clinical

Why Multi-Condition Screening Changes Patient Outcomes

by Brooke Dulka, PhD

Comorbid Mental Health Screening

There are many mental health screening tools, such as the Generalized Anxiety Disorder Screener (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9), but are these tools as good as they could be? In other words, are we screening for mental health disorders as efficiently and effectively as possible? The current approach during psychiatric intakes or assessments is to have patients fill out multiple, repetitive forms and questionnaires. This is exhausting not only for the patient but also for the practitioner who must score the questionnaires. This approach may be particularly ineffective in view of the fact that mental health conditions rarely occur in isolation — they are often comorbid.

Comorbid mental health conditions, such as mood and anxiety disorders, are very common. In fact, in one Swedish study, among participants with either depression or anxiety, nearly 50% had comorbid disorders.1 Depression and comorbid drug use is also common. In a meta-analysis of 22 unique epidemiological studies, the strongest associations found were between drug use and major depression.2 However, these aren’t the only commonly comorbid conditions. Bipolar disorder is highly comorbid with anxiety.3 Additionally, bipolar disorder also has high comorbidity with substance use disorder.4

Comorbidity Increases Medical Utilization

Comorbidity also implies interactions between mental health conditions that can worsen the course of each condition. In one study, it was found that the presence of comorbidity significantly increased medical utilization. Furthermore, comorbidity was associated with greater chronicity, slower recovery, increased rates of recurrence, and greater psychosocial disability.5 In other words, when multiple mental health conditions present themselves at the same time (as they often do) it makes them harder to treat. However, increasing recognition of the high prevalence and negative impact of comorbidity will lead to more effective treatment. Importantly, decreasing the time to identification will shorten the window to therapeutic treatment.

Improve Screening Efficiency

How can this be achieved? As mentioned previously, the current approach to psychiatric assessment involves filling out many repetitive forms. Unfortunately, tools like the GAD-7 (published in 2006) and PHQ-9 (published in 2001) may miss things outside of the common conditions of depression and anxiety. Additionally, the GAD-7 has low sensitivity even for generalized anxiety disorder. In one study of oncology patients, the sensitivity of the GAD-7 was determined to be low (<36%), which suggests that about 2 in every 3 cases are wrongly classified as not having GAD (false negatives).6 Although the sensitivity of the PHQ-9 is relatively high (76%), it is limited to detecting just depression.7 Additionally, under-identification of bipolar disorder by the PHQ-9 was the primary reason for false positives.8

It is critical that physicians find an efficient and reliable way to screen patients for multiple mental health disorders at once. We also need to broaden our consideration of comorbidity in substance use and mental disorders. To these ends, Connected Mind®‘s screening tool provides both patients and health providers with the opportunity for more efficient mental health care. This tool has been validated by a team of psychologists working as independent contractors out of the University of North Texas. It utilizes a branching logic engine to identify a person’s risk for multiple disorders, including depression, anxiety, attention deficit hyperactivity disorder (ADHD), bipolar disorder, substance use, and somatic symptom disorder, making it more comprehensive than existing screening practices. It also evaluates a person’s risk for suicidal behaviors. The tool supports both in-office and remote screening for use with telemedicine.

Helping patients receive appropriate identification and begin treatment quickly and efficiently is a priority.

Connected Mind can shorten this window by expediting the screening process.

Works Cited

  1. Johansson, Robert, et al. “Depression, anxiety and their comorbidity in the Swedish general population: point prevalence and the effect on health-related quality of life.” PeerJ 1 (2013): e98.

  2. Lai, Harry Man Xiong, et al. “Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990–2014: A systematic review and meta-analysis.” Drug and Alcohol Dependence 154 (2015): 1-13.

  3. Yapici Eser, Hale, et al. “Prevalence and associated features of anxiety disorder comorbidity in bipolar disorder: a meta-analysis and meta-regression study.” Frontiers in Psychiatry 9 (2018): 229.

  4. Hunt, Glenn E., et al. “Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990–2015: systematic review and meta-analysis.” Journal of Affective Disorders 206 (2016): 331-349.

  5. Hirschfeld, Robert MA. “The comorbidity of major depression and anxiety disorders: recognition and management in primary care.” Primary Care Companion to the Journal of Clinical Psychiatry 3.6 (2001): 244.

  6. Clover, Kerrie, et al. “Apples to apples? Comparison of the measurement properties of hospital anxiety and depression-anxiety subscale (HADS-A), depression, anxiety and stress scale-anxiety subscale (DASS-A), and generalised anxiety disorder (GAD-7) scale in an oncology setting using Rasch analysis and diagnostic accuracy statistics.” Current Psychology (2020): 1-10.

  7. Carey, Mariko, et al. “Comparison of a single self-assessment item with the PHQ-9 for detecting depression in general practice.” Family Practice 31.4 (2014): 483-489.

  8. Inoue, Takeshi, et al. “Utility and limitations of PHQ-9 in a clinic specializing in psychiatric care.” BMC Psychiatry 12.1 (2012): 73.

Frequently Asked Questions

What is comorbid mental health screening?

Comorbid mental health screening is the process of evaluating a patient for multiple co-occurring mental health conditions in a single assessment rather than administering separate instruments for each condition individually. This approach reflects the clinical reality that conditions like depression, anxiety, ADHD, bipolar disorder, and substance use disorder frequently co-occur.

Why is multi-condition screening more effective than single-condition tools?

Single-condition tools like the PHQ-9 and GAD-7 each cover only one condition, requiring patients to complete multiple forms while still missing conditions outside their scope. Multi-condition screening covers a broader range of conditions in one encounter, reducing patient burden, identifying co-occurring conditions that single tools miss, and providing clinicians with a more complete clinical picture from the first visit.

What conditions commonly co-occur with depression?

Depression frequently co-occurs with anxiety disorders, substance use disorders, ADHD, bipolar disorder, and somatic symptom disorder. Research shows that among individuals with either depression or anxiety, nearly 50% have comorbid conditions. The strongest epidemiological associations are between drug use and major depression.

What conditions commonly co-occur with anxiety?

Anxiety disorders frequently co-occur with depression, bipolar disorder, substance use disorders, ADHD, and somatic symptom disorder. Bipolar disorder is especially highly comorbid with anxiety, and this comorbidity is associated with greater symptom severity and longer time to appropriate care.

How does comorbidity affect clinical outcomes?

The presence of comorbid mental health conditions significantly increases medical utilization, is associated with greater chronicity, slower recovery, increased rates of recurrence, and greater psychosocial disability. Co-occurring conditions interact in ways that worsen the course of each individual condition, making early and comprehensive identification critical.

What are the limitations of the PHQ-9 for identifying co-occurring conditions?

The PHQ-9 has relatively high sensitivity for depression (approximately 76%) but is limited to that single condition. It cannot identify anxiety, ADHD, bipolar disorder, substance use, or somatic symptom disorder. Additionally, research has shown that under-identification of bipolar disorder is the primary reason for false positives on the PHQ-9.

What are the limitations of the GAD-7 for mental health screening?

The GAD-7, published in 2006, screens only for generalized anxiety disorder. Research in oncology populations found its sensitivity to be below 36%, meaning approximately two out of every three cases were wrongly classified as not having GAD. Like the PHQ-9, it cannot identify conditions outside its single-condition scope.

Can comorbid screening be performed during a routine office visit?

Yes. Modern multi-condition screening tools are designed for use during routine office visits, including telehealth encounters. Brief validated instruments can screen for multiple conditions simultaneously without adding significant time to the clinical workflow. Positive screens can then be followed by comprehensive evaluation as clinically indicated.

How does Connected Mind screen for comorbid conditions?

Connected Mind uses a branching logic engine with validated instruments to screen for six common co-occurring mental health conditions — depression, anxiety, ADHD, bipolar disorder, substance use disorder, and somatic symptom disorder — in a single encounter. The screening generates risk indicators that help providers determine appropriate next steps, including referral for comprehensive evaluation when warranted.

What billing codes apply to comorbid mental health screening?

CPT 96127 is the primary billing code for brief emotional and behavioral assessment with scoring and documentation, per standardized instrument. Providers can bill up to 3 units per date of service when multiple standardized instruments are administered. For comprehensive follow-up evaluation, CPT 96130, 96136, and 96138 cover psychological testing and evaluation services.