Published September 5, 2026

NCMHCE Screening Instruments Cheat Sheet (PHQ-9, GAD-7, PCL-5, AUDIT, C-SSRS, MoCA and More)

By David Zimmerman · 8 min read · Clinical content

Instrument questions are some of the most learnable points on the NCMHCE. The exam rarely asks you to score a measure; it asks you to pick the right tool for a presentation, or to notice when a plausible tool measures the wrong construct. This is the reference table, the traps, and an eight-item quiz to check yourself.

The table

Cut-offs are the commonly used clinical thresholds; the exam tests what an instrument is for far more than exact numbers.

InstrumentMeasuresFormatCommonly used thresholds
PHQ-9Depression severity (past 2 weeks)9 items, 0–27; item 9 = ideation flag5 mild · 10 moderate · 15 moderately severe · 20 severe
GAD-7Generalized anxiety severity7 items, 0–215 mild · 10 moderate · 15 severe
PCL-5PTSD symptom severity (DSM-5)20 items, 0–80Roughly 31–33 suggests probable PTSD; confirm clinically
CAPS-5PTSD diagnosis (clinician-administered)Structured interviewGold-standard diagnostic interview, not a screen
AUDIT / AUDIT-CHazardous alcohol use10 items (0–40) / 3 items (0–12)AUDIT ≥ 8; AUDIT-C ≥ 4 men, ≥ 3 women
CAGEAlcohol problem screen4 yes/no items≥ 2 positive
DAST-10Drug use (non-alcohol) problems10 items≥ 3 moderate concern
C-SSRSSuicidal ideation severity and behaviorStructured screen / full scaleAny specific plan or intent = high risk
BDI-II / BAIDepression / anxiety severity (Beck)21 items each, 0–63BDI-II: 14 mild · 20 moderate · 29 severe
MoCACognitive screen (sensitive to mild impairment)30 points< 26 abnormal
MMSECognitive screen (dementia-range impairment)30 points< 24 abnormal
MDQBipolar spectrum screen (lifetime)13 symptom items + clustering + impairmentPositive screen → clinical interview
Y-BOCSOCD symptom severity10 items, 0–4016+ moderate
ASRS v1.1Adult ADHD screen6-item screener4+ shaded items positive
VanderbiltChildhood ADHD (parent / teacher)Rating scalesSymptom counts by presentation
EPDSPerinatal depression10 items, 0–30≥ 10–13 warrants follow-up; check item 10 (self-harm)

The traps

  • Real instrument, wrong construct. The PHQ-9 offered for suicide risk; the BAI offered for a PTSD presentation; the AUDIT for drug use. Match the construct, then the tool.
  • Screen vs diagnosis. Screens (PHQ-9, GAD-7, PCL-5, MDQ) flag; structured interviews and clinical judgment diagnose. An item asking what “confirms” a diagnosis is not answered by a self-report screen.
  • Sensitivity matters for cognition. Mild cognitive complaints in an educated adult: MoCA over MMSE.
  • Item-level follow-ups. PHQ-9 item 9 and EPDS item 10 require a risk conversation regardless of total score.
  • Use scores to make decisions now, not only as baselines. A PHQ-9 of 22 with active ideation changes today’s plan; see Domain 3A.

Interactive

Which instrument?

1 of 8

A 42-year-old reports constant worry across work, health, and money, muscle tension, and poor sleep for eight months. Which instrument quantifies severity?

Instruments appear inside full cases

Practice choosing the right tool in context: 5 full case simulations and 18 drills are free, every option explained.

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Study move that works

Copy the table onto one page by hand, then cover the left column and try to name the instrument from the description. Ten minutes a day for a week and the distractors stop looking plausible. Pair it with the Domain 2B practice questions and the suicide risk assessment guide.

Sources

  1. Patient Health Questionnaire (PHQ-9) and GAD-7 screener instruments
  2. National Center for PTSD — PTSD Checklist for DSM-5 (PCL-5)
  3. Columbia-Suicide Severity Rating Scale (C-SSRS) — The Columbia Lighthouse Project
  4. Montreal Cognitive Assessment (MoCA)
  5. American Psychiatric Association — Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)
  6. Substance Abuse and Mental Health Services Administration (SAMHSA)

Frequently asked questions

Which screening instruments do I need to know for the NCMHCE?

At minimum the PHQ-9, GAD-7, PCL-5, AUDIT and AUDIT-C, CAGE, DAST-10, C-SSRS, MoCA and MMSE, MDQ, Y-BOCS, ASRS, Vanderbilt, and EPDS, including what each measures and what it does not.

Does the NCMHCE ask for exact cut-off scores?

Rarely. It tests matching the instrument to the presentation and recognizing screens versus diagnostic interviews. Knowing common thresholds helps but construct matching matters more.

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