A Two Question Screen for Mental Health Opportunities

Document Type : RESEARCH PAPER


1 UK Harkness Fellowship in Health Care Policy and Practice Innovations, The Value Institute / Department of Surgery and Peri-operative Care, The University of Texas at Austin, Dell Medical School, Austin, TX, USA

2 Department of Surgery and Peri-operative Care, The University of Texas at Austin, Dell Medical School, Austin, TX, USA

3 Center for Health Communication, The University of Texas at Austin, Dell Medical School, Austin, TX, USA


Background: Shortened versions of validated PRO measures of coping strategies e.g. PSEQ-2, may facilitate
screening and monitoring of psychological conditions such as depression and anxiety. The primary research
question in this study assesses the sensitivity and specificity of a PSEQ-2 score of less than 10 for important
symptoms of depression (a PHQ-2 score greater than 2), anxiety (GAD-2 score greater than 2), any impactful
prior episode of psychological trauma, and QuickDASH greater than 49. Secondarily we assess the associations
between self-efficacy and other demographic and psychological factors on the magnitude of limitations and pain
Methods: We performed a retrospective PRO evaluation in 926 adult patients attending upper extremity clinic
between 1st January 2018 and 31st January 2019. Demographic factors were assessed using electronic medical
records and PRO data using an online platform. Patients included 556 (60%) women, 370 (40%) men (mean 51
years + 14 (range, 19-88), mostly (n=584, 63%) with safety net insurance.
Results: A PSEQ-2 scoring threshold of less than 10 was 81% sensitive for a PHQ-2 score of 3 or greater, 84%
sensitive for a GAD-2 score of 3 or greater, 84% sensitive for one or more important psychological traumas, and 82%
sensitive for a QuickDASH of 50 or greater. PSEQ-2 less than 10 was independently associated with greater upper
extremity limitations (β=11 [6.3 to 17, 95% Confidence interval [C.I], p <0.001) and pain intensity (β=0.92 (0.31 to 1.5,
95% C.I) P=0.003) amongst other psychological and demographic factors.
Conclusion: A PSEQ-2 score less than 10 might, along with verbal and non-verbal signs of distress, be a useful
way to introduce the use of more sensitive screening questionnaires about anxiety or depression, or open up
the option of speaking directly to mental or social health professionals. Future studies are required to test this
Level of evidence: III


1. Porter ME, Larsson S, Lee TH. Standardizing Patient
Outcomes Measurement. N Engl J Med. 2016;
2. Bot AGJ, Nota SPFT, Ring D. The Creation of an
Abbreviated Version of the PSEQ: The PSEQ-2.
Psychosomatics. 2014;55(4):381–5.
3. Briet JP, Bot AGJ, Hageman MGJS, Menendez
ME, Mudgal CS, Ring DC. The pain self-efficacy
questionnaire: validation of an abbreviated two-item
questionnaire. Psychosomatics. 2014;55(6):578–85.
4. Nicholas MK, McGuire BE, Asghari A. A 2-Item
Short Form of the Pain Self-Efficacy Questionnaire:
Development and Psychometric Evaluation of PSEQ-
2. J Pain. 2015;16(2):153–63.
5. Kortlever JTP, Janssen SJ, van Berckel MMG,
Ring D, Vranceanu AM. What Is the Most Useful
Questionnaire for Measurement of Coping Strategies
in Response to Nociception? Clin Orthop Relat Res.
6. Ahmed SA, Shantharam G, Eltorai AEM, Hartnett DA,
Goodman A, Daniels AH. The effect of psychosocial
measures of resilience and self-efficacy in patients
with neck and lower back pain. Spine J Off J North Am
Spine Soc. 2019;19(2):232–7.
7. Chiarotto A, Vanti C, Cedraschi C, Ferrari S, de Lima
E Sà Resende F, Ostelo RW, et al. Responsiveness and
Minimal Important Change of the Pain Self-Efficacy
Questionnaire and Short Forms in Patients With
Chronic Low Back Pain. J Pain Off J Am Pain Soc.
8. Hageman M, Briet J, Oosterhoff T, Bot A, Ring
D, Vranceanu A-M. The Correlation of Cognitive
Flexibility with Pain Intensity and Magnitude
of Disability in Upper Extremity Illness. J Hand 
Microsurg. 2016;06(02):59–64.
9. Jayakumar P, Overbeek CL, Lamb S, Williams M,
Funes C, Gwilym S, et al. What Factors Are Associated
With Disability After Upper Extremity Injuries? A
Systematic Review. Clin Orthop. 2018;476(11):2190–
10. Menendez ME, Baker DK, Oladeji LO, Fryberger
CT, McGwin G, Ponce BA. Psychological Distress Is
Associated with Greater Perceived Disability and Pain
in Patients Presenting to a Shoulder Clinic. J Bone
Joint Surg Am. 2015;97(24):1999–2003.
11. Beaton DE, Wright JG, Katz JN. Development of the
QuickDASH: Comparison of Three Item-Reduction
Approaches. VO LU M E. 2005;9.
12. Kroenke K, Spitzer RL, Williams JBW. The Patient
Health Questionnaire-2: validity of a two-item
depression screener. Med Care. 2003;41(11):1284–92.
13. Löwe B, Kroenke K, Gräfe K. Detecting and monitoring
depression with a two-item questionnaire (PHQ-2). J
Psychosom Res. 2005;58(2):163–71.
14. Bingham CO, Noonan VK, Auger C, Feldman DE,
Ahmed S, Bartlett SJ. Montreal Accord on Patient-
Reported Outcomes (PROs) use series – Paper 4:
patient-reported outcomes can inform clinical
decision making in chronic care. J Clin Epidemiol.
15. Guattery JM, Dardas AZ, Kelly M, Chamberlain A,
McAndrew C, Calfee RP. Floor Effect of PROMIS
Depression CAT Associated With Hasty Completion
in Orthopaedic Surgery Patients. Clin Orthop.
16. Mintken PE, Glynn P, Cleland JA. Psychometric
properties of the shortened disabilities of the Arm,
Shoulder, and Hand Questionnaire (QuickDASH) and 
Numeric Pain Rating Scale in patients with shoulder
pain. J Shoulder Elbow Surg. 2009;18(6):920–6.
17. Tsang P, Walton D, Grewal R, MacDermid J. Validation
of the QuickDASH and DASH in Patients With Distal
Radius Fractures Through Agreement Analysis. Arch
Phys Med Rehabil. 2017;98(6):1217-1222.e1.
18. Kroenke K, Spitzer RL, Williams JBW, Monahan PO,
Löwe B. Anxiety disorders in primary care: prevalence,
impairment, comorbidity, and detection. Ann Intern
Med. 2007;146(5):317–25.
19. Skapinakis P. The 2-item Generalized Anxiety
Disorder scale had high sensitivity and specificity
for detecting GAD in primary care. Evid Based Med.
20. Prins A, Bovin MJ, Smolenski DJ, Marx BP, Kimerling R,
Jenkins-Guarnieri MA, et al. The Primary Care PTSD
Screen for DSM-5 (PC-PTSD-5): Development and
Evaluation Within a Veteran Primary Care Sample. J
Gen Intern Med. 2016;31(10):1206–11.
21. Hudak PL, Amadio PC, Bombardier C, Beaton D, Cole
D, Davis A, et al. Development of an upper extremity
outcome measure: The DASH (disabilities of the arm,
shoulder, and head). Am J Ind Med. 1996;29(6):602–8.
22. Bot AGJ, Vranceanu A-M, Herndon JH, Ring DC.
Correspondence of patient word choice with psychologic
factors in patients with upper extremity illness.
Clin Orthop. 2012;470(11):3180–6.
23. Wilkens SC, Lans J, Bargon CA, Ring D, Chen NC. Hand
Posturing Is a Nonverbal Indicator of Catastrophic
Thinking for Finger, Hand, or Wrist Injury. Clin Orthop.
24. Vranceanu A-M, Safren S, Zhao M, Cowan J, Ring D.
Disability and Psychologic Distress in Patients with
Nonspecific and Specific Arm Pain. Clin Orthop.