart began to beat rapidly, you were shaking or trembling, your stomach was upset, you felt dizzy or unsteady, as if you would faint?	YES	NO
15.	Have you ever had a persistent, lasting thought or impulse to do something over and over that caused you considerable distress and interfered with normal routines, work, or your social relations? Examples would include repeatedly counting things, checking and rechecking on things you had done, washing and rewashing your hands, praying, or maintaining a very rigid schedule of daily activities from which you could not deviate.	YES	NO
16.	Have you ever lost considerable sums of money through gambling or had problems at work, in school, with your family and friends as a result of your gambling?	YES	NO
17.	Have you ever been told by teachers, guidance counselors, or others that you have a special learning problem?	YES	NO
Print client’s name: ______ Program to which client will be assigned: ______
Name of admissions counselor: _________ Date: ______
Reviewer’s comments: ___________________________
_____________________________________________
_____________________________________________
_____________________________________________
Total Score: ______ (each yes = 1 point)

Source: J.F.X. Carroll, Ph.D., and John J. McGinley, Ph.D.; Project Return Foundation, Inc., 2000.

This material may be reproduced or copied, in entirety, without permission. www​.asapnys.org/Resources/mhscreen.pdf

Development of the SSI-SA

Routine screening for substance abuse can be used to initiate the process of assessment by identifying a client’s possible problems and determining whether he or she needs a comprehensive assessment. Ideally, a screening instrument for substance abuse should have a high degree of sensitivity: It should be broad in its detection of individuals who have a potential substance abuse problem, regardless of the specific drug or drugs being abused.

The substance abuse screening instrument presented in this section was designed to encompass a broad spectrum of signs and symptoms for substance use disorders. These conditions are characterized by substance use that leads to negative physical, social, and/or emotional consequences and loss of control over one’s pattern and amount of consumption of the substance(s) of abuse.

The view of substance abuse problems and disorders presented in this section and reflected in the screening instrument is consistent with that adopted by the World Health Organization and the American Psychiatric Association. Briefly stated, this view holds that substance abuse disorders are biopsychosocial disorders, causing impairment and dysfunction in physical, emotional, and social domains. Certain cognitive and behavioral signs and symptoms are also associated with substance abuse (see the observation checklist at the end of the screening instrument for substance abuse). Although many of these latter signs and symptoms can be the result of various medical, psychiatric, and social problems, individuals with a substance abuse disorder generally exhibit several of them.

The screening instrument for substance abuse was developed by first identifying five primary content domains, which are described in the sections that follow. The screening questions then devised were assigned to one or more of these categories. These screening questions were adapted from existing tools found in the published literature. Because most of these existing tools were designed to screen for alcohol abuse, many items needed to be revised to address other drugs. The sources for the screening items included in the instrument are shown in Figure H-1.

Domains Measured by the Instrument

Administration of the Simple Screening Instrument

Two versions of the simple screening instrument are presented in this section. They have been designed to be administered in the form of either an interview (Figure H-2) or a self-administered test (Figure H-3) to individuals who may be at risk of having a substance abuse problem.

Use of the screening instrument should be accompanied by a careful discussion about confidentiality^[2] issues. The interviewer should also be clear about the instrument’s purpose and should make it understood that the information elicited from the instrument will be used to benefit, not to punish, the individual being screened.

Ideally, the screening test should be administered in its entirety. Situations may arise, however, in which there is inadequate time to administer the entire test. Street outreach community workers, for example, may have very limited time with an individual.

In such situations, a subset of the screening instrument can be administered. The four boldfaced questions—1, 2, 3, and 16—constitute the short form of the screening instrument. These items were selected because they represent the prominent signs and symptoms covered by the full screening instrument. Although this abbreviated version of the instrument will not identify the variety of dimensions tapped by the full instrument and is more prone to error, it may serve as a starting point for the screening process.

Referral Issues

The substance abuse screening instrument, as a first step in the process of assessment for substance abuse problems, can help service providers determine whether an individual should be referred for a more thorough assessment. When an individual with a potential substance abuse problem is identified through the instrument, the interviewer has the further responsibility of linking the individual to resources for further assessment and treatment.

Agencies and providers using the substance abuse screening instrument should be prepared to make an appropriate referral when the screening identifies a person with a possible substance abuse problem. A phone number written on a piece of paper is not likely to be effective in linking the individual to the appropriate resource for assessment and treatment. Rather, a thorough familiarity with local community resources is needed on the part of the service provider. The referring provider should take a proactive role in learning about the availability of appointments or treatment slots, costs, transportation needs, and the names of contact people at the agencies to which referrals are made.

Because many individuals identified as having possible substance abuse problems receive services from more than one agency, it is essential that one agency assume primary responsibility for the client. The ideal model is a case management system. Through personal contacts, case managers can help patients progress through various programs and systems, cut red tape, and remove barriers to access to services.

Providing effective services for substance abuse requires close cooperation among agencies. Community linkages can help increase the quality of treatment for patients, whereas interagency competition decreases the quality of comprehensive care.

Substance abuse problems should be seen within the larger context of other problems, both current and past, confronted by the individual. Current problems such as instability in housing and employment, homelessness, and hunger often represent immediate needs that are more pressing for the individual than treatment for his or her substance abuse. Past crises, such as incest, rape, and sexual abuse, can also affect how an individual responds to the screening questions.

Some of the items in the screening instrument may trigger emotional distress or a crisis. Reactions may sometimes include anxiety or depression, which may be accompanied by suicidal thoughts and behaviors. Agencies should therefore develop specific protocols to manage such crises. These protocols should include inhouse management and appropriate referrals and followup.

See appendix C, Glossary, for substance abuse screening terms.

Sources for the Substance Screening Questions