Screening for risk and substance use: the instruments and the questions
Last reviewed September 2026 by Dr. Andrew Wichterman · Aligned to the current NCE blueprint. Valid for exams through June 30, 2027.
AI-narrated overview made with Google NotebookLM. The written lesson below is by Dr. Andrew Wichterman.
Every intake screens for suicide, violence and substance use, and the exam names specific tools. This lesson covers the brief instruments, what a positive screen means, and how screening differs from assessment.
Try to answer each from memory first, even if you have to guess. Guessing before reading makes the answer stick; reveal only after you have tried.
Screening versus assessment
A screen is brief, given to everyone, and answers one question: does this person need a closer look? An assessment is longer, given after a positive screen, and describes the problem's nature and severity. Screens are built for sensitivity, catching true cases, and accept more false positives; assessments are built for specificity. A positive screen is never a diagnosis. The exam asks which tool fits which purpose and what the counselor does with a result. The answer to a positive screen is always further assessment, not immediate treatment and not dismissal.
Suicide risk
Risk is assessed directly by asking about ideation, plan, intent, means and prior attempts; asking does not plant the idea. Static risk factors include prior attempts, family history, male sex, older age and chronic illness. Dynamic factors include current ideation, hopelessness, agitation, intoxication, recent loss and access to lethal means. Protective factors include reasons for living, connectedness, treatment engagement and restricted means. The Columbia Suicide Severity Rating Scale, C-SSRS, structures the questions from passive ideation to method, intent and plan. The PHQ-9 is a depression screen whose ninth item asks about thoughts of death and triggers a full risk assessment when endorsed. Safety planning, a collaborative written list of warning signs, coping steps, contacts and means restriction, has replaced no-suicide contracts, which the exam treats as ineffective.
Violence and abuse
Homicide risk uses the same structure: ideation, target, plan, means, history of violence, and current intoxication or psychosis, with the duty to protect following a credible threat toward an identifiable person. Intimate partner violence is screened with direct questions asked privately, never with the partner present, and the response is safety planning and resources, not couples counseling. Child abuse and elder or dependent-adult abuse are screened by observation and direct questions, and suspicion, not proof, triggers the mandated report. The exam distinguishes the screening question, asked of everyone, from the investigation, which is the job of protective services.
Substance use screens
The CAGE asks four questions: have you tried to Cut down, been Annoyed by criticism, felt Guilty, or needed an Eye-opener; two or more positives is a positive screen for alcohol problems. The AUDIT, from the World Health Organization, has ten items scoring consumption, dependence and harm, with a cutoff around eight; it is the exam's answer for a brief validated alcohol screen. The DAST-10 screens for drug use other than alcohol. The CRAFFT is the adolescent screen: Car, Relax, Alone, Forget, Friends, Trouble. The MAST is the older, longer alcohol instrument. SBIRT, screening, brief intervention and referral to treatment, is the public health model that puts these screens in every setting. The ASAM criteria are used after a positive screen to place a client in a level of care.
Depression, anxiety and trauma screens
The PHQ-9 scores the nine DSM criteria for a major depressive episode on a 0 to 27 scale; the PHQ-2 is its two-item gate. The GAD-7 screens anxiety on a 0 to 21 scale and is the tool named when a treatment plan sets a measurable anxiety goal. The Beck Depression Inventory, BDI-II, has twenty-one items and is the classic self-report depression measure; it is a symptom inventory, not a diagnostic test. The PCL-5 screens for PTSD against the DSM-5 criteria. The Edinburgh Postnatal Depression Scale screens perinatal depression. The MMSE and MoCA screen cognitive impairment. The ACE questionnaire counts adverse childhood experiences. The exam wants the name, the construct and the fact that each is a screen to be followed by clinical assessment.
Without scrolling up, write everything you remember from this lesson. Then check yourself against the key terms. Recalling the whole lesson once, right after reading it, does more than reading it twice.
Ten more questions from the whole domain, with an explanation after each answer.
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