Mental Health Screening

Overview

Administer, score, and document validated mental health screening instruments using FHIR QuestionnaireResponse and Observation resources. Supported tools: PHQ-2 (brief depression), PHQ-9 (depression severity), GAD-7 (generalized anxiety), AUDIT-C (alcohol use), Columbia Suicide Severity Rating Scale (C-SSRS), Mood Disorder Questionnaire (MDQ, bipolar), and PC-PTSD-5 (PTSD). Calculate scores, classify severity, generate clinical recommendations by score range, and trigger safety assessment workflows for positive suicidality screens. Record results as FHIR Observations with standardized LOINC codes.

FHIR Resources Used

Resource	Purpose	Key Fields
Patient	Demographics, age	birthDate, gender
QuestionnaireResponse	Screening instrument responses	questionnaire, item, answer, authored
Observation	Screening scores and interpretations	code, valueQuantity, interpretation, effectiveDateTime
Condition	Existing mental health diagnoses	code, clinicalStatus, onsetDateTime
MedicationRequest	Current psychotropic medications	medicationCodeableConcept, status, dosageInstruction
RiskAssessment	Suicide risk documentation	prediction, method, mitigation

Instructions

Step 1: Retrieve Patient Demographics and History

code

Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"

Extract age (screening tools may have age-specific versions) and gender.

Pull existing mental health conditions:

code

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&category=encounter-diagnosis&code=35489007,197480006,724689000,66590003,47505003,313182004&clinical-status=active"

SNOMED codes:

•35489007 = Depressive disorder
•197480006 = Anxiety disorder
•724689000 = Alcohol use disorder
•66590003 = Bipolar disorder
•47505003 = PTSD
•313182004 = Suicidal ideation

Step 2: Pull Prior Screening Results

code

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=44249-1,69737-5,75626-2,77564-3,89206-7&_sort=-date&_count=10"

LOINC codes for screening scores:

•44249-1 = PHQ-9 total score
•69737-5 = PHQ-2 total score
•75626-2 = GAD-7 total score
•77564-3 = AUDIT-C total score
•89206-7 = C-SSRS (Columbia suicide severity)

Extract prior scores and dates for trend analysis.

Step 3: Pull Current Psychotropic Medications

code

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active"

Identify psychotropic medications:

•SSRIs: sertraline, fluoxetine, escitalopram, citalopram, paroxetine
•SNRIs: venlafaxine, duloxetine, desvenlafaxine
•Benzodiazepines: alprazolam, lorazepam, clonazepam, diazepam
•Mood stabilizers: lithium, valproate, lamotrigine, carbamazepine
•Antipsychotics: quetiapine, aripiprazole, olanzapine, risperidone
•Stimulants: methylphenidate, amphetamine salts
•Bupropion, mirtazapine, trazodone, buspirone

Note current medications to inform treatment recommendations.

Step 4: Determine Which Screening Tool to Administer

Selection logic:

•Universal screening: PHQ-2 first; if score >=3, proceed to PHQ-9
•Depression concern: PHQ-9 directly
•Anxiety concern: GAD-7
•Alcohol use concern: AUDIT-C
•Suicidal ideation: C-SSRS (always if PHQ-9 item 9 > 0)
•Bipolar concern: MDQ (before starting antidepressant, if mood cycling history)
•Trauma history: PC-PTSD-5

If user does not specify, default to PHQ-2 + GAD-7 as standard primary care screening.

Step 5: Score the Screening Instrument

See references/screening-tools.md for complete item-level scoring. Summary scoring:

PHQ-2 (items 1-2 of PHQ-9, range 0-6):

•Score >=3: positive screen, proceed to full PHQ-9

PHQ-9 (9 items, range 0-27):

•0-4: minimal/none
•5-9: mild
•10-14: moderate
•15-19: moderately severe
•20-27: severe
•Item 9 (suicidal ideation) > 0: trigger C-SSRS safety assessment

GAD-7 (7 items, range 0-21):

•0-4: minimal
•5-9: mild
•10-14: moderate
•15-21: severe

AUDIT-C (3 items, range 0-12):

•Men: score >=4 positive
•Women: score >=3 positive

C-SSRS (severity scale 1-5):

•1: Wish to be dead
•2: Non-specific active suicidal thoughts
•3: Suicidal ideation with method (no plan or intent)
•4: Suicidal ideation with intent (no specific plan)
•5: Suicidal ideation with specific plan and intent

MDQ (13 yes/no items + 2 supplemental):

•Positive screen: >=7 "yes" items AND items occurred at same time AND caused moderate/serious problems

PC-PTSD-5 (5 yes/no items, range 0-5):

•Score >=3: positive screen, proceed to full PTSD evaluation

Step 6: Record Screening Score as Observation

code

Tool: fhir_create
resourceType: "Observation"
resource: {
  "resourceType": "Observation",
  "status": "final",
  "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "Survey"}]}],
  "code": {"coding": [{"system": "http://loinc.org", "code": "[LOINC-code]", "display": "[instrument-name] total score"}]},
  "subject": {"reference": "Patient/[patient-id]"},
  "effectiveDateTime": "[current-datetime]",
  "valueQuantity": {"value": [score], "unit": "{score}"},
  "interpretation": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation", "code": "[N/A/H]", "display": "[severity]"}]}]
}

Step 7: Record QuestionnaireResponse (if item-level data available)

code

Tool: fhir_create
resourceType: "QuestionnaireResponse"
resource: {
  "resourceType": "QuestionnaireResponse",
  "status": "completed",
  "subject": {"reference": "Patient/[patient-id]"},
  "authored": "[current-datetime]",
  "item": [
    {"linkId": "1", "text": "[question text]", "answer": [{"valueInteger": [score]}]},
    ...
  ]
}

Step 8: Safety Assessment for Positive Suicidality Screen

If PHQ-9 item 9 > 0 or C-SSRS positive:

•
Determine imminent risk level:
- •Imminent risk (C-SSRS 4-5, or active plan/intent): immediate psychiatric evaluation, do not leave patient unattended, contact crisis team
- •Elevated risk (C-SSRS 2-3, PHQ-9 item 9 = 2-3): same-day mental health evaluation, safety plan
- •Low risk (C-SSRS 1, PHQ-9 item 9 = 1): outpatient mental health referral within 1 week, safety plan
•
Document safety assessment:

code

Tool: fhir_create
resourceType: "Observation"
resource: {
  "resourceType": "Observation",
  "status": "final",
  "code": {"coding": [{"system": "http://loinc.org", "code": "89206-7", "display": "Columbia suicide severity rating scale"}]},
  "subject": {"reference": "Patient/[patient-id]"},
  "effectiveDateTime": "[current-datetime]",
  "valueQuantity": {"value": [severity-level], "unit": "{score}"},
  "note": [{"text": "Safety assessment completed. [Plan details]."}]
}

See references/mental-health-management.md for safety planning template and crisis resources.

Step 9: Generate Recommendations by Score

Present structured output:

code

MENTAL HEALTH SCREENING RESULTS -- [Patient Name] -- [Date]
=============================================================

SCREENING INSTRUMENT: [Name]
Score: [value] / [max] -- Severity: [classification]
Prior score: [value] on [date] -- Trend: [improved/stable/worsened]

CURRENT PSYCHOTROPIC MEDICATIONS
  [list or "None"]

INTERPRETATION
  [Clinical interpretation based on score and context]

RECOMMENDATIONS
  [Specific actions per severity level -- see references/screening-tools.md]

SAFETY STATUS
  Suicidal ideation screen: [Negative / Positive -- details]
  [If positive: safety plan status, risk level, disposition]

Examples

Example 1: Routine Depression and Anxiety Screening

User says: "Run depression and anxiety screening for patient MH-1120"

Actions:

•fhir_read Patient/MH-1120 -- 34-year-old female
•fhir_search Condition?patient=MH-1120&category=encounter-diagnosis&code=35489007,197480006&clinical-status=active -- generalized anxiety disorder (active since 2024)
•fhir_search Observation?patient=MH-1120&code=44249-1,75626-2&_sort=-date&_count=10 -- prior PHQ-9: 12 (moderate, 3 months ago), prior GAD-7: 14 (moderate, 3 months ago)
•fhir_search MedicationRequest?patient=MH-1120&status=active -- sertraline 100mg daily
•Score current PHQ-9 = 8 (mild), GAD-7 = 10 (moderate). PHQ-9 item 9 = 0 (no suicidal ideation).
•fhir_create Observation for PHQ-9 score (LOINC 44249-1, value 8)
•fhir_create Observation for GAD-7 score (LOINC 75626-2, value 10)

Result:

code

MENTAL HEALTH SCREENING RESULTS -- Sarah Mitchell -- 2026-02-07
================================================================

PHQ-9: 8/27 -- Mild depression
  Prior: 12 (moderate) on 2025-11-07 -- IMPROVED
  Item 9 (suicidal ideation): 0 -- NEGATIVE

GAD-7: 10/21 -- Moderate anxiety
  Prior: 14 (moderate) on 2025-11-07 -- IMPROVED (borderline)

CURRENT MEDICATIONS: sertraline 100mg daily (started 2024)

INTERPRETATION
  Depression improving from moderate to mild on current SSRI.
  Anxiety remains moderate but trending downward.
  No safety concerns.

RECOMMENDATIONS
  - Continue sertraline 100mg. Consider dose optimization for residual anxiety.
  - Rescreen in 4-6 weeks.
  - Consider CBT referral for anxiety management.
  - Discuss sleep hygiene, exercise, stress management.

Example 2: Positive Suicidality Screen with Safety Assessment

User says: "PHQ-9 screening for patient MH-4450, he endorsed suicidal thoughts"

Actions:

•fhir_read Patient/MH-4450 -- 52-year-old male
•fhir_search Condition?patient=MH-4450&clinical-status=active -- major depressive disorder, alcohol use disorder
•fhir_search MedicationRequest?patient=MH-4450&status=active -- bupropion 300mg daily
•Score PHQ-9 = 22 (severe). Item 9 = 2 (more than half the days).
•Administer C-SSRS: severity level 3 (suicidal ideation with method, no plan or intent).
•fhir_create Observation for PHQ-9 score (value 22, interpretation HH)
•fhir_create Observation for C-SSRS (value 3)

Result:

code

MENTAL HEALTH SCREENING RESULTS -- Robert Johnson -- 2026-02-07
================================================================

[SAFETY ALERT] POSITIVE SUICIDALITY SCREEN

PHQ-9: 22/27 -- SEVERE depression
  Item 9 (suicidal ideation): 2 -- endorsed "more than half the days"

C-SSRS: Severity Level 3 -- Suicidal ideation WITH METHOD (no plan or intent)
  Patient reports thinking about overdose but denies specific plan or intent.

RISK FACTORS IDENTIFIED
  - Severe depression (PHQ-9 = 22)
  - Active alcohol use disorder
  - Male sex, age >45
  - Has identified method

PROTECTIVE FACTORS
  - Denies specific plan or intent
  - Currently engaged in treatment
  - On antidepressant (bupropion)

IMMEDIATE ACTIONS REQUIRED
  1. Do not leave patient unattended until safety plan completed
  2. Same-day psychiatric evaluation recommended
  3. Lethal means counseling -- assess access to medications, firearms
  4. Complete safety plan (see references/mental-health-management.md)
  5. Provide crisis resources: 988 Suicide and Crisis Lifeline

TREATMENT RECOMMENDATIONS
  - Current bupropion may be insufficient -- psychiatric consultation for medication adjustment
  - Screen for alcohol use severity (AUDIT-C recommended)
  - Intensive outpatient or partial hospitalization may be appropriate
  - Follow-up within 48-72 hours if discharged

Troubleshooting

QuestionnaireResponse Resource Not Supported by Server

•Fall back to creating Observation resources only with the total score and LOINC code.
•Document individual item responses in Observation.note[].text as structured text.
•Some servers accept QuestionnaireResponse but require a canonical Questionnaire URL. Use standard URLs: http://loinc.org/vs/LL3342-0 for PHQ-9, http://loinc.org/vs/LL3318-0 for GAD-7.

Prior Screening Scores Not Found

•Scores may be stored in different Observation categories. Try searching without category filter: patient=[id]&code=44249-1&_sort=-date.
•Some systems store screening results as part of encounter notes (DocumentReference) rather than discrete Observations. Note that trend analysis is unavailable.
•Check if DiagnosticReport contains embedded screening results.

RiskAssessment Resource Not Supported

•Document suicide risk assessment entirely within Observation resources using LOINC 89206-7 (C-SSRS).
•Add clinical detail in Observation.note[] including risk level, protective factors, and disposition plan.
•If no structured resource is available, clearly present the safety assessment in the output for clinical documentation.

Related Skills

•medication-reconciliation -- for reviewing psychotropic medication lists
•clinical-summary-generator -- for comprehensive summary including behavioral health
•follow-up-task-generator -- for scheduling follow-up screening and safety check-ins
•referral-generator -- for generating psychiatry or therapy referrals