graded assignment mental and emotional problems

28 Mental Health Games, Activities & Worksheets (& PDF)

Despite this, increasing mental health awareness is crucial as it can have many positive outcomes.

For example, one study examining a British anti-stigma campaign found that people who were more familiar with the campaign were more likely to feel comfortable disclosing mental health issues to family, friends, or an employer, and were also more likely to seek professional help (Henderson et al., 2017).

Fortunately, there are all sorts of ways to learn about mental health issues, whether one is an introvert, an extrovert, or somewhere in between.

This article will cover tools that can supplement mental health interventions, worksheets and activities that help people learn about mental health, books dealing with mental health for adults and children, Facebook groups for mental health issues, and finally World Mental Health Day activities and events.

Before you read on, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises will explore fundamental aspects of positive psychology including strengths, values and self-compassion and will give you the tools to enhance the mental health of your clients, students or employees.

This Article Contains:

5 tools for mental health interventions.

• 5 Mental Health Worksheets & Awareness Activities (PDF)

5 Most Popular Books About Mental Health

• 5 Most Popular Children’s Books About Mental Health

Facebook Groups for Mental Health

World mental health day ideas for schools and workplaces, a take-home message.

Here are some tools that will help a psychotherapy treatment plan go more smoothly for both the client and the clinician:

1. Thought Record Worksheet

This PDF is a way to record one’s thoughts and reflect on them. It asks the user to log their emotions and thoughts as well as what was going on to make them feel that way, then has the user reflect on whether or not there is evidence to back up their automatic thoughts. This could be a valuable supplement to a psychotherapist-led CBT treatment, but could also help people teach themselves about CBT .

In fact, one study has shown that thought records are an effective way to modify beliefs, even when used by themselves and not in conjunction with a CBT treatment plan (McManus et al., 2012). Find the Thought Record Worksheet here.

2. The Feeling Wheel

The Feeling Wheel is a simple printout with 72 feelings sorted into 6 groups: angry, sad, scared, joyful, peaceful, and powerful. Represented as a colorful pie, it can be an excellent tool for psychotherapy clients who have difficulty articulating or expressing their feelings.

While this can make it easier for clients to describe their relationships and experiences outside of therapy, it can also help them give immediate feedback on how they feel during a session.

This technique is commonly used to help clients identify emotions, expand their emotional vocabulary, and develop their emotional regulation (Kircanski et al., 2012).

3. Daily Mood Tracker

This Daily Mood Tracker was developed for people dealing with anger management issues but can be helpful for anyone who wants to track their mood.

It splits the day up into several two-hour blocks and asks the user to track their emotions, as well as allowing for notes to explain these moods.

This can also be helpful for clients who have trouble expressing themselves but can provide valuable self-reflection opportunities for anybody. Interestingly, some research has even shown that depressed clients can improve their mood by tracking it (Harmon et al., 1980).

4. Self-Care Checkup

This worksheet is a self-report Self-Care Checkup that therapists can give their clients after each appointment, to fill in between the sessions. The client is meant to consider the activities they are engaging in to keep up good mental health and wellbeing.

While many could be considered routine, such as exercising or getting sufficient sleep, they can often be neglected when they matter most – during times of stress.

This way, the Self-Care Checkup invites clients to become more aware of the frequency with which they practice self-care, categorizing these activities into five groups:

• Professional; and
• Spiritual self-care.

By filling it out regularly, clients can compare their self-care practices from week to week, spotting areas for development and brainstorming more activities that might help them maintain their mental health.

5. Preventing Mental Health Relapse

This is a worksheet that can help clients learn more about possible mental health relapse. It can be used near the end of a therapy treatment plan to help the client recognize a relapse when it is coming, but can also teach strategies to avoid relapse.

This would likely be most helpful for mental health issues that flare up at specific times (as opposed to more chronic mental health issues), and can also be helpful during treatment changes.

For example, patients with anxiety disorders receiving both psychotherapy and antidepressants are at risk of relapse when they discontinue their antidepressant treatment (Batelaan et al., 2017).

Download and use this Preventing Mental Health Relapse activity here.

5 Mental Health Games & Awareness Activities (PDF)

One way to get around this is to have them complete worksheets or participate in activities related to mental health awareness, so they can learn in a more hands-on way.

These worksheets and activities are excellent for cultivating mental health awareness:

1. Mindfulness Exercises For Children

This article includes a huge collection of easy mindfulness exercises that children can do to learn more about mindfulness. It includes activities for teachers, parents, caregivers, and teenagers, along with a host of meditation scripts, books, quotes, and more.

Check out the following, too, for some great ways to get children thinking about mindfulness, while subtly introducing them to mental health issues more broadly: 18 Mindfulness Games, Worksheets and Activities for Kids .

2. Mental Illness: Myths and Reality

Mental Illness – Myths and Reality is a helpful lesson plan for teachers who want to educate students about mental illness stigma.

This activity requires less than 30 minutes and very little preparation – it’s also great for any class size and can be a useful talking point to start insightful discussions around mental health.

It includes 8 myths and 8 facts about mental illness for students to sort out in pairs, to distinguish between common misconceptions and objective facts about diagnosis and life with a mental health condition.

3. Exercise and Mental Health

Exercise and Mental Health  introduces younger children to the importance of exercise and physical activity, illustrating how they go hand-in-hand before giving suggestions for students who want to get more active on a daily basis.

This informational resource is a great handout as part of a lesson about mental health.

4. Understanding Mental Health Stigma

Introducing youths to the concept of stigma can be quite tough, but it’s important.

This Understanding Mental Health Stigma sheet can be used as an aid to help raise awareness of the stigma that surrounds mental illness , as well as what it looks like.

5. Mental Health Management Bingo

Mental Health Management Bingo  is a fun classroom game that can be played with slightly older students.

While it aims to raise awareness about the importance of positive coping strategies, it can also be a great way for students to bond with one another and discover new, healthy ways to look after their mental health..

To play, students require a copy of each sheet and a pencil, and each Bingo square worksheet contains 22 positive coping mechanisms that are related to maintaining good mental health. It’s easy for students to play, and just as easy for teachers or parents to join in!

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We suggest picking at least one of these popular to broaden your understanding of mental health.

1. Mental Health Emergencies: A Guide to Recognizing and Handling Mental Health Crises – Nick Benas and Michele Hart

Written by a mental health associate and a social worker, this book aims to help people recognize mental health crises in the people around them.

This book also aims to teach the reader how to support people in the midst of a mental health crisis.

The authors targeted this book to teachers, human resources workers and other professionals who are concerned with the mental wellbeing of other people, but it can be helpful for anyone who wishes to know more about mental health.

Find the book on Amazon .

2. Ten Days in a Mad-House – Nellie Bly

This book details investigative reporter Nellie Bly’s exposé of a New York City insane asylum in the late 1800s.

In the book, the author details how she checked into a boarding house, feigned insanity and was promptly declared insane and sent to an insane asylum.

Bly spent 10 days in the asylum, during which she uncovered the horrific conditions that patients were subjected to, causing the city and the country to reevaluate how they treated the mentally ill.

This book illustrates how horribly mental health patients were treated in the late 1800s, but can also cause the reader to think about how society treats mental health issues today.

3. Stigma: The Many Faces Of Mental Illness – Joy Bruce M.D.

This book, from a doctor with a mood disorder, aims to educate people about mental health issues and ultimately destigmatize mental health issues.

The book describes various mental health disorders and the nuances of them, making it a great educational book.

The author also discusses a wide variety of people with mental health issues, breaking down stereotypes about mental health along the way. This is a great book for someone who wants to understand more about mental health issues in themselves or others.

4. Look Me in the Eye: My Life with Asperger’s – John Elder Robison

This memoir discusses the author’s experience of living with Asperger’s syndrome.

The author was not diagnosed with Asperger’s syndrome until he was 40 years old, so before then he just lived as someone who felt that he could not connect very well with others for some reason but displayed an affinity for machines and electronics.

This book is an excellent way to gain some insight into the world of Asperger’s syndrome and may help the reader better understand someone in their life who deals with Asperger’s syndrome.

5. Man Who Mistook His Wife For A Hat – Oliver Sacks and Jonathan Davis

This book from Oliver Sacks is a pop psychology classic. In it, Sacks discusses a few different cases of mental health disorders, focusing on the person rather than the disorder the whole way through.

This is an excellent book for learning about mental health disorders in a way that doesn’t necessarily otherize people with mental health issues. The book’s scope also makes it a great introduction to mental health disorders.

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5 Most Popular Children’s Books About Mental Health

Nurturing an understanding of mental health from a young age can be done with these great reads.

1. Can I Catch It Like a Cold?: Coping With a Parent’s Depression – Centre for Addiction and Mental Health and Joe Weissmann

This book from the Centre for Addiction and Mental Health (CAMH) in Canada is aimed at children whose parents struggle with depression.

The book describes what depression is and is not, and gives the reader strategies to cope with the situation. It is aimed at children as young as five years old and can be a child’s first official introduction to mental health disorders.

2. Dear Allison : Explaining Mental Illness to Young Readers – Emma Northup Flinn

This book discusses mental health in an adventurous, conversational way that can help children start to understand the subject.

Written from the perspective of the reader’s cousin (who has teamed up with an ant to explore mental health issues across parts of the United States), this is another excellent book for introducing children to mental health.

The book is partially a collection of letters from the narrator to her nine-year-old cousin, “Allison”, so this book is definitely appropriate for children as young as 9 to start learning about mental health.

3. Marvin’s Monster Diary: ADHD Attacks! (But I Rock It, Big Time) – Raun Melmed, Annette Sexton, and Jeff Harvey

This book is an excellent way to teach children as young as 7 years old about attention-deficit hyperactivity disorder (ADHD), particularly if they have it.

Aside from helping children understand ADHD, it offers a mindfulness-based solution the author calls ST4 – “Stop, Take Time To Think”.

This book is an excellent resource for children with ADHD to learn more about themselves and strategies they can use every day to focus.

4. How Full Is Your Bucket? For Kids – Tom Rath, Mary Reckmeyer, and Maurie J. Manning

This book was written by Tom Rath, an important author in positive psychology and particularly strengths finding (as he wrote StrengthsFinder 2.0).

It is a children’s adaptation of another one of his popular books, How Full Is Your Bucket?, which claims that people can either “fill your bucket” with positivity or “dip from your bucket” with negativity.

This is an excellent book to show kids how social interactions can affect their self-esteem and wellbeing, and how the way they treat people can affect the self-esteem and wellbeing of others.

5. Please Explain Anxiety to Me! Simple Biology and Solutions for Children and Parents – Laurie E. Zelinger, Jordan Zelinger, and Elisa Sabella

This book, co-authored by a play therapist and a child psychologist, aims to explain anxiety to children in a simplified but still accurate way.

This means describing the physiology of anxiety in a way that children as young as 5 can start to understand.

It also includes some actionable exercises that children can use when they are feeling anxious. This book can help children deal with their own anxiety and learn some concrete psychology along the way.

Sometimes, the best thing for someone struggling with mental health issues is the ability to reach out to someone who will understand them.

Facebook is great for this, as people can start community-based groups focused around mental health issues.

That said, as is always the case with the internet, anybody can contribute to these groups, which has the potential to be harmful to members of that group.

For that reason, we have only highlighted closed groups (as opposed to open groups), which require admin approval to join. This way, it is more likely that someone will find a group full of people who only want to help.

Someone looking for a Facebook group to discuss mental health should try joining one of these:

Adult ADHD/ADD Support Group… By Reach2Change

This is a support group for adults with attention deficit hyperactivity disorder (ADHD), or attention deficit disorder (ADD).

Anxiety/Depression Mental Health Support Group

This is a support group for people (18+) who struggle with depression or anxiety .

Bipolar Disorder

This is a support group for people with bipolar disorder, people who know someone with bipolar disorder, or people who want to learn more about bipolar disorder.

Mental Health Inspiration (Support & Awareness)

This is a support group for people with all sorts of mental health issues, as well as people who wish to be an ally or learn more about mental health.

PTSD Buddies

This is a support group for people (19+) with post-traumatic stress disorder (PTSD).

30 Minute relaxing yoga for mental health – Jessica Richburg

October 10th is World Mental Health Day.

The objective of this important day is to spread awareness about mental health issues, express thanks to mental health care providers, and do more to make mental health care a reality for those who need it. Overall, the day represents a valuable opportunity to start a dialog about mental health with others in your life.

If you’re a teacher, manager, or principal looking for ways to start this conversation in your school or workplace, here are four ideas to get started.

Yoga and pilates have both been shown to reduce a range of mental health symptoms, such as fatigue and feelings of anxiety, while simultaneously increasing feelings of energy (Fleming & Herring, 2018; Hagen & Nayar, 2014).

To leverage these benefits, consider bringing in a yoga or pilates expert (or linking up with a nearby studio) to do a guided class with your staff or students.

Host a charity event

There are many charitable organizations around the world that are working hard to provide mental health support to those who may otherwise not have access to it.

To help, you can work with your students or staff to identify a cause they feel passionate about and run an event to raise money for a worthy cause. For example, consider hosting a raffle, games evening, cake stall, or fete open to the public.

Wellness gift exchange

A simple gift can do a lot to start a conversation, so consider hosting a wellness gift exchange.

To start, randomly assign your students or staff a ‘gift buddy.’ If you like, you can make the identity of gift-givers and receivers anonymous, much like a Secret Santa, by having your staff or students draw names from a hat.

Next, allocate a spending limit and have each person purchase a gift for someone else. The focus of the gift should encourage the recipient to relax and take some time out for him or herself. Examples of good gifts include movie tickets, a pampering face mask, or a soap and candle gift basket.

Information sessions

Teaching children how to start a conversation with someone about mental health is a skill that can serve them for a lifetime. At the same time, the stigma associated with mental illness may act as a barrier for adults to start a conversation with someone they’re concerned about or seek help.

To help, consider bringing in a mental health speaker or expert and host an information session. The aim of the session should be to connect your students or staff to resources and give them the skills to check in with the mental health of those they care about.

Further, you can take this opportunity to remind your students or staff about internal support services in your school or office, such as forms of personal leave or internal counselors.

In addition to the ideas above, it is likely that public spaces around you, such as libraries and community centers, will have planned events around World Mental Health Day. So consider linking up with groups in your local community to support this important cause.

17 Top-Rated Positive Psychology Exercises for Practitioners

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At the end of the day, nobody can know everything there is to know about mental health issues. The key is constantly being willing to learn, so that you know how to help when someone you love deals with mental health issues, and have the strategies to deal with your own mental health issues if and when they arise.

Some people prefer reading books, others prefer more hands-on learning such as worksheets, and still, others just prefer going out and talking to people. No matter what type of learning you prefer, the important thing is that you make an effort to make this world a better place for everyone, no matter what mental health issues they are or aren’t facing.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• Batelaan, N.M., Bosman, R.C., Muntingh, A., Scholten, W.D., Huijbregts, K.M., van Balkom, A.J.L.M. (2017). Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials. BMJ, 358(1) , j3927.
• Fleming, K. M., & Herring, M. P. (2018). The effects of pilates on mental health outcomes: A meta-analysis of controlled trials. Complementary Therapies in Medicine , 37, 80-95.
• Hagen, I., & Nayar, U. S. (2014). Yoga for children and young people’s mental health and well-being: research review and reflections on the mental health potentials of yoga. Frontiers in Psychiatry , 5.
• Harmon, T.M., Nelson, R.O., Hayes, S.C. (1980). Self-monitoring of mood versus activity by depressed clients. Journal of Consulting and Clinical Psychology, 48(1) , 30-38.
• Henderson, C., Robinson, E., Evans-Lacko, S., Thornicroft, G. (2017). Relationships between anti-stigma programme awareness, disclosure comfort and intended help-seeking regarding a mental health problem. British Journal of Psychiatry, 211(5) , 316-322.
• Kaduson, H.G., Schaefer, C.E. (Eds.). (2003). 101 favorite play therapy techniques. Volume III. Lanham, MA: Rowman & Littlefield Publishers, Inc.
• Kircanski, K., Lieberman, M. D., & Craske, M. G. (2012). Feelings into words: contributions of language to exposure therapy. Psychological Science, 23 (10), 1086.
• Lambert, M.J. (2015). Progress Feedback and the OQ-System: The Past and the Future. Psychotherapy, 52(4) , 381-390.
• McManus, F., Van Doorn, K., Yiend, J. (2012). Examining the effects of thought records and behavioral experiments in instigating belief change. Journal of Behavior Therapy and Experimental Psychiatry, 43(1) , 540-547.

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Resources: Course Assignments

Assignment: Psychological Disorders

Disorder at-a-glance.

STEP 1 : Pick one of the disorders you read about in this module and learn more about it in order to make a “At-a-Glance” page with details about the disorder. Visit the National Institute of Mental Health and search for the disorder, read through the information, then scroll to the section on “Research and Statistics” or “Journal Articles or Reports” to find helpful links to outside information. Look elsewhere as well for details about the prevalence, signs, symptoms, details, and research related to the disorder. Keep track of all of your sources as you investigate.

STEP 2 : In a format of your choosing (Microsoft Word, PowerPoint, Canva, Infogr.am, Photoshop, Google Doc, etc.), create a 1 page visual that includes the following information about the disorder:

• Description
• Causes and Risk Factors
• Recent Research (referencing at least 2 research articles)
• Either as a footnote on the same page, or on a separate page, include the citations in APA format

STEP 3 : Create a simple, yet visually interesting “At-a-Glance” page with information about the order. Although not required, we recommend adding a Creative Commons license to your completed work and uploading it to either  Flickr  or Wikimedia Commons  so that other psychology instructors and students can use your work.

CC licensed content, Original

• Disorder At-a-Glance Assignment. Provided by : Lumen Learning. License : CC BY: Attribution

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In this demonstration Dr. Nina Josefowitz covers graded task assignments and how to create an effective behaviour change plan. Graded task assignments involve breaking a large, overwhelming task into doable chunks and then planning the first couple of chunks. When a large task is broken down into chunks it starts to feel more manageable.

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In this demonstration Dr. Nina Josefowitz covers how to incorporate relaxation strategies into therapy. These relaxation strategies involve consciously slowing down breathing. Two breathing strategies, Deep Breathing and Box Breathing, are demonstrated, as well as how and when to practice them.

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The Emotional Weight of Being Graded, for Better or Worse

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As most parents know, kids respond emotionally to the grades they receive -- and well beyond the jubilation that goes with an A+ or the despair that accompanies a D. When Jessie, an eighth-grader, got an uncharacteristically low score on a Spanish test, she felt not only embarrassed -- “because I’d never done that badly before” -- but lousy as well: “I didn’t feel as good about myself,” she said.

Not that every 95 percent is cause for celebration, at least for Xavier McCormick, now a college freshman. In high school, when he got top marks with little effort, McCormick felt indifferent to the teacher’s evaluation. “I felt ... meh,” he said. “It was just kind of a number at that point.” Ordinarily, McCormick didn’t get too worked up about grades, focusing more on learning than dutifully carrying out every last assignment. “I’m not going to do it just to get the grade,” he said. “I’d rather get two hours more sleep.”

A more typical teenage response to grades, especially bad ones? Fear. “My friends get so caught up in grades,” Jessie said. When they underperform, their first reaction is: “My parents are going to kill me!”

EMOTIONS AND LEARNING

The trouble with these extreme emotional reactions to grades is that students’ knowledge of a subject is tied to their experience of the grade, says Mary Helen Immordino-Yang, associate professor of education, psychology and neuroscience at the University of Southern California. Powerful emotions attached to grades drown children’s inherent interest in any given subject.

“Whether the grade is good or bad, you’re taking the student away from focusing on intrinsic interest and tying their experience to grades,” Immordino-Yang explained. Under such circumstances, genuine interest in learning for its own sake wilts. “Grades can be an impetus to work, and can be really satisfying,” she said. “But when emotions about the grade swamp students’ emotions about a subject, that’s a problem.”

Once considered obstacles to thinking, emotions are now understood to be interdependent with various cognitive processes. A better way to think about emotion’s centrality to learning, Immordino-Yang writes in Emotions, Learning, and the Brain , is this: “We only think about things we care about.” When kids care mainly about grades, they’re devoting more mental resources to the assessment than to the actual subject matter.

Students seem to appreciate the distinction between studying to learn and working for the grade.

For Elizabeth Gilbert, now a graduate of the University of Chicago, writing the best essay mattered more than getting an A+. In her pursuit of excellence, she sometimes turned in assignments after they were due, enhancing her scholarship but diminishing her GPA. She gradually realized that submitting work for the grade became a sensible exit strategy. “To just settle for the grade helped,” she said.

McCormick put it differently. If grades were a pure reflection of learning, he added, students wouldn’t be graded on whether they did their homework. For example, in classes where homework makes up 20 percent of a student’s grades, even achieving 100 percent on every test — and so demonstrating complete understanding of a subject — won’t guarantee an A.

“School is about teaching kids how to follow rules, and having grades as the emphasis is how they do that,” he said.

TEACHERS AND GRADES

Some teachers agree. Starr Sackstein, a veteran teacher in Flushing, New York, and author of Hacking Assessment: 10 Ways to Go Gradeless in a Traditional Grades School , realized that she had started to use grades as a tool to control her students: For every day a paper came in past the deadline, for example, she’d deduct five points. She also started to recoil when she noticed students flipping to the back of papers she’d spent hours marking up, just to see their score. Sackstein understood how powerful grades could be to students. A self-described grade-grubber, she decided to change the way she evaluated students to maximize their learning by giving up grades.

Sackstein is part of a movement of teachers who are replacing grades with more nuanced kinds of student assessments. Encouraged by educators like Alfie Kohn and Mark Barnes , who reject grades as blunt and reductive, these teachers educate and evaluate their students using portfolios, one-on-one conferences, peer assessments and other forms of qualitative feedback.

Sackstein started slowly and worked to get student buy-in. She advised her students that they were going to figure out together how to improve their learning and evaluation, and told everyone they could get an A as far as she was concerned. She dropped cumulative assessments entirely -- “because we have so much access to information all the time, it’s not a skill we need to test” -- and invited students to set their own goals and develop their own standards. Sackstein then used everything the students did in class to measure them against their own goals.

“I do different types of conferences with students. I have oral projects, I set up meetings with kids,” Sackstein explained about the multiplicity of ways she tailors student work. “I’m not determining what they need; they are. I’m just a reader giving feedback,” she said. Students have responded to her methods, because assessments are more personal and she provides abundant opportunities for them to express themselves.

Sackstein often talks to students about how grades affect them, and understands how weighty regular numerical evaluations can be.

“Grades have the ability to make kids feel stupid or smart, and that’s a huge power,” she said. Teachers are human, she added, and will respond emotionally and sometimes arbitrarily to different kids and various types of work. When students define themselves positively or negatively by those judgments, they cede control over their well-being to someone — a teacher — who may not understand them.

“We as teachers and administrators have to be acutely aware of the kids in front of us,” Sackstein said. “Their learning is all that matters.”

By her senior year of high school, Caroline Wohl began to realize that striving to get A's in every subject, no matter her enthusiasm for the material, was foolish and unnecessary. “I just grew up, and got less caught up in winning,” she said. She tolerated a B in AP physics, and threw herself into the school debate team, where she indulged her authentic interests and embraced the freedom from grades. Wohl missed several classes to compete in national debate tournaments, without regret.

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Graded Homework for Depression

Depression is one of the most common mental health conditions worldwide, affecting people of all ages and lifestyles. Although there are different approaches and treatments to address depression, in this article we will focus on the graded task assignment technique as an effective strategy to treat this disorder.

What is the graded task assignment technique?

The graded task assignment technique is a psychological strategy used in the treatment of depression and other anxiety disorders. It involves breaking down a challenging task or activity into smaller, more manageable steps, allowing the person to gradually approach the entire task. This technique is based on the principle that gradually confronting difficult situations can help reduce anxiety and avoidance, and improve feelings of achievement and self-efficacy.

Depression is characterized by feelings of sadness, hopelessness, lack of interest in daily activities, low self-esteem and loss of energy. People with depression may experience difficulty fulfilling their daily responsibilities, which in turn may increase feelings of inefficiency and hopelessness.

The graded task assignment technique has been shown to be effective in the treatment of depression. depression by helping people regain motivation, self-esteem and a sense of control over their lives. By breaking down daily activities into manageable steps, individuals can experience a sense of accomplishment and overcome the paralysis and avoidance associated with depression.

Benefits of the Graded Task Assignment Technique in the Treatment of Depression depression

Some of the key benefits of the graded task assignment technique in the treatment of depression include:

• Increased motivation: By experiencing small but significant achievements, people with depression can regain motivation and interest in their daily activities.
• Improved self-esteem: Overcoming obstacles and completing tasks can increase self-esteem and a sense of self-efficacy.
• Reduced avoidance: By gradually confronting challenging situations, people can reduce the avoidance and anxiety associated with those situations.
• Developing coping skills: The graded task assignment technique helps people develop coping skills and manage stress more effectively.

Implementation of the graded task assignment technique in cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) is one of the most widely used therapeutic approaches in the treatment of depression. CBT is based on the premise that thoughts, emotions, and behaviors are interrelated, and that by modifying dysfunctional patterns of thinking and behavior, it is possible to improve mood and reduce depressive symptoms.

CBT Graded task assignment technique is effectively integrated into cognitive behavioral therapy to address symptoms of depression. By breaking down activities into manageable steps, the technique helps individuals identify and challenge negative thought patterns, as well as experience changes in their behavior and mood.

Process of implementing the technique graded task assignment in CBT

The process of implementing the graded task assignment technique in cognitive behavioral therapy generally follows the following steps:

• Initial assessment: The therapist assesses the nature and severity of depressive symptoms, as well as the areas of daily life that are affected by depression.
• Goal setting: Specific and measurable therapeutic objectives are defined that will guide the implementation of the graded task assignment technique.
• Task breakdown: The daily or challenging activities that They can be broken down into smaller, more manageable steps.
• Implementation and monitoring: The person works to complete each step, with the support and guidance of the therapist, who provides feedback and positive reinforcement.

While the graded task assignment technique can be effective in the treatment of depression, it is important to keep some key considerations in mind when apply this therapeutic strategy:

• Collaboration: Collaboration between the therapist and the person is essential to establish realistic goals and work together to implement the technique.
• Monitoring and adjustment : It is important to monitor the person's progress and make adjustments to the strategy as necessary to ensure its effectiveness.
• Integration with other strategies: The mapping technique Graded tasks can be combined with other therapeutic strategies, such as cognitive restructuring or social skills training, for a comprehensive approach to the treatment of depression.

In conclusion, the graded task assignment technique is an effective therapeutic strategy for the treatment of depression. By breaking down challenging activities into manageable steps and encouraging gradual exposure to feared situations, this technique helps people regain motivation, self-esteem, and control over their life. When integrated into cognitive behavioral therapy, the graded task assignment technique can enhance the positive effects of this therapeutic approach and improve depression treatment outcomes.

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WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. Related to mental health, WHO Sri Lanka office aims to improve quality of life people in Sri Lanka by supporting the government in prevention and control of priority mental health, substance use and neurological disorders, preventing suicides, and promoting mental health, advocating for integrated mental health and social care services in PHC and community-based settings, preparing and responding to mental health and psychosocial issues during health emergencies and promoting the rights of people with psychosocial, intellectual and cognitive disabilities.

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3. Provide technical tools, SOPs etc. to ensure provision of comprehensive, integrated mental health and social care services in primary care and community-based settings;

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5. Provide technical assistance to strengthen information systems and research to improve data on burden of mental and neurological disorders;

6. Provide technical assistance to the country in developing mental health related tools and guidelines including LIVE LIFE: an implementation guide for suicide prevention;

7. Support the country to update the mental health law taking into consideration regional and international human rights instruments;

8. Provide support to improve mental health literacy, address stigma and discrimination and promote the rights, opportunities and care of individuals with mental disorders;

9. Encourage using WHO Quality Rights toolkit to evaluate quality of mental health services;

10. Increase awareness of disability issues, and promote the inclusion of disability as a component in national and sub-national health programmes;

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12. Support the country to conduct the WHO/WB Model Disability Survey and/or WHO Disability Assessment Schedule (WHO DAS 2.0);

13. Represent WHO country office in the UN Disability Inclusion Inter-Agency Coordination mechanism at the country level, and contribute to reporting via the UNCT Accountability Scorecard on Disability Inclusion tool;

14. Support proposal writing and donor reporting for Mental Health, Psycho-Social Support and Disability programs;

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Essential: Sound understanding of principles of public health, to be able to provide quality technical inputs, and good problem-solving, analytical and negotiation skills

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• Introduction
• Conclusions
• Article Information

Overall sample includes 499 participants; subgroup with PPCS present, 305 participants; and subgroup with PPCS absent, 194 participants. AUC indicates area under the curve; GAD-7, Generalized Anxiety Disorder–7; MDE, major depressive disorder; PC-PTSD-5, Primary Care PTSD (Posttramatic Stress Disorder) Screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition); and PHQ-9, Patient Health Questionnaire–9.

eMethods. Case Ascertainment

eFigure. STARD Flowchart of Participants

eTable 1. Recommended Cutoff Scores for the Screening Tools

eTable 2. Severity of Depression According to PHQ-9

eTable 3. PHQ-9 Diagnostic Accuracy for Overall Sample (N = 499)

eTable 4. True and False Positive and Negative Rates for Each Cutoff for PHQ-9 in Overall Sample (N = 499)

eTable 5. PHQ-9 Diagnostic Accuracy for Sample With PPCS Present (n = 158)

eTable 6. True and False Positive and Negative Rates for Each Cutoff for PHQ-9 for Sample With PPCS Present (n = 158)

eTable 7. PHQ-9 Diagnostic Accuracy for Sample With PPCS Absent (n = 341)

eTable 8. True and False Positive and Negative Rates for Each Cutoff for PHQ-9 for Sample With PPCS Absent (n = 341)

eTable 9. Severity of Anxiety According to GAD-7

eTable 10. Diagnostic Accuracy of GAD-7 to Diagnose at Least 1 Anxiety Disorder for Overall Sample (N = 499)

eTable 11. True and False Positive and Negative Rates for Each Cutoff for GAD-7 to Diagnose at Least 1 Anxiety Disorder for Overall Sample (N = 499)

eTable 12. Diagnostic Accuracy of GAD-7 to Diagnose at Least 1 Anxiety Disorder for Sample With PPCS Present (n = 158)

eTable 13. True and False Positive and Negative Rates for Each Cutoff for GAD-7 to Diagnose at Least 1 Anxiety Disorder for Sample With PPCS Present (n = 158)

eTable 14. Diagnostic Accuracy of GAD-7 to Diagnose at Least 1 Anxiety Disorder for Sample With PPCS Absent (n = 341)

eTable 15. True and False Positive and Negative Rates for Each Cutoff for GAD-7 to Diagnose at Least 1 Anxiety Disorder for Sample With PPCS Absent (n = 341)

eTable 16. Diagnostic Accuracy of GAD-7 to Diagnose Generalized Anxiety Disorder for Overall Sample (N = 499)

eTable 17. True and False Positive and Negative Rates for Each Cutoff for GAD-7 to Diagnose at Least 1 Anxiety Disorder for Overall Sample (N = 499)

eTable 18. Diagnostic Accuracy of GAD-7 to Diagnose Generalized Anxiety Disorder for Sample With PPCS Present (n = 158)

eTable 19. True and False Positive and Negative Rates for Each Cutoff for GAD-7 to Diagnose Generalized Anxiety Disorder for Sample With PPCS Present (n = 158)

eTable 20. Diagnostic Accuracy of GAD-7 to Diagnose Generalized Anxiety Disorder for Sample With PPCS Absent (n = 341)

eTable 21. True and False Positive and Negative Rates for Each Cutoff for GAD-7 to Diagnose Generalized Anxiety Disorder for Sample With PPCS Absent (n = 341)

eTable 22. Severity of PTSD According to PC-PTSD-5

eTable 23. Diagnostic Accuracy of PC-PTSD-5 for Overall Sample (N = 499)

eTable 24. True and False Positive and Negative Rates for Each Cutoff for PC-PTSD-5 for Overall Sample (N = 499)

eTable 25. Diagnostic Accuracy of PC-PTSD-5 for Sample With PPCS Present (n = 158)

eTable 26. True and False Positive and Negative Rates for Each Cutoff for PC-PTSD-5 for Sample With PPCS Present (n = 158)

eTable 27. Diagnostic Accuracy of PC-PTSD-5 for Sample With PPCS Absent (n = 341)

eTable 28. True and False Positive and Negative Rates for Each Cutoff for Sample With PPCS Absent (n = 341)

eTable 29. Diagnostic Accuracy of GAD-7 to Diagnose PTSD for Overall Sample (N = 499)

eTable 30. True and False Positive and Negative Rates for Each Cutoff for GAD-7 to Diagnose PTSD for Overall Sample (N = 499)

eTable 31. Multivariable Regression Model

eTable 32. AUC Comparison for Each Screening Questionnaire in the Overall, PPCS Present, and PPCS Absent Samples

eReferences

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Gitaari M , Mikolić A , Panenka WJ , Silverberg ND. Diagnostic Accuracy of Mental Health Screening Tools After Mild Traumatic Brain Injury. JAMA Netw Open. 2024;7(7):e2424076. doi:10.1001/jamanetworkopen.2024.24076

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Diagnostic Accuracy of Mental Health Screening Tools After Mild Traumatic Brain Injury

• 1 Department of Psychology, University of British Columbia, Vancouver, Canada
• 2 Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
• 3 BC Mental Health and Substance Use Research Institute, Burnaby, British Columbia, Canada
• 4 British Columbia Provincial Neuropsychiatry Program, Vancouver, British Columbia, Canada
• 5 Department of Psychiatry, University of British Columbia, Vancouver, Canada
• 6 Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada

Question   Can self-report screening tools accurately detect a major depressive episode, anxiety disorder, and posttraumatic stress disorder (PTSD) after mild traumatic brain injury (mTBI)?

Findings   In this diagnostic study with 499 participants with mTBI, the Patient Health Questionnaire–9, Generalized Anxiety Disorder–7, and Primary Care PTSD Screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) screening tools had acceptable diagnostic accuracy; the Generalized Anxiety Disorder–7 accurately identified not only anxiety disorders but also PTSD. In patients with persistent postconcussive symptoms, specificity was lower and mental health disorders were more common.

Meaning   These findings suggest that brief self-report tools can reliably screen for mental health disorders after mTBI.

Importance   Mental health disorders are common after mild traumatic brain injury (mTBI) and likely exacerbate postconcussive symptoms and disability. Early detection could improve clinical outcomes, but the accuracy of mental health screening tools in this population has not been well established.

Objective   To determine the diagnostic accuracy of the Patient Health Questionnaire–9 (PHQ-9), Generalizaed Anxiety Disorder–7 (GAD-7), and Primary Care PTSD (Posttramatic Stress Disorder) Screen for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( DSM-5 ) (PC-PTSD-5) in adults with mTBI.

Design, Setting, and Participants   This diagnostic study was performed as a secondary analysis of a cluster randomized clinical trial. Self-report mental health screening tools (PHQ-9, GAD-7, and PC-PTSD-5) were administered online 12 weeks after mTBI and compared against a structured psychodiagnostic interview (Mini-International Neuropsychiatric Interview for DSM-5 (MINI) over videoconference at the same time. Adults with mTBI (N = 537) were recruited from February 1, 2021, to October 25, 2022.

Main Outcomes and Measures   Presence of a major depressive episode, anxiety disorders, and PTSD were determined by a blinded assessor with the MINI. Diagnostic accuracy statistics were derived for the PHQ-9, GAD-7, and PC-PTSD-5. Findings were disaggregated for participants with and without persistent postconcussion symptoms (PPCS) by International and Statistical Classification of Diseases, Tenth Revision criteria.

Results   Data were available for 499 of 537 trial participants, 278 (55.7%) of whom were female; the mean (SD) age was 38.8 (13.9) years. Each screening questionnaire had strong diagnostic accuracy in the overall sample for optimal cut points (area under the curve [AUC], ≥0.80; sensitivity, 0.55-0.94; specificity, 0.64-0.94). The AUC (difference of 0.01-0.13) and specificity (difference, 5-65 percentage points) were lower in those with PPCS present compared with PPCS absent, but the prevalence of at least 1 mental health disorder was 3 to 5 times higher in patients with PPCS present. The GAD-7 had slightly better performance than the PC-PTSD-5 for detecting PTSD (AUC, 0.85 [95% CI, 0.80-0.89] vs 0.80 [95% CI, 0.72-0.87]). The optimal cutoff on the PHQ-9 was 5 or more symptoms experienced on more than half of days; on the GAD-7, a total score of at least 7.

Conclusions and Relevance   The findings of this diagnostic study suggest that the PHQ-9, GAD-7 and PC-PTSD-5 accurately screen for mental health disorders in patients with mTBI. Future research should corroborate optimal test cutoffs for this population.

Individuals with mild traumatic brain injury (mTBI) are more likely to develop mental health conditions such as depression, anxiety disorders, and posttraumatic stress disorder (PTSD) compared with the general population and those with orthopedic injuries. 1 - 5 The prevalence rates for mental health conditions 3 to 12 months after mTBI are 17% to 27% for depressive disorders, 1 , 6 , 7 11% to 24% for anxiety disorders, 6 , 8 , 9 and 10% to 21% for PTSD. 3 , 5 , 10 , 11 Mental health disorders likely exacerbate persistent postconcussion symptoms (PPCS) 11 - 15 and contribute to the substantial rate (30%-50%) of chronic disability after mTBI. 12 , 16 Outcomes from mTBI could be optimized by proactively monitoring for new or worsened mental health disorders (eg, with self-report screening scales) and initiating mental health treatment. 15

Mental health disorders can be efficiently detected in primary care with self-report screening tools such as the Patient Health Questionnaire–9 (PHQ-9) for a current major depressive episode (MDE), 17 , 18 General Anxiety Disorder–7 (GAD-7) for anxiety disorders, 19 and Primary Care PTSD Screen for the DSM-5 ( Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) (PC-PTSD-5) for PTSD. 20 , 21 The PHQ-9 and GAD-7 are among the most extensively studied and widely used mental health screens in primary care. Meta-analyses have demonstrated good diagnostic accuracy for the PHQ-9 in identifying MDE, with no substantial differences between investigated subgroups (eg, sex and recruitment setting), 22 - 24 and that the GAD-7 can detect generalized anxiety disorder and other anxiety disorders. 25 Preliminary evidence suggests that these tools have comparable diagnostic accuracy in mTBI, at least in outpatient 26 - 28 and hospitalized samples with trauma-related intracranial lesions, 29 but establishing diagnostic accuracy in larger and more generalizable samples with mTBI is needed (only 15% of adults with mTBI have trauma-related intracranial lesions). 30 It is also unclear whether optimal cutoff scores differ for patients with mTBI, especially in the presence of PPCS. Sleep disturbance, fatigue, concentration difficulties, and mood symptoms are transdiagnostic, that is, common to both PPCS and mental health disorders, 14 , 31 raising concerns about the performance of self-report screening tools in mTBI.

The PC-PTSD-5 was originally developed for use with military service members and veterans. 32 It appears to be useful in primary care 20 but has not been evaluated as extensively as the PHQ-9 or GAD-7, nor has it been previously studied in mTBI. Its appeal in this population is that it only queries core PTSD symptoms that are specific to PTSD (ie, those that do not overlap with PPCS). Evidence from primary care studies suggests that the GAD-7 may be sensitive to PTSD, 25 , 33 - 36 but this has not been evaluated within the context of mTBI.

Clinical practice guidelines for mTBI recommend routine screening for mental health disorders, 37 , 38 but insufficient evidence is available to guide implementation of this recommendation. The present study evaluated the diagnostic accuracy of the PHQ-9, GAD-7, and PC-PTSD-5 screening tools against a criterion standard structured diagnostic interview identification of MDE, anxiety disorders, and PTSD. Secondary aims were to compare diagnostic accuracy in those with and without PPCS, to determine whether the GAD-7 can simultaneously screen for PTSD as well as a PTSD-specific screening tool (the PC-PTSD-5), and to determine whether the combination of the GAD-7 and PC-PTSD-5 can optimize PTSD screening.

This diagnostic study was a secondary analysis of a cluster randomized clinical trial that analyzed whether a clinical practice guideline implementation tool designed to support early detection of mental health disorders after mTBI could lower the risks of mental health complications. 39 , 40 The study was reviewed and approved by the University of British Columbia Clinical Research Ethics Board, and all participants gave informed consent to participate. We followed the Standards for Reporting of Diagnostic Accuracy ( STARD ) reporting guidelines.

Participants were recruited from February 1, 2021, to October 15, 2022. A total of 537 participants with an mTBI were recruited from 6 emergency departments and 2 urgent care centers in the Greater Vancouver area in British Columbia, Canada. Participants were included if they were aged 18 to 69 years, presented to care within 72 hours, met World Health Organization Neurotrauma Task Force criteria for mTBI (eMethods in Supplement 1 ), 41 were fluent in English, had their primary residence in British Columbia, and designated a general practitioner or a walk-in clinic where they would seek follow-up care. Individuals with preexisting unstable or serious illnesses were excluded.

Participant race and ethnicity were self-reported and included the following categories: Arab; Black; Caribbean; East or Southeast Asian; Fijian; First Nation, Inuit, or Métis; Latinx; Middle Eastern; South Asian; White; and preferred not to answer. These data were collected to provide information about the generalizability of the study results.

Participants consented by completing an online form through REDCap (Research Electronic Data Capture; Vanderbilt University). 42 Details about the recruitment procedures are available in the trial protocol paper. 39

The PHQ-9 17 is a 9-question assessment developed to measure depressive symptoms. Participants rate how frequently they experienced symptoms in the past 2 weeks, from 0 (not at all) to 3 (nearly every day). The total score ranges from 0 to 27. A range of cutoffs have been proposed, with total score of 10 or more being most common. Additionally, 3 algorithms have been considered for identifying MDEs that require the endorsement of at least 1 cardinal symptom (depression or anhedonia) and 1 of the following: a score of at least 10, 28 , 29 5 or more symptoms rated as experienced more than half of the days (suicidal ideation is counted if endorsed with any frequency), 17 , 29 and 5 or more symptoms rated as experienced several days (eTable 1 in Supplement 1 ). 29

The GAD-7 is a 7-question screening tool that measures anxiety symptoms. 19 Participants rate how frequently they have experienced symptoms over the past 2 weeks from 0 (not at all) to 3 (nearly every day). The total scores range from 0 to 21. The cutoff scores of at least 7 27 and at least 10 19 have been proposed for the indication of an anxiety disorder (eTable 1 in Supplement 1 ). In addition to these accepted cutoff scores, we also investigated cutoff scores ranging from 5 to 15 (eTables 10, 12, and 14 in Supplement 1 ). The diagnostic accuracy of the GAD-7 for generalized anxiety disorder is provided in eTables 16 to 21 in Supplement 1 .

The PC-PTSD-5 is a 5-question instrument. 32 First, participants are asked about their lifetime trauma exposure. If they indicate that they have had no exposure to an unusual, frightening, traumatic, or horrific event, their score is 0. If they have been exposed to such an event, participants respond 0 (indicating no) or 1 (indicating yes) to 5 questions about symptoms they may be experiencing, with the total score ranging from 0 to 5. Cutoff scores of at least 3 21 , 32 and at least 4 20 have been proposed for indication of PTSD (eTable 1 in Supplement 1 ).

The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) consists of 16 symptoms. Each symptom is rated on a scale from 0 (indicating not experienced at all) to 4 (indicating a severe problem). 43

The MINI is a structured diagnostic interview that is designed to assess the most common psychiatric disorders in clinical and research settings. 44 We administered 8 modules assessing MDEs, anxiety disorders (ie, panic disorder, agoraphobia, social anxiety disorder, specific phobia, generalized anxiety disorder, or obsessive-compulsive disorder), and PTSD. Version 7.0.2 of the MINI is designed to align with DSM-5 . 31

At 12 weeks post injury, outcome assessors (ie, graduate students of clinical psychology or rehabilitation science) administered the MINI through a video-conferencing platform under the supervision of a registered psychologist (N.D.S.) to eligible participants. The outcome assessors were certified in Adult Standard MINI 7.0.2 Training provided by the publisher and participated in weekly group supervision with the psychologist to discuss complex cases and resolve uncertain MINI coding. To ensure standardized administration, assessors were periodically audited (by the supervising psychologist observing an assessment live) to prevent drift from standardized administration.

After administering the MINI, participants were e-mailed a REDCap 42 online survey that included the PHQ-9, GAD-7, PC-PTSD-5, and the RPQ. The outcome assessors were blind to the results of the screening questionnaires.

Participant characteristics and responses on the screening questionnaires were described in terms of central tendency. Missing responses on the screening tools were replaced with the mean score of the questionnaire if participants missed fewer than 20% of items (26 participants [5.2%] missed 1 to 3 responses on the RPQ, 19 [3.8%] missed 1 response on the PHQ-9, 8 [1.6%] missed 1 response on the GAD-7, and 3 [0.6%] missed 1 response on the PC-PTSD-5).

We derived the receiver operating characteristics curve to determine the area under the curve (AUC) of the total scores of each screening questionnaire for the diagnosis of MDE (based on meeting criteria for a current MDE), any anxiety disorder (≥1), or PTSD according to the results of the MINI. An AUC of 1.0 describes perfect discrimination. 45 Additionally, we investigated the sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), and likelihood ratios at various cutoff scores. Finally, we determined 95% CIs by using the exact binomial confidence interval method. 46

We assessed the diagnostic accuracy in the overall sample and separately for those with and without PPCS. Patients were categorized as having PPCS present or absent based on their endorsement of symptoms on the RPQ that met the International and Statistical Classification of Diseases, Tenth Revision , category C criteria for postconcussional syndrome (F07.81), as in previous studies. 47 , 48 The RPQ assesses for categories I through IV (physical, emotional, and cognitive symptoms and poor sleep) of postconcussional syndrome, and participants were categorized as having PPCS present if they endorsed at least 1 symptom as moderate to severe (ie, item scoring ≥3) in at least 3 categories. 49

To determine whether the diagnostic accuracy of the GAD-7 is equivalent to the PC-PTSD-5 when detecting symptoms of PTSD, we compared their AUCs, sensitivity, and specificity at various cutoffs. Additionally, we performed a multivariable logistic regression to explore whether combining the questionnaires’ total scores would improve the ability to detect PTSD, measured by using likelihood ratio tests.

The analyses were performed using R packages pROC, version 1.18.0 50 ; rms, version 6.8-1 51 ; and dplyr, version 1.1.4 52 (R Project for Statistical Computing), and the DAG_STAT spreadsheet (Andew J. Mackinnon). 53 Comparisons were made using a 1-tailed t test; statistical significance was set at P  < .05 (eTables 2-31 in Supplement 1 ).

The final sample included 499 participants (278 [55.7%] female; 221 [44.3%] male; mean [SD] age, 38.8 [13.9] years) who completed the MINI, PHQ-9, GAD-7, and PC-PTSD-5 at 12 weeks (eFigure in Supplement 1 ). In terms of race and ethnicity, 1 participant (0.2%) was Arab; 7 (1.4%) were Black; 2 (0.4%) were Caribbean; 103 (20.6%) were East or Southeast Asian; 1 (0.2%) was Fijian; 12 (2.4%) were First Nation, Inuit, or Métis; 11 (2.2%) were Latinx; 21 (4.2%) were Middle Eastern; 30 (6.0%) were South Asian; 324 (64.9%) were White; and 10 (2.0%) preferred not to answer. Participant characteristics are summarized in Table 1 .

On the MINI, one-third of patients met criteria for at least 1 mental health disorder: 140 (28.1%) for at least 1 anxiety disorder, 102 (20.4%) for MDE, and 48 (9.6%) for PTSD ( Table 2 ). The prevalence of at least 1 mental health disorder was greater in participants with PPCS present (117 of 158 [74.1%]) compared with participants with PPCS absent (68 of 341 [19.9%]; relative risk [RR], 3.71 [95% CI, 2.95-4.68]), including MDE (RR, 10.97 [95% CI, 6.64-17.53]), at least 1 anxiety disorder (RR, 2.96 [95% CI, 2.25-3.91]), and PTSD (RR, 9.35 [95% CI, 4.65-18.83]).

The AUC for the PHQ-9 in the overall sample was 0.91 (95% CI, 0.88-0.94). The conventional cutoff point of at least 10 had the best balance of sensitivity and specificity ( Table 3 ). The criteria of 5 or more symptoms rated at a score of least 2 favored specificity (0.94 [95% CI, 0.91-0.96] vs sensitivity of 0.67 [95% CI, 0.57-0.76])), while the criteria of 5 or more symptoms rated at a score of at least 1 favored sensitivity (0.94 [95% CI, 0.88-0.98] vs specificity of 0.64 [95% CI, 0.59-0.69]) ( Table 3 ). For each cutoff, the positive likelihood ratios were greater than 2.00 and the negative likelihood ratios were less than 1.00. Additionally, the NPVs were 0.88 or greater, and the PPVs were 0.78 or less. Other cutoffs can be found in eTable 4 in Supplement 1 .

The AUC for the GAD-7 was 0.85 (95% CI, 0.81-0.88). The cutoff with the best balance between sensitivity and specificity (>0.70 for both) was at least 7 (eTable 10 in Supplement 1 ). The conventional cutoff score of at least 10 had a low sensitivity (0.55 [95% CI, 0.46-0.63]) and favored specificity (0.89 [95% CI, 0.85-0.92]) ( Table 3 ). The positive likelihood ratios for each threshold were greater than 1.80 and the negative likelihood ratios were less than 0.70. Additionally, the NPVs were greater than 0.75, and the PPVs were less than 0.85.

The AUC for the PC-PTSD-5 in the overall sample was 0.80 (95% CI, 0.72-0.87). A cutoff score of at least 3 had a sensitivity of 0.67 (95% CI, 0.52-0.80) with a specificity of 0.87 (95% CI, 0.84-0.90) ( Table 3 ). A cutoff score of at least 4 yielded a poor sensitivity of 0.56 (95% CI, 0.41-0.71) with a specificity of 0.92 (95% CI, 0.90-0.95) ( Table 3 ). The cutoff with the best balance between sensitivity and specificity, where both indices were at least 0.70, was a total score of at least 2 (eTable 23 in Supplement 1 ). The positive likelihood ratios for each threshold were greater than 2.00 and the negative likelihood ratios were less than 0.70. Additionally, the NPVs were greater than 0.90, and the PPVs were less than 0.60.

The GAD-7 had a higher AUC (0.85 [95% CI, 0.80-0.89]) than the PC-PTSD-5 (0.80 [95% CI, 0.72-0.87]; difference, 0.05 [ P < .001]). The GAD-7 and PC-PTSD-5 combined modestly increased discriminability (AUC, 0.88 [95% CI, 0.80-0.96]). Using a likelihood ratio test, we found that the combined GAD-7 and PC-PTSD-5 model was a significantly better fit for the data than the GAD-7 (χ 2 1  = 26.61; P < .001) or the PC-PTSD-5 (χ 2 1  = 21.35; P < .001) alone, showing that the use of both questionnaires was better at identifying PTSD, as expected (eTable 31 in Supplement 1 for the multivariable regression model).

The AUCs were lower in the PPCS-present subgroup (≥0.75) compared with the PPCS-absent subgroup (≥0.76) and overall sample (≥0.80; difference, 0.01-0.13 percentage points) ( Figure , A-C, and eTable 32 in Supplement 1 provide a comparison of AUC values for each questionnaire). Across cutoffs, sensitivity was higher (difference, 14-33 percentage points) and specificity was lower (difference, 5-65 percentage points) in the PPCS-present subgroup compared with the PPCS-absent subgroup and overall sample. However, PPV remained high for the PPCS-present subgroup, as it was offset by a higher base rate of mental health disorders (ie, 3 to 5 times higher). Also of note, the cutoff of at least 5 symptoms with a total score of at least 2 on the PHQ-9 was relatively robust to PPCS status, maintaining reasonable specificity (0.74 [95% CI, 0.62-0.84]). Relative to the PHQ-9 and GAD-7, the diagnostic accuracy of the PC-PTSD-PC was less affected by PPCS status ( Figure , C vs A and B and Table 4 ).

The present study supports the diagnostic accuracy of the PHQ-9 for detecting MDE, GAD-7 for detecting anxiety disorders, and PC-PTSD-5 for detecting PTSD in patients with mTBI. The overall diagnostic accuracy was high (AUC ≥0.80) for all questionnaires. 45 Similar to previous studies in primary care patients and TBIs of all severities, the PHQ-9 had outstanding accuracy (≥0.90). 17 , 29 , 45 The AUCs for the GAD-7 and PC-PTSD-5 were somewhat lower (0.80-0.85) compared with previous literature. 21 - 23 , 33 , 42 Our study strengthens the evidence for the PHQ-9 and GAD-7 in a large and more representative sample with mTBI than previous studies and supports the diagnostic accuracy of the PC-PTSD-5.

When investigating previously recommended cutoffs for each questionnaire, we found some deviations in sensitivity and specificity. For the PHQ-9, we obtained results similar to those reported in previous studies at most cutoffs, including a total score of at least 10. 17 , 28 , 29 However, when considering 5 or more symptoms rated with a score of at least 1 (with ≥1 symptom being a cardinal symptom), specificity was lower compared with that found by Fann et al. 29 Further, the recommended cutoffs of 7 and 10 for the GAD-7 and 3 and 4 for the PC-PTSD-5 yielded lower sensitivity and higher specificity values compared with prior studies. 19 - 21 , 27 , 32

To our knowledge, this is the first study to evaluate the diagnostic accuracy of the PHQ-9, GAD-7, and PC-PTSD-5 in adults with vs without PPCS. The AUC values were lower but still acceptable (≥0.75) in participants with PPCS present. Despite reduced specificity in the PPCS-present subgroup, PPV was similar in the PPCS-present subgroup and the full sample because the base rate of mental health disorders was much higher in this group (relative risk, 2.96-10.97). In other words, a positive mental health screen result was associated with comparable likelihood of mental health diagnosis in the PPCS-present subgroup and full sample, across cutoffs. This finding suggests that the same cutoffs could be used for all patients with mTBI. The co-occurrence of PPCS and mental health disorders is not surprising because of their symptom overlap, but also because PPCS can be distressing and, in turn, emotional distress can exacerbate PPCS. 12 , 54

Although the PHQ-9 total score cutoff of at least 10 and the algorithm of 5 or more symptoms with a score of at least 2 performed similarly in the full sample, the latter was more robust in the PPCS-present subgroup, providing a reason to favor it in specialty concussion clinic settings. The relatively simple and familiar cutoff of at least 10 could be used in primary care with only a modest loss of PPV. Further, because PPCS and mental health symptoms overlap, a detailed clinical assessment is needed to disentangle which symptoms are attributable to a mental health diagnosis, such as by querying the onset and course to determine whether they align better with that diagnosis.

Our analyses also revealed that the GAD-7 was slightly better at detecting the presence of PTSD compared with the PC-PTSD-5. The AUC for the GAD-7 was greater than 0.80, similar to a previous study of patients seen in primary care settings. 33 Combining both questionnaires (PC-PTSD-5 and GAD-7) compared with each questionnaire alone was associated with a modest increase in the ability to detect PTSD (difference in AUC, 0.05; P  < .001), but was likely not clinically meaningful. Using only the GAD-7 to screen for both anxiety disorders and PTSD is most efficient. However, if a high specificity (>0.85) is important, using the PC-PTSD-5 with a higher cutoff—or combining both questionnaires—may be more appropriate.

This study has some limitations. Although past or current mental health problems were not inclusion criteria, a self-selection bias may have resulted in an overrepresentation of patients with these characteristics. However, our sample is likely representative of patients who seek follow-up care for mTBI and undergo mental health screening for clinical purposes. Older adults and Black and Hispanic patients were underrepresented in our sample. Our sample size was larger than those of previous diagnostic accuracy studies in mTBI, but still relatively small for establishing the optimal cutoffs and precise confidence intervals of the estimates. 55 Because of the low prevalence of PTSD (48 cases [9.6%]) and of all mental health disorders in the PPCS-absent subgroup, the estimates of diagnostic accuracy in these analyses had wider 95% CIs. Another limitation is that psychodiagnostic interviewing to determine the “true state” of mental health disorders was performed by research personnel rather than physicians or psychologists. Standardized assessor training, use of a highly structured and validated diagnostic interview (the MINI), and ongoing supervision by a psychologist mitigate this concern. The MINI is a relatively streamlined diagnostic interview and may overidentify cases of depression compared with the Structured Clinical Interview for DSM-5 . 56

The findings of this diagnostic study suggest that the PHQ-9 can be used to accurately identify MDE, the GAD-7 can be used to identify anxiety disorders, and the PC-PTSD-5 can be used to identify PTSD after mTBI, regardless of PPCS burden. Concurrent PPCS lower their specificity, but given the higher prevalence of mental health disorders in this patient group, a positive mental health screen result should similarly trigger a formal diagnostic evaluation. The combination of GAD-7 and PC-PTSD-PC optimize detection of PTSD after mTBI but are marginally better than the GAD-7 alone. Future research should corroborate optimal test cutoffs for this population.

Accepted for Publication: May 24, 2024.

Published: July 23, 2024. doi:10.1001/jamanetworkopen.2024.24076

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Gitaari M et al. JAMA Network Open .

Corresponding Author: Noah D. Silverberg, PhD, Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC V6T 1Z4, Canada ( [email protected] ).

Author Contributions: Dr Silverberg had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Silverberg.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Gitaari, Panenka.

Critical review of the manuscript for important intellectual content: Mikolić, Panenka, Silverberg.

Statistical analysis: Gitaari, Mikolić.

Obtained funding: Panenka, Silverberg.

Administrative, technical, or material support: Silverberg.

Supervision: Mikolić, Silverberg.

Conflict of Interest Disclosures: Dr Silverberg reported receiving grant funding from the Canadian Institutes of Health Research, Canada Foundation for Innovation, Mitacs, Ontario Brain Institute, US Department of Defense, WorkSafeBC, and VGH&UBC Hospital Foundation for operating costs during the conduct of the study; receiving clinical and medical-legal neuropsychological consulting fees (<10% of total income) from Dr Noah Silverberg Inc outside the submitted work; receiving speaker fees for providing continuing medical education on concussion and traumatic brain injury; and serving as chair of the American Congress of Rehabilitation Medicine’s Brain Injury Special Interest Group Task Force on Mild TBI, as an expert panel member for the Living Concussion Guidelines, and as an external reviewer for other clinical practice guidelines on concussion and traumatic brain injury (unpaid). No other disclosures were reported.

Funding/Support: The parent study was funded by a Canadian Institutes of Health Research Project Grant and by the VGH&UBC Hospital Foundation. Dr Mikolić was supported by the University of British Columbia Institute of Mental Health Marshall Fellows Program during her work on this study. Ms Gitaari received an Undergraduate Student Research Award from the Canadian Institutes of Health Research during her work on this study.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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