There is nothing new about screening tools for mental disorders. However when a topnotch family medicine training program comes up with a check list which they claim can be completed in under five minutes in the waiting room and has very good results, it is worth taking a look at it. The thinking here is that family doctors have less and less time to spend with patients and anything that can clue them in on emotional problems should be helpful
My Mood Monitor is the Test
In a recent journal article in the Annuals of Family Medicine there is a report of the My Mood Monitor (M-3) a self administered 27 item check list that was tested on a sample of consecutive patients who were seeking primary care at the academic family medicine clinic at the University of North Carolina. Those completing the M-3 were then contacted by a research assistant and asked to take the much longer 15 minutes Mini International Psychiatric Interview (MINI) by telephone in order to validate the results of the M3. The MINI is a well established test that has been validated against the Structured Clinical Interview for DSM (SCID) which can take up to hour or even more time to administer by a trained person which is more or less the gold standard for research tools using the current psychiatric categories. In this particular study the MINI test results administered by phone were discussed with a psychiatrist before final scoring. If the M-3 is validated against the MINI and the MINI is validated against the SCID, they believe they have test which will be an accurate screening test.
Each of the 27 questions of the M-3 is answered by a check mark in a column which offers the responses: Not at All, Rarely, Sometimes, Often , Most of the Time. Since just having a bunch of symptoms doesn’t necessarily mean that a person is having diagnosable condition or a serious problem, there were four questions, which assessed if there was a functional impairment. If there were no functional impairments of the person’s life style AND if the suicide question was negative, no further scoring was done and therefore no condition was identified
The test was not set up to pick up psychosis, dementia, marital, sexual or personality problems unless they would show up with significant anxiety or depression, which could very well be the case.
Participants and Completers– 723 people, which were 54 % of the patients approached to participate, agreed to be in the study. 99% of this group also completed the MINI follow-up test.
Diagnosis According to the MINI Test- According to the MINI test, 22% of the people had a depressive disorder (16 % had a major depressive disorder, while 6% had bipolar disorder and 9.3% had bipolar spectrum illness), 28.1% had an anxiety disorder and 6.3% had PTSD. Overall, 35% of the study participants met MINI criteria for at least one psychiatric diagnosis. 12.1 % had co-morbidity for anxiety and depression.
How Well Did the Brief M-3 Test Do? First of all 349 people (53%) were eliminated from being scored because they did not have a functional impairment. Of the 298 patients who were then scored using the M-3 (meaning that they had a functional impairment according to M-3), 62.4% met the criteria being used for a psychiatric diagnosis. Without going into detailed statistical analysis, it was found that the M3 showed a 95% confidence level for diagnosing depression and anxiety as well as PTSD with a sensitivity and specificity of about 80%. Most screening tools don’t integrate screening for bipolar and PTSD while screening for other anxiety and mood disorders, which is an added bonus. Overall, that is pretty darned good for a waiting room brief screening tool.
Added Benefits of the M-3
Additional questions about the process yielded information that 70 % of the participants reported talking to their clinician about mood or feelings. 70% said they did so for at least one minute (certainly better than not at all). 63% of all participants reported that the M-3 helped them talk to their doctors about their mood or feelings. Among participants assigned a MINI diagnosis, 75% stated that the M-3 facilitated talking to their clinician about mood or feelings. 83 % of clinicians reviewed the checklist in 30 or fewer seconds. None found the M-3 too complicated and 80% thought it was helpful in reviewing participants’ emotional health.
Words of Caution
Anything that helps doctors become of aware of the patient’s emotional health has to be a good thing.
However, we must keep in mind that 46% of the people approached refused to participate in the study. That number is standard for research but any patient who refused to take a mental health screening test in a clinical practice should receive extra attention by the doctor.
53% people were not scored because even if they had positive symptoms, since they did not indicate that they had functional impairment or suicidal ideas. I hope that their physician would at least inquire about the symptoms, which were checked, and determine if the patient is having a problem and hasn’t yet come to the point of being impaired or is suicidal or perhaps just doesn’t want to readily acknowledge the severity of the problem.
The paper made a point that the M-3 had questions, which led to a distinction between major depression and bipolar depression. It was stated that the failure to do so can lead to the prescribing of antidepressants without a mood stabilizer, potentially destabilizing the illness and leading to the risk of hypomania, manic or mixed episodes. This is certainly true but I would hope that patients with first time bipolar disorder should ideally not be treated with mood stabilizers without psychiatric consultation. This condition can be difficult to manage and treatment is often not straightforward.
The diagnosis of any major depression may not only require medication, but also close monitoring, especially in the early phase of treatment. When there is the potential for suicidal ideation, an effective dosage of medication can increase the low energy of a depressed patient so they become more of suicidal risk than they were before starting medication.
Medications used for treating anxiety of course can be over used and create serious dependency issues.
Both anxiety and depression can be symptoms of underlying marital and other interpersonal problems as well personality disorders. PTSD once identified usually has complicated determinants and may not be easily treated by just medication.
The multidisciplinary team that put together the M-3 and the testing of it come from both Departments of Family Medicine and Psychiatry. As effective as these short diagnostic tools may be in identifying emotional problems for family physicians, they should be part a systematic approach to diagnosing and treating this condition. Family doctors need to spend more time with patients when these conditions are suspected, diagnosed and are being treated. It is also very important that physicians using the M-3 have a collaborative relationship with psychiatrists and other mental health professionals.