In caring for patients with mental illness or distress as a naturopathic physician, I am either indirectly or directly working with the conventional (allopathic) mental health care system. I say this, as my patients do not exist in isolation; often a patient’s desire for ‘exclusively’ naturopathic approaches is a reaction against the current mental health care system, either philosophically or as a result of adverse experiences with provider(s), medication(s) or other administered treatment(s). I will not argue that the current mental health care system needs to evolve, but if I collude with patients in distancing them from conventional medical services and providers, I only serve to limit their recovery further and to polarize medical disciplines. (And as we have seen from politics of late, polarization does not lend itself to forward movement and growth, but rather limits it.)
However, there are numerous obstacles to overcome when it comes to working collaboratively in mental health; namely, the time that it takes and the absence of a common language between providers of disparate training. I have found self-administered mental health (and general health) screeners to be invaluable in this regard. Screeners provide an efficient and effective means of communicating with other providers (general practitioners, psychiatric mental health nurse practitioners and psychiatrists). In addition, screeners help to capture symptoms and stressors that might otherwise be missed or underappreciated, empower the patient to be involved and interested in his/her progress, and can improve treatment outcomes.
In using such screeners, I have encountered resistance from a minority of patients who think that I am going to use them in order to label them with a disorder that they feel limits them. Upon explaining that they are not used diagnostically per se, but rather as an ongoing monitoring & collaborative tool, these patients are often more amenable to their use. Generally I find that my patients readily fill out the screeners and appreciate their use as one of many tools that can be employed to better understand and monitor their health and well-being. I have even had some take matters into their own hands and fill out every screener on my site – perhaps to be sure that I capture every condition and comorbidity that they may have!
There are a number of easy-to-use, sensitive and specific validated instruments that are available. I have found the following to be particularly helpful:
- Patient Health Questionnaire- 9 (PHQ-9) for detecting Depression and monitoring its severity.
- Mood Disorder Questionnaire (MDQ) to screen for possible Bipolar I disorder.
- Generalized Anxiety Disorder-7 (GAD-7) to screen for and to monitor the severity of Generalized Anxiety, Panic, Social Anxiety & Post-Traumatic Stress Disorder (PTSD).
- Yale-Brown Obsessive- Compulsive Scale (YBOCS) for monitoring symptom severity in Obsessive-Compulsive disorder.
- Morningness-Eveningness Questionnaire (MEQ) to assess circadian rhythm type so as to optimize the timing of the sleep-wake cycle and to determine when to administer bright light therapy used for seasonal affective disorder and other conditions.
- Measure Your Medical Outcome Profile (MYMOP) to measure changes in a patient’s perception of his/her symptoms and overall well-being. This instrument is particularly helpful in monitoring the effects of holistic care (Naturopathy, Homeopathy, Chinese Medicine, Ayurvedic Medicine and other approaches). In working with patients naturopathically, this scale allows one to assess more than one condition at a time, gives insight into which symptoms are most distressing to a patient and reflects a patient’s overall sense of well-being.
There are additional screeners that can be helpful as well, including the Patient Health Questionnaire- 15 (PHQ-15) for Somatic Symptom Severity, the PTSD Civilian Checklist (PCL-C) for Post-traumatic Stress disorder, the Personal Inventory for Depression and S.A.D. (or Seasonal Affective Disorder) (PIDS) for Depression and S.A.D. and the Structured Interview Guide for Hamilton Depression Rating Scale Seasonal Affective Disorder Version- Self-Administered (SIGH-SAD-SA) for Seasonal Affective Disorder.
Bipolar disorder is a condition that is important to monitor closely (due to its cyclical nature and the lack of insight* that accompanies hypomania and mania). (*Insight refers to the widely-observed phenomenon that those in a hypomanic or manic phase of bipolar are generally not aware that their behavior has changed or that there is anything problematic about it). There are a number of scales and symptom logs that I have found helpful in working with Bipolar; including the MDQ to detect possible bipolar I, a mood diary (adapted from the STABLE toolkit) for the patient to fill out on a daily basis and to bring to practitioner visits, and the Social Rhythm Metric (SRM-5 (click on the figures tab of this article to view)). There is also a more extended version of the Social Rhythm Metric, the SRM-17. (The Social Rhythm metric was developed by Ellen Frank, Ph.D.)
In addition, in working with those suffering from bipolar disorder, a timeline, documenting each manic, depressive and euthymic period since the first known episode is also immensely helpful in understanding each patient’s unique cycles, stressors and triggers and can be used to guide treatment. Including family to collaborate with providers (with the appropriate permissions) is imperative as well and is referred to as ‘collateral’ by clinicians. In some cases, I have even suggested that a trusted family member (let’s say ‘Jill’ for the sake of this example) fills out a mood diary on behalf of her family member, George, who is affected by bipolar. Then once a day Jill & George can compare how they each perceived George’s mood to be for that day as a way of monitoring and improving George’s well-being and maintaining rapport in difficult times.
So whether you are suffering from a mental health condition and seeking to optimize your care, have a friend or family member affected by mental illness, or are a clinician working with patients suffering from mental illness, screeners may be of help to you. Screening instruments have the capacity to improve both the detection and monitoring of mental health conditions, can facilitate collaboration between healthcare providers and can improve the outcomes of treatment. If you are suffering from a mental health condition, you may wish to print out the appropriate screening instrument(s), complete the form(s) and bring a copy to your provider(s). Not only can this empower you in your road to recovery, but it can be a powerful way to advocate for greater integration and collaboration in your care, and hopefully the care of others in the future.
The screening instruments listed herein are largely available from my website. Scoring information for the PHQ & GAD-7 scales can be found at the PHQ screeners site. And for the MDQ, see the STABLE toolkit (p.14 ). The YBOCS has both self-administered and clinician- administered scoring information. For the self-administered scoring information, see the OCD Center.org. The PCL-C scoring information can be found at the US Department of Veterans Affairs site. For automated online assessment versions of the PIDS, SIGH-SAD & MEQ, see the Center for Environmental Therapeutics site. Clinicians can purchase these instruments for use with patients from the same site. MYMOP scoring and other information can be found at the MYMOP dedicated site. Click here for other videos and information on the MYMOP.