What components should be included in a comprehensive mental health assessment questionnaire for a patient presenting with anxiety, including past history, current present illness, and risk assessment?

Comprehensive Mental Health Assessment Questionnaire for Anxiety

Use the GAD-7 as your primary screening tool for anxiety assessment, supplemented by the PHQ-9 for comorbid depression, followed by structured evaluation of past psychiatric history, current symptomatology, functional impairment, and immediate risk to self or others. 1

Initial Screening Instruments

GAD-7 (Generalized Anxiety Disorder-7 Scale)

Administer this 7-item self-report scale asking about the past two weeks: 1, 2

• Feeling nervous, anxious, or on edge
• Not being able to stop or control worrying
• Worrying too much about different things
• Trouble relaxing
• Being so restless that it is hard to sit still
• Becoming easily annoyed or irritable
• Feeling afraid as if something awful might happen

Scoring: Rate each item 0-3 (0="not at all," 1="several days," 2="more than half the days," 3="nearly every day"). Total scores range 0-21: 0-4 minimal anxiety, 5-9 mild anxiety, 10-14 moderate anxiety, 15-21 severe anxiety. 1, 2

Include the functional impairment question: "If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?" (Not difficult at all/Somewhat difficult/Very difficult/Extremely difficult) 1

PHQ-9 (Patient Health Questionnaire-9)

Screen for comorbid depression given the high comorbidity rate between anxiety and depression: 1, 3

Assess the 9 DSM criteria for depression over the past two weeks, including the critical item about thoughts of self-harm or death. 1 Scores range 0-27: 0-4 minimal, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe depression. 2

Immediate Risk Assessment

Before proceeding with comprehensive assessment, evaluate for emergency psychiatric conditions: 1

• Risk of harm to self: Suicidal ideation, intent, plan, access to means, prior attempts, hopelessness
• Risk of harm to others: Homicidal ideation, intent, plan, access to weapons
• Severe agitation: Inability to remain calm, aggressive behavior
• Psychosis: Hallucinations, delusions, disorganized thinking
• Confusion/delirium: Altered mental status, disorientation, fluctuating consciousness

If YES to any of the above: Immediate referral for emergency psychiatric evaluation, facilitate safe environment, initiate one-to-one observation. 1

Past Psychiatric History

Prior Anxiety and Mood Disorders

Document the following: 1

• Personal history: Previous diagnoses of anxiety disorders (GAD, panic disorder, social anxiety disorder, specific phobias, OCD, PTSD), depression, or other psychiatric conditions
• Family history: First-degree relatives with anxiety disorders, depression, or other mental illness
• Prior treatment: Previous psychotherapy (type, duration, response), medications (names, doses, duration, efficacy, side effects, reasons for discontinuation)
• Treatment response: What worked, what didn't work, and why

Comorbid Psychiatric Conditions

Screen for conditions that commonly co-occur with anxiety: 1, 4

• Other anxiety disorders: Panic disorder (6.8% prevalence in primary care), social phobia (6.2%), specific phobias, OCD, PTSD 1, 3
• Mood disorders: Major depression (22% prevalence in anxiety patients), bipolar disorder 1
• Substance use: Current or past alcohol use disorder, drug use disorder, prescription medication misuse 1
• History of substance abuse: Timing, substances used, treatment received, current sobriety status 1

Developmental and Trauma History

Assess for early-life factors and traumatic experiences: 1

• Childhood anxiety or behavioral problems
• History of trauma (physical, sexual, emotional abuse; neglect; witnessing violence)
• Adverse childhood experiences
• Age of onset of first anxiety symptoms

Current Present Illness

Onset and Duration

Characterize the current anxiety episode: 1

• When did current symptoms begin?
• Was onset gradual or sudden?
• What was happening in the patient's life at onset?
• Have symptoms been continuous or episodic?

Core Anxiety Symptoms

Assess the specific manifestations of anxiety: 1, 3

• Excessive worry: Multiple areas of concern (finances, health, family, work), difficulty controlling worry, worry disproportionate to actual risk
• Physical symptoms: Restlessness, fatigue, muscle tension, trembling, sweating, palpitations, shortness of breath, chest pain, dizziness, nausea, paresthesias 3, 5
• Cognitive symptoms: Difficulty concentrating, mind going blank, irritability, fear of losing control, fear of dying 1, 5
• Sleep disturbance: Difficulty falling asleep, staying asleep, or restless unsatisfying sleep 1, 5

Panic Attacks (if present)

If patient reports panic attacks, document: 1

• Frequency and duration of attacks
• Unexpected versus situationally triggered
• Specific symptoms during attacks (palpitations, sweating, trembling, shortness of breath, choking sensation, chest pain, nausea, dizziness, derealization/depersonalization, fear of losing control, fear of dying, paresthesias, chills/hot flushes)
• Anticipatory anxiety between attacks
• Avoidance behaviors (agoraphobia)

Social Anxiety Features (if present)

Evaluate for social anxiety disorder: 1

• Fear of social or performance situations
• Fear of embarrassment or humiliation
• Avoidance of social situations
• Impact on work, school, or relationships

Functional Impairment

Quantify the impact on daily life: 1

• Occupational: Ability to work, productivity, absenteeism, job performance
• Social: Relationships with family and friends, social activities, isolation
• Self-care: Personal hygiene, household responsibilities, medical care adherence
• Quality of life: Overall life satisfaction, enjoyment of activities

Stressors and Precipitants

Identify current life stressors: 1

• Medical illness (cancer diagnosis, chronic disease, recent hospitalization)
• Relationship problems (marital conflict, divorce, family crisis)
• Financial difficulties
• Occupational stress (job loss, work conflicts)
• Bereavement or loss
• Major life transitions

Medical History and Physical Symptoms

Medical Causes of Anxiety

Rule out medical conditions that can mimic or cause anxiety: 1

• Endocrine: Hyperthyroidism, hypoglycemia, pheochromocytoma, Cushing's syndrome
• Cardiac: Arrhythmias, angina, myocardial infarction, heart failure
• Pulmonary: Asthma, COPD, pulmonary embolism, hypoxia
• Neurological: Seizure disorders, vestibular dysfunction, multiple sclerosis
• Other: Anemia, electrolyte imbalances, vitamin deficiencies

Current Medications

Document all medications that may cause or worsen anxiety: 1

• Stimulants (caffeine, amphetamines, methylphenidate)
• Corticosteroids
• Thyroid hormones
• Bronchodilators
• Decongestants
• Interferon
• Withdrawal from benzodiazepines, alcohol, or opioids

Substance Use

Current use of substances that affect anxiety: 1

• Alcohol (quantity, frequency, pattern)
• Caffeine (coffee, energy drinks, amount per day)
• Nicotine
• Cannabis
• Illicit drugs
• Over-the-counter medications

Risk Factors and Protective Factors

Risk Factors for Severe or Chronic Anxiety

Identify factors associated with worse outcomes: 1

• Presence of other chronic illnesses
• Multiple comorbid psychiatric disorders
• History of trauma
• Poor social support
• Low socioeconomic status
• Unemployment
• Younger age at onset
• Family history of anxiety or mood disorders

Protective Factors

Assess strengths and resources: 1

• Effective coping skills
• Strong social support network
• Stable housing and employment
• Access to healthcare
• Prior positive response to treatment
• Motivation for treatment
• Insight into illness

Suicide Risk Assessment

For any patient with moderate to severe anxiety, conduct formal suicide risk assessment: 1

Suicidal Ideation

• Passive thoughts of death ("I wish I were dead")
• Active suicidal thoughts ("I want to kill myself")
• Frequency and intensity of thoughts
• Ability to control thoughts

Suicidal Intent and Plan

• Intent to act on thoughts
• Specific plan (method, location, timing)
• Access to means (firearms, medications, other lethal means)
• Preparatory behaviors (giving away possessions, saying goodbye)

Risk Factors for Suicide

• Prior suicide attempts (strongest predictor)
• Family history of suicide
• Recent psychiatric hospitalization
• Comorbid depression (especially with hopelessness)
• Substance abuse
• Social isolation
• Recent significant loss
• Chronic pain or medical illness
• Impulsivity

Protective Factors Against Suicide

• Reasons for living (children, religious beliefs, future plans)
• Strong therapeutic alliance
• Family support
• No access to lethal means
• Help-seeking behavior

Additional Assessment Measures (if indicated)

Beck Anxiety Inventory (BAI)

Consider for more detailed somatic symptom assessment: 1

21-item scale assessing autonomic arousal and panic symptoms. Score ≥10 suggests mild anxiety, ≥19 suggests moderate anxiety. 1

Beck Depression Inventory (BDI)

If comorbid depression suspected: 1

21-item scale with scores ≥20 suggesting clinical depression. 1

Clinical Pitfalls to Avoid

Common assessment errors: 1

• Failing to screen for comorbid depression: Up to 75% of anxiety interventions show significant reduction in depressive symptoms, indicating high comorbidity. 1
• Overlooking substance-induced anxiety: Always assess for medical and substance-induced causes before attributing symptoms to primary anxiety disorder. 1
• Missing subthreshold conditions: Subthreshold anxiety is 2-4 times more common than diagnostic-level disorders in primary care and warrants treatment. 1
• Inadequate suicide risk assessment: Patients with anxiety are at increased risk for suicide, particularly when comorbid with depression. 1, 3
• Ignoring functional impairment: Symptom severity alone is insufficient; always assess impact on work, relationships, and self-care. 1
• Assuming single anxiety disorder: Patients commonly have multiple anxiety disorders; screen for panic disorder, social anxiety, specific phobias, OCD, and PTSD. 1, 4