MSDP Study MSDP Study

Mental and Substance Use Disorders Prevalence Study (MDPS)

MDPS Attachments A-J

OMB: 0930-0388

Document [pdf]
Download: pdf | pdf
Attachment Table of Contents

Attachment

Page

Attachment A – Household Roster .....................................................................................4
Attachment B – Household Roster PAPI Instrument ..........................................................19
Attachment C – Household Screening Instrument .............................................................24
Attachment D – Household Screening PAPI Instrument ....................................................91
Attachment E – Clinical Interview .......................................................................................104
MDPS Clinical Interview (non-SCID) ........................................................................105
Medication Showcard for use with the MDPS Clinical Interview ...........................186
Income Showcard for use with the MDPS Clinical Interview .................................187
Structured Clinical Interview for DSM-IV (SCID) .....................................................188
SCID for Prison Inmates ..........................................................................................257
Short Blessed Test ...................................................................................................309
Attachment G – Informed Consent Forms..........................................................................311
Screening Survey Informed Consent.......................................................................312
Household Consent to Participate ..........................................................................315
Hospital Volunteers Consent to Participate ...........................................................319
Jail Volunteers .........................................................................................................323
Prisoner Volunteers Consent to Participate ...........................................................326
Shelter Volunteers Consent to Participate .............................................................330
Proxy Consent to Participate ..................................................................................334
Attachment H – Household Respondent Materials ............................................................338
Roster Mailing 1 Lead Letter ...................................................................................339
Roster Mailing 2 Pressure Seal Self-Mailer .............................................................340
Roster Mailing 3 Postcard 1 ....................................................................................342
Roster Mailing 4 Reminder Letter...........................................................................343

i

Roster Mailing 5 Paper Reminder Letter ................................................................344
Roster Mailing 6 Postcard 2 ....................................................................................345
Roster Mailing 7 Final Pressure Seal Self-Mailer ....................................................346
Screener Mailing 1 Lead Letter ...............................................................................348
Screener Mailing 2 Pressure Seal Self-Mailer .........................................................349
Screener Mailing 3 Reminder Letter .......................................................................351
Screener Mailing 4 Follow-up Reminder Letter ......................................................352
Screener Mailing 5 Final Postcard...........................................................................353
Screener Mailing 6 Final Pressure Seal Self-Mailer ................................................354
Screener Reminder Emails ......................................................................................355
Screener Notification Card......................................................................................360
Clinical Interview Scheduling Script ........................................................................361
Clinical Interview Appointment Emails & Letters ...................................................365
Clinical Interview Follow-Up Letter ........................................................................372
Clinical Interview Recontact Letter (Screener CI Reluctance) ................................373
Letters (Unable to Contact, Controlled Access, Call Me, Reluctance) ....................374
Automated Emails: New, Rescheduled, Canceled, Missed Appointments ............383
Texts ........................................................................................................................385
Unable to Contact Text ...........................................................................................386
Website Content .....................................................................................................387
COVID Risk Form Vaccinated Protocol A ................................................................393
COVID Risk Form Unvaccinated Protocol B ............................................................395
Incentive/Thank You E-mail (Roster, Screener, CI) .................................................397
Incentive Receipt In-person ....................................................................................398
Brochure Text..........................................................................................................399
FAQs ........................................................................................................................401
Field and Clinical Interviewer Authorization Letter ................................................405

ii

Attachment I – Nonhousehold Facility Materials ...............................................................406
Recruitment Commencement Letter State DOCs...................................................407
Recruitment Commencement Letter Combined ....................................................408
National Organizations Letter of Support Combined .............................................410
SAMHSA NSMH Letter of Support ..........................................................................411
NSMH 1-page study description .............................................................................412
Recruitment Commencement Letter Follow-up Email ...........................................413
Letter to Facility POC ..............................................................................................414
NSMH FAQs Facility Staff ........................................................................................416
Summary of Clinical Interview Questionnaire Nonhousehold ...............................419
SAMHSA NSMH Thank You Letter...........................................................................421
Attachment J – Nonhousehold Respondent Materials.......................................................422
NSMH FAQs Respondents .......................................................................................423
Contact Cards ..........................................................................................................424
Shelter Flyer ............................................................................................................425
Shelter Flyer No Incentive .......................................................................................426
Jail Flyer...................................................................................................................428
Jail Contact Card......................................................................................................429
COVID Risk Form Nonhousehold ............................................................................430

iii

Attachment A
Household Roster
1) Household Roster Specifications

NSMH Roster Specifications
MODE = WEB, PHONE, OR IN-PERSON
PROGRAMMER NOTE: FOR WEB, INCLUDE “Not sure” AND “Prefer not to answer” AS RESPONSE
OPTIONS IF A RESPONDENT MOVES FORWARD WITHOUT SELECTING AN ANSWER. FOR PHONE AND
IN-PERSON, INCLUDE DK AND REF ON ALL QUESTIONS.
** INDICATES THAT RESPONSE OPTIONS SHOULD BE IN ALL CAPS FOR INTERVIEWER ADMINISTERED
MODES.
*** INDICATES THAT TEXT SHOULD BE IN ALL CAPS FOR INBOUND CATI ONLY
STUDY INTRO [IF WEB] RTI International, an independent nonprofit research institute, is conducting a
nationwide study sponsored by the Substance Abuse and Mental Health Services
Administration. You should have received a letter explaining the study.
***[IF PHONE] Hello, my name is [FI NAME], and I’m calling from RTI International, an
independent nonprofit research institute. We are conducting a nationwide study
sponsored by the Substance Abuse and Mental Health Services Administration. You
should have received a letter explaining the study.
[IF IN-PERSON] Hello, my name is [FI NAME] with RTI International in North Carolina.
We are conducting a nationwide study sponsored by the Substance Abuse and Mental
Health Services Administration. You should have received a letter explaining the study.
R1

[IF WEB] Would you prefer to respond in English or Spanish?
English
Spanish [SWITCH TO SPANISH TRANSLATION IF SELECTED]

**R2

First, to verify, do you receive mail at [ADDRESS FILL]?
1
YES
2
NO

R2a

[IF R2 = NO] We need to speak to a resident of this address. Thank you for your time.
END ROSTER

EDITAD [IF CITY_STYLE_ADDRESS = 0] What is the physical address, including zip code, for this property?
STREET: (NUMBER AND STREET NAME)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
1

PROGRAMMER NOTE: EDITAD REPLACES ADDRESSFILL IF EDITAD IS NOT BLANK OR DK OR REF;
IF ANY FIELD IN EDITAD = DK/REF, ADDRESSFILL = “this address”;
ADDRESSFILL1 STORES THE ORIGINAL MAILING ADDRESS.
PROGRAMMER NOTE: ALLOW FOR FOR D.C.
R3

[IF R2 = YES OR CITY_STYLE_ADDRESS = 0] How old are you?
_______ Years old (RANGE 1-110)

POP UP: [IF WEB AND R3 < 18] These questions must be answered by someone aged 18 or older. Please
ask an adult to complete these questions. CLOSE [BACK TO R3]
[IF (PHONE OR IN-PERSON) AND R3 < 18] These questions must be answered by someone aged
18 or older. Is there someone who lives here and is over 18 years old available? CLOSE [BACK TO STUDY
INTRO]
**CARI [IF PHONE] This call may be recorded for quality assurance purposes.
[IF IN-PERSON] I am recording part of this interview so my supervisor can make sure I am
following the correct procedures. The recording will be kept private and will be deleted after my
work has been reviewed. If you don’t want me to record the interview I will stop the recording.
We can still do the interview even if you don’t want it to be recorded.
May we record part of the interview?
1
2
**R4

YES
NO

[IF (WEB OR PHONE) AND R3 ≥ 18] Your address is one of 60,000 in the United States randomly
chosen for the National Study of Mental Health. This study, sponsored by the Substance Abuse
and Mental Health Services Administration, collects information for research and program
planning by asking about:
•
Mental health;
•
health behaviors;
•
access to, and use of, medical care or treatment; and
•
tobacco, alcohol, and drug use or non-use.
If you answer a brief set of questions about the people who live here, you will receive a $10
electronic pre-paid Visa or check. And, if there are people in the household who are eligible,
they will be paid $20 to complete a 15-minute screening survey. Your answers will be used for
statistical purposes only and your participation is voluntary.

[IF IN-PERSON AND R3 ≥ 18] Your address is one of 60,000 in the United States randomly chosen
for the National Study of Mental Health. This study, sponsored by the Substance Abuse and
Mental Health Services Administration, collects information for research and program planning
by asking about:
•
Mental health;
2

•
•
•

health behaviors;
access to, and use of, medical care or treatment; and
tobacco, alcohol, and drug use or non-use.

If you answer a brief set of questions about the people who live here, you will receive $10 in
cash. And, if there are people in the household who are eligible, they will be paid $20 to
complete a 15-minute screening survey. Your answers will be used for statistical purposes only
and your participation is voluntary.
**GQU Does anyone not related to you live at [ADDRESS FILL OR] to receive help or support for:
•
•
•
•
•

Developmental disabilities
Physical disabilities
Mental health issues
Substance use issues
Elder care

1
2

YES
NO

**R5

[IF R4 = NEXT] To begin, do you or anyone else in this household consider this to be your or their
primary residence? In other words, is this the address where you or they receive mail?
1
YES
2
NO

R5a

[IF R5 = NO] This needs to be a primary residence to participate. Thank you for your time.
END ROSTER

R6

[IF R3 ≥ 18] Including yourself, how many people consider [ADDRESS FILL] their primary
residence?
• Do include students who live in on-campus housing while at school.
• Do not include anyone who lives most of their time somewhere else even if they are
currently staying here.
_______ # of people, including yourself (RANGE 1-20)

R6a

[IF WEB AND GQU = 0 AND R6 > 8] Thank you for answering these questions. We are unable to
complete this portion of the survey online. Please call 877-267-2910 to complete these
questions or an interviewer will follow up with your household in person.
[EXIT]

PROGRAMMER NOTE: IF WEB AND isGQU = 1 AND R6 > 8, CONTINUE WITH ROSTER. ALLOW UP TO 20
HH MEMBERS TO BE ROSTERED.
R6b

[IF R6 = DK OR REF] We need to know how many people consider this their primary residence to
continue. Thank you for your time.
3

END ROSTER
PROGRAMMER: IF RECORDING CONSENT = YES, STOP RECORDING
R7

[IF R6 > 1]

Of these [R6 FILL] people, how many are now ages 18 and older?
_______ # of adults, including yourself (RANGE 0-R6 FILL)

R7a

[IF R6 > R7]

Of these [R6 – R7] people, how many are ages 12 to 17 years old?
_______ # of children 12 to 17 years old (RANGE 0-(R6-R7))

R7b

[IF R7 = DK OR REF] We need to know how many people at this residence are ages 18 and older
to continue. Thank you for your time.
END ROSTER

R17

[IF R7 ≥ 1]

Is [ADDRESS FILL] …
Owned by you or someone else in this household?
Rented by you or someone else in this household?
Owned or managed by a third party, such as a college dorm or nursing home?
Occupied without payment of rent?

PROGRAMMER NOTE: IF WEB AND R17 = BLANK, SHOW ERROR MESSAGE: This question is important
for classification purposes. Please try to answer if you can. Otherwise select 'Not sure' or 'Prefer
not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND R17 = BLANK, SHOW ERROR MESSAGE: This
question is important for classification purposes. Please try to answer if you can.
R8

[IF R7 > 1]

Next are a few questions about the people who live here. Let’s start with you.

[IF R7 ≥ 1]

What is your first name?
OPEN ENDED RESPONSE
NEXT

DEFINE RRNAMEFILL
RRNAMEFILL = R8
IF R8 = DK/REF, NAMEFILL = you
**R9

[IF R7 ≥ 1]

What is your sex?
Male
Female

4

R11

[IF R7 = 2]
Now we need some general information about the other person in this
household who is age 18 or older.
What is the first name of the other person in this household who is age 18 or older? This
information will only be used to contact this person if they are selected for a screening survey.
OPEN ENDED RESPONSE
[IF R7 > 2]
Now we need some general information about all of the other people in this
household who are ages 18 and older. Let's start with the oldest and work down to the
youngest, not including yourself.
What is the first name of the [oldest/next oldest] person in this household who is age 18 or
older, not including yourself? This information will only be used to contact this person if they are
selected for a screening survey.
OPEN ENDED RESPONSE

DEFINE NAMEFILL
NAMEFILL = R11
IF R11 = DK/REF, NAMEFILL = person # [FILL ROSTER NUMBER]
R11a

[IF R11 NE BLANK] How old is [NAMEFILL]?
______ Years old

**R12 [IF R7 > 1]
What is [NAMEFILL]’s sex?
Male
Female
PROGRAMMER NOTE: [IF WEB] REPEAT R11 THROUGH R12 FOR ALL ROSTER MEMBERS. ONLY INCLUDE
INTRO STATEMENT IN R11 FOR FIRST ROSTER MEMBER.
**R14 [IF WEB AND R7 > 0 AND NO ONE ELSE TO ROSTER] These are the people listed as ages 18 and
older living at [ADDRESS FILL]. Please review this information.
[IF (PHONE OR IN-PERSON) AND R7 > 1 AND NO ONE ELSE TO ROSTER: REVIEW INFORMATION
WITH RESPONDENT AND DETERMINE IF CORRECTIONS NEED TO BE MADE.]
Is this correct?
YES
NO
LIST NAMEFILL, AGE, AND SEX FOR EACH ROSTER MEMBER
5

R14a

[IF WEB AND R14 = NO] Please make any corrections below. To remove a person, delete their
first name. To add a new person, enter the new information in the bottom row.
[IF (PHONE OR IN-PERSON) AND R14=NO] (What needs to be corrected?)
INTERVIEWER: MAKE APPROPRIATE CHANGES
LIST NAMEFILL, AGE, AND SEX FOR EACH ROSTER MEMBER IN EDITABLE TABLE

R15

[IF WEB AND R7 = 1]
Below is a list of health conditions. Have you ever been told by a doctor
or other health care professional that you had any of these conditions?
[IF WEB AND R7 > 1] Below is a list of health conditions. Have any of these household
members ever been told by a doctor or other health care professional that they had any of
these conditions?
[IF (PHONE OR IN-PERSON) AND R7 = 1] Have you ever been told by a doctor or other health
care professional that you had any of the following conditions?
[IF (PHONE OR IN-PERSON) AND R7 > 1] Have any of these household members ever been told
by a doctor or other health care professional that they had any of the following conditions?
Condition
Diabetes?
Heart problems?
Cancer?
Schizophrenia or schizoaffective disorder?
Other problems with emotions, nerves or mental
health?
Problems with alcohol or drugs?

YES

NO

Not
Sure

1
1
1
1
1

2
2
2
2
2

8
8
8
8
8

Prefer
Not to
Answer
9
9
9
9
9

1

2

8

9

Next [START SELECTION]
R18

[IF ONE SELECTED] Thank you for your help. The following household member is eligible to
participate in a short screening survey.
Each person who participates will receive $20 at the end of their screening survey.
RRNAMEFILL (You) OR NAMEFILL
SELECTIONS

AGE

SEX

[IF TWO SELECTED] Thank you for your help. The following household members are eligible to
participate in a short screening survey.
6

Each person who participates will receive $20 at the end of their screening survey.
RRNAMEFILL (You) OR NAMEFILL
SELECTIONS

AGE

SEX

[IF NO ONE SELECTED] Thank you for providing your household listing. No one in your
household was selected to complete a screening survey.
R19a

[IF IN-PERSON] Now we need some contact information so we can complete the screening
survey.

R19

[IF (WEB OR IN-PERSON) AND ((ONE SELECTED BUT NOT RR) OR TWO SELECTED)] Please enter
[NAMEFILL]’s phone number and email address so that we can contact [him/her] about this
upcoming screening survey.
[IF PHONE AND ((ONE SELECTED BUT NOT RR) OR TWO SELECTED)] What is [NAMEFILL]’s phone
number and email address so that we can contact [him/her] about this upcoming screening
survey.
Phone Number:
OPEN ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO PROMPT
USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
Email Address:
OPEN ENDED RESPONSE OPTION
Confirm Email Address:
OPEN ENDED RESPONSE OPTION
PROGRAMMER NOTE: IF TWO SELECTED INCLUDING RR USE NON-RR FILLS FOR R19
PROGRAMMER NOTE: IF WEB AND R19 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact this person about the next survey in this study. Please enter their
contact information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to
continue.
IF (PHONE OR IN-PERSON) AND R19 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact this person about the next survey in this study. Please try to
answer if you can.

**R20 [IF (ONE SELECTED BUT NOT RR) OR TWO SELECTED] Generally, what are good days and times in
the next few weeks for an interviewer to contact [NAMEFILL] to conduct the screening survey?
CHECK ALL THAT APPLY
Day:

Time of Day:
7

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
No Preference
Other times

Morning
Afternoon
Evening
No Preference

OPEN ENDED RESPONSE OPTION

PROGRAMMER NOTE: IF IN-PERSON, ALLOW BLANKS
**R20b [IF (ONE SELECTED BUT NOT RR) OR TWO SELECTED] In which time zone does [NAMEFILL] live?
1
2
3
4
5
6

Eastern Time
Central Time
Mountain Time
Pacific Time
Alaska Time
Hawaii-Aleutian Time
DK/REF

**R21 [IF (ONE SELECTED BUT NOT RR) OR TWO SELECTED] Does [NAMEFILL] currently stay at
[ADDRESS FILL] or is [he/she] staying somewhere else, like in a college dorm or other temporary
housing?
Staying at [ADDRESS FILL]
Staying somewhere else
R22

[IF (WEB OR IN-PERSON) AND TWO SELECTED BUT NOT RR] Please enter [NAMEFILL]’s phone
number and email address so that we can contact [him/her] about this screening survey.
[IF PHONE AND TWO SELECTED BUT NOT RR] What is [NAMEFILL]’s phone number and email
address so that we can contact [him/her] about this upcoming screening survey.
Phone Number:
OPEN ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO PROMPT
USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
Email Address:
OPEN ENDED RESPONSE OPTION
Confirm Email Address:
OPEN ENDED RESPONSE OPTION

8

PROGRAMMER NOTE: IF WEB AND R22 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact this person about the next survey in this study. Please enter their
contact information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to
continue.
IF (PHONE OR IN-PERSON) AND R22 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact this person about the next survey in this study. Please try to
answer if you can.
PROGRAMMER NOTE: IF WEB and EMAIL IN R22 IS THE SAME AS EMAIL IN R19, SHOW ERROR
MESSAGE: This information is important so we can contact you about the next survey in this
study. Please enter your own, unique email address. If you do not have your own email address,
please be sure to enter an accurate phone number.
IF (PHONE OR IN-PERSON) AND EMAIL IN R22 IS THE SAME AS EMAIL IN R19, SHOW ERROR
MESSAGE: This information is important so we can contact you about the next survey in this
study. Please provide your own, unique email address if you can.
**R23 [IF TWO SELECTED BUT NOT RR] Generally, what are good days and times in the next few weeks
for an interviewer to contact [NAMEFILL] to conduct the screening survey?
CHECK ALL THAT APPLY
Day:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
No Preference
Other times

Time of Day:
Morning
Afternoon
Evening
No Preference

OPEN ENDED RESPONSE OPTION

PROGRAMMER NOTE: IF IN-PERSON, ALLOW BLANKS
**R23b [IF TWO SELECTED BUT NOT RR] In which time zone does [NAMEFILL] live?
1
2
3
4
5
6

Eastern Time
Central Time
Mountain Time
Pacific Time
Alaska Time
Hawaii-Aleutian Time
DK/REF

9

**R24

[IF TWO SELECTED BUT NOT RR] Does [NAMEFILL] currently stay at [ADDRESS] or is
[he/she] staying somewhere else, like in a college dorm or other temporary housing?
Staying at [ADDRESS FILL]
Staying somewhere else

R25

[IF (WEB OR IN-PERSON) AND RR SELECTED] Please enter your first name, phone number, and
email address so that we can contact you about this upcoming screening survey.
[IF PHONE AND RR SELECTED] What is your first name, phone number, and email address so that
we can contact you about this screening survey.
First Name:
OPEN ENDED RESPONSE OPTION
Phone Number:
OPEN ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO PROMPT
USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
Email Address:
OPEN ENDED RESPONSE OPTION
Confirm Email Address:
OPEN ENDED RESPONSE OPTION
PROGRAMMER NOTE: IF WEB AND R25 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact you about the next survey in this study. Please enter your contact
information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND R25 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact you about the next survey in this study. Please try to answer if you
can.
PROGRAMMER NOTE: IF WEB and EMAIL IN R25 IS THE SAME AS EMAIL IN R19 OR R22, SHOW
ERROR MESSAGE: This information is important so we can contact you about the next survey in
this study. Please enter your own, unique email address. If you do not have your own email
address, please be sure to enter an accurate phone number.
IF (PHONE OR IN-PERSON) AND EMAIL IN R25 IS THE SAME AS EMAIL IN R19 OR R22, SHOW
ERROR MESSAGE: This information is important so we can contact you about the next survey in
this study. Please provide your own, unique email address if you can.

**R25a [IF RR SELECTED AND R25 PHONE NUMBER NE BLANK] Is [FILL R25 PHONE NUMBER] your
personal cell phone?
1
2

YES
NO
10

**R25b [IF R25a = YES] May we send text messages to your personal cell phone to contact you about the
upcoming screening survey?
1
YES
2
NO
**RR VERIFICATION

[IF IN-PERSON AND RR SELECTED AND R25 PHONE NUMBER NE BLANK] We may
contact you to verify the information you have given us. May we call you at
[PHONE NUMBER FILL] for that verification?
1
2

**RRSTART

YES
NO

[IF IN-PERSON AND RR SELECTED] Would you like to begin your screening survey now?
1
YES
2
NO

INTERVIEWER NOTE: CLICK NEXT TO CLOSE OUT THE CASE, THEN RETURN TO LAUNCH THE SCREENER
**R26 [IF ((WEB OR PHONE) AND RR SELECTED) OR (IN-PERSON AND RRSTART = NO)] Generally, what
are good days and times in the next few weeks for an interviewer to contact you to conduct the
screening survey?
CHECK ALL THAT APPLY
Day:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
No Preference
Other times

Time of Day:
Morning
Afternoon
Evening
No Preference

OPEN ENDED RESPONSE OPTION

PROGRAMMER NOTE: IF IN-PERSON, ALLOW BLANKS
**R26b [IF ((WEB OR PHONE) AND RR SELECTED) OR (IN-PERSON AND RRSTART = NO)] In which time
zone do you live?
1
2
3
4
5
6

Eastern Time
Central Time
Mountain Time
Pacific Time
Alaska Time
Hawaii-Aleutian Time
DK/REF
11

VERIFICATION

[IF IN-PERSON AND RR NOT SELECTED] We may contact you to verify the
information you have given us. Please enter your first name and telephone
number so that we can contact you for this verification.
FIRST NAME:
PHONE: (Area code and phone number)

PROGRAMMER NOTE: IF IN-PERSON, ALLOW BLANKS
PROGRAMMER: IF RECORDING CONSENT = YES, RESUME RECORDING
**R30 You can receive your payment either as an electronic pre-paid Visa or as a check . You should allow 1 to
2 weeks to receive the electronic pre-paid Visa and about 4 weeks to receive the check.
[IF WEB] How would you like to receive your incentive payment?
[IF PHONE] Would you like to receive your payment as an electronic prepaid Visa or as a check?
[IF IN-PERSON] Would you like to receive your payment as an electronic prepaid Visa, a check or
in cash?
1
2
4

Electronic pre-paid Visa. Please allow 1 to 2 weeks for processing.
Check. Please allow up to 4 weeks for processing and delivery.


3

NO, THANKS. DECLINE THE INCENTIVE.

PROGRAMMER: IF RECORDING CONSENT = YES, STOP RECORDING
R31

[IF IN-PERSON & R30 == 4] IF NOT DONE EARLIER HAND RESPONDENT $10 CASH.
1 CASH ACCEPTED
2 CASH REFUSED
I have checked a box to indicate that [you accepted/you refused] the $10 in cash for
completing this screening.

R30b [IF R30 = 1] Please provide your email address to receive the electronic pre-paid Visa.
________________[OPEN-ENDED, FORMAT CHECK FOR VALID EMAIL ADDRESS]
PROGRAMMER NOTE: IF WEB AND R30b = BLANK, SHOW ERROR MESSAGE: This
information is important so we can send you your incentive. Please enter your contact
information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to
continue.
12

IF (PHONE OR IN-PERSON) AND R30b = BLANK OR DK OR REF, SHOW ERROR MESSAGE:
THIS INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY
TO ANSWER IF YOU CAN.
R30c [IF R30 = 2] Please provide your first and last name to receive your check.
First Name:**
OPEN-ENDED RESPONSE OPTION
Last Name:**
OPEN-ENDED RESPONSE OPTION
PROGRAMMER NOTE: IF WEB AND R30c = BLANK, SHOW ERROR MESSAGE: This
information is important so we can send you your incentive. Please enter your contact
information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to
continue.
IF (PHONE OR IN-PERSON) AND R30c = BLANK OR DK OR REF, SHOW ERROR MESSAGE:
THIS INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY
TO ANSWER IF YOU CAN.
**R30d

[IF R30 = 2] Would you like us to mail your check to [ADDRESS FILL] or to another
address?
1
2

Yes, mail to [ADDRESS FILL]
No, mail to another address

DK/REF
R30e

[IF R30= 2 AND R30d = 2] What address do you want us to mail the check to?
STREET: (NUMBER AND STREET NAME)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
PROGRAMMER NOTE: IF WEB AND R30e = BLANK, SHOW ERROR MESSAGE: This
information is important so we can send you your incentive. Please enter your contact
information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to
continue.
IF (PHONE OR IN-PERSON) AND R30e = BLANK OR DK OR REF, SHOW ERROR MESSAGE:
THIS INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY
TO ANSWER IF YOU CAN.
PROGRAMMER NOTE: ALLOW FOR FOR D.C.

**R28 [IF (WEB OR PHONE) AND RR SELECTED] Would you like to begin your screening survey now?
[IF (PHONE OR IN-PERSON) AND ONE SELECTED BUT NOT RR] Is [NAMEFILL] available for me to
speak with now?
13

YES
NO
PROGRAMMER NOTE: IF YES, BEGIN INTERVIEW.
**R29 [IF (PHONE OR IN-PERSON) AND TWO SELECTED BUT NOT RR]
available for me to speak with now?

Is [NAMEFILL] or [NAMEFILL]

[IF (PHONE AND (TWO SELECTED INCLUDING RR AND R28 = NO)) OR (IN-PERSON AND (TWO
SELECTED INCLUDING RR AND RRSTART = NO))] Is [NAMEFILL] available for me to speak with
now?
YES FOR [NAMEFILL]
YES FOR [NAMEFILL]
NO
PROGRAMMER NOTE: ALLOW ONLY ONE YES RESPONSE IN R29.
IF YES FOR EITHER, BEGIN INTERVIEW.
R30a

[IF RRSTART = NO OR R28 = NO OR R29 = NO] We will contact you soon to complete the
interview. Thank you for your time.
[IF (R28 = NO OR R29 = NO) AND ONE SELECTED BUT NOT RR] We will contact [NAMEFILL] soon
to complete the interview. Thank you for your time.
[IF (R28 = NO OR R29 = NO) AND TWO SELECTED BUT NOT RR] We will contact [NAMEFILL] and
[NAMEFILL] soon to complete the interview. Thank you for your time.

PROGRAMMER NOTE: Incentive Flags for Screener
DEFINE ROSTERINCAMOUNT
IF WEB OR PHONE, ROSTERINCAMOUNT = $10
IF IN-PERSON, ROSTERINCAMOUNT = $10
DEFINE ROSTERPAYMENTINFO
IF IN-PERSON, ROSTERPAYMENTINFO = 1
IF (WEB OR PHONE) AND R28 = YES, ROSTERPAYMENTINFO = 2
IF (WEB OR PHONE) AND R29 = ANY YES, ROSTERPAYMENTINFO = 2
IF (WEB OR PHONE) AND R30 = 3, ROSTERPAYMENTINFO = 2
IF (WEB OR PHONE) AND (R30b OR R30c OR R30d OR R30e = DK OR REF), ROSTERPAYMENTINFO = 2
ELSE, ROSTERPAYMENTINFO = 1

14

Attachment B
Household Roster PAPI Instrument
1) Paper and Pencil Household Roster

Household Membership Listing

Your address is one of 60,000 in the United States randomly chosen for the National Study of
Mental Health. This study, sponsored by Substance Abuse and Mental Health Services
Administration, collects information for research and program planning by asking about:
•
•
•
•

Mental health;
health behaviors;
access to, and use of, medical care or treatment; and
tobacco, alcohol, and drug use or non-use.

If you answer this brief set of questions about the people who live here, we would like to send
you a $10 check. And, if there are people in the household who are eligible, they will be paid $20
to complete a 15-minute screening survey. Your answers will be used for statistical purposes
only and your participation is voluntary.
Please answer this survey for the address listed below.
CITY RESIDENT
ADDRESS1
ADDRESS2
CITY, STATE ZIP

1
1

6412107753

1. Does anyone not related to you live at the
address on the cover of the survey receive
help or support for:
•
•
•
•
•

7. Next are a few questions about the people
who live here. Let’s start with you.
What is your first name?

Developmental disabilities
Physical disabilities
Mental health issues
Substance use issues
Elder care

This information will only be used if you are
selected to participate in the next survey in this
study.
First Name:

Yes
No

8. How old are you?
years old

2. Do you or anyone else in this household
consider this to be your or their primary
residence? In other words, is this the
address where you or they receive mail?
Yes
No  Skip to question 17

9. What is your sex?
Male
Female
10. Do you currently stay at the address on the
cover of the survey or are you staying
somewhere else, like in a college dorm or
other temporary housing?
Staying at this address
Staying somewhere else

3. Including yourself, how many people
consider the address on the cover of the
survey their primary residence?
•

Do include students who live in oncampus housing while at school.

•

Do not include anyone who lives most of
their time somewhere else even if they are
currently staying here.

11. Please enter your phone number so that we
can contact you if you are selected for the
next survey in this study.

# of people, including yourself

−

 If you entered 0, skip to question 17

-

−

-

12. Is the phone number you provided in Q11
your personal cell phone?
Yes
No  Skip to question 14

4. Of the people who live here, how many are
now ages 18 and older?
# of people now age 18 and older,
including yourself
5. Of the people who live here, how many are
ages 12 to 17 years old?

13. If you are selected, may we send text
messages to your personal cell phone
to contact you about the survey?
Yes
No

# of people now age 12 to 17 years old
6. Is the address on the cover of the survey …
Owned by you or someone else in this
household?
Rented by you or someone else in this
household?
Owned or managed by a third party, such as
a college dorm or nursing home?
Occupied without payment of rent?

14. Please enter your email address so that we
can contact you if you are selected for the
next survey in this study.

2

8670107751

15. Now we need some general information about all of the other people in this household who are
ages 18 and older. Not including you, please start with the oldest and work down to the youngest.
This information will only be used to contact this person if they are selected for the next survey in this study.
First Name

Household
member 1 Phone Number:

Age

Sex
Male
Female

-

Does this person currently stay…
At this address (see cover)
Somewhere else (like a college
dorm or other temporary housing)

-

Email Address:
First Name

Household
member 2 Phone Number:

Age

Sex
Male
Female

-

Does this person currently stay…
At this address (see cover)
Somewhere else (like a college
dorm or other temporary housing)

-

Email Address:
First Name

Household
member 3 Phone Number:

Age

Sex
Male
Female

-

Does this person currently stay…
At this address (see cover)
Somewhere else (like a college
dorm or other temporary housing)

-

Email Address:
First Name

Household
member 4 Phone Number:

Age

Sex
Male
Female

-

Does this person currently stay…
At this address (see cover)
Somewhere else (like a college
dorm or other temporary housing)

-

Email Address:
First Name

Household
member 5 Phone Number:

Age

Sex
Male
Female

-

Does this person currently stay…
At this address (see cover)
Somewhere else (like a college
dorm or other temporary housing)

-

Email Address:

3

0788107753

16. Below is a list of health conditions. Have any of the household members you listed on the
previous page ever been told by a doctor or other health care professional that they had any of
these conditions?
Select one response per row.
Don’t
Rather
Yes
No
Know
Not Say
Diabetes?
Heart problems?
Cancer?
Schizophrenia or schizoaffective disorder?
Other problems with emotions, nerves or mental
health?
Problems with alcohol or drugs?

17. To show our appreciation for completing this short survey today, we would like to send you a $10
check. Please enter your first and last name to receive this check. Print in all CAPS.
Please allow up to 4 weeks for processing and delivery.
First Name:
Last Name:

Please return your questionnaire in the enclosed return envelope or mail it to:
NSMH
RTI International
ATTN: Data Capture
5265 Capital Boulevard
Raleigh, NC 27690

Thank you for participating in the NSMH
Household Membership Listing.
4
4

1825107756

Attachment C
Household Screening Instrument

1) MDPS Screener Specifications for Household and Jail Populations
2) CAT-MH™ Item Bank

MDPS Screening Survey Instrument
MDPS Screening Specifications
Acronyms used:
• HH = household population
• GQU = group quarters
• NHH = non-household population
• JA = jail population
• PR = prison population
• SH = state psychiatric hospital population
• HL = homeless population

Symbols used
• [] skips
• <> fills
• != = not equal
• | = OR
• ** = indicates that we need two versions of response options, i.e., one for selfadministration in “Sentence case” and one for interviewer administration in “ALL CAPS”.
GENERIC ERROR MESSAGE FOR BLANK: “If you are not sure or prefer not to answer, simply select 'Not
sure' or 'Prefer not to answer' and then click 'Next' to continue.” **
PROGRAMMER: FOR DK PLEASE DISPLAY “Not sure”** and for REF “Prefer not to answer’**; FOR PHONE
AND IN-PERSON (NOT IN-PERSON SELF-ADMINISTERED), WHERE APPLICABLE, PLEASE DISPLAY ON
SCREEN IMMEDIATELY.
Populations:
• The routing through the instruments for the different populations will be based on a
preloaded case ID which differentiates the populations.
• HH/GQU:
• Up to two randomly selected individuals in separate sessions.
• Self-completion via web, (inbound) phone with TI, or self-completion in-person with FI
(note April 2021: due to COVID, in-person will always be CASI).
• Pilot sample of 200-250 cases will only be administered the CIDI screener
• Replicate 2: Randomly assign individuals who complete on the web or in-person selfadministered (CASI) to either non-adaptive CIDI screener or to CAT-MH screener. Switch
CAT-MH to CIDI only if in-person interviewer is offline.
• JA
• JA are exempted from the screener randomization to non-adaptive CIDI screener or
CAT-MH. They will only receive the non-adaptive CIDI screener.
• Everyone in the JA population completing the screener will be invited to complete the
NetSCID – no subsampling.
• JA will not be asked for consent to the clinical interview at the end of the screener.
• Note April 2021: currently FI administration is not planned, possibly later. Older
comment: The JA where FI administered will not be via self-completion section.
1

Line #

Pop.

1. Introduction and consent
1

Variable
Name

Variable Description / Original
Variable Name

Spre

Programmer preload
instructions
CIDI or CAT-MH random
assignment
Study introduction
Screener overview
Confirmation of correct
respondent
Interview language selection
(if known: from roster)
Age

Source

2

HH, CAT-MH

Sscreen

3
4
5

HH, JA, CAT-MH
HH, CAT-MH
HH, JA, CAT-MH

Sintro
Sopen
Sconf

6

HH, CAT-MH

S1

7

HH, JA, CAT-MH

SSD1

8
9
10
11

HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH

SSD1a
SSD1b
S3a
S3

12

HH, JA, CAT-MH

S3_int

Age verification
Age verification
Recording allowance / start
Informed consent and indepth study introduction
Interview consent

13

JA

S3_rec

Recording consent

New

14
15
16
17

HH, JA, CAT-MH
JA
JA
JA

S3b
S3c
SOL1
SOL2

New
New
NIS
NIS

18
19
30

HH, JA, CAT-MH
CAT-MH
HH, JA, CAT-MH

SFIID3
SFIID3a
SSD2

Non-consent interview end
Programmer note recording
Date admitted to this facility
Estimate when admitted to
facility
Interview administration mode
Interviewer online/offline
Sex

31

CAT-MH

SCAT1

Pregnancy / post-partum
status
32
HH, JA, CAT-MH
SSF1
General health
33
CAT-MH
CATMHIntro CAT_MH transition
2. Depression – reference period: past 12 months
34
HH, JA
SMDD1a
Dysphoria
35
HH, JA
SMDD1b
Discouragement
36
HH, JA
SMDD1c
Anhedonia
37
HH, JA
SMDD1d
Worthlessness

Note(s)

New
New
New
NSDUH
NSDUH
Redesign
NIS
NIS
New
New
New

New
New
Modified
ACS
Modified
NSDUH
SF12

In consent
document
In consent
document

Adapted to
“you”
instead of
this person
Added postpartum

CIDI

2

3. Anxiety – GAD; reference period: past 12 months
38
HH, JA
SGAD1a
39
HH, JA
SGAD1b
40

HH, JA

SGAD1c

41
HH, JA
SGAD1d
4. Mania/Hypomania – reference period: lifetime
42
HH, JA
SCI1
43
HH, JA
SCI2
5. PTSD – reference period: past 12 months

CIDI
Feeling worried/anxious
Worried about a number of
different things
Feeling more worried than
other people
Trouble controlling worry
CIDI
Episode mood higher or more
irritable y/n
Duration of longest episode
PTSD
checklist
(PCL-5)

44
HH, JA
SPC1a
45
HH, JA
SPC1b
46
HH, JA
SPC1c
47
HH, JA
SPC1d
6. Substance Abuse – reference period: past 12 months
48
HH
SAU1

Reexperiencing
Avoiding external reminders
Felt distant
Irritable behavior
How often drink/alcohol

Modified
AUDIT-C

49

HH

SAU2

How many drinks typical day

Modified
AUDIT-C

50

HH

SDA1

Definition of drug use

51

HH

SDU1

How often drugs

Modified
DAST
DUDIT

52

HH

SDU2

How often heavily influenced
by drugs

SCI3a
SCI3b
SCI3c
SCI3d
SCI3e
SCI3f
SCI3g

Seeing visions
Hearing voices
Thought insertion
Thoughts stolen
Mind control
Force communication
Conspiracy

7. Psychosis – lifetime reference period
53
HH, JA
54
HH, JA
55
HH, JA
56
HH, JA
57
HH, JA
58
HH, JA
59
HH, JA
8. Health and Health Care

DUDIT

Added
reference
period.
Added
reference
period.
Deleted
‘standard’
drinks
Added
reference
period.
Added
reference
period.

CIDI

3

60

HH, JA, CAT-MH

SH1

Health insurance

Modified
NSDUH
New
New

61
62

HH, JA, CAT-MH
HH, JA, CAT-MH

SH2
SH3

63

HH, JA, CAT-MH

SH4

64
65

HH, JA, CAT-MH
HH, JA, CAT-MH

SH5
SH6

Disability benefits
Reasons for disability mental
or physical health
Reasons for disability mental
health follow-up
Ever diagnosed with …
Height

66

HH, JA, CAT-MH

SH7

Weight

67
68
69
70

HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH

SH8a
SH8b
SH8c
SH8d

71

HH, JA, CAT-MH

SH8e

72

HH, JA, CAT-MH

SH9

73
74
75

HH, CAT-MH
HH, CAT-MH
HH, CAT-MH

SH10
SH11
S4

COVID-19 self-diagnosed
COVID-19 tested positive
COVID-19 self-hospitalization
COVID-19 hospitalization of
someone close
COVID-19 death of someone
close
COVID-19 mental health
change
COVID-19 alcohol use change
COVID-19 drug use change
Selection mechanism

9. Socio-demographics
76
HH, JA, CAT-MH

SSD3

Marital status

Modified
ACS

77
78
79

HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH

SSD3a
SSD4
S2

Living with partner
Ethnicity
Speaking English/Spanish

NSDUH 2025
NSDUH
NLAAS

80
81

HH, JA, CAT-MH
HH, JA, CAT-MH

SSD5
SSD6

Race
Highest educational degree

NSDUH
Modified
ACS

82

HH, JA, CAT-MH

SSD7

Student status

Modified
B&B:08/18

Simplified to
y/n

New
CIDI
Modified
NSDUH
Modified
NSDUH
New
New
New
New

Only asked in
feet
Only asked in
pounds

New
New
New
New
New

Everyone in
jail is invited
to clinical
interview
Adapted to
“you”
instead of
this person
asked in
English
Adapted to
“you”
instead of
this person
and
aggregated
categories
Wording
adjusted to
current,
4

83

HH, JA, CAT-MH

SSD7a

First enrollment (in months)

New

84

HH, JA, CAT-MH

SSD7b

New

85

HH, JA, CAT-MH

SSD7e

86

HH, JA, CAT-MH

SSD7c

87

HH, JA, CAT-MH

SSD7d

88
89

HH, JA, CAT-MH
HH, JA, CAT-MH

SSD8
SSD9

On campus housing current
y/n
On campus housing any time
past 12 months y/n
On campus housing mostly
past 12 months y/n
Off campus housing type past
12 months
Veteran status
Active duty

90

HH, JA, CAT-MH

SSD10

Paid work

Modified
ACS

91
92
93

HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH

SSD10a
SSD10b
SSD10c

Paid work any
Layoff
Temporary absence

94
95
96

HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH

SSD10d
SSD10e
SSD10f

Recalled to work
Actively looking for work
Could have started work

ACS
ACS
Modified
ACS
ACS
ACS
Modified
ACS

10. Overlap with (non-)HH population – reference period: past 12 months
97
JA
SOL3
Sentenced
98
JA
SOL4
County & state lived in most
prior to incarceration
99
JA
SOL5a
State lived in most prior to
incarceration

New
New
New
NIS
Modified
ACS

irrespective
of degree
seeking or
not, full time
or part time
or not.
Added
instruction to
answer yes if
on break.
Maps to
NPSAS
Maps to
NPSAS
Maps to
NPSAS
Maps to
NPSAS
Maps to
NPSAS
Simplified to
current in
U.S. armed
forces
Added
introduction,
exact
reference
period, and
unpaid
instructions

NIS
New
New

5

100

JA

SOL5b

101
102
103

JA
HH, CAT-MH
HH, JA, CAT-MH

SOL6
SOL7
SOL8

104
105
106
107
108

HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
JA
JA

SOL8N
SOL8W
SOL8M
SOL9
SOL10

109

JA

SOL10N

110

JA

SOL10W

111

JA

SOL10M

112
113

HH, JA, CAT-MH
HH, JA, CAT-MH

SOL11
SOL12

114
115
116
117
118
119

HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH

SOL12N
SOL12W
SOL12M
SOL13
SOL13a
SOL14

120

HH, JA, CAT-MH

SOL14N

121

HH, JA, CAT-MH

SOL14W

122

HH, JA, CAT-MH

SOL14M

123
124
125

HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH

SOL15
SOL15a
SOL16

126
127

HH, JA, CAT-MH
HH, JA, CAT-MH

SOL16N
SOL16W

128

HH, JA, CAT-MH

SOL16M

11. Scheduling CI and Incentives
129
HH, JA, CAT-MH

S6a

County lived in most prior to
incarceration
Jail more than once
Jail stay
Jail length of stay reporting
unit
Jail stay in nights
Jail stay in weeks
Jail stay in months
House/apartment lived
House/apartment length of
stay reporting unit
House/apartment stay in
nights
House/apartment stay in
weeks
House/apartment stay in
months
Prison stay
Prison length of stay reporting
unit
Prison stay in nights
Prison stay in weeks
Prison stay in months
Psychiatric hospital stay
State psychiatric hospital stay
State psychiatric hospital
length of stay reporting unit
State psychiatric hospital stay
in nights
State psychiatric hospital stay
in weeks
State psychiatric hospital stay
in months
Homeless stay
Homeless shelter stay
Homeless shelter length of
stay reporting unit
Homeless shelter stay in nights
Homeless shelter stay in
weeks
Homeless shelter stay in
months

New

Respondent hands tablet back
to interviewer

New

New
New
New
New
New
New
New
New

If multiple:
overall

New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New
New

6

130
131
132

HH, JA, CAT-MH
HH, JA, CAT-MH
HH, CAT-MH

133
134
135
136

HH, CAT-MH
HH, CAT-MH
HH, CAT-MH
HH, CAT-MH

S6b
S5a
S5b_1,
S5b_2,
S5b_3
S5c
S5d
S5e
S5f

137
138

HH, CAT-MH
HH, CAT-MH

S6c
S6

139
140
141
142
143

HH, CAT-MH
HH, JA, CAT-MH
JA
JA
JA

144

Interviewer passcode
Selection and transition
Selection and transition

New
New

Email incentive payment
Name incentive payment
Address incentive payment
Address new incentive
payment
Recording start
Informed consent for clinical
interview

New
New
New
New

S6_int
S3d
S7
S8
S9

Main interviewing consent
Programmer note recording
Release date y/n
Expected release date
Type of residence post-release

New
New
NIS
NIS
Modified
NSHAPC

HH, JA, CAT-MH

S10

Video call

New

145

HH, JA, CAT-MH

S11

Contacting information for
selected RR (post-release)

New

146
147
148
149
150
151

HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH
HH, JA, CAT-MH

S11a
S11b
S11c
S11d
S12
S13

New
New
New
New
New
New

152

HH, JA, CAT-MH

S14

153

HH, JA, CAT-MH

S14a

Landline y/n
Landline #
Text message consent
Mode preference
Additional contact y/n
Contacting information for
additional contact (postrelease)
Best days and times for
selected RR
Time zone for selected RR

New
New

Administered
for jail
population
as part of
clinical
interview
and not
here.

Adjusted
question
wording and
response
categories.
Make smartphone more
explicit
First name,
email, and
phone
number.

New
New
7

154

HH, JA, CAT-MH

155
156
157
158
159

HH, CAT-MH
HH, CAT-MH
HH, CAT-MH
HH, CAT-MH
HH, CAT-MH

S15_1,
S15_2,
S15_3,
S15_4
S15b1
S15b2
S15c
S15d
S15e

Incentive information

New

New
New
New
New
New

New
Modified
NSFG
Modified
NSFG
NSDUH
NSDUH
NSDUH
NSDUH
NSFG
NSFG
NSFG

160
HH, JA, CAT-MH
161
HH, CAT-MH
162
HH, CAT-MH
12. INTERVIEWR DEBRIEFING
163
164

S16
S17
S17_a

Email incentive payment
Email incentive payment
Name incentive payment
Address incentive payment
Address new incentive
payment
END
Screener transition
Screener transition

IDB0
IDB1

Complete or breakoff
Mode of completion

165

IDB2

Assistance during completion?

166
167
168
169
170
171
172

IDB3
IDB4
IDB5
IDB6
IDB6a
IDB7
IDB8

173
174
175

IDB9
IDB10
IDB11

176

IDB13

At home?
Where
Privacy
Who observed
Type of influence
Interview atmosphere
Type of
distractions/interruptions
Attentiveness of respondent
Upset respondent
Trouble completing the
interview and which
See respondent’s screen

177
178
179

IDB14
IDB15
IDBBR1

Comments interview length
Anything else
Breakoff codes

New
New
New

NSFG
NSFG
Modified
NBS
Modified
NSFG
NSDUH
NSDUH
Modified
NBS

8

SECTION 1: INTRODUCTION AND CONSENT
Spre PROGRAMMER, PLEASE PRELOAD
- WEB = YES/NO FROM SYSTEMS
- JA = YES/NO FROM SAMPLING
- HH = YES/NO FROM SAMPLING
- SAMPLINGFRACTION = # FROM SAMPLING
- STATE = FROM SAMPLING FOR JA ONLY
- COUNTY = FROM SAMPLING FOR JA ONLY
- TARGET RESPONDENT = FROM ROSTER (1st SELECTED PERSON WITHIN THE HOUSEHOLD)
- SELECTED2 = FROM ROSTER (2ND SELECTED PERSON WITHIN THE HOUSEHOLD)
- AGE FROM ROSTER: FOR TARGET RESPONDENT AND SELECTED2
- NAME FROM ROSTER: FOR TARGET RESPONDENT AND SELECTED2
- SEX FROM ROSTER: FOR TARGET RESPONDENT AND SELECTED2
- # OF INDIVIDUALS SELECTED FOR SCREENING FROM ROSTER
- EMAIL FROM ROSTER IF ROSTER R = SCREENING R
- TELEPHONE FROM ROSTER IF ROSTER R = SCREENING R
- LANGUAGE FROM ROSTER IF ROSTER R = SCREENING R
- ROSTER INCENTIVE PAID Y/N IF ROSTER R = SCREENING R
- ROSTERINCAMOUNT FROM ROSTER
- MODE IN WHICH ROSTER WAS COMPLETED IF ROSTER R = SCREENING R. WEB, TELEPHONE,
MAIL, IN-PERSON
- ADDRESS FILL FROM SYSTEMS/ROSTER
- ROSTERPAYMENTINFO Y/N FROM ROSTER
- R30 FROM ROSTER
- INCENTIVES:
o ROSTERINCF2F = $10
o ROSTERINC = $10
o SCREENERINC = $20
o CLINICALINC = $30
o JASCREENERINC = “INTERVIEWER: PLEASE CHECK LOGISTICS PLAN FOR THIS [JAIL]”
- SCREENERRANDOMIZATION:
o PILOT: 100% CIDI;
o REPLICATE 2: 50:50
o REMAINDER: 100% CIDI
PROGRAMMER: SPANISH SCREENER IS HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\ScreenerContent_20201012_PostAdvarra_ToProgrammi
ngTranslation_SPA.docx
\\RTPNFIL02\mdps\Instrumentation\Screening\ScreenerContent_20201123_PostAdvarra_ToProgrammi
ngTranslation_SPA.docx
\\RTPNFIL02\mdps\Instrumentation\Screening\ScreenerContent_20201209_PostAdvarra_ToProgrammi
ngTranslation_SPA.docx

9

AND MOST RECENT VERSION
\\RTPNFIL02\mdps\Instrumentation\Screening\ScreenerContent_20210119_PostAdvarra_ToProgrammi
ngTranslation_SPA.docx
Sscreen [IF MAIN SAMPLE RELEASE 2 & HH = YES] PROGRAMMER, PLEASE RANDOMLY ASSIGN
INDIVIDUAL TO CIDI OR CAT-MH SCREENER WITH THE FOLLOWING RATIO:

PROGRAMMER BASED ON RANDOMIZATION GENERATE SCR = CIDI OR SCR = CAT-MH
INTERVIEWER: THIS RESPONDENT HAS BEEN ASSIGNED TO COMPLETE THE  SCREENING INTERVIEW.
PROGRAMMER TIME STAMP SET: START
Sintro [IF (S17 = 1) | (TI ADMINISTERED & SCREENER RESPONDENT != ROSTER RESPONDENT) | (FI
ADMINISTERED & (SCREENER RESPONDENT!= ROSTER RESPONDENT) | (SCREENER RESPONDENT
= ROSTER RESPONDENT & COMPLETE IN SEPARATE SESSION)))]  FOR YOUR TIME.>
: IF INCENTIVES ARE ALLOWED IN THIS FACILITY
READ: AND YOU WILL RECEIVE “FILL INCENTIVE” FOR YOUR TIME>.>
[IF WEB & HH = YES| (TI ADMINISTERED & SCREENER RESPONDENT = ROSTER RESPONDENT)]
Thank you for agreeing to participate in the National Study of Mental Health screening survey.
The screening survey will take about 15 minutes to complete and you will receive a
 electronic pre-paid Visa or check for your time. Please click next to start the
screening survey.**
PROGRAMMER: INCLUDE FOR EVERY NEW SESSION THAT IS STARTED IN CASE OF
INTERRUPTIONS
Sopen [IF HH = YES & FI | TI ADMINISTERED & # OF INDIVIDUALS SELECTED FOR SCREENING = 2 &
BOTH INTERVIEWS ARE YET TO BE COMPLETED] INTERVIEWER: YOU WILL NEED TO SCREEN 2
INDIVIDUALS IN THIS HOUSEHOLD.
[IF TARGET RESPONDENT = YES & SELECTED2 != SCREENER COMPLETE] THE TARGET
RESPONDENT FOR THE SCREENING SURVEY YOU ARE ABOUT TO START IS: NAME: , AGE: , SEX: 
[IF TARGET RESPONDENT = YES & SELECTED2 != SCREENER COMPLETE] AFTER COMPLETING THIS
SCREENING SURVEY, YOU SHOULD COMPLETE THE NEXT SCREENING SURVEY IN THIS
HOUSEHOLD WITH: NAME: , AGE: , SEX: 
[IF TARGET RESPONDENT = NO & TARGET RESPONDENT != SCREENER COMPLETE] THE TARGET
RESPONDENT FOR THE SCREENING SURVEY YOU ARE ABOUT TO START IS: NAME: , AGE: , SEX: 
[IF TARGET RESPONDENT = NO & TARGET RESPONDENT != SCREENER COMPLETE] AFTER
COMPLETING THIS SCREENING SURVEY, YOU SHOULD COMPLETE THE NEXT SCREENING SURVEY
IN THIS HOUSEHOLD WITH: NAME: , AGE: , SEX: 
Sconf [IF FI|TI ADMINISTERED]
, AGE: , SEX: ) IS COMPLETING THE SCREENER.>

1
YES – CORRECT RESPONDENT, CONTINUE
2
NO
PROGRAMMER IF Sconf = YES CONTINUE;
ELSE DISPLAY “INTERVIEWER, PLEASE IDENTIFY THE CORRECT RESPONDENT , AGE: , SEX: )>. IF THAT IS NOT
POSSIBLE END THE INTERVIEW AND ASSIGN THE CORRESPONDING STATUS CODE.”
PROGRAMMER: INCLUDE FOR EVERY NEW SESSION THAT IS STARTED IN CASE OF
INTERRUPTIONS
S1

[IF FI|TI ADMINISTERED AND ROSTER RESPONDENT = SCREENING RESPONDENT] INTERVIEWER:
CONFIRM/SELECT THE LANGUAGE TO BE USED FOR THIS INTERVIEW. THE ROSTER WAS
COMPLETED IN .
[IF FI|TI-ADMINISTERED AND ROSTER RESPONDENT != SCREENING RESPONDENT] INTERVIEWER:
SELECT THE LANGUAGE TO BE USED FOR THIS INTERVIEW ESTABLISHED DURING THE INITIAL
CONTACT.
11

1
2

ENGLISH
SPANISH

[IF WEB ADMINISTERED & HH = YES] If you need to change the language of the survey between
Spanish and English, please use the dropdown menu in the top right of the survey or press F3.
PROGRAMMER: IF WEB ADMINISTERED & ROSTER RESPONDENT = SCREENING RESPONDENT &
LANGUAGE = ENGLISH, DISPLAY IN ENGLISH. IF WEB ADMINISTERED & ROSTER RESPONDENT =
SCREENING RESPONDENT & LANGUAGE = SPANISH, DISPLAY IN SPANISH. IF WEB ADMINISTERED
& ROSTER RESPONDENT != SCREENING RESPONDENT, DISPLAY IN QUESTION TEXT IN ENGLISH
FOLLOWED BY SPANISH.
SSD1

[IF ROSTER RESPONDENT != SCREENING RESPONDENT | JA = YES | (AGE = MISSING)] We will
start by asking you some background questions. How old are you?
_______ years old (RANGE 1-110) **
DK/REF

SSD1a [IF SSD1 < 18 | SSD1 > 65] Thank you for your willingness to participate, but we cannot interview
anyone who is  65: older than 65> for this study.
[PROGRAMMER: ROUTE THESE CASES TO S16]
SSD1b [IF SSD1 = DK/REF] Thank you for your willingness to participate, but we cannot interview you if
we don’t know how old you are.
[PROGRAMMER: ROUTE THESE CASES TO S16]
S3a


PROGRAMMER: PLEASE START RECORDING THE CONSENT PROCESS AND, TURN RECORDINGS
OFF AFTER


S3

[IF HH = YES] PROGRAMMER PLEASE DISPLAY ABBREVIATED INFORMED CONSENT TEXT FROM “1
Household Screening Informed Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
12

PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE HOUSEHOLD POPULATION:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Screener ICF Pro00042170
Aug1320_approved_toProgrammingTranslation_Jan 0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Screener ICF Pro00042170
Aug1320_approved_toProgrammingTranslation_SPA_Jan 0721_clean.pdf
[IF SCR = CIDI & JA = YES] PROGRAMMER PLEASE DISPLAY ABBREVIATED INFORMED CONSENT
TEXT FROM “2 Jail Screening Informed Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER THIS WILL BE A JOB AID FOR THE FULL CONSENT FORM FOR THE JAIL
POPULATION:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\Ringeisen Jail ICF Pro00042170
Aug1320_approved_toProgrammingTranslation.docx
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\Ringeisen Jail ICF Pro00042170
Aug1320_approved_toProgrammingTranslation_SPA.docx
PROGRAMMER USE S3_int FOR INTERVIEW CONSENT FOR BOTH POPULATIONS AS APPLICABLE.
DO NOT DISPLAY S3_rec IF FI ADMINISTERED AND END CONSENT RECORDING AFTER CONSENT
QUESTION.
S3b

[IF S3_int = NO] Thank you for your willingness to participate, but we cannot interview you
without your consent.
PROGRAMMER: THIS CONCLUDES THE INTERVIEW

S3c

[IF FI ADMINISTERED & JA = YES & S3_rec = NO] PROGRAMMER, THE RESPONDENT DOES NOT
WISH TO BE RECORDED; PLEASE TURN OFF THE RECORDING NOW

SOL1

[IF JA = YES] When were you admitted to this facility?
SOL1a. 2-DIGIT Month**: _________ [RANGE: 1 – 12] DK/REF
SOL1b. 2-DIGIT Day**: ____________ [RANGE: 1 – 31] DK/REF
SOL1c. 4-DIGIT Year**: ___________ [RANGE: 1915 – CURRENT YEAR]
DK/REF
[PROGRAMMER: CALCULATE LENGTH OF STAY; USE THE 15TH IF SOL1b = DK/REF]

SOL2

[IF SOL1a = DK/REF AND SOL1c != DK/REF] What time of year was it? Was it winter, spring,
summer, or fall when you were admitted to this facility?
1
Winter**
2
Spring**
3
Summer**
4
Fall**
13

DK/REF
PROGRAMMER: CALCULATE LENGTH OF STAY. FOR WINTER USE JANUARY AS THE
MONTH; FOR SPRING APRIL, FOR SUMMER JULY, FOR FALL OCTOBER
PROGRAMMER: IF SOL2 = DK/REF & (SOL1c = CURRENT YEAR OR CURRENT YEAR – 1)
then “LENGTH OF STAY IN MONTHS” = 11 (Less than 12 months)
IF SOL2 = DK/REF & (SOL1c >= CURRENT YEAR -2) then “LENGTH OF STAY IN MONTHS” =
12* (CURRENT YEAR – SOL1c) (More than 12 months)
SFIID3 [IF FI|TI ADMINISTERED] PROGRAMMER PLEASE ASSIGN THE INTERVIEW ADMINSTRATION
MODE
1
TELEPHONE
2
IN-PERSON AND SELF ADMINISTERED
[IF JA = YES] INTERVIEWER: IF JA = YES IN-PERSON AND INTERVIEWER ADMINISTERED ONLY
PROGRAMMER: INCLUDE FOR EVERY NEW SESSION THAT IS STARTED IN CASE OF
INTERRUPTIONS
PROGRAMMER: REASSIGN SCR = CIDI IF SFIID3 = 1 & HH = YES
NOTE: OPTION 3 (IN-PERSON AND INTERVIEWER ADMINISTERED) WAS REMOVED ON 4/26 AND
WAS NEVER IN EFFECT. SIMILAR TO THE SELF-ADMINISTRATION TUTORIAL WHICH WAS
REMOVED ON 4/26.
SFIID3a [IF FI-ADMINISTERED SCR = CAT-MH] PROGRAMMER INSTRUCTION – AUTOMATICALLY ASSIGN 1
ONLINE / 2 OFFLINE STATUS BASED ON INTERVIEWER TABLET CONNECTIVITY
PROGRAMMER: IF SFIID3a = 1 & SCR = CAT-MH & CAPI APP = NO CONTINUE WITH SCR = CATMH; ELSE REASSIGN CASE TO SCR = CIDI
SI1

[IF SFIID3 = 2] You will complete the rest of this interview on your own using this tablet.

INTERVIEWER: PLEASE HAND THE TABLET TO THE RESPONDENT. PROGRAMMER TIME STAMP SET:
INTRO
SSD2

[IF (ROSTER RESPONDENT != SCREENING RESPONDENT) | (SEX = MISSING)] What is your sex?
1
Male**
2
Female**
DK/REF

SCAT1 [IF (ROSTER RESPONDENT != SCREENING RESPONDENT & SCR = CAT-MH & SSD2 = FEMALE &
SSD1 = 18 – 44) | (ROSTER RESPONDENT = SCREENING RESPONDENT & SCR = CAT-MH & SEX =
FEMALE AND AGE = 18-44)]  Are you currently pregnant or did you give birth in
the past 6 weeks, that is since ?
1
Yes**
2
No**
14

DK/REF
SSF1

This question is about your overall health. Would you say your health in general is:
1
Excellent
2
Very Good
3
Good
4
Fair
5
Poor
DK/REF

CATMHIntro [IF SCR = CAT-MH & (WEB = YES | SFIID3 = 2 )] When you click Next you will be
redirected to the “Computerized Adaptive Testing Mental Health” (CAT-MH) website to
complete the next part of the screening survey. The CAT-MH website is hosted by Adaptive
Testing Technologies and use of the CAT-MH website is governed by the terms of service that
you can access here.
By clicking on “Next” you agree to the terms of service.
After you complete the CAT-MH you will be automatically redirected back to this site to
complete the rest of the screening survey and receive your .
Please click “Next” to begin the CAT-MH.
PROGRAMMER: IF SCR = CIDI OR JA = YES CONTINUE; IF SCR = CAT-MH SWITCH TO CAT-MH;
SPECIFICALLY, SWITCH TO CAT-MH PREGNANCY IF SCAT1 = 1; ELSE SWITCH TO NORMAL CAT-MH
MODULE
CATMHfinish1 [IF CAT-MH Sign off] Please select “Continue” and click “Next” to finish the survey.
1

Continue

CATMHfinish2 [IF CATMHfinish1 = NEXT] It looks like you have not yet completed all of the questions at
the CAT-MH website. What would you like to do …
1
Go to the CAT-MH website and finish those questions, or
2
Continue without answering the remaining CAT-MH questions?
DK/REF
CATMHfinish3 [IF CATMHfinish2 = 1] When you click “Next” you will be redirected to the CAT-MH
website.
PROGRAMMER: PLEASE LAUNCH CAT-MH IF CATMHfinish2 = 1; ELSE RETURN TO BLAISE PORTION

15

SECTION 2: DEPRESSION
PROGRAMMER TIME STAMP SET: DEPRESSION
SMDD1 The next questions are about emotional difficulties you might have experienced at some time in
the past year.
Almost everyone has times when they feel sad, depressed, or discouraged about how things are
going in their life. Think about a time in the past 12 months lasting 2 weeks or longer when you
had the strongest feelings of this sort. During those 2 weeks, how often did you have each of
the following feelings?
If you are one of the few people that never had such times,   “none of the time” to all the following questions.

a.
b.

Felt sad or depressed
Felt discouraged about how things
were going in your life
c. Took little or no interest or pleasure in
things
d. Felt down on yourself, no good, or
worthless
DK/REF

All or
almost
all the
time
4

Most of
the time
3

Some of
the time
2

A little of
the time
1

None of
the time
0

[MOBILE ONLY: AFTER FIRST SCREEN, USE THE FOLLOWING ABBREVIATED QUESTION TEXT: During
those 2 weeks, how often did you have each of the following feelings?]
DEFINE DEPCIDI
IF (SMDD1a OR SMDD1c = 3 OR 4) AND (AT LEAST THREE OF SMDD1a OR SMDD1b OR SMDD1c OR
SMDD1d = 3 OR 4), THEN DEPCIDI = 2
ALL ELSE, DEPCIDI = 3

16

SECTION 3: GAD
PROGRAMMER TIME STAMP SET: GAD
SGAD1 Think about a time lasting 6 months or longer in the past 12 months when you had the
strongest feelings of worry and anxiety. During those 6 months, how often did you have each of
the following feelings?

a.
b.
c.
d.

You felt worried or anxious
You worried about a number of different
things in your life, such as your work,
family, health, or finances
You felt more worried than other people
in your same situation
You had trouble controlling your worry
DK/REF

Just
about
every
day
4

More
days
than not
3

1-3 days
a week
2

Less
than 1
day a
week
1

Never
0

[MOBILE ONLY: AFTER FIRST SCREEN, USE THE FOLLOWING ABBREVIATED QUESTION TEXT: During
those 6 months, how often did you have each of the following feelings?]
DEFINE GADCIDI
IF (SGAD1a OR SGAD1b OR SGAD1c OR SGAD1d = 4) AND (SGAD1a AND SGAD1b AND SGAD1c AND
SGAD1d = 3 OR 4), THEN GADCIDI = 2
ALL ELSE, GADCIDI = 3

17

SECTION 4: MANIA/HYPOMANIA
PROGRAMMER TIME STAMP SET: MANIA
SCI1

The next question is about whether you ever in your life had an episode lasting 4 days or
longer when your mood was either much higher than usual most of the day, much more
irritable than usual most of the day, or a mix of these things.
During these episodes, people are often much more excitable than usual or are extremely selfconfident or optimistic. They often do things they would normally not do. And this sometimes
gets them into trouble or puts them at risk of trouble.
With this definition in mind, did you ever in your life have an episode of this sort lasting 4 days
or longer?
1
Yes**
2
No**
DK/REF

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
SCI2

[IF SCI1 = YES] What is the longest episode of this sort you ever had in your life?
1
4 to 7 days
2
8 to 14 days
3
More than 14 days
DK/REF

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
DEFINE MANCIDI
IF SCI2 = 2 OR 3, THEN MANCIDI = 2
IF SCI2 = 1, THEN MANCIDI = 2
ALL ELSE, MANCIDI = 3

18

SECTION 5: PTSD
PROGRAMMER TIME STAMP SET: PTSD
SPC1

Many people have extremely stressful experiences that affect them psychologically for many
years. Think of a time lasting 1 month or longer in the past 12 months when you had the most
severe reactions to such an extremely stressful experience. During that month, how much were
you bothered by each of the following problems:
Extremely

a.

b.

c.
d.

Suddenly feeling or acting as if the
stressful experience were actually
happening again – as if you were
actually back there reliving it?
Avoiding external reminders of the
stressful experience, for example,
people, places, conversations,
activities, objects, or situations?
Feeling emotionally distant or
depressed?
Irritable behavior, angry outbursts, or
acting aggressively?
DK/REF

4

Quite
a bit
3

Moderately
2

A little
bit
1

Not at all
0

[MOBILE ONLY: AFTER FIRST SCREEN, USE THE FOLLOWING ABBREVIATED QUESTION TEXT: During that
month, how much were you bothered by each of the following problems?]
DEFINE PTSDCIDI
IF THE SUM OF SPC1a AND SPC1b AND SPC1c AND SPC1d ≥ 6, THEN PTSDCIDI = 2
ALL ELSE, PTSDCIDI = 3

19

SECTION 6: SUBSTANCE ABUSE
PROGRAMMER TIME STAMP SET: SUBSTANCE
SAU1

[IF HH = YES] The following questions are about drinking alcohol. During the past 12 months,
how often did you have a drink containing alcohol?
1
Never
2
Once a month or less often
3
2 to 4 times a month
4
2 to 3 times a week
5
4 times a week or more
DK/REF

SAU2

[IF HH = YES & SAU1 != NEVER] During the past 12 months, how many drinks containing alcohol
did you have on a typical day when you drank?
1
1 or 2
2
3 or 4
3
5 or 6
4
7 to 9
5
10 or more
DK/REF

SDA1

[IF HH = YES] These next questions are about drug use. "Drug use" refers to:
• Use of marijuana or cannabis,
• illegal drug use,
• use of prescribed drugs without your own prescription, and
• use of prescribed drugs in greater amounts, more often, or longer than you were told
to take them.
[IF (SFIID3 = 2 | WEB = YES) & HH = YES] The various classes of drugs include cannabis
(marijuana, hashish), cocaine, methamphetamine, heroin, fentanyl, hallucinogens (such as LSD),
and prescription medications such as benzodiazepines (such as Xanax, Ativan), stimulants (such
as Ritalin, Adderall) and opioids (such as hydrocodone, oxycodone).
[IF SFIID3 = 1 | 3 & HH = YES] The various classes of drugs include cannabis, which includes
marijuana and hashish, cocaine, methamphetamine, heroin, fentanyl, hallucinogens, such as
LSD, and prescription medications such as benzodiazepines – such as Xanax or Ativan –
stimulants – such as Ritalin or Adderall – and opioids – such as hydrocodone or oxycodone.

SDU1

[IF HH = YES] During the past 12 months, how often did you use drugs other than alcohol?
1
Never
2
Once a month or less often
3
2 to 4 times a month
4
2 to 3 times a week
5
4 times a week or more
DK/REF

20

SDU2

[IF HH = YES & SDU1 != NEVER] During the past 12 months, how often were you influenced
heavily by drugs other than alcohol?
1
Never
2
Less often than once a month
3
Every month
4
Every week
5
Daily or almost daily
DK/REF

DEFINE ALCCIDI
IF SAU1 = 5 AND (SAU2= 3 OR 4 OR 5), THEN ALCCIDI = 2
ALL ELSE, ALCCIDI = 3
DEFINE DRUGCIDI
IF SDU1 = 5 AND (SDU2 = 4 OR 5), THEN DRUGCIDI = 2
ALL ELSE, DRUGCIDI = 3

21

SECTION 7: PSYCHOSIS
PROGRAMMER TIME STAMP SET: PSYCHOSIS
SCI3

The next questions are about unusual experiences, like seeing visions or hearing voices. Recent
research suggests that they are common and may be normal, but we do not know exactly how
common because this is the first large-scale survey to ask about them comprehensively. So
please take your time and think carefully before answering the following questions.
Please do not count times you had these experiences when you were having a fever, dreaming,
half-asleep, or under the influence of alcohol or drugs.
Not counting those things, did you ever in your life have any of the following experiences?
Yes**
a.

The first one is seeing a vision that other people said was not there
like a face, an animal, a figure, or colors. Remember not to count
times when you were having a fever, dreaming, half-asleep or under
the influence of alcohol or drugs. Did you ever see a vision at any
other time?

b.

Did you ever hear voices that other people did not hear like voices
coming from inside your head talking to you or about you, or voices
coming out of the air when there was no one around?

c.

Did you ever believe that some mysterious force was inserting
thoughts that were definitely not your own thoughts, directly into
your head by means of x-rays, laser beams, or other methods?

d.

Did you ever believe your thoughts were being stolen out of your
mind by some force?

e.

Did you ever think your mind was being taken over by forces with
laser beams or other methods that were making you do things you
did not choose to do?

f.

Did you ever think some force was trying to communicate directly
with you by sending special signs or signals, like through the radio or
television, that you could understand but that no one else could
understand?

g.

Did you ever believe there was a plot to harm you or to have people
follow you, but your friends or family did not think this was true?

No**

DK/REF
[MOBILE ONLY: AFTER FIRST SCREEN, USE THE FOLLOWING ABBREVIATED QUESTION TEXT: Not
counting times when you were having a fever, dreaming, half-asleep, or under the influence of alcohol
or drugs, did you ever in your life have any of the following experiences?]
DEFINE PSYCIDI
22

IF SCI3b OR SCI3c OR SCI3d OR SCI3e OR SCI3f OR SCI3g = YES, THEN PSYCIDI = 1
IF ( SCI3b AND SCI3c AND SCI3d AND SCI3e AND SCI3f AND SCI3g != YES) AND SCI3a = YES, THEN PSYCIDI
=2
ALL ELSE, PSYCIDI = 3

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”

23

SECTION 8: HEALTH AND HEALTH CARE
PROGRAMMER: IF SCR = CIDI | JA = YES CONTINUE; IF SCR = CAT-MH SWITCH BACK AT THE END OF THE
CAT-MH TO BLAISE AND CONTINUE HERE
PROGRAMMER: PLEASE USE THE FOLLOWING FOR THE CAT-MH
DEPRESSION:
ANXIETY:
MANIA/HYPOMANIA:
PTSD:
SUD:
PSYCHOSIS:

TEST-TYPE = p-dep OR dep
TEST-TYPE = p-anx OR anx
TEST-TYPE = p-m/mh OR m/mh
TEST-TYPE = ptsd
TEST-TYPE = sud
TEST-TYPE = psy-s

PROGRAMMER: IF SCR = CAT-MH DEFINE RISK VARIABLES AS FOLLOWS:
DEFINE DEPCATMH
IF DEPRESSION = SEVERE OR MODERATE, THEN DEPCATMH = 2
ALL ELSE, DEPCATMH = 3
DEFINE GADCATMH
IF ANXIETY = SEVERE OR MODERATE, THEN GADCATMH = 2
ALL ELSE, GADCATMH = 3
DEFINE MANCATMH
IF MANIA/HYPOMANIA = SEVERE, THEN MANCATMH = 2
IF MANIA/HYPOMANIA = MODERATE, THEN MANCATMH = 2
ALL ELSE MANCATMH = 3
DEFINE PTSDCATMH
IF PTSD = DEFINITE OR HIGHLY LIKELY, THEN PTSDCATMH = 2
ALL ELSE PTSDCATMH = 3
DEFINE SUDCATMH
IF SUD = HIGH RISK OR INTERMEDIATE RISK, THEN SUDCATMH = 2
ALL ELSE SUDCATMH = 3
DEFINE PSYCATMH
IF PSYCHOSIS = SEVERE, THEN PSYCATMH = 1
IF PSYCHOSIS = MODERATE, THEN PSYCATMH = 2
ALL ELSE PSYCATMH = 3
PROGRAMMER TIME STAMP SET: HEALTH
The next few questions are about your health and health care.
SH1

Are you currently covered by any kind of health insurance, that is, any policy or program that
provides or pays for medical care?
1
Yes**
24

2
No**
DK/REF
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”

SH2

[IF SFIID3 = 2 | (WEB = YES & HH = YES)] Are you currently receiving disability benefits such as
SSI (Supplemental Security Income), SSDI (Social Security Disability Insurance), or disability
benefits from the VA (U.S. Department of Veterans Affairs)?
[IF SFIID3 = 1 | 3] Are you currently receiving disability benefits such as Supplemental Security
Income or SSI, Social Security Disability Insurance or SSDI, or disability benefits from the U.S.
Department of Veterans Affairs or VA?
1
Yes**
2
No**
DK/REF

SH3

[IF SH2 = 1] Are you currently receiving disability benefits for:
Yes**
a.

Problems with emotions, nerves, or mental health?

b.

Problems with your physical health?

No**

DK/REF
SH4

[IF SH3a = 1] Which of the following mental health problems are reasons for your disability:
Yes**
a.

Depression

b.

Bipolar disorder

c.

Post-traumatic stress disorder

d.

Schizophrenia or schizoaffective disorder

e.

Any other mental health problem

No**

DK/REF
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **

25

[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”

26

SH5

Below is a list of health conditions. Have you ever been told by a doctor or other health care
professional that you had any of these conditions?
Yes**
a.

Diabetes

b.

Heart problems

c.

Cancer

d.
e.

Any other life-threatening or seriously impairing physical health
problem
Depression

f.

Mania, manic-depression, or bipolar disorder

g.

Schizophrenia or schizoaffective disorder

h.

Any other seriously impairing emotional health problem

No**

DK/REF
[MOBILE ONLY: AFTER FIRST SCREEN, USE THE FOLLOWING ABBREVIATED QUESTION TEXT: Have you
ever been told by a doctor or other health care professional that you had any of these conditions?]
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”

SH6

The next question asks about your height. About how tall are you, without shoes? Please   your height in feet and
inches.
______feet** [RANGE: 2-8]
______inch(es)** [RANGE: 0-11]
DK/REF
PROGRAMMER IF OUTSIDE OF FEET RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your response for height in feet is out
of range. Please enter your height in feet using a number between 2 and 8.
PROGRAMMER IF OUTSIDE OF INCHES RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your response for height in inches is
out of range. Please use a number between 0 and 11 to specify inches.

SH7

And, about how much do you weigh in pounds?
________pounds** [RANGE: 40-999]
DK/REF

27

PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your response is out of range. Please
enter a number between 40 and 999.
PROGRAMMER: CALCULATE BMI = 703*(weight (lbs)/(height (in))2)
SH8a

Now I have a few questions about your personal experiences with the Coronavirus Disease
2019 pandemic, also referred to as COVID-19. Since the beginning of the COVID-19 pandemic,
… did you think or know that you had COVID-19?
1
Yes**
2
No**
DK/REF

SH8b

[IF SH8a = YES] Since the beginning of the COVID-19 pandemic,**
… at any time, did you test positive for the COVID-19 virus or for COVID-19 antibodies?
1
Yes**
2
No**
DK/REF

SH8c

[IF SH8b = YES] Since the beginning of the COVID-19 pandemic, **
… were you yourself hospitalized due to COVID-19?
1
Yes**
2
No**
DK/REF

SH8d

Since the beginning of the COVID-19 pandemic, **
… was someone in your immediate family or close friend(s) hospitalized due to COVID-19?
1
Yes**
2
No**
DK/REF
PROGRAMMER: PLEASE INSERT A CHECK BOX FOR ‘Does not apply’**

SH8e

Since the beginning of the COVID-19 pandemic, **
… did someone in your immediate family or close friend(s) die due to COVID-19?
1
Yes**
2
No**
DK/REF
28

PROGRAMMER: PLEASE INSERT A CHECK BOX FOR ‘Does not apply’**
SH9

How much, if at all, has the coronavirus pandemic negatively affected your emotional or mental
health?
1
Not at all
2
A little
3
Some
4
Quite a bit
5
A lot
DK/REF

SH10

[IF HH = YES & ((SCR = CIDI & SAU1 != NEVER) | (SCR = CAT – MH & ALCOHOL != 0))] How much,
if at all, has the coronavirus pandemic affected the amount of alcohol you drink?
1
I drink much less than I did before the coronavirus pandemic began
2
I drink a little less than I did before the coronavirus pandemic began
3
I drink about the same amount as I did before the coronavirus pandemic began
4
I drink a little more than I did before the coronavirus pandemic began
5
I drink much more than I did before the coronavirus pandemic began
DK/REF

SH11

[IF HH = YES & ((SCR = CIDI & SDU1!= NEVER) | (SCR = CAT – MH & SEDATIVES/HYPNOTICS != 0 |
OPIOIDS/ANALGESICS != 0 | HEROIN/METHADONE != 0 | COCAINE/AMPHETAMINES != 0 |
MARIJUANA != 0))] How much, if at all, has the coronavirus pandemic affected your use of drugs
other than alcohol?
[IF (SFIID3 = 2 | WEB = YES) & HH = YES] By drugs we mean various classes of drugs including
cannabis (marijuana, hashish), cocaine, methamphetamine, heroin, fentanyl, hallucinogens
(such as LSD), and use of prescription medications that you took without your own prescription
or in greater amounts, more often or for longer than you were told to take them. These
prescription medications include benzodiazepines (such as Xanax, Ativan), stimulants (such as
Ritalin, Adderall) and opioids (such as hydrocodone, oxycodone).
[IF SFIID3 = 1 | 3 & HH = YES] By drugs we mean various classes of drugs including cannabis,
which includes marijuana and hashish, cocaine, methamphetamine, heroin, fentanyl,
hallucinogens, such as LSD, and use of prescription medications that you took without your own
prescription or in greater amounts, more often or for longer than you were told to take them.
These prescription medications include benzodiazepines – such as Xanax or Ativan – stimulants
– such as Ritalin or Adderall – and opioids – such as hydrocodone or oxycodone.
1
I use much less than I did before the coronavirus pandemic began
2
I use a little less than I did before the coronavirus pandemic began
3
I use about the same amount as I did before the coronavirus pandemic began
4
I use a little more than I did before the coronavirus pandemic began
5
I use much more than I did before the coronavirus pandemic began
DK/REF

DEFINE HLTHCIDI
IF SH4d OR SH5g = YES, THEN HLTHCIDI = 1
29

IF (SH4a OR SH4b OR SH4c OR SH4e = YES) OR (SH5e OR SH5f OR SH5h = YES) OR (AGE < 40 AND BMI <
17 AND SH5c = NO AND (SMDD1a ≥ 2 OR SMDD1b ≥ 2 OR SMDD1c ≥ 2 OR SMDD1d ≥ 2 OR SGAD1a ≥
3 OR SGAD1b ≥ 3 OR SGAD1c ≥ 3 OR SGAD1d ≥ 3)), THEN HLTHCIDI = 2
ALL ELSE, HLTHCIDI = 3
NOTE: IF BMI IS MISSING ASSIGN TO TIER 3. BMI WAS ACCIDENTALLY CODED AS “0” IF ONLY SH6 WAS
DK/REF AND AS SUCH INDIVIDUALS WERE ERRONEOUSLY CODED TO TIER 2 (IF ALL OTHER ANOREXIA
CONDITIONS WERE MET AND NOTHING ELSE APPLIED; IF SH7 WAS DK/REF BMI WAS CORRECTLY SET TO
MISSING). THIS WAS CORRECTED AS OF 5/3/2021 AT 4:11 EDT AND IS NO ISSUE FOR HLTHCATMH.
DEFINE HLTHCATMH
IF SH4d OR SH5g = YES, THEN HLTHCATMH = 1
IF (SH4a OR SH4b OR SH4c OR SH4e = YES) OR (SH5e OR SH5f OR SH5h = YES) OR (AGE < 40 AND BMI <
17 AND SH5c = NO AND ((ANXIETY = MODERATE OR SEVERE) OR (DEPRESSION MODERATE OR
SEVERE))), THEN HLTHCATMH = 2
ALL ELSE, HLTHCATMH = 3
DEFINE PARTIALCOMPLETE
IF HEALTH AND HEALTH CARE SECTION = COMPLETE, THEN PARTIALCOMPLETE = YES
ALL ELSE, PARTIALCOMPLETE = NO
S4

NOTE: THE DIAGNOSIS AND STRATA DEFINITIONS ENCOMPASS ALL POSSIBLE DISORDERS AT ALL
LEVELS EVEN IF THEY HAVE NOT BEEN DEFINED ABOVE (E.G., DEPCIDI = 1). THIS GIVES US
MAXIMUM FLEXIBILITY SHOULD WE NEED TO ADJUST ANYTHING IN THE GENERATION OF THE
DISORDERS ABOVE. AT THIS POINT THEY JUST EVALUATE AS FALSE AND ARE ULTIMATELY
IGNORED IN THE BELOW.
DEFINE CIDIDIAGNOSIS
IF (DEPCIDI = 1 OR 2) OR (GADCIDI = 1 OR 2) OR (MANCIDI = 1 OR 2) OR (PTSDCIDI = 1 OR 2) OR
(ALCCIDI = 1 OR 2) OR (DRUGCIDI = 1 OR 2) OR (PSYCIDI = 1 OR 2) OR (HLTHCIDI = 1 OR 2), THEN
CIDIDIAGNOSIS = YES
ALL ELSE, CIDIDIAGNOSIS = NO
DEFINE CATMHDIAGNOSIS
IF (DEPCATMH = 1 OR 2) OR (GADCATMH = 1 OR 2) OR (MANCATMH = 1 OR 2) OR (PTSDCATMH
= 1 OR 2) OR (SUDCATMH = 1 OR 2) OR (PSYCATMH = 1 OR 2) OR (HLTHCATMH = 1 OR 2), THEN
CATMHDIAGNOSIS = YES
ALL ELSE, CATMHDIAGNOSIS = NO
DEFINE STRATA
IF DEPCIDI = 1 OR GADCIDI = 1 OR MANCIDI = 1 OR PTSDCIDI = 1 OR ALCCIDI = 1 OR DRUGCIDI =
1 OR PSYCIDI = 1 OR HLTHCIDI = 1, THEN STRATA = 1
IF DEPCATMH = 1 OR GADCATMH = 1 OR MANCATMH = 1 OR PTSDCATMH = 1 OR SUDCATMH =
1 OR PSYCATMH = 1 OR PSYCATMH = 2 OR HLTHCATMH = 1, THEN STRATA = 1
IF DEPCIDI = 2 OR GADCIDI = 2 OR MANCIDI = 2 OR PTSDCIDI = 2 OR ALCCIDI = 2 OR DRUGCIDI =
2 OR PSYCIDI = 2 OR HLTHCIDI = 2, REPLACE STRATA = 2 IF STRATA != 1
30

IF DEPCATMH = 2 OR GADCATMH = 2 OR MANCATMH = 2 OR PTSDCATMH = 2 OR SUDCATMH =
2 OR HLTHCATMH = 2, REPLACE STRATA = 2 IF STRATA != 1
IF DEPCIDI = 3 OR GADCIDI = 3 OR MANCIDI = 3 OR PTSDCIDI = 3 OR ALCCIDI = 3 OR DRUGCIDI =
3 OR PSYCIDI = 3 OR HLTHCIDI = 3, REPLACE STRATA = 3 IF STRATA != (1 | 2)
IF DEPCATMH = 3 OR GADCATMH = 3 OR MANCATMH = 3 OR PTSDCATMH = 3 OR SUDCATMH =
3 OR PSYCATMH = 3 OR HLTHCATMH = 3, REPLACE STRATA = 3 IF STRATA != (1 | 2)
IF (STRATA = 1 & HH = YES) | (JA = YES) THEN SELECT 100% SAMPLINGFRACTION
IF STRATA = 2 & HH = YES THEN SELECT 80% SAMPLINGFRACTION
IF STRATA = 3 & HH = YES THEN SELECT 20% SAMPLINGFRACTION
DEFINE UNBLINDMDE
IF (SCR = CIDI AND (SMDD1a OR SMDD1c = 3 OR 4)) OR (SCR = CAT-MH AND (DEPRESSION =
MODERATE OR SEVERE)), THEN UNBLINDMDE = YES; ELSE UNBLINDMDE = NO
DEFINE UNBLINDMANIA
IF (SCR = CIDI AND SCI1 = 1) OR (SCR = CAT-MH AND (MANIA/HYPOMANIA = MODERATE OR
SEVERE)), THEN UNBLINDMANIA = YES; ELSE UNBLINDMANIA = NO
DEFINE UNBLINDPSYCHOS1
IF (SH5g = 1), THEN UNBLINDPSYCHOS1 = YES; ELSE UNBLINDPSYCHOS1 = NO
DEFINE UNBLINDPSYCHOS2
IF (SH5g != 1 AND SH4d = 1), THEN UNBLINDPSYCHOS2 = YES; ELSE UNBLINDPSYCHOS2 = NO
DEFINE UNBLINDPSYCHOS3
IF (SCR = CIDI AND SH5g != 1 AND SH4d != 1 AND (SCI3a OR SCI3b OR SCI3c OR SCI3d OR SCI3e
OR SCI3f = 1)) OR (SCR = CAT-MH AND SH5g != 1 AND SH4d != 1 AND (PSYCHOSIS = MILD TO
MODERATE OR SEVERE)), THEN UNBLINDPSYCHOS3 = YES; ELSE UNBLINDPSYCHOS3 = NO
DEFINE UNBLINDGAD
IF (SCR = CIDI AND (SGAD1= 3 OR 4)) OR (SCR = CAT-MH (ANXIETY = MODERATE OR SEVERE)),
THEN UNBLINDGAD = YES; ELSE UNBLINDGAD = NO
DEFINE UNBLINDPTSD
IF (SCR = CIDI AND (SPC1a OR SPC1b OR SPC1c OR SPC1d = 2 OR 3 OR 4)) OR (SCR = CAT-MH AND
(PTSD = POSSIBLE OR DEFINITE OR HIGHLY LIKELY)), THEN UNBLINDPTSD = YES; ELSE
UNBLINDPTSD = NO

PROGRAMMER INTERNAL NOTE ONLY REGARDING THE TIERS [IF SCR = CIDI]
TIER 1 (HIGH PRIORITY DISORDER):
Psychosis: SCI3 Yes to at least 1 item in B thru G
Health: SH4 – Yes to d; SH5 – Yes to g
31

TIER 2 (ANY DISORDER):
Depression: 3 of the 4 items must be at least most of the time and the three items must
include one or both of items A and C
GAD: Must have at least 1 item at the “just about every day” level and the other 3
items at least at the “more days than not” level
Mania/Hypomania: If SCI2 = 4 days or longer
PTSD: SPC1, a score of 6 or more summed across all items (where not at all = 0; a little
bit = 1; moderately = 2; quite a bit = 3; and extremely = 4)
Alcohol: SAU1 = category 5 (4 or more times a week) and SAU2 = category 3 or higher
(5 drinks or more)
Drugs: SDU1 = category 5 (4 times a week or more) and SDU2 = category 4 or 5 (every
week or more)
Psychosis: SCI3 Yes to only item A
Health:

•
•
•

SH4 Any other item(s) = yes except d;
SH5 Yes to e, f or h;
SH6/SH7 – If respondent is younger than 40 and BMI is less than 17 and
SH5c = NO and at least (“some of the time” in one of the questions on the
GAD scale or the MDE scale). Update from Mark, go with 3 “3. More days
than not” for GAD.

And not already in tier 1.
TIER 3 (NO DISORDER):
Everyone who does not meet Tier 1 or Tier 2 requirements.
PROGRAMMER INTERNAL NOTE ONLY REGARDING THE TIERS [IF SCR = CAT-MH]
TIER 1 (HIGH PRIORITY DISORDER):
Psychosis: Severe or moderate
Health: SH4 – Yes to d; SH5 – Yes to g
TIER 2 (ANY DISORDER):
Depression: moderate or severe
Anxiety: moderate or severe
Mania/hypomania: moderate or severe
PTSD: definite or highly likely
SUD: intermediate or high risk
32

Psychosis: There will be no CAT-MH Psychosis cases assigned to Tier 2
Health:
• SH4 Any other item(s) = yes except d;
• SH5 Yes to e, f or h [diagnosed depression, mania, other seriously impairing
emotional health problem];
• SH6/SH7 – If respondent is younger than 40 and BMI is less than 17 and ((anxiety
moderate or severe) or (depression moderate or severe))
TIER 3 (NO DISORDER):
Everyone who does not meet Tier 1 or Tier 2 requirements.

33

SECTION 9: SOCIO-DEMOGRAPHICS
PROGRAMMER TIME STAMP SET: DEMOGRAPHICS
SSD3

We now have a few more background questions about yourself.
Are you now married, widowed, divorced, separated, or have you never married?
1
Now married**
2
Widowed**
3
Divorced**
4
Separated**
5
Never married**
DK/REF

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”

SSD3a [IF SSD3 != 1] Are you now living with a partner?
1
Yes**
2
No**
DK/REF
SSD4

Are you of Hispanic, Latino or Spanish origin?
That is, do any of these groups describe your national origin or ancestry—Puerto Rican, Cuban,
Cuban-American, Mexican, Mexican-American, Chicano, Central or South American, or origin in
some other Spanish-speaking country?
1
Yes**
2
No**
DK/REF

S2

[IF SSD4 = 1] Do you speak Spanish only, mostly Spanish with some English, Spanish and English
about the same, mostly English with some Spanish, or English only?
1
Spanish only**
2
Mostly Spanish, but some English **
3
Spanish and English about the same**
4
Mostly English, but some Spanish **
5
English only**
DK/REF

SSD5

Are you White, Black or African American, American Indian or Alaska Native, Native Hawaiian or
other Pacific Islander, or Asian? Please mark all that apply.
34

□
White**
□
Black or African American**
□
American Indian or Alaska Native**
□
Native Hawaiian or Other Pacific Islander**
□
Asian**
DK/REF
SSD6

What is the highest grade or level of school you have completed? 
If currently enrolled,  previous grade or highest degree received.
1
Less than a high school diploma
2
High school degree or equivalent (for example: GED)
3
Some college, no degree
4
Associate degree (for example: AA, AS)
5
Bachelor’s degree (for example: BA, BS)
6
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
7
Professional degree (for example: MD, DDS, DVM, LLB, JD)
8
Doctorate degree (for example: PhD, EdD)
DK/REF

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”

SSD7

Are you currently attending a college, university, or trade school either full-time or part-time?
If you are on a holiday or break from school, such as spring break or summer vacation, but plan
to return when the break is over, please answer yes.
1
Yes**
2
No**
DK/REF

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”
35

SSD7a [IF SSD7 = YES] How long ago did you first enroll at this college, university, or trade school? If
you transferred to your current institution directly from another college or university, please
include that time. Was that …
1
Within the past 12 months, or
2
More than 12 months ago
DK/REF
SSD7b [IF SSD7 = YES] Do you currently live in college-owned housing on campus, such as a dorm or a
residence hall?
1
Yes**
2
No**
DK/REF
SSD7e [IF SSD7b = NO] At any time  did you live in college-owned housing on campus, such as a dorm or
a residence hall?
1
Yes**
2
No**
DK/REF
SSD7c [IF SSD7b = YES | SSD7e = YES]  did you mostly live in college-owned housing on campus, such as a
dorm or a residence hall?
1
Yes**
2
No**
DK/REF
SSD7d [IF SSD7c = NO | SSD7e = NO] You said you did not live on campus . In what type of off-campus housing did you mostly live in during that time? Is
that …
1
Off-campus housing, owned or managed by the school,
2
Off campus with relatives, such as parents or guardians, or
3
Other off-campus housing?
DK/REF
SSD8

Have you ever served in the United States Armed Forces?
1
Yes**
2
No**
DK/REF

SSD9

[IF SSD8 = YES] Are you currently serving on active duty in the United States Armed Forces?
1
Yes**
2
No**
36

DK/REF
SSD10 The next question is about working. Last week, did you work for pay at a job or business? By last
week, I mean the week beginning on Sunday,  and ending on Saturday,
.
To view information about unpaid work please click on the question mark or press F2.**
1
Yes**
2
No – Did not work or are retired**
DK/REF
HELPTEXT**:
• Please include
- unpaid work in a family farm or business if you usually work more than
15 hours each week, or
- personal labor you provide in exchange for work done for you, rather
than for pay.
•

Please do not include
- work done as part of a student stipend, or
- volunteer work.

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue. **
[IF TI | FI ADMINISTERED] PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF
IS SELECTED: “This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT ‘SKIP’ TO CONTINUE.”

SSD10a [IF SSD10 = NO] Last week, did you do any work for pay, even for as little as one hour?
1
Yes**
2
No**
DK/REF
SSD10b [IF SSD10a = NO] Last week, were you on layoff from a job?
1
Yes**
2
No**
DK/REF
SSD10c [IF SSD10b = NO] Last week, were you temporarily absent from a job or business, for example,
because of vacation, temporary illness, maternity leave, other family or personal reasons, or
bad weather?
1
Yes**
2
No**
DK/REF
37

SSD10d [IF SSD10b = YES] Have you been informed that you will be recalled to work within the next 6
months or been given a date to return to work?
1
Yes**
2
No**
DK/REF
SSD10e [IF SSD10c = NO | SSD10d = NO] During the last 4 weeks, have you been actively looking for
work?
1
Yes**
2
No**
DK/REF
SSD10f [IF SSD10d = YES | SSD10e = YES] Last week, could you have started a job if you had been
offered one, or returned to work if you had been recalled?
1
Yes, you could have gone to work,
2
No, you could not have gone to work because of your own temporary illness,
3
No, you could not have gone to work for some other reason, such as, being in
school or taking care of house or family

38

SECTION 10: OVERLAP WITH (NON-)HH POPULATION
PROGRAMMER TIME STAMP SET: OVERLAP
SOL3

[IF JA = YES] The next few questions are about your stay at this and other facilities. Are you
currently in this facility because you have been sentenced to serve time for an offense?
1
Yes**
2
No**
DK/REF

SOL4

[IF JA = YES] During the 12 months before your incarceration, did you live in  in
 for most of the time?
1
Yes**
2
No**
DK/REF

SOL5a [IF SOL4 = NO] During the 12 months before your current incarceration, in which state did you
live in for most of the time?
__________ [State**]
PROGRAMMER: ALLOW FOR OUT OF COUNTRY CODE AND FOR D.C.
DK/REF
SOL5b [IF SOL4 = NO & SOL5a != OUTSIDE OF US | DK | REF] And what county was that in?
__________ [County**]
DK/REF
SOL6

[IF JA = YES & LENGTH OF STAY < 12 MONTHS/DK/REF] Other than your current incarceration,
have you stayed overnight or longer in a jail at any time during the past 12 months?
1
Yes**
2
No**
DK/REF

SOL7

[IF HH = YES] During the past 12 months, have you stayed overnight or longer in a jail? Please do
not count any time spent in prison.
1
Yes**
2
No**
DK/REF

SOL8

[IF (SOL7 = YES) | (SOL6 = YES/DK/REF)] During the past 12 months, how much time  have you spent in a jail? If you are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
Nights**
2
Weeks**
3
Months**
DK/REF
39

SOL8N

[IF SOL8 = 1 OR DK/REF] During the past 12 months, how many nights  have you spent in a jail? Again, if you are not sure, just make
your best guess.
_______night(s)** [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.

SOL8W

[IF SOL8 = 2] During the past 12 months, how many weeks  have you spent in a jail? Again, if you are not sure, just make your best
guess.
_______week(s)** [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.

SOL8M

[IF SOL8 = 3] During the past 12 months, how many months  have you spent in a jail? Again, if you are not sure, just make your best
guess.
_______month(s)** [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.

SOL9

[IF JA = YES & LENGTH OF STAY < 12 MONTHS/DK/REF] During the past 12 months, have you
lived in a house, an apartment, or a mobile home, even if just for a short period of time?
1
Yes**
2
No**
DK/REF

SOL10 [IF SOL9 = YES] During the past 12 months, how much time have you spent in a house, an
apartment, or a mobile home? If you are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
Nights**
2
Weeks**
3
Months**
DK/REF
SOL10N

[IF SOL10 = 1 OR DK/REF] During the past 12 months, how many nights have you spent
in a house, an apartment, or a mobile home? Again, if you are not sure, just make your
best guess.
40

_______night(s)** [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
SOL10W

[IF SOL10 = 2] During the past 12 months, how many weeks have you spent in a house,
an apartment, or a mobile home? Again, if you are not sure, just make your best guess.
_______week(s)** [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.

SOL10M

[IF SOL10 = 3] During the past 12 months, how many months have you spent in a house,
an apartment, or a mobile home? Again, if you are not sure, just make your best guess.
_______month(s)** [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.

SOL11 [IF (JA = YES & LENGTH OF STAY < 12 MONTHS/DK/REF) OR HH = YES] During the past 12
months, have you stayed overnight or longer in a prison?
1
Yes**
2
No**
DK/REF
SOL12 [IF SOL11 = YES] During the past 12 months, how much time have you spent in a prison? If you
are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
Nights**
2
Weeks**
3
Months**
DK/REF
SOL12N

[IF SOL12 = 1 OR DK/REF] During the past 12 months, how many nights have you spent
in a prison? Again, if you are not sure, just make your best guess.
_______night(s)** [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
41

SOL12W

[IF SOL12 = 2] During the past 12 months, how many weeks have you spent in a prison?
Again, if you are not sure, just make your best guess.
_______week(s)** [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.

SOL12M

[IF SOL12 = 3] During the past 12 months, how many months have you spent in a
prison? Again, if you are not sure, just make your best guess.
_______month(s)** [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.

SOL13 During the past 12 months, have you stayed overnight or longer in a psychiatric hospital?
1
Yes**
2
No**
DK/REF
SOL13a [IF SOL13 = YES/DK/REF] During the past 12 months, have you stayed overnight or longer in a
state psychiatric hospital? State psychiatric hospitals are public psychiatric hospitals operated by
a state for treatment of serious mental disorders.
1
Yes**
2
No**
DK/REF
SOL14 [IF SOL13a = YES] During the past 12 months, how much time have you spent in a state
psychiatric hospital? If you are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
Nights**
2
Weeks**
3
Months**
DK/REF
SOL14N

[IF SOL14 = 1 OR DK/REF] During the past 12 months, how many nights have you spent
in a state psychiatric hospital? Again, if you are not sure, just make your best guess.
_______night(s)** [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
42

SOL14W

[IF SOL14 = 2] During the past 12 months, how many weeks have you spent in a state
psychiatric hospital? Again, if you are not sure, just make your best guess.
_______week(s)** [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.

SOL14M

[IF SOL14 = 3] During the past 12 months, how many months have you spent in a state
psychiatric hospital? Again, if you are not sure, just make your best guess.
_______month(s)** [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.

SOL15 [IF (JA = YES & LENGTH OF STAY < 12 MONTHS/DK/REF) OR HH = YES] During the past 12
months, have you been homeless, even if just for a short period of time?
1
Yes**
2
No**
DK/REF
SOL15a [IF SOL15 = YES/DK/REF] The next question is about shelters that provide a place for people who
are homeless to stay. These shelters may also serve meals. Not counting living on the street, in a
vehicle, or in some type of makeshift housing like a tent or empty building, during the past 12
months, have you stayed overnight or longer in a homeless shelter?
1
Yes**
2
No**
DK/REF
SOL16 [IF SOL15a = YES] During the past 12 months, how much time have you spent in a homeless
shelter? If you are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
Nights**
2
Weeks**
3
Months**
DK/REF
SOL16N

[IF SOL16 = 1 OR DK/REF] During the past 12 months, how many nights have you spent
in a homeless shelter? Again, if you are not sure, just make your best guess.
_______night(s)** [RANGE 1-366]
DK/REF

43

PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
SOL16W

[IF SOL16 = 2] During the past 12 months, how many weeks have you spent in a
homeless shelter? Again, if you are not sure, just make your best guess.
_______week(s)** [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.

SOL16M

[IF SOL16 = 3] During the past 12 months, how many months have you spent in a
homeless shelter? Again, if you are not sure, just make your best guess.
_______month(s)** [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.

44

SECTION 11: SCHEDULING CLINICAL INTERVIEW AND INCENTIVES
PROGRAMMER TIME STAMP SET: SELECTION
S6a

Thank you for completing this portion of the interview. We are almost done. 

S6b

[IF SFIID3 = 2] INTERVIEWER: ENTER PASSCODE TO CONTINUE: _____
PROGRAMMER: PLEASE DISPLAY AN ERROR MESSAGE IF THE INTERVIEWER ENTERS THE WRONG
CODE.

S5a

[IF SELECT = YES] You are eligible to participate in the main interview. If you agree to take part,
you will receive < CLINICALINC> 

S5b_1 [IF SELECT = NO] Based on your responses, you are not eligible to participate in the main
interview.
[IF SELECT = NO & ((SFIID3 = 1 | WEB = YES) & HH = YES)) & (ROSTER = SCREENER RESPONDENT
& ROSTERPAYMENTINFO = YES & R30 = 1 | 2)] To show our appreciation for completing this
short screening survey today, we would like to send you the additional .
S5b_2 [IF SELECT = NO & ((SFIID3 = 1 | 2 | 3 | WEB = YES) & HH = YES)) & (ROSTER != SCREENER
RESPONDENT | ROSTERPAYMENTINFO = NO | ((SFIID = 1 | WEB = YES) & R30 = 3 | 4 | DK | REF)
| ((SFIID = 2 | 3)))] To show our appreciation for completing this short screening survey today,
we would like to send you the 
 by either electronic pre-paid Visa or check .

1
2
4

Electronic pre-paid Visa. Please allow 1 to 2 weeks for processing.**
Check. Please allow up to 4 weeks for processing and delivery.**

45

3
NO, THANKS. DECLINE THE INCENTIVE.
DK/REF
HELPTEXT: The electronic pre-paid Visa card can be used for online shopping only.
S5b_3 [IF SELECT = NO & HH = YES & S5b_2 = 4] PLEASE HAND RESPONDENT THE CASH INCENTIVE.
 IF THEY COMPLETED THIS SCREENING SURVEY.>
 IF THEY COMPLETED THE HOUSEHOLD MEMBERSHIP LISTING WITH YOU AND
AN ADDITIONAL  FOR COMPLETING THIS SCREENING SURVEY.>
I have checked a box to indicate that you  the payment for
completing this short survey.
S5c

[IF SELECT = NO & HH = YES & S5b_2 = 1] Please provide your email address to receive the
electronic pre-paid Visa.
________________[OPEN-ENDED, FORMAT CHECK FOR VALID EMAIL ADDRESS]
DK/REF
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
PROGRAMMER NOTE: IF WEB AND S5c = BLANK, SHOW ERROR MESSAGE: This information is
important so we can send you your incentive. Please enter your contact information. Otherwise
select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S5c = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.

S5d

[IF SELECT = NO & HH = YES & S5b_2 = 2] Please provide your first and last name to receive your
check.
First Name:**
OPEN-ENDED RESPONSE OPTION
Last Name:**
OPEN-ENDED RESPONSE OPTION
DK/REF
PROGRAMMER NOTE: IF WEB AND S5d = BLANK, SHOW ERROR MESSAGE: This information is
important so we can send you your incentive. Please enter your contact information. Otherwise
select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S5d = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.

46

S5e

[IF SELECT = NO & HH = YES & S5b_2 = 2] Would you like us to mail your check to [ADDRESS FILL]
or to another address?
1
Yes, mail to [ADDRESS FILL]**
2
No, mail to another address**
DK/REF

S5f

[IF S5e = 2] What address do you want us to mail the check to?
Street**: (NUMBER AND STREET NAME)
City**: (CITY)
State**: (STATE)
ZIP: (ZIP)
DK/REF
PROGRAMMER NOTE: IF WEB AND S5f = BLANK, SHOW ERROR MESSAGE: This information is
important so we can send you your incentive. Please enter your contact information. Otherwise
select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S5f = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.

PROGRAMMER: GO TO S16_TRANS IF SELECT = NO
PROGRAMMER TIME STAMP SET: SCONSENT
S6c

[IF FI ADMINISTERED & HH = YES] PROGRAMMER PLEASE START RECORDING OF THE CLINICAL
CONSENT QUESTION S6_int AND END RECORDING AFTER CONSENT QUESTION S6_int.

S6

[IF SELECT = YES & HH = YES] PROGRAMMER PLEASE DISPLAY ABBREVIATED INFORMED
CONSENT TEXT FROM “3 Household Clinical Interview Informed Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE HOUSEHOLD POPULATION:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170 Aug1320_v4_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_SPA_Jan0721_clean.pdf
PROGRAMMER USE S6_int FOR CLINICAL INTERVIEW CONSENT AND GENERATE CONSENT Y/N

S3d

[IF FI ADMINISTERED & HH = YES] PROGRAMMER, PLEASE TURN OFF THE RECORDING.

Sknow1 [IF SELECT = YES & HH = YES & CONSENT = YES] To ensure you understand your rights as a
NSMH respondent,  need to ask you
47

a few questions about the information  You are being asked to participate in the National Study of
Mental Health – the NSMH. Would you say the NSMH is about:
a. How pets improve our mental health
b. Mental health and other health issues
c. The health of kids in schools
d. Public transportation
PROGRAMMER NOTE: PLEASE REMOVE THIS QUESTION ENTIRELY (DATE: MM/DD/2021)
Sknow2 [IF SELECT = YES & HH = YES & CONSENT = YES] Your participation in the NSMH interview will
take about:
a. 15 minutes
b. 6 hours
c. 80 minutes
d. 3 days
PROGRAMMER NOTE: AS OF MARCH, 1, 2021 PLEASE DEACTIVATE THE FIRST RESPONSE OPTION
(15 minutes)
PROGRAMMER NOTE: PLEASE REMOVE THIS QUESTION ENTIRELY (DATE: 06/15/2021)
Sknow3 [IF SELECT = YES & HH = YES & CONSENT = YES] You have been asked to:
a. Take part in a group discussion with 10 to 12 other people
b. Call your local health department to participate
c. Participate in an interview with an interviewer
d. Send a letter with information about your health
PROGRAMMER NOTE: PLEASE REMOVE THIS QUESTION ENTIRELY (DATE: 06/15/2021)
Sknow4a [IF SELECT = YES & HH = YES & CONSENT = YES] True or False: Your participation is voluntary.
1
True**
2
False**
DK/REF
PROGRAMMER NOTE: PLEASE REMOVE THIS QUESTION ENTIRELY (DATE: 06/15/2021)
Sknow4b [IF SELECT = YES & HH = YES & CONSENT = YES] True or False: You can refuse to answer any
questions.
1
True**
2
False**
DK/REF
PROGRAMMER NOTE: PLEASE REMOVE THIS QUESTION ENTIRELY (DATE: 06/15/2021)
PROGRAMMER NOTE PRIOR TO MM/DD/2021: GENERATE SKNOWLEDGEPASS IF HH = YES
REPLACE SKNOWLEDGEPASS = 1 IF Sknow1 = b & Sknow2 = c & Sknow3 = c & Sknow4a = 1 &
Sknow4b = 1 & HH = YES
ELSE SKNOWLEDGEPASS = 0 IF HH = YES
48

PROGRAMMER NOTE: PLEASE GENERATE SKNOWLEDGEPASS = 1 FOR ALL RESPONDENTS, I.E.,
HH|JA = YES (DATE: 06/15/2021)
PROGRAMMER TIME STAMP SET: SCHEDULING
S7

[IF JA = YES] Do you have a definite date on which you expect to be released from jail?
1
Yes**
2
No**
DK/REF

S8

[IF JA = YES & S7 = YES] Do you expect to be released...
1
Within the next 7 days,
2
More than 7 days but within the next 30 days, or
3
More than 30 days from now.
DK/REF

S9

[IF JA = YES] Where are you planning to live once you are released from your incarceration …
1
In your own house or apartment, meaning your name is on the deed, mortgage,
or lease
2
In someone else’s house or apartment, including your parents’ home
3
In a residential treatment facility
4
In a transitional housing facility or halfway house
5
In a group home
6
In a state psychiatric hospital
7
In a homeless shelter
8
On the street
9
In no set place
10
In some other place or situation
DK/REF

S10

[IF SELECT = YES & HH = YES & CONSENT = YES] Can you participate in a private video call, for
example using a smartphone, tablet, or a computer?
1
Yes**
2
No**
DK/REF
[IF JA = YES] Do you think you will be able to participate in a video call, for example using a
smartphone, tablet or computer, once you are released from your incarceration?
1
Yes**
2
No**
DK/REF

S11

[IF (SELECT = YES & HH = YES & CONSENT = YES & ROSTER RESPONDENT != SCREENING
RESPONDENT) OR (ROSTER RESPONDENT = SCREENING RESPONDENT & (NAME | PHONE |
EMAIL FROM ROSTER = MISSING)) OR (JA = YES)] Please  your first name, cell phone number, and email address so that we can
contact you  to schedule
this upcoming interview.
49

First Name:**
OPEN-ENDED RESPONSE OPTION
Cell Phone Number:**
OPEN-ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO
PROMPT USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
I don’t have a cell phone PROGRAMMER PLEASE INCLUDE CHECK BOX
Email Address:**
OPEN-ENDED RESPONSE OPTION
DK/REF
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
PROGRAMMER GENERATE EMAIL AND CELL PHONE TO DIFFERENTIATE IF EITHER ARE
MISSING
PROGRAMMER NOTE: IF WEB AND S11 = BLANK, SHOW ERROR MESSAGE: This information is
important so we can contact you about the next survey in this study. Please enter your contact
information. Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S11 = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN CONTACT YOU ABOUT THE NEXT SURVEY IN THIS
STUDY. PLEASE TRY TO ANSWER IF YOU CAN.
S11a

[IF S11 CELL PHONE = MISSING OR ‘I DON’T HAVE A CELL PHONE’] You indicated that you don’t
have a cell phone. Do you have a landline number so that we can contact you to schedule the
upcoming interview?
1
Yes**
2
No**
DK/REF

S11b

[IF S11a = YES] And what is that number?
Landline Phone Number:**
OPEN-ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO
PROMPT USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
DK/REF

S11c

[IF S11 CELL PHONE != MISSING] May we send text messages to your personal cell phone to
contact you about the upcoming interview?
1
Yes**
2
No**
DK/REF

S11d

[IF (S11 CELL PHONE != MISSING & S11 EMAIL != MISSING) | (S11 EMAIL != MISSING & S11b !=
MISSING) | (ROSTER RESPONDENT = SCREENING RESPONDENT & (PHONE & EMAIL FROM
ROSTER != MISSING)] And how would you prefer that we reach out to you?
1
Via telephone, or
50

2
Via email
DK/REF
S12

[IF (SELECT = YES & CONSENT = YES) | JA = YES] And, is there another person who would know
how to get in touch with you if we cannot reach you?
1
Yes**
2
No**
DK/REF

S13

[IF S12= YES] Please  their first name,
their phone number, and their email address.
First Name:**
OPEN-ENDED RESPONSE OPTION
Phone Number:**
OPEN-ENDED RESPOSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO
PROMPT USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
Email Address:**
OPEN-ENDED RESPONSE OPTION
DK/REF
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS

S14

[(IF SELECT = YES & HH = YES & CONSENT = YES & (ROSTER RESPONDENT != SCREENING
RESPONDENT | ROSTER COMPLETED IN SEPARATE SITTING)) OR ( JA = YES)] Please  a specific date and time when you can be available
for the upcoming 80-minute main interview. Please note that the earliest we can schedule you
for this interview is  and no later than .
PROGRAMMER: ROUTE TO SCHEDULING CALENDAR TO SELECT MAIN INTERVIEW DATE AND
TIME.
PROGRAMMER NOTE: CALENDAR VIEW FOR POSSIBLE DATES (CURRENT DATE +7 TO +60) AND
DROPDOWN WITH ONE HOUR TIME SLOTS FROM 9AM TO 7PM.
Please use the calendar to select a convenient date and time for your clinical interview. Note
that the interview takes 80 minutes on average and the appointments are usually set up for two
hours. Please specify your time zone from the dropdown list so that we can adjust the calendar
accordingly. Also, specify your language from the dropdown list so that we can adjust available
appointments. If you modify time zone or language, click the refresh scheduler button.
51

S15_2 [IF ((SFIID3 = 1 | WEB = YES) & HH = YES & SELECT = YES) & (ROSTER = SCREENER RESPONDENT
& ROSTERPAYMENTINFO = YES & R30 = 1 | 2)] Thank you for your time. To show our
appreciation for completing this short survey today, we would like to send you the additional
.
 , by either electronic pre-paid Visa or check .

 incentive
payment, electronic pre-paid Visa, or check?> 
1
2
4

Electronic pre-paid Visa. Please allow 1 to 2 weeks for processing.**
Check. Please allow up to 4 weeks for processing and delivery.**


3
NO, THANKS. DECLINE THE INCENTIVE.
DK/REF
HELPTEXT: The electronic pre-paid Visa card can be used for online shopping only.
S15_1 [IF S15_3 = 4 & HH = YES & SELECT = YES] Thank you for your time .
PLEASE HAND RESPONDENT THE CASH INCENTIVE.
 IF THEY COMPLETED THIS SCREENING SURVEY.>
 IF THEY COMPLETED THE HOUSEHOLD MEMBERSHIP
LISTING IN THIS SESSION WITH YOU AND AN ADDITIONAL  FOR COMPLETING
THIS SCREENING SURVEY. IF THEY ONLY COMPLETE THE SCREENING SURVEY THEY SHOULD
ONLY RECEIVE .>

52

 IF THEY COMPLETED THIS SCREENING SURVEY.
 IF THEY COMPLETED THE HOUSEHOLD MEMBERSHIP
LISTING WITH YOU, AN ADDITIONAL  FOR COMPLETING THIS SCREENING
SURVEY. IF THEY ONLY COMPLETE THE SCREENING SURVEY THEY SHOULD ONLY RECEIVE
 the  incentive as a thank you for completing this short interview.
S15_4 [IF JA = YES] Thank you for your time.
INTERVIEWER: PLEASE COLLECT FIRST AND LAST NAME OF THE RESPONDENT
FIRST NAME:
OPEN-ENDED RESPONSE OPTION
LAST NAME:
OPEN-ENDED RESPONSE OPTION
DK/REF
 AND THEN SELECT IF INCENTIVES ARE ALLOWED FOR THIS RESPONDENT
1 INCENTIVES ALLOWED
2 INCENTIVES NOT ALLOWED
INTERVIEWER IF INCENTIVES ARE ALLOWED AND ARE NONELECTRONIC PAYMENTS PLEASE
PROCEED HERE: PLEASE HAND RESPONDENT INCENTIVE OR TELL THE RESPONDENT
THAT THE FACILITY WILL HAND OUT THE INCENTIVE ().
1 INCENTIVE ACCEPTED / WILL ACCEPT INCENTIVE
2 INCENTIVE REFUSED
I HAVE CHECKED A BOX TO INDICATE THAT YOU  THE INCENTIVE FOR COMPLETING THIS SCREENING SURVEY.
INTERVIEWER IF INCENTIVES ARE ALLOWED AND ARE ELECTRONIC PAYMENTS PLEASE PROCEED
HERE: PLEASE COLLECT NECESSARY INFORMATION TO MAKE INCENTIVE PAYMENTS, E.G., TO
COMMISSARY OR JPAY. PLEASE DOUBLE-KEY ALL PAYMENT-RELATED INFORMATION.
______________________________(Allow 500 characters)

S15b1 [IF HH = YES & S15_3 = 1 & S11 EMAIL = BLANK] Please provide your email address to receive
the electronic pre-paid Visa.
53

________________[OPEN-ENDED, FORMAT CHECK FOR VALID EMAIL ADDRESS]
DK/REF
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
PROGRAMMER NOTE: IF WEB AND S15b1 = BLANK, SHOW ERROR MESSAGE: This information
is important so we can send you your incentive. Please enter your contact information.
Otherwise select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S15b1 = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.
S15b2 [IF HH = YES & S15_3 = 1 & S11 EMAIL != BLANK] We will send your electronic pre-paid Visa to
the email address you provided earlier.
S15c

[IF HH = YES & S15_3 = 2] Please provide your first and last name to receive your check.
First Name:**
OPEN-ENDED RESPONSE OPTION
Last Name:**
OPEN-ENDED RESPONSE OPTION
DK/REF
PROGRAMMER NOTE: IF WEB AND S15c = BLANK, SHOW ERROR MESSAGE: This information is
important so we can send you your incentive. Please enter your contact information. Otherwise
select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S15c = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.

S15d

[IF HH = YES & S15_3 = 2] Would you like us to mail your check to [ADDRESS FILL] or to another
address?
1
Yes, mail to [ADDRESS FILL]**
2
No, mail to another address**
DK/REF

S15e

[IF S15d = 2] What address do you want us to mail the check to?
Street**: (NUMBER AND STREET NAME)
City**: (CITY)
State**: (STATE)
ZIP: (ZIP)
DK/REF
PROGRAMMER NOTE: IF WEB AND S15e = BLANK, SHOW ERROR MESSAGE: This information is
important so we can send you your incentive. Please enter your contact information. Otherwise
select 'Not sure' or 'Prefer not to answer' and click 'Next' to continue.
IF (PHONE OR IN-PERSON) AND S15e = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO ANSWER
IF YOU CAN.
54

S16_trans
S16

[IF FI | TI ADMINISTERED] INTERVIEWER, PLEASE CLICK “NEXT” TO FINALIZE THIS CASE,
OTHERWISE CLICK BACK BUTTON TO MODIFY PREVIOUSLY ENTERED ANSWERS

This concludes our screening survey. Thank you for your participation. 


S17

[IF HH = YES & FI | TI ADMINISTERED & # OF INDIVIDUALS SELECTED FOR SCREENING = 2] Is  available for me to speak with now?
1
Yes**
2
No**
DK/REF
INTERVIEWER: IF ON THE PHONE: THE NEW INTERVIEW WILL OPEN IN A NEW WINDOW. PLEASE
COMPLETE THE DEBRIEFING ITEMS FOR THE FIRST INTERVIEW ONLY IF YOU HAVE TO WAIT FOR
THE SECOND PERSON TO COME TO THE PHONE. OTHERWISE, COMPLETE BOTH DEBRIEFINGS
AFTER THE INTERVIEWS.
PROGRAMMER NOTE: IF YES, BEGIN SECOND SCREENING SURVEY BY OPENING THAT CASE IN A
SEPARATE TAB/WINDOW.

S17_a Thank you.
PROGRAMMER TIME STAMP SET: END

55

SECTION 12: INTERVIEWER DEBRIEFING QUESTIONS
PROGRAMMER TIME STAMP SET: DEBRIEF
[IF SFIID3 = 1 | 2 | 3] THESE QUESTIONS ARE FOR THE INTERVIEWER TO ANSWER. DO NOT READ TO THE
R.
INTERVIEWER: ENTER PASSCODE TO CONTINUE:_____
IDB0

Did the respondent complete the entire screening survey or is this an incomplete
interview/breakoff?
1. RESPONDENT COMPLETE INTERVIEW
2. INCOMPLETE INTERVIEW/BREAKOFF
PROGRAMMER: GO TO IDBBR1 IF IDB0 = INCOMPLETE INTERVIEW/BREAKOFF
ELSE CONTINUE

IDB1

[IF SFIID3 = 2] How did the respondent complete the screening survey?
1. THE RESPONDENT COMPLETED THE SCREENING SURVEY WITH NO ASSISTANCE
FROM ME
2. THE RESPONDENT COMPLETED THE SCREENING SURVEY, BUT NEEDED
ASSISTANCE ON A FEW SCREENS
3. THE RESPONDENT COMPLETED THE SCREENING SURVEY, BUT NEEDED
ASSISTANCE ON MANY SCREENS
4. I ADMINISTERED THE ENTIRE INTERVIEW

IDB2

[IF IDB1 != 1|4] What type of assistance did you provide to R?
Check all that apply.
1. READ ONE OR MORE QUESTIONS TO R
2. HELPED R ENTER ONE OR MORE ANSWERS
3. HELPED R MOVE TO NEXT SCREEN
4. HELPED R BACK UP TO PREVIOUS SCREEN
5. HELPED R HIDE QUESTION TEXT
6. ANSWERED QUESTIONS ABOUT WHAT A QUESTION MEANT
7. OTHER (SPECIFY:_______________)

IDB3

[IF HH = YES & SFIID3 = 2 | 3] Did you conduct this interview at the respondent’s home,
either inside or outside?
1. YES
2. NO

IDB4

[IF IDB3 = NO | JA = YES] Where did you conduct this interview?
1. 
2. 
3. 
4. 
56

5. 
6. 
7. 
8. 
9. 
10. SOME OTHER PLACE (SPECIFY: _______________)
IDB5

[IF SFIID3 = 2 | 3] Please indicate how private the interview was. Do not count yourself
or a project observer as another person in the .
1. COMPLETELY PRIVATE – NO ONE WAS IN THE  OR LISTENING
2. MOSTLY PRIVATE – PERSON(S) IN THE  OR LISTENING LESS THAN HALF OF THE TIME
3. SOMEWHAT PRIVATE – PERSON(S) IN THE  OR LISTENING ABOUT HALF OF THE TIME
4. NOT VERY PRIVATE – PERSON(S) IN THE  OR LISTENING MORE THAN HALF OF THE TIME
5. NOT AT ALL PRIVATE – CONSTANT PRESENCE OF OTHER PERSON(S) IN THE  OR LISTENING

IDB6

[IF IDB5 !=1] Not including yourself or project observers, who were the other people
present or listening to the interview?
Check all that apply.
1. PARENT(S)
2. SPOUSE
3. LIVE-IN PARTNER/BOYFRIEND/GIRLFRIEND
4. OTHER ADULT RELATIVE(S)
5. 
6. 
7. CHILD(REN) UNDER 18
8. OTHER

IDB6a

[IF IDB5 !=1] In what ways did the other people’s presence influence the interview?
Check all that apply.
1. PERSON(S) CAME INTO THE AND
YOU PAUSED THE INTERVIEW UNTIL THEY LEFT
2. PERSON(S) CAME INTO THE ,
YOU OR R ANSWERED THEIR QUESTION OR EXPLAINED THAT PRIVACY WAS
NEEDED, AND THEY LEFT
3. PERSON(S) STAYED IN THE  BUT
DID NOT PARTICIPATE IN INTERVIEW
4. PERSON(S) STAYED IN THE  AND
OFFERED R HELP WITH ANSWERS
5. PERSON(S) STAYED BUT WAS TOO YOUNG TO UNDERSTAND THE INTERVIEW
6. OTHER (SPECIFY: ___________________)
57

IDB7

During the interview, was the atmosphere at the interview site:
1. EXTREMELY CHAOTIC AND NOISY; DISRUPTIVE TO INTERVIEW
2. SOME NOISE OR INTERRUPTIONS BUT INTERVIEW WENT REASONABLY
SMOOTHLY
3. VERY QUIET AND CALM, IDEAL FOR INTERVIEW

IDB8

What types of distractions or interruptions were present during the interview?
Check all that apply.
□ TELEVISION ON DURING INTERVIEW BUT R NOT WATCHING
□ TELEVISION ON DURING INTERVIEW WITH R WATCHING AT LEAST SOME OF THE
TIME
□ R RECEIVED 1 OR 2 PHONE CALLS
□ R RECEIVED 3 OR MORE PHONE CALLS
□ CHILDREN PRESENT NEEDED ATTENTION
□ OTHER (SPECIFY: ___________________)
□ NO DISTRACTIONS OR INTERRUPTIONS PRESENT

IDB9

How attentive was the respondent to the questions during the interview?
1. NOT AT ALL ATTENTIVE
2. SOMEWHAT ATTENTIVE
3. VERY ATTENTIVE

IDB10

Was the respondent upset during the interview?
1. YES, UPSET BECAUSE OF INTERVIEW CONTENT
2. YES UPSET, BUT NOT RELATED TO INTERVIEW CONTENT
3. NO, NOT UPSET

IDB11

While completing the interview, did the respondent experience any of the following
difficulties?
a.
b.
c.
d.

LANGUAGE/TRANSLATION PROBLEMS
READING OR VISION PROBLEMS
COMPREHENSION PROBLEMS
SUBSTANCE OF THE INTERVIEW (I.E., TOPICS WE
WERE ASKING ABOUT)
e. OTHER (SPECIFY: ___________________)
IDB13

Yes

No

[IF IDB1 = 1 | 2 | 3] Were you able to see the computer screen < IF IDB1 = 2 | 3: during
the parts of the interview that the respondent self-completed?>
1. I COULD SEE THE SCREEN THE ENTIRE TIME
2. I COULD SEE THE SCREEN ON MOST, BUT NOT ALL OF THE SELF-ADMINISTERED
QUESTIONS
3. I COULD SEE THE SCREEN ON A FEW SELF-ADMINISTERED QUESTIONS
4. I COULD NEVER SEE THE SCREEN DURING THE SELF-ADMINISTRATION
58

IDB14

Did the respondent make any comments about the interview being too long?
1. YES
2. NO

IDB15

Please note anything else you think would be helpful for the interpretation and
understanding of this interview.
___________ALLOW 250 CHARACTERS
PROGRAMMER ALLOW FOR BLANK SUBMISSIONS

PROGRAMMER TIME STAMP SET: ENDDB
PROGRAMMER TIME STAMP SET: BEGINDBBR
IDBBR1
[IF BREAKOFF = YES] Please indicate if any of the following contributed to the interview
termination.
Yes

a. DISTRESSED RESPONDENT PROTOCOL INITIATED
b. RESPONDENT IS PHYSICALLY OR MENTALLY
INCABPABLE OF COMPLETING THE INTERVIEW
c. RESPONDENT NOTED THE INTERVIEW WAS TOO
LONG AND DID NOT WISH TO CONTINUE
d. RESPONDENT DID NOT HAVE TIME TO COMPLETE
THE INTERVIEW BUT IS WILLING TO COMPLETE AT
A LATER TIME
e. RESPONDENT DOES NOT WISH TO CONTINUE THE
INTERVIEW ALONE
f. RESPONDENT WAS STRESSED ABOUT THE
CONTENT OF THE INTERVIEW
g. EQUIPMENT PROBLEM
h. ABRUPT END, RESPONDENT DIDN’T GIVE A
REASON
i. OTHER (SPECIFY: ___________________)
PROGRAMMER CHECKBOX: NA (INTERVIEW WAS COMPLETED)

No

PROGRAMMER: IF IDBBR1 = NA GO TO IDB1
PROGRAMMER TIME STAMP SET: ENDDBBR
Next [RECORD OF CALLS]

59

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215

Were you serious, introverted, or gloomy?
The littlest thing could make you sad.
Did you feel persistently sad or empty, blue, or down in the dumps?
Did your mood change rapidly from happy to sad and back again?
I felt sad.
Did you generally feel content?
How much did you experience positive feelings in your life?
How often did you have negative feelings, such as blue mood, despair, anxiety, depression?
How much did any feelings of depression bother you?
I felt gloomy.
Have you been depressed or sad?
Has there been a time when you have been seriously depressed?
I had a sense of harmony with myself.
How much of the time did you feel depressed?
I felt depressed.
How much of the time have you felt downhearted and blue?
How much have you felt really lively?
How much have you felt cheerful?
How much have you felt really happy?
How much have you felt sad?
How much have you felt dissatisfied with things?
How much have you been troubled or bothered by psychological or emotional problems?
How much of the time have you been in low or very low spirits?
I felt sad.
Were you in good spirits most of the time?
Did you feel happy most of the time?
How much were you distressed by feeling blue?
I have been feeling bad lately.
Did you experience long periods of sadness?
Have you had a significant period (that was not a direct result of drug/alcohol use) in which you have experienced serious depression?
Have you felt emotionally exhausted?
I was happy.
I was unhappy.
Did you receive care for feeling depressed or blue?
How sad did you feel?
How happy did you feel?
Did you feel unhappy?
How often did you feel content with your life?
How often did you feel happy?
How often did you feel sad?
Have you been in low or very low spirits?
How depressed (at its worst) have you felt?
I was bothered by things that usually don''t bother me.
Did you often feel upset for no obvious reason?
Did you find yourself crying very easily?
Did you feel like crying and laughing at the same time?
Did you ever become very distressed or did you avoid things that evoked episodes of crying and/or intense emotions?
Have you cried?
Have you felt like crying even though you did not?
I had crying spells.
How often have you felt like crying?
I cry more than I used to.
I had crying spells or felt like it.
How much were you distressed by crying easily?
Did you find yourself needing to cry?
I felt weepy or tearful.
Were you deeply annoyed with everything?
Were you constantly complaining?
Did you tend to do the opposite of what people wanted you to do or to play the devil''s advocate?
Were you very irritable (for example, even the smallest thing could make you very irritable)?
Were you very irritable (for example, you found that you were particularly critical or sarcastic)?
Were you very irritable (for example, you had great difficulty seeing others'' points of view)?
Were you very irritable (for example, you were unusually argumentative or showed unusual hostility)?
Have you had trouble controlling your temper (for example, you felt that you really needed to even the score)?
Have you had trouble controlling your temper (for example, you found yourself shouting at people or starting arguments or fights, even over minor matters)?
Were you very impatient?
Did you ever feel irritable, have outbursts of anger or rage, or lose your temper over minor things?
How much of the time have you been in firm control of your behavior, thoughts, emotions, or feelings?
How much of the time have you felt emotionally stable?
How much of the time have you been moody or brooded about things?
How much difficulty have you been having in the area of mood swings or unstable moods?
Were you an excessively emotional person?
How often have you felt emotionally stable?
How often have you been moody or brooded about things?
My mood has been sad, but this sadness is like the sad mood I would feel if someone close to me died or left.
You completely lost your capacity to laugh, have fun, or enjoy your life.
How much did you enjoy life?
Were you bothered by any difficulties in your sex life?
How much were you able to relax and enjoy yourself?
How much did you enjoy your free time?
How much has pain interfered with your enjoyment of life?
I enjoyed life.
How much have you been able to laugh easily?
How much have you felt that nothing was enjoyable?
How much have you felt like you were having a lot of fun?
How much of the time has living been a wonderful adventure for you?
How much difficulty have you been having in the area of feeling satisfaction with your life?
I didn''t enjoy things the way I used to.
Have you been basically satisfied with your life?
Have you been able to enjoy your normal day-to-day activities?
I felt satisfied.
Did you have difficulty in becoming sexually aroused?
How happy, satisfied or pleased have you been with your personal life?
How much of the time have you generally enjoyed the things you do?
I could laugh and see the funny side of things.
I looked forward with enjoyment to things.
I could enjoy a good book, radio or tv program.
I still enjoyed sex.
My life was pretty full.
Have you had decreased libido?
Did you actually receive care for sexual problems or concerns?
I enjoyed sex as much as ever.
Did you enjoy the things you usually do for fun?
Was your sense of humor reduced?
You lost interest in how you looked.
Did your mood become depressed as a result of using alcohol, sleeping pills, anti-anxiety drugs, nicotine, caffeine, stimulants or similar substances even though you took them in order to feel better?
Did you lose interest and pleasure in your social life and did you prefer spending most of your time alone, withdrawing from your family and friends?
Did you lose interest in making new friends or find it difficult to make new friends?
Did you lose interest in your romantic life?
Did you lose interest in your hobbies or in playing games or sports?
Did you feel indifferent about everything (either positive or negative) that happened to you or your family?
Did you lose interest or pleasure in all or almost all the things you usually enjoyed?
Did you find that activities or things that used to be interesting or important to you became pointless, meaningless, or insignificant?
I was not interested in having sex.
How much of the time has your daily life been full of things that were interesting to you?
How much have you felt bored?
How much have you felt nothing was interesting or fun?
How much have you felt there were many interesting things to do?
I noticed that I was less interested in people or activities.
I was less interested in sex than I used to be.
How much of a problem was lack of sexual interest?
How much were you distressed by feeling no interest in things?
I did not feel like embracing, kissing, or caressing my partner.
Did you feel interest in anything?
Have you lost interest in the things you used to do?
Has your daily life been full of things that were interesting to you?
Did you feel frustrated and defeated although you couldn''t think of any reason for this?
Did you feel that you no longer had emotions you used to have or that your feelings were dulled?
I felt that I could not shake off the blues even with help from my family or friends.
How much of the time have you felt so down in the dumps that nothing could cheer you up?
My mood brightened when good events occurred, but I did not feel like my normal self.
My thinking was clear.
Did you drift in and out of conversations?
I had difficulty concentrating.
How much of the time did you have difficulty doing activities involving concentration and thinking?
I had trouble keeping my mind on what I was doing.
How much have you had trouble paying attention?
How much difficulty have you been having in the area of confusion, concentration, or memory?
How much were you distressed by trouble concentrating?
How much of the time did you have trouble keeping your attention on any activity for long?
My mind was as clear as it used to be.
Have you had difficulty in concentrating on things, like reading a newspaper or watching television?
You had difficulty making even minor decisions (such as what shirt to wear, what household task to do first).
Did you have a lot of trouble thinking or concentrating, such as trouble taking part in a discussion, reading, writing, doing math, or following a television program?
How much of the time did you have difficulty reasoning and solving problems; for example, making plans, making decisions, learning new things?
How much have you had trouble making decisions?
I put off making decisions more than I used to.
I occasionally felt indecisive.
I found that my attention wandered.
I felt indecisive.
I found it easy to make decisions.
You couldn''t make decisions easily?
Did you have problems with your memory, such as finding the right word or remembering things that should have been easy to remember?
I had trouble remembering things.
How much of the time did you forget things that happened recently, where you put things, or appointments?
How much have you had trouble remembering things?
Did you feel you had more problems with memory than most?
How much were you distressed by trouble remembering things?
How much have you been bothered by poor memory for recent events?
Did you feel you had become forgetful?
Did you feel that your memory was failing?
Did your speech or thinking seem slowed down?
Did you experience time as passing very slowly?
Did you feel mentally dull or confused?
How much of the time did you react slowly to things that were said or done?
I found that my thinking was slowed down.
My voice sounded dull or flat.
Could you think as quickly as you used to?
How much have you been bothered by thoughts that are slow?
How much have you been bothered by not being able to find the right words?
Did you find that silly or unreasonable thoughts kept recurring in your mind?
Did you think there was nothing you could do to change the way things were going?
Did you see the future as very bleak?
How positive did you feel about the future?
How much have you been pessimistic about the future?
I felt discouraged about the future.
How often did you feel your life was moving in a positive direction?
Were you hypercritical or skeptical about all the things that people ordinarily value in life?
You felt very vulnerable.
You felt constantly afraid of doing something wrong.
Were you disappointed in yourself?
Did you feel useless, as if you were without any talent and you couldn''t do anything right?
How much have you been proud of yourself?
How much have you been disappointed in yourself?
How much have you felt good about yourself?
How much have you blamed yourself for things?
How much difficulty have you been having in the area of lack of self-confidence or feeling bad about yourself?
I felt I have failed more than the average person.
I was disappointed in myself.
I was critical of myself for my weaknesses or mistakes.
I was more self-blaming than usual.
How much were you distressed by blaming yourself for things?
I sometimes had bad thoughts that made me feel ashamed of myself.
How often did you feel good about yourself?
You felt you had no purpose, as if everything had lost its significance?
Did you feel unappreciated because others did not understand or share your optimistic or imaginative ideas?
Did you feel happy about yourself as a person?
My life has been productive.
I felt that I was just as good as other people.
How much have you felt like a failure?
How much have you felt inferior to others?
How much have you felt successful?
How much have you felt confident?
How much have you felt worthless?
Did you think that most people were better off than you?
How much were you distressed by feelings of worthlessness?
I felt that I was useful and needed.
How often have you felt worthless?
Nothing you put on looked or felt right.
Was there any part of your appearance which made you feel uncomfortable?
I was self-conscious about my appearance.
I was self-conscious about how my face and neck looked.
How much have you felt unattractive?
I was worried that I was looking old or unattractive.
I lost interest in my appearance.

216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430

Did you avoid activities that evoked feelings of loneliness or other distressing emotions?
Have you felt lonely?
How much of the time have you felt loved and wanted?
How much difficulty have you been having in the area of isolation or feelings of loneliness?
How much difficulty have you been having in the area of being able to feel close to others?
How much were you distressed by feeling lonely?
Did you feel isolated from others?
Did you find it unusually hard to take rejections, particularly those involving friendships or romantic relationships?
You felt as if others were causing all of your problems.
I felt that people disliked me.
How much of the time did you feel left out?
I occasionally felt rejected, slighted, criticized, or hurt by others.
How much were you distressed by feeling others were to blame for most of your troubles?
How much were you distressed by feeling others did not understand you or were unsympathetic?
How often did you feel disappointed and resentful?
How often did you feel rejected?
I was more sensitive than usual.
How often have you felt ignored by people?
How often did you feel left out?
I felt a sense of purpose in my life.
My life lacked meaning and purpose.
How much have you felt discouraged?
How much difficulty have you been having in the area of goals or direction in life?
Did you feel that your life was empty?
How much were you distressed by feeling hopeless about the future?
How much of the time did you feel that you had nothing to look forward to?
How often did you feel hopeless?
Did you believe that you had come to a "dead end"?
How much control did you feel you have had over your life?
How much difficulty have you been having in the area of developing independence?
Did you often feel helpless?
How often have you felt that you can''t take it anymore?
Did you feel you wanted to give up trying?
Did you have the feeling that you just didn''t have what it takes anymore?
Did you feel defeated?
I felt like I was at the end of my rope.
How often did you feel that the changes in your life were overwhelming?
I felt I should be punished.
I cheated at something and suffered unbearable feelings of remorse.
It depressed me that I did not do more for my parents.
I was concerned about being forgiven for my sins.
I did many things that made me feel remorseful afterward.
Failure gave me a feeling of remorse.
When I did wrong my conscience punished me quickly.
I often felt that I have not lived the right kind of life.
How much were you distressed by the idea that you should be punished for your sins?
How much were you distressed by feelings of guilt?
Did you regret much of your past behavior?
Did you feel guilty?
Have you had problems accomplishing less than you would like with your work or other regular daily activities as a result of emotional problems (such as feeling depressed or anxious)?
How often has feeling depressed interfered with what you usually do?
I found that the frequency of sexual intercourse had decreased for me.
I found it easy to do the things I used to do.
Have you cut down the amount of time you spent on work or other activities as a result of any emotional problems (such as feeling depressed or anxious)?
Did you have difficulty starting to do anything?
You felt passive, sluggish, and failed to take care of your usual commitments and responsibilities?
Have you had difficulty taking care of yourself (for example, you showered less, wore the same clothes, did not put on make-up or shave)?
Did your housework, child care or your performance at school, work, sports, or hobbies deteriorate?
How much did feelings of sadness or depression interfere with your everyday functioning?
Did you stop taking care of yourself (for example, not getting enough rest, not eating right)?
I felt motivated to do things.
How much emotional strain, stress, or pressure was associated with your usual daily activity (job, schoolwork, housework, or whatever you usually do)?
How much difficulty have you been having in the area of school (for example, academic performance, completing assignments, attendance)?
How often has feeling depressed interfered with what you usually do?
I felt emotionally drained from my work.
I felt burned out from my work.
Has feeling depressed interfered with what you usually do?
Have you accomplished less than you would like?
You didn''t do work or other activities as carefully as usual as a result of any emotional problems (such as feeling depressed or anxious)?
Did you have a lot of trouble getting out of bed in the morning?
Have you felt fatigued, weak, or tired as though the smallest task was an effort and required a great deal of energy?
I felt that everything I did was an effort.
I could not get "going".
How much have you needed to give extra effort to get started?
It took an extra effort to get started at doing something.
Did you have to make a special effort to face up to a crisis or difficulty?
How much were you distressed by feeling everything was an effort?
Did you feel that life was too much effort?
Did you shrink from your regular work as if it were a mountain to climb?
How easily did you get tired?
How much were you bothered by fatigue?
Have you felt as if you did not have enough energy?
Have you actually been sitting around a lot because of lack of energy?
How much have you gotten fatigued easily?
How much have you felt tired or sluggish?
I got tired more easily than I used to.
Have you been feeling run down?
Have you been feeling out of sorts?
Did you feel overly tired and exhausted?
I got tired for no reason.
Did fatigue interfere with your mood?
I felt guilty that I was too tired to do the things that I normally do.
When you felt sad, empty or depressed did you feel tired?
My fatigue-related limitations made me feel guilty.
To what degree has fatigue caused you distress?
Tiredness often made me irritable and I wanted to be left alone.
Did you feel physically slowed down, as if every movement was in slow motion?
Have you been feeling sluggish?
Did you feel that you had become slowed down in your physical movements?
How much have you felt slowed down?
I experienced periods of feeling physically weighted down and without physical energy but without a negative effect on my work, my school or my activity level.
Have you been taking longer with the things you do?
How much were you distressed by feeling low in energy or slowed down?
How much were you distressed by feeling blocked in getting things done?
How much were you distressed by having to do things very slowly to ensure correctness?
I felt as if I was slowed down.
Did you feel cut-off or detached, like you couldn''t connect with people or enjoy their company?
How much have you felt like being alone?
How much have you felt withdrawn from others?
How much have you felt like being with others?
Did you prefer to stay at home rather than going out and doing new things?
How often did you withdraw from other people?
Did you find it difficult to sit still or to lie down, or you needed to pace the room or to be constantly in motion?
Did you find your interests shifting frequently from one thing to another and were easily distracted?
I felt restless as if I had to always be on the move.
Did you repeatedly wake up in the middle of the night and have difficulty falling asleep again?
Did you repeatedly wake up much earlier than you wanted to, and were unable to go back to sleep?
I slept well.
Did you have more difficulty falling asleep or staying asleep than you did before?
I had difficulty sleeping.
Did you wake very early in the morning?
My sleep was restless.
More than half the time I awakened more than thirty minutes before I needed to get up.
Have you had difficulty staying asleep?
I had a restless, light sleep with a few brief awakenings each night.
How much were you distressed by trouble falling asleep?
How much were you distressed by awakening in the early morning?
How much were you distressed by sleep that was restless or disturbed?
Did you feel that your sleep was not quiet (moving restlessly, feeling tense, speaking, etc., while sleeping)?
Have you had trouble falling asleep?
Did you awaken from sleep and have trouble falling asleep again?
Did you wake unusually early in the morning?
I used sleep as an escape.
I felt sleepy all the time.
I needed much more sleep than usual either at night or during the day.
Did you have bad dreams which upset you when you woke up?
I did not feel like eating; my appetite was poor.
How much have you had a loss of appetite?
My appetite was not as good as it used to be.
Has your appetite decreased?
I found food unappealing.
Have you lacked an appetite?
Have you been eating well?
I ate somewhat less often or lesser amounts of food than usual.
I felt the need to eat more frequently than usual.
How much were you distressed by overeating?
I was bothered by a change in weight.
I gained too much weight.
I lost more than five pounds.
I noticed that I was losing weight.
Did you repeatedly have distressing physical symptoms, for instance you were constipated?
Did you repeatedly have distressing physical symptoms, for instance you had nausea or other stomach or bowel problems?
Did you repeatedly have distressing physical symptoms, for instance frequent headaches?
Did you repeatedly have distressing physical symptoms, for instance your mouth felt dry?
Were you more sensitive or less sensitive than usual to heat, cold or pain?
Did your mood become depressed when you had some sort of medical problem such as the flu or a cold?
Did your mood become more depressed when you took medications, such as antibiotics, contraceptives, or steroids?
Did you feel as if your body were diseased or somehow transformed?
Have you felt that you were ill?
It was difficult (that is, more difficult than is common for your friends or acquaintances) for you to work or be productive in the early morning.
It was difficult (that is, more difficult than is common for your friends or acquaintances) for you to work or be productive in the evening or night.
Did you become irritable or have difficulty functioning if your daily routine was disrupted (for instance, you had to get up, eat or work at a time that wasn''t usual for you)?
Has there been any time of day when you felt slower and less energetic?
Did you think that life was not worth living?
Have you felt that life was not worth living?
I had a reason for living.
How often did you feel that others would be better off if you were dead?
I felt that life was empty or wondered if it was worth living.
Have you felt that life wasn''t worth living?
Did you think it was wonderful to be alive?
I felt that others would be better off if I were dead.
Have you found yourself wishing you were dead and away from it all?
Did you want to be dead at times?
Did you think about taking your own life?
Did you ever feel like you just couldn''t relax or let your guard down?
How much of the time have you been anxious or worried?
I felt anxious or tense.
How much of the time have you been anxious or worried?
I felt secure.
Have you had a significant period (that was not a direct result of drug/alcohol use) in which you have experienced serious anxiety or tension?
I felt anxious.
I felt fearful.
How much have you felt afraid?
How much difficulty have you been having in the area of fear, anxiety or panic?
I felt frightened.
How much were you distressed by feeling fearful?
I got a sort of frightened feeling like "butterflies" in my stomach.
How much have you been bothered by feeling terrified?
How much have you been bothered by feeling scared?
Did you feel fearful?
Did you ever startle easily at the sound of sudden noises, when someone touched you, spoke to you, or approached you unexpectedly?
How much difficulty have you been having in the area of recognizing and expressing emotions appropriately?
How often have you experienced psychological or emotional problems?
How much have you been troubled or bothered by psychological or emotional problems?
I felt upset.
I felt comfortable.
I felt content.
I felt pleasant.
How much of the time have you felt emotionally stable?
Were you an excessively emotional person?
How often did you feel emotionally exhausted?
How often did you experience being troubled?
I felt upset because I didn''t get enough accomplished.
I was distressed.
Have you felt emotionally stable?
Did you have difficulty calming down?
Did you get rattled, upset, or flustered?
Have you ever suddenly and unexpectedly experienced the feeling that things around you were no longer familiar, but were unreal and strange?
Did you awaken in a panic for no reason?
I had mild panic episodes that did not change my behavior or stop me from functioning.
Have you recently been getting scared or panicky for no good reason?
How much were you distressed by suddenly feeling scared for no reason?
Did you feel panicky in crowds?
How much were you distressed by spells of terror or panic?
I had sudden feelings of panic.

431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546
547
548
549
550
551
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
567
568
569
570
571
572
573
574
575
576
577
578
579
580
581
582
583
584
585
586
587
588
589
590
591
592
593
594
595
596
597
598
599
600
601
602
603
604
605
606
607
608
609
610
611
612
613
614
615
616
617
618
619
620
621
622
623
624
625
626
627
628
629
630
631
632
633
634
635
636
637
638
639
640
641
642
643
644
645

Did you sometimes feel really panicky?
Have you ever worried about hurting people''s feelings because of something you said or did?
Have you ever worried about disapproval or hostility from others?
How much did you worry about your safety and security?
How much did you worry about money?
Did you worry about almost everything?
Have you worried a lot about things?
I wished I could get over worrying about the things I have said that may have injured other people''s feelings.
Have you lost much sleep over worry?
I was worrying over possible misfortunes.
I worried about being fired.
How much were you distressed by worrying too much about things?
Did you find yourself worrying unreasonably about things that did not really matter?
My worries overwhelmed me.
Many situations made me worry.
I could not help myself from worrying about things.
I worried a lot when I was under pressure.
I was always worrying about something.
I found it easy to dismiss worrisome thoughts.
As soon as I finished one task, I started to worry about everything else I had to do.
Once I started worrying I couldn''t stop.
I worried about projects until they were all done.
Worrying thoughts went through my mind.
Would you say you were a worrying person?
I think that my fatigue came from worries, or stress.
Did you feel worried about your future?
Did you worry?
Did you experience a lot of distress because of thoughts that you might lose someone close to you or some harm might come to them?
Did you worry a lot that something bad would happen to you and lead to separation from someone close to you?
Have you worried that there might be something terribly wrong that you cannot define?
I felt uneasy.
How much have you felt something awful would happen?
I felt at ease.
Were you afraid that something bad was going to happen to you?
How much were you distressed by the feeling that something bad was going to happen to you?
How much have you been bothered by fear of the worst happening?
Did you stay in a relationship even when it was not in your best interest, rather than risk being alone?
Did you feel that you got involved in things when you didn''t want to because you couldn''t say no?
Did you feel particularly uncomfortable working or playing as part of a team?
Did you feel particularly embarrassed or uncomfortable meeting a new person?
Because of fear or unpleasant feelings, how much did you avoid worrying about projects until they were all done?
Because of fear or unpleasant feelings, how much would you avoid injections or minor surgery?
Because of fear or unpleasant feelings, how much would you avoid eating or drinking with other people?
Because of fear or unpleasant feelings, how much would you avoid hospitals?
Because of fear or unpleasant feelings, how much would you avoid traveling alone by bus?
Because of fear or unpleasant feelings, how much would you avoid walking alone in busy streets?
Because of fear or unpleasant feelings, how much would you avoid being watched or stared at?
How much were you distressed by having to avoid certain things, places or activities because they frightened you?
Because of fear or unpleasant feelings, how much would you avoid going into crowded shops?
Because of fear or unpleasant feelings, how much would you avoid talking to people in authority?
Because of fear or unpleasant feelings, how much would you avoid the sight of blood?
Because of fear or unpleasant feelings, how much would you avoid being criticized?
How much would you avoid going far from home alone because of fear or unpleasant feelings?
Because of fear or unpleasant feelings, how much would you avoid thoughts of injury or illness?
Because of fear or unpleasant feelings, how much would you avoid speaking or acting to an audience?
Because of fear or unpleasant feelings, how much would you avoid large open spaces?
Because of fear or unpleasant feelings, how much would you avoid going to the dentist?
Have you had distressing thoughts, feelings, or images that came into your head out of the blue?
How much difficulty have you been having with disturbing or unreal thoughts or beliefs?
How much difficulty have you had in the area of uncontrollable or compulsive behavior (for example, eating disorder, hand-washing, hurting yourself)?
How much were you distressed by repeated unpleasant thoughts?
How much were you distressed by worries of sloppiness or carelessness?
How much were you distressed by having to check and double check what you do?
Did you have to check things you do to an unnecessary extent?
Did it irritate you if your normal routine was disturbed?
How much were you distressed by having to repeat the same actions such as touching, counting, or washing?
How much were you distressed by having thoughts about sex?
How much were you distressed by thoughts and images of a frightening nature?
Did people ever say you were too conscientious?
I felt emotionally drained from my work.
I felt burned out from my work.
Have you cut down the amount of time you spent on work or other activities as a result of emotional problems?
Have you accomplished less than you would like as a result of emotional problems?
Did you often or were you told that you used very short phrases?
Did you often or were you told that you lowered your body and your head?
Did you often or were you told that you found it difficult to look others straight in the eye?
Did you often feel afraid that someone might misinterpret your glance?
Did you often feel afraid to look someone in the eyes because you felt that they could tell what you were thinking or feeling?
Did you often or were you told that you apologized frequently even when it was not necessary?
Did you often or were you told that you carefully controlled your movements?
Did you often or were you told that you fidgeted to reduce your anxiety?
Did you often or were you told that you clowned around to reduce your anxiety?
Did you often or were you told that you found it difficult to know where to look when talking to someone?
Did you often or were you told that you found it difficult to know what to do with your hands in social situations?
Did you often or were you told that you found you lost your breath when you talked to others?
Did you often or were you told that you played a role (not being yourself), in order to be more comfortable?
Did you often or were you told that you lied in order to be more comfortable?
Did you feel put upon or resentful because you couldn''t say no to a request?
How much of the time did you have difficulty reasoning and solving problems; for example, making plans, making decisions, learning new things?
How much have you had trouble making decisions?
I had a change of heart about my life''s work.
How much were you distressed by difficulty making decisions?
I found it easy to make decisions.
How much have you been bothered by not being able to make decisions?
My thinking was clear.
I had difficulty concentrating.
Were you bewildered or confused?
I did not do work or other activities as carefully as usual.
How much of the time did you have difficulty doing activities involving concentration and thinking?
How much have you felt confused?
How much of the time did you forget things (for example, things that happened recently, where you put things or appointments)?
How much were you distressed by your mind going blank?
Have you had difficulty in concentrating on things, like reading a newspaper or watching television?
Have you ever suddenly and unexpectedly experienced feeling afraid that you might lose control or go crazy?
Have you ever suddenly and unexpectedly experienced feeling afraid that you might die?
Did you feel that you were about to lose control of your behavior?
Have you been afraid of or did you avoid taking prescribed medication because it might cause you to lose control or might change your personality?
Have you worried a lot that there might be something terribly wrong with you mentally, like losing your mind or losing control?
Have you had any reason to wonder if you were losing your mind?
How much have you felt afraid of losing control?
How much have you felt like you were going crazy?
How much have you felt afraid of dying?
When I noticed my heart was beating rapidly, I worried that I might have a heart attack.
How much were you distressed by feeling afraid you will faint in public?
How much have you been bothered by a fear of dying?
How much were you distressed by the idea that something serious was wrong with your body?
How much were you distressed by the idea that something was wrong with your mind?
Have you felt frightened or worried about falling in public?
Did you experience a lot of distress if you were separated or anticipated separation from home or loved ones?
Did you have trouble going to school or work because of fear of separation?
Has it been very difficult for you to be alone or with a loved one, either at home or in other places?
Did you have repeated nightmares about being separated from your family?
Did you feel nervous or uncomfortable when you were alone outside your home or somewhere far from home?
Did you feel nervous or uncomfortable when home alone?
Did you feel nervous or uncomfortable when you were in a crowded place?
Did you feel nervous or uncomfortable when you were in closed places?
Did you feel nervous or uncomfortable being in an open place like a town square or a wide street?
Did you ever feel afraid to go to bed or to go to sleep?
I became nervous when I was waiting to see the doctor.
I became nervous when I got my blood drawn.
How much were you distressed by feeling afraid in open spaces or on the streets?
How much were you distressed by feelings of being trapped or caught?
How much were you distressed by feeling afraid to go out of your house alone?
How much were you distressed by feeling afraid to travel on buses, subways or trains?
Did you worry excessively when relatives were late coming home?
Were you scared of heights?
How much were you distressed by feeling uneasy in crowds such as shopping or at a movie?
How much were you distressed by feeling nervous when you were left alone?
Did you have an unreasonable fear of being in enclosed spaces such as stores, elevators, etc.?
Did you feel uneasy traveling on buses or the subway even if they were not crowded?
Did you dislike going out alone?
How often did you feel trapped?
When my stomach was upset, I worried that I might be seriously ill.
It scared me when I was unable to keep my mind on a task.
Other people noticed when I felt shaky.
Unusual body sensations scared me.
It scared me when I was nervous.
It was important to me not to appear nervous.
When I couldn''t keep my mind on task, I worried that I might be going crazy.
It scared me when I felt shaky.
It scared me when I felt faint.
It scared me when my heart beat rapidly.
It embarrassed me when my stomach growled.
It scared me when I was nauseous or sick to my stomach.
It scared me when I became short of breath.
I had difficulty asking doctors questions.
Have you ever been very worried that people might be critical of you?
Have you ever felt that the fear of being judged by others affected your relationships?
Have you ever worried that you might be unappealing to others?
Have you ever worried that others considered you stupid, clumsy or ridiculous?
Did you feel you were physically unattractive?
Did you feel you needed to dress in a manner that didn''t call any attention to yourself?
Did you feel particularly embarrassed or uncomfortable when you had to undress in front of another person?
When talking on the phone did you sometimes become self-conscious of the sound of your voice?
When talking on the phone did you sometimes find it difficult to understand or remember what the other person said?
When talking on the phone did you sometimes feel embarrassed to talk when other people were present?
When talking on the phone did you sometimes find it difficult to think of what to say?
When attending or giving a party or meeting your friends, did you feel embarrassed or uncomfortable?
When attending or giving a party or meeting your friends, did you feel afraid of meeting people?
When attending or giving a party or meeting your friends, did you feel afraid of not being able to make conversation?
When at a party or meeting with your friends, did you feel afraid that you were not interesting?
When attending or giving a party or meeting your friends, did you feel afraid of being judged?
When attending or giving a party or meeting your friends, did you feel afraid that your guests might criticize your home or hospitality?
Did you feel embarrassed or uncomfortable when you had to ask someone you liked to get together, work on a project, play a sport or join you in some other activity?
Did you feel embarrassed or uncomfortable when you had to express romantic feelings to someone you liked?
Did you feel embarrassed or uncomfortable when you had to think about getting undressed in front of someone you liked?
I was self-conscious about my appearance.
I felt that people disliked me.
At parties I was more likely to sit by myself or with just one other person than to join in with the crowd.
I did not want to be a member of a crowd or gang.
How much were you distressed by feeling shy or uneasy with the opposite sex?
How much were you distressed by your feelings being easily hurt?
How much were you distressed by feeling that people were unfriendly or disliked you?
How much were you distressed by feeling inferior to others?
How much were you distressed by feeling that you were watched or talked about by others?
Did you sometimes find yourself posing or pretending?
How much were you distressed by feeling uneasy when people were watching or talking about you?
How much were you distressed by feeling very self-conscious with others?
How much were you distressed by feeling uncomfortable about eating or drinking in public?
How much were you distressed by feeling lonely even when you are with people?
I had difficulty initiating contact with potential dates.
How much have you been bothered by not being able to take things in when speaking to people?
I was more sensitive than usual.
I felt embarrassed in public.
I felt worried about other people''s reaction to me.
Did you feel particularly embarrassed or uncomfortable meeting a person of the opposite sex?
Did you feel that no one could be interested in you romantically?
Did you feel that it was difficult to reject the advances of someone out of fear of hurting them?
Did you feel that it was difficult to accept the advances of someone because you couldn''t believe that he or she was really interested in you?
Did you feel that your partner was judging your performance during sexual activities?
Did you feel inadequate in everyday relationships, even with people like co-workers, sales people, or peers?
Did you feel unable to criticize your partner''s behavior even if you thought you should?
Did you feel extremely uncomfortable or wounded when others did not approve of your ideas or what you do?
Did you feel unable to state your opinions during a discussion?
Did you feel unable to disagree during a discussion?
Did you avoid, if possible, disagreeing with or expressing disapproval to others?
How much difficulty have you been having in the area of lack of self-confidence or feeling bad about yourself?
Did you avoid going to bed because you might become ill or die while asleep?
Did you feel as though you were about to suffocate because of hot, stale or humid air, or because of perfume, or other smells?
Did you feel nervous or uncomfortable because of the dark?
Did you feel nervous or uncomfortable because of noises, even when the noise was not loud?
Did you feel nervous or uncomfortable because of a blurred view such as fog, open sea, or snowy landscape?
Did you read the package inserts more carefully than most other people because of feeling nervous or uncomfortable about taking medication?
I had trouble feeling peace of mind.
How much of the time have you been a very nervous person?

646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694
695
696
697
698
699
700
701
702
703
704
705
706
707
708
709
710
711
712
713
714
715
716
717
718
719
720
721
722
723
724
725
726
727
728
729
730
731
732
733
734
735
736
737
738
739
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
757
758
759
760
761
762
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
784
785
786
787
788
789
790
791
792
793
794
795
796
797
798
799
800
801
802
803
804
805
806
807
808
809
810
811
812
813
814
815
816
817
818
819
820
821
822
823
824
825
826
827
828
829
830
831
832
833
834
835
836
837
838
839
840
841
842
843
844
845
846
847
848
849
850
851
852
853
854
855
856
857
858
859
860

How much have you felt nervous?
I believed I was more nervous than other people.
I have been made especially nervous over trouble with members of my family.
Have you recently been feeling nervous and uptight all the time?
Have you found you couldn''t do anything because your nerves were too bad?
How much were you distressed by nervousness or shakiness inside?
How much have you been bothered by nervousness or your nerves?
I felt calm.
How much have you been able to relax and enjoy yourself?
Did you feel tense?
How tense or anxious have you been?
I felt irritable.
Have you felt constantly under strain?
Have you felt overwhelmed and found everything getting on top of you?
I was relaxed.
Did you often feel tense or strung up inside?
How much were you distressed by feeling tense or keyed up?
How much have you been bothered by being unable to relax?
How tense did you feel?
How often did you feel that the changes in your life were overwhelming?
How much have you been restless?
How much have you felt "on edge" or keyed up?
How much were you distressed by feeling so restless you couldn''t sit still?
Did you feel uneasy and restless?
I have been restless and couldn''t keep still.
Have you felt restless, fidgety, or impatient?
How much have you been easily startled?
Did you often complain of physical symptoms when separated from someone close to you, or when you thought you might be separated from someone close to you?
Have you ever suddenly and unexpectedly experienced feeling cut-off from yourself or from parts of your body?
Did you feel as if something had broken in your brain or body?
Have you noticed that any of the above symptoms come on very easily when you''re in a stressful situation, even when it was not that severe?
Have you noticed that any of the above symptoms come on right after a stressful situation is over?
Did you experience any of the above symptoms when you used coffee, tea or other caffeinated beverages?
Did you experience any of the above symptoms when you used cold medicine, nasal sprays, thyroid, sleep, or antidepressant medications?
Did you experience any of the above symptoms when you used cocaine, amphetamines, or other uppers?
Did you avoid taking prescribed medications because you thought they might hurt you?
Have you been afraid of or did you avoid taking a prescribed medication because you thought it might cause you permanent brain damage?
Have you worried a lot that there might be something terribly wrong with you physically, as if, for instance, you were about to have a heart attack, stroke, suffocate, or die?
Did you worry about having a serious physical illness, when you heard about someone else who had it?
Did you worry about reading medical articles or hearing someone talk about medical topics?
Did you worry about getting results of lab tests or having your pulse or blood pressure checked?
Did you worry about seeing medical tools or being in medical settings?
Did you feel that you needed to be comforted and reassured by your friends and family?
Did you seek help from your parents, spouse, friends or neighbors because of these symptoms?
Did you use emergency services or call a doctor at home because you needed reassurance?
Did you request admission to a hospital in order to be protected or reassured even though your doctor felt this was unnecessary?
Did you have your pulse or blood pressure checked repeatedly, even though your doctor didn''t recommend it?
Did you make repeated requests for special diagnostic procedures even though your doctor didn''t recommend it?
Did you ask for medical lab tests even when your doctor didn''t recommend them?
Did you need to check whether there was a doctor or emergency service nearby when you were going someplace new?
In order to cope with the above symptoms did you need to have someone with you most of the time?
In order to cope with the above symptoms did you need to sit near the exit at the movies, theater, church or similar places?
In order to cope with the above symptoms did you need to take a cellular phone with you or check for the availability of a public telephone in the place where you were going?
In order to cope with the above symptoms, did you need to be sure you had tranquilizers in your pocket or purse, although your doctor hadn''t prescribed them, or prescribed them in the past but thought they weren''t necessary anymore?
In order to cope with the above symptoms did you need to take a bottle of water or another beverage with you when you went somewhere?
In order to cope with the above symptoms did you need to take your dog with you?
In order to cope with the above symptoms did you need to wear a hat when you went out?
In order to cope with the above symptoms did you need to take candy or gum with you when you went out?
In order to cope with the above symptoms did you need to take a good luck charm with you?
In order to cope with the above symptoms did you need to wear sunglasses, even in a dark environment?
In order to cope with the above symptoms did you need to use alcohol or sedatives?
In order to cope with the above symptoms did you need to have a special relationship with doctors to be sure they would take good care of you?
In order to cope with the above symptoms did you need to keep a light on in the bedroom in order to fall asleep?
I worried about dying.
I worried that my condition will get worse.
I had a change in weight.
I worried about the effect of stress on my illness.
Did you feel weighed down by your health problems?
Were you afraid because of your health?
Did you feel despair over your health problems?
I worried about catching diseases.
I was worried about physical problems such as aches and pains, upset stomach or constipation.
I have been concerned about my health.
How much were you distressed by thoughts of death or dying?
I was so sick I thought I might die.
Did you find yourself worrying about getting some incurable illness?
I noticed that I am losing weight.
Have you ever suddenly and unexpectedly experienced your heart pounding, racing, or skipping?
Have you ever suddenly and unexpectedly experienced feeling chest pain or pressure?
How much have you had pain in your chest?
How much have you had a racing or pounding heart?
How much were you distressed by pains in your heart or chest?
How much were you distressed by your heart pounding or racing?
Did you often suffer from excessive sweating or fluttering of the heart?
How much have you been bothered by your heart pounding or racing?
My heart beat faster than usual.
I had trouble breathing.
How much have you had shortness of breath?
How much have you been bothered by difficulty breathing?
Were you troubled by dizziness or shortness of breath?
Have you ever suddenly and unexpectedly experienced feeling nauseated, having an upset stomach, or diarrhea?
Did you feel that you could not control your bladder or bowels?
Did you often have the urge to urinate?
Have you had a sinking feeling in the pit of your stomach?
How much have you had diarrhea?
How much have you felt nauseous or sick to your stomach?
How much have you had an upset stomach?
How much were you distressed by nausea or upset stomach?
Did you often feel sick or have indigestion?
I had trouble with constipation.
Have you ever suddenly and unexpectedly experienced feeling dizzy, unsteady, or faint?
Have you ever suddenly and unexpectedly experienced having flushes or chills?
Did you often tremble?
Did you often sweat?
How easily did you get tired?
Did you have headaches?
How much have you gotten fatigued easily?
How much have you felt faint?
How much have you had to frequently urinate?
How much have you had shaky hands?
How much have you had cold or sweaty hands?
How much have you felt dizzy or lightheaded?
How much have you had dry mouth?
How much have you had twitching or trembling muscles?
How much have you had tense or sore muscles?
How much have you been trembling or shaking?
How much have you felt numbness or tingling?
How much difficulty have you been having in the area of physical symptoms (for example, headaches, aches and pains, sleep disturbance, stomach aches, dizziness)?
I felt pain in the back of my neck.
Have you had hand tremors?
I felt nervous or on edge.
I felt steady.
How much were you distressed by headaches?
How much were you distressed by faintness or dizziness?
How much were you distressed by trembling?
How much were you distressed by poor appetite?
How much were you distressed by pains in your lower back?
How much were you distressed by hot or cold spells?
How much were you distressed by numbness or tingling in parts of your body?
How much were you distressed by feeling weak in parts of your body?
How much were you distressed by heavy feelings in your arms and legs?
How much have you been bothered by feeling hot?
How much have you been bothered by wobbliness in your legs?
How much have you been bothered by feeling unsteady?
How much have you been bothered by your hands trembling?
How much have you been bothered by feeling shaky?
How much have you been bothered by feeling faint?
How much have you been bothered by your face being flushed?
How much have you been bothered by sweating (not due to heat)?
Have you felt as though you might faint?
I got tired for no reason.
To what degree did fatigue cause you distress?
Did you feel as if you were walking on foam rubber or had the sensation that your legs were jelly?
Did you feel that you were walking awkwardly, or like your legs were made of wood?
How much did any sleep problems worry you?
Have you had any physical sensations, such as pain, palpitations, sweating, headache, etc.?
Have you had trouble sleeping?
Did you have trouble falling asleep?
Did tension prevent you from falling asleep?
My sleep was restless.
How much of the time have you had trouble falling asleep?
How much of the time have you had trouble staying asleep?
I have been easily awakened by noise.
I didn''t sleep as well as usual.
More than half the time I woke up more than 30 minutes before I needed to get up.
Have you had difficulty staying asleep?
I had a restless, light sleep with a few brief awakenings each night.
I had trouble sleeping at night.
How much were you distressed by trouble falling asleep?
Could you fall asleep quickly?
Did you have bad dreams which upset you when you woke up?
How much were you distressed by awakening in the early morning?
How much were you distressed by sleep that is restless or disturbed?
Did you feel overly tired and exhausted?
How often did you feel that your sleep was not quiet (moving restlessly, feeling tense, speaking, etc., while sleeping)?
How often did you have trouble falling asleep?
How often did you awaken during your sleep time and have trouble falling asleep again?
Did you wake unusually early in the morning?
Have you slept more than usual in response to physical health or emotional problems?
Have you ever suddenly and unexpectedly experienced the feeling that you are choking?
Have you ever suddenly and unexpectedly experienced tingling or numbness in parts of your body?
Did you feel that you had lost your sight or hearing for a few seconds?
Did you often blush?
Did you have trouble going to sleep without someone nearby, or trouble sleeping away from home?
Did you avoid having anesthesia or taking sleeping pills because you might feel sick or even die while going to sleep?
Have you had periods of at least 3 days in which your mood became irritable or elevated when you had a medical problem such as the flu or a cold?
Have you had periods of at least 3 days in which your mood became irritable or elevated when you took medications, such as antibiotics, contraceptives, or steroids?
Have you had periods of at least 3 days in which your mood became irritable or elevated when you were abusing alcohol, sedatives, hypnotics, anxiolytics, other substances?
Have you had periods of at least 2 days in which your mood became irritable or elevated within a month of withdrawal from alcohol, sedatives, hypnotics, anxiolytics, or other substances?
Have you had periods of at least 3 days in which you felt persistently good or high?
Have you had periods of at least 3 days in which even the smallest thing could make you very enthusiastic?
Have you had periods of at least 3 days in which you were full of plans or got involved in many projects, jumping from one activity to another?
Have you had periods of at least 3 days in which you (or others) found that your sense of humor was very acute?
Have you had periods of at least 3 days in which you liked to make jokes, puns, or plays on words?
Have you had periods of at least 3 days in which you liked to make a lot of jokes, even ones that might have been inappropriate or out of place?
Have you had periods of at least 3 days in which you were intrusive, insulting, or tactless, or others thought that you were?
Have you had periods of at least 3 days in which you were warm, extroverted and sociable and it was very easy to introduce yourself to others or to make new friends?
Have you had periods of at least 3 days in which you were the kind of person to whom others were attracted because of your confidence, enthusiasm, and energy?
Have you had periods of at least 3 days in which you enjoyed being the center of attention or were particularly seductive or flirtatious, as if you were playing a role?
Have you had periods of at least 3 days in which you felt an irresistible urge to communicate by phone calls, letters, e-mails or faxes?
Have you had periods of at least 3 days in which you felt a strong desire to reconnect with people you hadn''t seen or spoken with for a long time?
Have you had periods of at least 3 days in which you were overly talkative, spoke rapidly and loudly, or were difficult to interrupt or had little regard for others'' wishes to speak?
Have you had periods of at least 3 days in which you were so noisy that others complained?
Have you had periods of at least 3 days in which you were overly curious and interested in everything and everybody?
Have you been the type of person or have others told you that you liked being the center of attention?
Have you had periods of at least 3 days in which you spent a lot of time on social, political or religious causes?
Have you had periods of at least 3 days in which you wore clothing or a hairstyle that was dramatic, extravagant, very high fashion or very unusual?
Have you been the type of person or have others told you that you were provocative?
Have you had periods of at least 3 days in which you were very assertive?
Have you had periods of at least 3 days in which you felt vigorous, much livelier than usual and full of energy?
Have you had periods of at least 3 days in which you were constantly active and had the pleasant sensation of never getting tired and your energy was so high that it exhausted or irritated others?
Have you had periods of at least 3 days in which your housework, child care, or your performance at school, work, sports, or hobbies improved a lot?
Have you had periods of at least 3 days in which you found it very pleasurable and easy to buy things, even things you didn''t need?
Have you had periods of at least 3 days in which you gave lots of presents, even when you really couldn''t afford them?
Have you had periods of at least 3 days in which you had difficulty saying no to business or social opportunities, even when you knew you did not have time for them?
Have you had periods of at least 3 days in which you found it very pleasurable and exciting to get involved in dangerous, risky, challenging or emotionally intense activities?
Have you had periods of at least 3 days in which you were (or other people judged you to be) irresponsible?
Have you had periods of at least 3 days in which you made a very important decision (such as selling or buying a house or car, or changing jobs) extremely rapidly?
Have you had periods of at least 3 days in which you did such things as spend too much money?
Have you had periods of at least 3 days in which you did such things as drive recklessly or speeding?
Have you had periods of at least 3 days in which you did such things as make foolish business decisions?
Have you had periods of at least 3 days in which you tended to ignore everyday rules and social etiquette or engaged in illegal activities?
Did you ever engage in risk-taking behaviors, such as driving fast, promiscuous sex, hanging out in dangerous neighborhoods?
Did you ever intentionally cut or burn yourself?
Have you been the type of person or have others told you that you usually found exciting what others would find frightening?

861
862
863
864
865
866
867
868
869
870
871
872
873
874
875
876
877
878
879
880
881
882
883
884
885
886
887
888
889
890
891
892
893
894
895
896
897
898
899
900
901
902
903
904
905
906
907
908
909
910
911
912
913
914
915
916
917
918
919
920
921
922
923
924
925
926
927
928
929
930
931
932
933
934
935
936
3996
3999
4000
4001
4002
4003
4004
4005
4006
4007
4008
4009
4010
4011
4012
4013
4014
4015
4016
4017
4018
4019
4020
4021
4022
4023
4024
4025
4026
4027
4028
4029
4030
4031
4032
4033
4034
4035
4036
4037
4038
4039
4040
4041
4042
4043
4044
4045
4046
4047
4048
4049
4050
4051
4052
4053
4054
4055
4056
4057
4058
4059
4060
4061
4062
4063
4064
4065
4066
4067
4068
4069
4070
4071
4072
4073
4074
4075
4076
4077
4078
4079
4080
4081
4082
4083
4084
4085
4086
4087
4088
4089
4090
4091
4092
4093
4094
4095
4096
4097
4098
4099
4100
4101
4102
4103
4104
4105
4106
4107
4108
4109
6294
6295
6296
6297
6298
6299
6300
6301
6302
6303
6304
6305
6306
6307
6308
6309
6310
6311
6312
6313
6314
6315
6316
6317
6318
6319
6320

Have you been the type of person or have others told you that you often engage in reckless or dangerous activities?
Have you had periods of at least 3 days in which you had a particularly intense romantic life?
Have you had periods of at least 3 days in which you felt as if you would like to run away from your current life, for example, by getting on the highway and driving away or just getting on a bus or a plane with no destination in mind?
Have you had periods of at least 3 days in which you felt surrounded by hostility, as if everybody was against you, for example, you thought that everybody accused and hated you?
Have you had periods of at least 3 days in which you felt surrounded by hostility, as if everybody was against you, for example, you felt as if everybody was looking at you?
Have you had periods of at least 3 days in which you felt surrounded by hostility, as if everybody was against you, for example, you thought you were being persecuted or that you were wanted by the police?
Have you had periods of at least 3 days in which you felt as if everyone was talking about you?
Did you ever find that you were especially watchful, on edge, or on guard, for example, checking to see who or what was around you, feeling uncomfortable with your back to the door or needing to have your bed in a protected position?
Have you had periods of at least 3 days in which you were preoccupied with yourself and your own problems, thoughts, and feelings?
Have you had periods of at least 3 days in which you were very preoccupied with money even though you didn''t have any real financial problems?
Have you had periods of at least 3 days in which you felt self-assured, charismatic or tended to assume a leadership role?
Have you had periods of at least 3 days in which you felt you were always right, incapable of making mistakes and indifferent to criticism?
Have you had periods of at least 3 days in which you thought that you could make decisions for others because you knew their thoughts, intentions, or wishes?
Have you had periods of at least 3 days in which you had unusually high self-esteem, feelings of superiority or unrealistic ideas that you had amazing abilities, talents, knowledge or powers?
Have you had periods of at least 3 days in which you felt that your ideas came and went unusually easily, as if your thoughts were racing?
Have you had periods of at least 3 days in which you had so many thoughts and ideas all at once that you found it difficult to express them?
Have you been the type of person or have others told you that you often follow your instinct without really thinking about what you are doing?
Have you had periods of at least 3 days in which you heard voices speaking against you, or voices that were hostile to you or swore at you?
Have you had periods of at least 3 days in which you heard voices clearly?
Have you had periods of at least 3 days in which you (or others) thought you were very artistic or creative?
Have you had periods of at least 3 days in which you had bursts of inspiration or creativity (for instance, rapidly and easily wrote prose or poetry or composed music, painted, sculpted, or did other crafts)?
Have you had periods of at least 3 days in which you felt you were mentally very sharp, brilliant and clever?
Have you had periods of at least 3 days in which you felt like you had ESP?
Have you had periods of at least 3 days in which you were particularly sensitive to the forms and harmony in nature?
Have you had periods of at least 3 days in which you felt a strong need to take refuge in religion or prayer?
Have you had periods of at least 3 days in which you were unusually spiritual or mystical?
Have you had periods of at least 3 days in which you felt you had direct access to the truth, could see the grand scheme of things, understand the meaning of existence?
Have you had periods of at least 3 days in which you heard voices that inspired or praised you?
Have you had periods of at least 3 days in which you had mystical experiences or visions?
Have you had periods of at least 3 days in which you felt particularly strong and invulnerable, resistant to illnesses and accidents?
Have you had periods of at least 3 days in which you found that your mood, energy, interest and efficiency improved if you were in a regular routine?
Have you had periods of at least 3 days in which you were the kind of person whose mood, energy and physical well-being changed over the course of your menstrual cycle?
Have you had periods of at least 3 days in which you were the kind of person whose mood, energy and physical well-being changed when you traveled across more than 4 time zones?
Have you had periods of at least 3 days in which the quality of your sleep or your need for sleep increased when you traveled across at least 4 time zones?
Have you had periods of at least 3 days in which the quality of your sleep or your need for sleep decreased when you traveled across at least 4 time zones?
Have you had periods of at least 3 days in which you were the kind of person whose mood, energy and physical well-being changed in a dependable way in response to the weather?
Have you had periods of at least 3 days in which you had a lot of difficulty sleeping before or after stimulating physical, social, or professional activities?
Have you had periods of at least 3 days in which if, for some reason, you got much less sleep than is normal for you, you found that you actually had more energy rather than less the next day?
Have you had periods of at least 3 days in which you went for days without sleeping or with much less sleep than usual but didn''t feel tired?
Have you had periods of at least 3 days in which you were less sexually active than is typical for you?
Have you had periods of at least 3 days in which you had difficulty becoming sexually aroused?
Have you had periods of at least 3 days in which you were more interested in sex?
Have you had periods of at least 3 days in which you frequently changed sexual partners?
Have you had periods of at least 3 days in which there was no food that appealed to you or tasted good to you?
Have you had periods of at least 3 days in which you constantly craved sweets or carbohydrates?
Have you had periods of at least 3 days in which your appetite or weight increased?
Have you had periods of at least 3 days in which your appetite or weight decreased?
How much of the time did you have difficulty doing activities involving concentration and thinking?
Have you had difficulty in concentrating on things, like reading a newspaper or watching television?
How much were you distressed by feeling so restless you couldn''t sit still?
I have been restless and couldn''t keep still.
How much have you felt slowed down?
How much have you felt tired or sluggish?
I felt that everything I did was an effort.
How easily did you get tired?
Did you feel guilty?
How much have you blamed yourself for things?
How much were you distressed by blaming yourself for things?
I had difficulty concentrating.
How much difficulty have you been having in the area of confusion, concentration, or memory?
Did you feel persistently sad or empty, blue, or down in the dumps?
I felt sad.
How much of the time did you feel depressed?
How much of the time have you felt downhearted and blue?
How much did any feelings of depression bother you?
Did you experience long periods of sadness?
How much have you felt nothing was interesting or fun?
How much were you distressed by feeling no interest in things?
How much have you felt that nothing was enjoyable?
Did you think about taking your own life?
I felt that life was empty or wondered if it was worth living.
How often did you feel that others would be better off if you were dead?
Have you actually had any thoughts of killing yourself?
Have you had any intention of acting on these thoughts of killing yourself? As opposed to you have the thoughts, but you definitely would not act on them?
Have you started to work out, or actually worked out, the specific details of how to kill yourself and did you actually intend to carry out the details of your plan?
In the past 3 months, have you done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn''t swallow any, held a gun but changed your mind about hurting yourself or it was grabbed from your hand, went to the roof to jump but didn''t; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
Is the child participating in this assessment 12 or older?
How much have you felt afraid?
How much were you distressed by feeling fearful?
How much have you been troubled or bothered by psychological or emotional problems?
I felt upset.
I was distressed.
Did you have difficulty calming down?
How much were you distressed by spells of terror or panic?
How much have you felt something awful would happen?
Because of fear or unpleasant feelings, how much would you avoid eating or drinking with other people?
How much were you distressed by having to avoid certain things, places or activities because they frightened you?
How much would you avoid going far from home alone because of fear or unpleasant feelings?
How much difficulty have you been having with disturbing or unreal thoughts or beliefs?
How much were you distressed by repeated unpleasant thoughts?
How much of the time did you have difficulty reasoning and solving problems; for example, making plans, making decisions, learning new things?
Were you bewildered or confused?
How much have you felt confused?
Did you feel that you were about to lose control of your behavior?
Have you worried a lot that there might be something terribly wrong with you mentally, like losing your mind or losing control?
Have you had any reason to wonder if you were losing your mind?
How much have you felt afraid of losing control?
How much have you felt like you were going crazy?
How much were you distressed by the idea that something was wrong with your mind?
Did you feel uneasy traveling on buses or the subway even if they were not crowded?
It scared me when I was nervous.
When I couldn''t keep my mind on task, I worried that I might be going crazy.
I felt that people disliked me.
How much were you distressed by feeling that people were unfriendly or disliked you?
How much were you distressed by feeling lonely even when you are with people?
How much have you been bothered by not being able to take things in when speaking to people?
Did you feel inadequate in everyday relationships, even with people like co-workers, sales people, or peers?
How much difficulty have you been having in the area of lack of self-confidence or feeling bad about yourself?
I worried that my condition will get worse.
How much were you distressed by thoughts of death or dying?
I felt sad.
How often did you have negative feelings, such as blue mood, despair, anxiety, depression?
I felt gloomy.
How much of the time did you feel depressed?
I felt depressed.
How much of the time have you felt downhearted and blue?
How much have you been troubled or bothered by psychological or emotional problems?
How much of the time have you been in low or very low spirits?
How much were you distressed by feeling blue?
Did you experience long periods of sadness?
I was unhappy.
How sad did you feel?
How often did you feel sad?
Have you been in low or very low spirits?
How often have you felt like crying?
You completely lost your capacity to laugh, have fun, or enjoy your life.
How much have you felt that nothing was enjoyable?
How much difficulty have you been having in the area of feeling satisfaction with your life?
Did you lose interest in making new friends or find it difficult to make new friends?
Did you find that activities or things that used to be interesting or important to you became pointless, meaningless, or insignificant?
How much have you felt nothing was interesting or fun?
How much were you distressed by feeling no interest in things?
Have you lost interest in the things you used to do?
I felt that I could not shake off the blues even with help from my family or friends.
How much of the time have you felt so down in the dumps that nothing could cheer you up?
I had trouble keeping my mind on what I was doing.
How much have you had trouble making decisions?
You couldn''t make decisions easily?
Did you see the future as very bleak?
How much have you been disappointed in yourself?
How much difficulty have you been having in the area of lack of self-confidence or feeling bad about yourself?
How much were you distressed by blaming yourself for things?
You felt you had no purpose, as if everything had lost its significance?
How much have you felt like a failure?
How much have you felt inferior to others?
How much have you felt worthless?
How much were you distressed by feelings of worthlessness?
How often have you felt worthless?
How much difficulty have you been having in the area of isolation or feelings of loneliness?
How much difficulty have you been having in the area of being able to feel close to others?
Did you feel isolated from others?
I felt that people disliked me.
How much of the time did you feel left out?
How often did you feel disappointed and resentful?
How often have you felt ignored by people?
How often did you feel left out?
My life lacked meaning and purpose.
How much have you felt discouraged?
How much were you distressed by feeling hopeless about the future?
How much of the time did you feel that you had nothing to look forward to?
How often did you feel hopeless?
Did you believe that you had come to a "dead end"?
Did you often feel helpless?
How often have you felt that you can''t take it anymore?
Did you feel you wanted to give up trying?
Did you have the feeling that you just didn''t have what it takes anymore?
I felt like I was at the end of my rope.
I felt I should be punished.
How much were you distressed by feelings of guilt?
Did you feel guilty?
How much did feelings of sadness or depression interfere with your everyday functioning?
Has feeling depressed interfered with what you usually do?
Did you feel that life was too much effort?
Have you been feeling out of sorts?
How much have you felt withdrawn from others?
How often did you withdraw from other people?
Have you been feeling in need of some medicine to pick you up?
Did you think that life was not worth living?
Have you felt that life was not worth living?
I had a reason for living.
How often did you feel that others would be better off if you were dead?
I felt that life was empty or wondered if it was worth living.
Have you felt that life wasn''t worth living?
Did you think it was wonderful to be alive?
I felt that others would be better off if I were dead.
Have you found yourself wishing you were dead and away from it all?
Did you want to be dead at times?
Did you think about taking your own life?
Have you experienced any of the following: felt sadness, hopelessness, loss of interest, change of appetite or sleep pattern, difficulty going about your daily activities?
Have you experienced a period of time when your thinking speeds up and you have trouble keeping up with your thoughts, doing risky or impulsive things, such as driving very quickly or spending too much money?
Have you been preoccupied with drinking alcohol and/or using other drugs like marijuana, or with taking medications without a prescription or more than they were prescribed?
Did you, at times, drink alcohol and/or use other drugs or medication more than you intended?
Have you felt the need to drink more alcohol and/or use more drugs or medication to get the same effect you used to get with less?
Did you, at times, drink alcohol and/or use other drugs or medication to alter the way you feel?
Have you tried to stop drinking alcohol and/or using other drugs or medication, but couldn''t?
Have you experienced problems caused by drinking alcohol and/or using other drugs or prescription medications and you kept using?
Have you experienced thoughts of harming yourself or others?
Have you ever thought that life is not worth living, or planned or attempted suicide?
Have you had periods of time when you felt that you could not trust family or friends?
Have you been prescribed medication for any psychological or emotional problem?
Have you experienced hallucinations (heard or seen things others do not hear or see)?
Have you ever been hit, slapped, kicked, emotionally or sexually hurt, or threatened by someone?
Have you experienced a traumatic event and since had repeated nightmares/dreams and/or anxiety which interferes with you leading a normal life?
How soon after you wake up do you smoke your first cigarette?
Do you find it difficult to refrain from smoking in places where it is forbidden (e.g., in church, at the library, at the movies, etc.)?
Which cigarette would you hate most to give up?
Do you smoke more frequently during the first hours after waking than during the rest of the day?
Do you smoke even if you are so ill that you are in bed most of the day?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# opiates/analgesics (including painkillers such as Morphine, Dilaudid, Demerol, Percocet, Darvon, Talwin, Codeine, Fentanyl, OxyContin)?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# sedatives, hypnotics, tranquilizers, or barbiturates (such as Valium, Xanax, Ativan, Seconal, Nembutal)?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# more than one substance/drug per day (including alcohol)?
How troubled or bothered have you been #5:in the past 30 days/in the past 12 months/during your adult lifetime# by alcohol problems?
How important to you now is treatment for alcohol problems?
How troubled or bothered have you been #5:in the past 30 days/in the past 12 months/during your adult lifetime# by drug problems?
How important to you now is treatment for drug problems?

6321
6322
6323
6324
6325
6326
6327
6328
6329
6330
6331
6332
6333
6334
6335
6336
6337
6338
6339
6340
6341
6342
6343
6344
6345
6346
6347
6348
6349
6350
6351
6352
6353
6354
6355
6356
6357
6358
6359
6360
6361
6362
6363
6364
6365
6366
6367
6368
6369
6370
6371
6372
6373
6374
6375
6376
6377
6378
6379
6380
6381
6382
6383
6384
6385
6386
6387
6388
6389
6390
6391
6392
6393
6394
6395
6396
6397
6398
6399
6400
6401
6402
6403
6404
6405
6406
6407
6408
6409
6410
6411
6412
6413
6414
6415
6416
6417
6418
6419
6420
6421
6422
6423
6424
6425
6426
6427
6428
6429
6430
6431
6432
6433
6434
6435
6436
6437
6438
6439
6440
6441
6442
6443
6444
6445
6446
6447
6448
6449
6450
6451
6452
6453
6454
6455
6456
6457
6458
6459
6460
6461
6462
6463
6464
6465
6466
6467
6468
6469
6470
6471
6472
6473
6474
6475
6476
6477
6478
6479
6480
6481
6482
6483
6484
6485
6486
6487
6488
6489
6490
6491
6492
6493
6494
6495
6496
6497
6498
6499
6500
6501
6502
6503
6504
6505
6506
6507
6508
6509
6510
6511
6512
6513
6514
6515
6516
6517
6518
6519
6520
6521
6522
6523
6524
6525
6526
6527
6528
6529
6530
6531
6532
6533
6534
6535

Have you used drugs other than those required for medical reasons?
Have you abused more than one drug at a time?
Were you always able to stop using drugs when you wanted to?
Have you had "blackouts" or "flashbacks" as a result of drug use?
Have you felt bad or guilty about your drug use?
#4:Have your parents/Has your spouse (or parents)# ever complained about your involvement with drugs?
Have you neglected #4:important relationships/your family# because of your use of drugs?
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
Have you had medical problems #4:that were so bad that you had to see a doctor as a result of your drug use/as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)#?
Was there any time when you thought you had a nervous, emotional, drug (prescription or non-prescription) or alcohol problem?
Was there any other person (relative, friend, neighbor, minister, priest or other), who thought you had a nervous, emotional, drug, medication (prescription or non-prescription) or alcohol problem?
At any time in your life did you think that you should talk to a medical doctor or other health professional about problems with your emotions, nerves, mental health, or your use of alcohol or drugs or medications (prescription or non-prescription)?
At any time in your life did a family member, friend, co-worker, or any other person tell you to talk to a medical doctor or other health professional about problems with your emotions, nerves, or mental health or your use of alcohol, drugs or medications (prescription or non-prescription)?
Have you ever been admitted for an overnight stay in the hospital for problems with your emotions, nerves, mental health, alcohol, drug or medication use (prescription or non-prescription)?
Have you ever gotten a prescription or medicine for your emotions, nerves or mental health, alcohol, drug use or medication (prescription or non-prescription) from any type of professional?
Urine test results for amphetamines.
Urine test results for benzodiazepines.
Urine test results for cocaine.
Urine test results for methamphetamine.
Urine test results for opioids.
Have you ever taken benzodiazepines like xanax, diazepam, alprazolam, lorazepam, lexatin, klonopin, tranxilium, valium, noctamid or loramet?
Have you ever taken sleeping pills like lunesta, zaleplon or ambien?
Have you ever taken sedatives?
Have you ever taken hypnotics like atarax, seroquel, trazadone or zolpidem?
Have you ever taken minor tranquilizers like passiflora or valerian?
Have you ever taken muscular relaxants like flexenil or cyclobenzaprine?
Have you ever taken other sedatives, tranquilizers or sleeping pills?
Have you taken sedatives, hypnotics, benzodiazepines, minor tranquilizers, or muscular relaxants?
Have you taken sedatives, tranquilizers, sleeping pills or muscular relaxants because you like the way they make you feel?
Have you taken another sedative or tranquilizer as soon as the effects of the previous one began to wear off?
Have you tried to reduce the number of sedatives, tranquilizers, sleeping pills or muscular relaxants you take because they interfered with your life?
Have you found that you needed to take more tranquilizers, sedatives, sleeping pills or muscular relaxants to get the same effect compared to when you first took them?
Did you need to take sedatives, tranquilizers, sleeping pills or muscular relaxants to deal with the problems in your life?
Could you stop taking sedatives tranquilizers, sleeping pills or muscular relaxants tomorrow without any difficulties?
Have you felt bad or sick as the effects of sedatives, tranquilizers, sleeping pills or muscular relaxants wore off?
Have you taken a sedative, tranquilizer, sleeping pill or muscular relaxant to reduce the unpleasant after-effects of sedatives, tranquilizers, sleeping pills or muscular relaxants?
Have you taken sedatives, tranquilizers, sleeping pills or muscular relaxants against your doctor''s advice or more frequently than recommended?
Were you concerned about the number of sedatives, tranquilizers, sleeping pills or muscular relaxants you have taken?
Did a doctor ever say you were manic-depressive or had bipolar disorder?
Did a doctor ever say you have schizophrenia or a schizoaffective disorder?
How often have you been bothered by little interest or pleasure in doing things?
How often have you been bothered by feeling down, depressed, or hopeless?
How often have you been bothered by trouble falling asleep, staying asleep, or sleeping too much?
How often have you been bothered by feeling tired or having low energy?
How often have you been bothered by poor appetite or overeating?
How often have you been bothered by feeling bad about yourself? Or that you are a failure or have let yourself or your family down?
How often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?
How often have you been bothered by moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual?
How often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?
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?
How often have you been bothered by feeling nervous, anxious, or on edge?
How often have you been bothered by not being able to stop or control worrying?
How often have you been bothered by worrying too much about different things?
How often have you been bothered by trouble relaxing?
How often have you been bothered by being so restless that it is hard to sit still?
How often have you been bothered by becoming easily annoyed or irritable?
How often have you been bothered by feeling afraid as if something awful might happen?
Before age 18, were you ever physically punished or beaten by a parent, caretaker, or teacher so that: you were very frightened; or you thought you would be injured; or you received bruises, cuts, welts, lumps or other injuries?
Have you ever been attacked, beaten, or mugged by anyone, including friends, family members or strangers?
Has anyone ever made or pressured you into having some type of unwanted sexual contact? By sexual contact we mean any contact between someone else and your private parts or between you and someone else''s private parts.
Have you ever been in any situation in which you were seriously injured, or feared you might be seriously injured or killed?
How much were you bothered by repeated, disturbing, and unwanted memories or images of a very stressful experience?
How much were you bothered by repeated, disturbing dreams of a very stressful experience?
How much were you bothered by suddenly feeling or acting as if a very stressful experience were actually happening again (as if you were actually back there reliving it)?
How much were you bothered by feeling very upset when something reminded you of a very stressful experience?
How much were you bothered by having strong physical reactions when something reminded you of a very stressful experience (for example, heart pounding, trouble breathing, sweating)?
How much were you bothered by avoiding memories, thoughts, or feelings related to a very stressful experience?
How much were you bothered by avoiding external reminders of a very stressful experience (for example, people, places, conversations, activities, objects, or situations)?
How much were you bothered by trouble remembering important parts of a very stressful experience?
How much were you bothered by having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
How much were you bothered by blaming yourself or someone else for a very stressful experience or what happened after it?
How much were you bothered by having strong negative feelings such as fear, horror, anger, guilt, or shame?
How much were you bothered by loss of interest in activities that you used to enjoy?
How much were you bothered by feeling distant or cut off from other people?
How much were you bothered by trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
How much were you bothered by irritable behavior, angry outbursts, or acting aggressively?
How much were you bothered by taking too many risks or doing things that could cause you harm?
How much were you bothered by being "super alert" or watchful or on guard?
How much were you bothered by feeling jumpy or easily startled?
How much were you bothered by having difficulty concentrating?
How much were you bothered by trouble falling or staying asleep?
Have you taken any medication due to problems with your emotions, drug and alcohol use, nerves, energy level, concentration, sleep, or ability to cope with stress?
How much were you bothered by loss of sexual interest or pleasure?
How much were you bothered by feeling low in energy or slowed down?
How much were you bothered by thoughts of ending your life?
How much were you bothered by poor appetite?
How much were you bothered by crying easily?
How much were you bothered by feelings of being trapped or caught?
How much were you bothered by blaming yourself for things?
How much were you bothered by feeling lonely?
How much were you bothered by feeling blue?
How much were you bothered by worrying too much about things?
How much were you bothered by feeling no interest in things?
How much were you bothered by trouble falling asleep?
How much were you bothered by feeling hopeless about the future?
How much were you bothered by thoughts of death or dying?
How much were you bothered by overeating?
How much were you bothered by awakening in the early morning?
How much were you bothered by restless or disturbed sleep?
How much were you bothered by feeling everything is an effort?
How much were you bothered by feelings of worthlessness?
How much were you bothered by feelings of guilt?
Do you have or have you had chronic pain?
Do you have or have you had heart problems?
In general, would you say your physical health is:
In general, would you say your mental health is:
Please rate how much your problems impair your ability to carry out certain activities, where 1 is not at all and 9 is severely. Because of my [problem], my ability to work is impaired.
Please rate how much your problems impair your ability to carry out certain activities, where 1 is not at all and 9 is severely. Because of my [problem], my home management (such as cleaning, tidying, shopping, cooking, looking after the home or children, paying bills) is impaired.
Please rate how much your problems impair your ability to carry out certain activities, where 1 is not at all and 9 is severely. Because of my [problem], my social leisure activities (with other people, such as parties, bars, clubs, outings, visits, dating, home entertaining) are impaired.
Please rate how much your problems impair your ability to carry out certain activities, where 1 is not at all and 9 is severely. Because of my [problem], my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired.
Please rate how much your problems impair your ability to carry out certain activities, where 1 is not at all and 9 is severely. Because of my [problem], my ability to form and maintain close relationships with others, including those I live with, is impaired.
How much difficulty have you had standing for long periods such as 30 minutes?
How much difficulty have you had taking care of your responsibilities?
How much difficulty have you had learning a new task, for example, learning how to get to a new place?
How much difficulty have you had joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
How much have you been emotionally affected by your health condition?
How much difficulty have you had concentrating on doing something for ten minutes?
How much difficulty have you had walking a long distance such as a mile?
How much difficulty have you had washing your whole body?
How much difficulty have you had getting dressed?
How much difficulty have you had dealing with people you do not know?
How much difficulty have you had maintaining a friendship?
How much difficulty have you had with your day to day work/school?
How frequently have you had the following experience: I experienced some emotion and was not conscious of it until sometime later.
How frequently have you had the following experience: I broke or spilled things because of carelessness, not paying attention, or thinking of something else.
How frequently have you had the following experience: I found it difficult to stay focused on what''s happening in the present.
How frequently have you had the following experience: I tended to not notice feelings of physical tension or discomfort until they really grabbed my attention.
How frequently have you had the following experience: It seemed as if I was "running on automatic" without much awareness of what I was doing.
How frequently have you had the following experience: I rushed through activities without being really attentive to them.
How frequently have you had the following experience: I drove places on "automatic pilot" and then wondered why I went there.
How frequently have you had the following experience: I found myself preoccupied with the future or the past.
How frequently have you had the following experience: I found myself doing things without paying attention.
How frequently have you had the following experience: I snacked without being aware that I was eating.
How much do your symptoms get in the way of you doing things that you would like to or need to do?
How well do you feel like you are coping with your mental, emotional illness or substance use from day to day?
How much did drug use get in the way of your functioning (e.g., relationships, money, housing, legal concerns, missed appointments, increased symptoms)?
Can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?
In your day-to-day life, how often do people act as if they think you are not smart?
In your day-to-day life, how often do people act as if they think you are dishonest?
In your day-to-day life, how often do people act as if they''re better than you are?
In your day-to-day life, how often are you are called names or insulted?
In your day-to-day life, how often are you threatened or harassed?
#5:How many days in the past 30 days/In the past 12 months on average, how many days per month/During your adult lifetime on average, how many days per month# did you drink alcohol (including beer, wine and liquor)?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# heroin or methadone?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# cocaine (including crack and rock cocaine) or amphetamines (including Methamphetamine)?
Experienced auditory hallucinations of voices, noises, music, etc.
Auditory hallucinations in which a voice keeps up a running commentary on the subject's behaviors or thoughts as they occur.
Sees things that are not there.
Severity of hallucinations of any type. Consider conviction in reality of hallucination, preoccupation, and effects on actions.
Experience that her feelings, impulses, thoughts or actions are not her own and the belief that they are imposed on him by some external force.
Belief or experience that her thoughts, as they occur, are broadcast from her head into the external world so that others can hear them.
The experience that thoughts, which are not her own, are inserted into her mind.
Belief that thoughts have been removed from her head resulting in a diminished number of thoughts remaining.
A persistent denial of the existence of particular things or of everything, including oneself (died several years ago).
Delusional belief that her appearance, or an organ or organ system, is diseased or changed (e.g. Brain is rotting, blood turning to ice).
Extent to which the content of any of the delusional beliefs (whether suspected or definite) have a bizarre of fantastic quality (e.g. people from another world are talking about her).
Delusional belief that she has done something terrible or is responsible for some event or condition which has had disastrous consequences.
Claims power, knowledge or identity beyond the bounds of credibility.
Somatic, grandiose, religious, nihilistic, or other delusions without persecutory or jealous content lasting at least 1 week.
Severity of delusions of any type -- consider conviction in delusion, preoccupation, and effect on her actions.
Accelerated, pressured, or increased amount of speech during a period when she had at least 1 other manic-like symptom.
Visible manifestations of generalized motor hyperactivity which occurred when she had at least 1 other manic-like symptom.
Increase in goal-directed activity as compared to usual (e.g. changes in involvement or activity level associated with work, family, friends, sex drive).
Bizarre behavior not commonly seen with simple depression, mania, alcohol or drugs or some other physical impairment in brain functioning.
The patient reports voices, noises, or other sounds that no one else hears.
The patient reports a voice, which makes a running commentary on her behavior or thoughts.
The patient reports hearing two or more voices conversing.
The patient reports experiencing peculiar physical sensations in the body.
The patient sees shapes or people that are not actually present.
This rating should be based on the duration and severity of the hallucinations and their effects on the patient's life.
The patient believes she has special powers or abilities.
The patient is preoccupied with false beliefs of a religious nature.
The patient believes that somehow her body is diseased, abnormal, or changed.
The patient believes that insignificant remarks or events refer to him or have special meaning.
The patient feels that people can read her mind or know her thoughts.
The patient believes that her thoughts are broadcast so that she or others can hear them.
The patient believes that thoughts that are not her own have been inserted into her mind.
The patient believes that thoughts have been taken away from her mind.
The patient develops a set of repetitive actions or rituals that she must perform over and over.
This rating should reflect the type of behavior and the extent to which it deviates from social norms.
A pattern of speech in which ideas slip off track onto ideas obliquely related or unrelated.
Lack of spontaneous interaction, isolation deficiency in relating to others.
Peculiar, bizarre, unnatural motor behavior (not including tics).
Affect is incongruous with content of speech, for example, giggles while discussing reason for hospitalization.
The patient's affect is inappropriate or incongruous, not simply flat or blunted.
The patient's replies are adequate in amount but tend to be vague, over concrete or overgeneralized, and convey little information.
The patient indicated, either spontaneously or with prompting, that her train of thoughts was interrupted.
The patient takes a long time to reply to questions prompting indicates the patient is aware of the question.
The core features of alogia are poverty of speech and poverty of content.
The patient's clothes may be sloppy or soiled, and she may have greasy hair, body odor, etc.
The patient has difficulty seeking or maintaining employment, completing schoolwork, keeping house, etc.
Strong weight may be given to one or prominent symptoms if particularly striking.
The patient may have few or no friends and may prefer to spend all her time isolated.
The patient appears uninvolved or unengaged. She may seem "spacey".
Test of "serial 7s" (at least five subtractions) and spelling "world" backwards. Score 2 = 1 error, score 3 = 2 errors, score 3 = 2 errors, score 4 = 3 errors
This rating should assess the patient's overall concentration, clinically and on tests.
Thought processes confused, disconnected, disorganized, disrupted.
Confusion or lack of proper association for person, place or time.
Insight refers to being aware that they have a psychotic illness.
Repeatedly saying things in juxtaposition, which lack a readily understandable relationship (e.g. "I'm tired. All people have eyes.")
Speech is adequate in amount but conveys little information because of vagueness, talking past the point, empty repetitions or use of stereotyped or obscure phrases.
Impaired understandability of speech due to psycho-pathology (e.g. lack of logical or meaningful connections between words, phrases, or sentences; abrupt changes in subject matter).
A pattern of speech that is essentially incomprehensible at times.
A pattern of speech in which conclusions are reached that do not follow logically.
A pattern of speech that is very indirect and delayed in reaching its goal idea.
Extent to which the patient's ability to communicate is affected.
Heightened emotional tone, agitation, increased reactivity.
Elevated or expansive mood and/or optimistic attitude toward the future lasting at several hours and out of proportion to the circumstances.
Increased self-esteem and appraisal of her worth, contacts, power or knowledge (up to grandiose delusions) as compared with usual level.
Making future plans of a hypomanic, grandiose or manic nature
Overt expression of irritability, annoyance, and anger, when she had at least 1 other manic-like symptom.
Accelerated speech with abrupt changes from topic to topic usually based on understandable associations, distracting stimuli or play on words.
The patient may do things considered inappropriate according to usual social norms (e.g. masturbating in public).
The patient may behave in an aggressive, agitated manner, often unpredictably.
The patient replies to a question in an oblique or irrelevant manner.

6536
6537
6538
6539
6540
6541
6542
6543
6544
6545
6546
6547
6548
6549
6550
6551
6552
6553
6554
6555
6556
6557
6558
6559
6560
6561
6562
6563
6564
6565
6566
6567
6568
6569
6570
6571
6572
6573
6574
6575
6576
6577
6578
6579
6580
6581
6582
6583
6584
6585
6586
6587
6588
6589
6590
6591
6592
6593
6594
6595
6596
6597
6598
6599
6600
6601
6602
6603
6604
6605
6606
6607
6608
6609
6610
6611
6786
6787
6788
6789
6790
6791
6792
6793
6794
6795
6796
6797
6798
6799
6800
6801
6802
6803
6804
6805
11713

The patient's speech is rapid and difficult to interrupt; the amount of speech produced is greater than that considered normal.
The patient is distracted by nearby stimuli, which interrupts her flow of speech.
A pattern of speech in which sounds rather than meaningful relationships govern word choice.
I have experienced hearing voices, noises, music, etc.
I hear a voice commenting upon what I am doing or thinking.
I have had visions, or seen things that are invisible to other people.
I see and/or hear things that other people do not, but I know that they are real.
I have had the feeling that I was being controlled by some force or power outside of myself, as though I was a robot and without a will of my own.
I have felt that my thoughts were broadcast so that other people knew what I was thinking.
I feel that thoughts were put into my head that were not my own.
I feel that thoughts were taken away from me by some external force.
I feel that things in this world do not really exist and that I am living in a limbo world or parallel universe.
I feel that my body and organ systems are diseased.
I feel that I am living in a fantasy world, for example where people from another world are talking to me.
I feel that I have committed a crime, or have done some terrible things and deserve punishment.
I feel that I am a particularly important person or that I have special powers or abilities.
I feel that I have infinite power.
I am concerned/preoccupied about something, but other people do not believe me.
There were times that I spoke very rapidly or talked on and on and couldn't be stopped.
There were times when I was unable to sit still or I always had to be moving or pacing up and down.
There was a time when I was more active or involved in things compared to the way I usually am.
I have done things to call attention to myself (the way I dressed or acted).
I hear voices, noises, or other sounds that no one else hears.
I hear a voice which makes a running commentary on my behavior or thoughts.
I hear two or more voices conversing.
I have experienced peculiar physical sensations in my body.
I see shapes or people that are not actually present.
I see and/or hear things that others do not frequently and they affect my life.
I have special powers or abilities.
I am preoccupied with thoughts of a religious nature.
My body is diseased, abnormal, or has changed.
I believe that insignificant remarks or events refer to me or have special meaning.
People can read my mind or know my thoughts.
My thoughts are broadcast so that others or myself can hear them.
Thoughts that are not my own have been inserted into my mind.
My thoughts have been taken away from my mind.
I have a set of repetitive actions or rituals that I must perform over and over.
My behavior deviates from social norms that most other people conform to.
When I speak, my ideas slip off track into unrelated topics.
I feel emotionally withdrawn, lack spontaneity, and am isolated from others.
My movements are unusual and unnatural.
My expressions are inconsistent with what I am talking about (e.g., I giggle when talking about someone's death).
My emotions are inappropriate for the situation.
When I respond to questions, my answers are vague, very concrete, and convey little information.
My train of thought is interrupted.
I take a long time to reply to questions.
I have difficulty having normal conversations.
My clothes are sloppy or soiled, and I have greasy hair, and body odor.
I have difficulty seeking or maintaining employment, completing schoolwork, keeping up my house, etc.
I feel drained of energy and interest in normal things.
I have few or no friends and prefer to spend all my time isolated.
I am uninvolved or unengaged. I feel "spacey."
I have trouble subtracting numbers or spelling words backwards.
I am having trouble concentrating on this interview.
I am confused, disconnected, disorganized, and/or disrupted.
I feel disorientated and am often confused about whom I am talking to, where I am and what time it is.
I am aware that I have a psychotic/mental illness and am dealing with its effects.
I say things that are unrelated to each other, for example, "I'm tired. All people have eyes."
When I talk, I have trouble conveying information, because of being vague and using obscure phrases.
When I talk, I have trouble providing a logical connection between words and phrases and have abrupt changes in subject matter.
My speech is essentially incomprehensible at times.
When I talk, the conclusions I reach do not follow logically from what I am saying.
When I speak, I have trouble expressing the idea that I am trying to convey.
I have trouble communicating with others.
I feel heightened emotions, agitation, and/or increased reactivity.
There have been times when I felt very good or too cheerful or high - not just my normal self.
I have felt more self-confident than usual. I have felt that I am a particularly important person or that I had special talents or abilities.
I feel that I have big plans in store for me in the future, such as I will be president or walk on the moon.
I am very irritable, annoyed, and/or angry.
My speech is accelerated and I change topics frequently.
I do things considered inappropriate according to usual social norms (e.g. masturbating in public).
I behave in an aggressive, agitated manner, often unpredictably.
I reply to questions in with answers that do not make sense to the person I am talking to.
My speech is rapid and difficult to interrupt; the amount of my speech is greater than what is considered normal.
When I am talking, I am distracted by nearby things, which interrupt my flow of speech.
When I talk, I choose words based on how they sound rather than what they mean.
How much were you bothered by repeated, disturbing, and unwanted memories or images of a very stressful experience?
How much were you bothered by repeated, disturbing dreams of a very stressful experience?
How much were you bothered by suddenly feeling or acting as if a very stressful experience were actually happening again (as if you were actually back there reliving it)?
How much were you bothered by feeling very upset when something reminded you of a very stressful experience?
How much were you bothered by having strong physical reactions when something reminded you of a very stressful experience (for example, heart pounding, trouble breathing, sweating)?
How much were you bothered by avoiding memories, thoughts, or feelings related to a very stressful experience?
How much were you bothered by avoiding external reminders of a very stressful experience (for example, people, places, conversations, activities, objects, or situations)?
How much were you bothered by trouble remembering important parts of a very stressful experience?
How much were you bothered by having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
How much were you bothered by blaming yourself or someone else for a very stressful experience or what happened after it?
How much were you bothered by having strong negative feelings such as fear, horror, anger, guilt, or shame?
How much were you bothered by loss of interest in activities that you used to enjoy?
How much were you bothered by feeling distant or cut off from other people?
How much were you bothered by trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
How much were you bothered by irritable behavior, angry outbursts, or acting aggressively?
How much were you bothered by taking too many risks or doing things that could cause you harm?
How much were you bothered by being "super alert" or watchful or on guard?
How much were you bothered by feeling jumpy or easily startled?
How much were you bothered by having difficulty concentrating?
How much were you bothered by trouble falling or staying asleep?
#5:How many days in the past 30 days have you used/In the past 12 months on average, how many days per month did you use/During your adult lifetime on average, how many days per month did you use# marijuana?

Attachment D
Household Screening PAPI Instrument

1) Paper and Pencil Household Screener

Screening Survey

Your address was randomly chosen for the National Study of Mental Health. This is a research study about
mental health and tobacco, alcohol and drug use. If you choose to take part in the study, you will be one of
about 44,500 people to do so.
We would like to conduct a short screening survey with you to determine if you are eligible to be interviewed
for the overall study.
If you decide to participate you can complete the screening survey online or by telephone, by mail, or a
professional interviewer will come to your home to complete the survey in person. For more information
please see the invitation letter you received.
The screening survey should take about 15 minutes to complete and to show our appreciation you will
receive $20. A check for $20 will be mailed to you if you complete this paper screening survey. Or, you may
receive a $20 electronic pre-paid Visa if you choose to complete the online or telephone screening survey,
or $20 in cash if you complete the screening survey with an interviewer in your home. This study is for
research purposes only. There is no direct benefit to you from your participation in the study. Information
learned from the study may help other people in the future. You might find some of the questions we ask to
be upsetting or stressful. Your participation is voluntary, and you can refuse to answer any questions.
It is up to you whether or not to be in this study. The following information is meant to help you decide.

1
1

7320503516

General Information
This study, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), collects
information for research and program planning by asking about:

•
•
•
•

Mental health;
Health behaviors;
Access to, and use of, medical care or treatment; and
Tobacco, alcohol, and drug use or non-use.

We will be asking questions about substance abuse and mental health. You cannot be identified through any
information you give us. Your name and address will never be connected to your answers. In addition, federal law
requires us to keep all your answers confidential. Any answers you give will only be used by authorized researchers for
statistical purposes. Your participation is voluntary and you can stop at any time. Your alternative is not to participate,
and there is no expected benefit to you from your participation in the study.
This screening survey will take about 15 minutes and we will send you a $20 check through the mail when you finish.
We will request your email address at the end of this survey which will only be used to contact you if you are selected
for the main interview. It will not be stored with your answers. We included a stamped business return envelope so there
will be no additional cost to you for participating in this short survey.
If you are chosen for the main interview, it will be done on a different day that we will schedule at your convenience. The
interview takes about 80 minutes, on average.
Each person who is chosen and completes the main interview will receive a $30 electronic gift card, a $30 check, or $30
cash if in person.

Protecting Your Confidentiality
To help keep information about you confidential, we have obtained a Certificate of Confidentiality from the Department of
Health and Human Services (DHHS). This adds special protection for the research information about you because it
protects the research team from being forced, even under a court order or subpoena, to release information that could
identify you. However, there are some exceptions to this privacy rule. If you tell us about the abuse of a child or that you
plan to hurt yourself or others, we may need to notify a mental health professional or other authorities.

Whom To Contact About This Study
During the study, if you have questions, concerns or complaints about the study, please contact the project at
833-947-2575.
An institutional review board (IRB) is an independent committee established to help protect the rights of research
participants. If you have any questions about your rights as a research participant, and/or concerns or complaints
regarding this research study, contact:
•

By mail:
Study Subject Adviser
Advarra IRB
6940 Columbia Gateway Drive, Suite 110
Columbia, MD 21046

•

or call toll free:

877-992-4724

•

or by email:

[email protected]

Please reference the following number when contacting the Study Subject Adviser: Pro00042170.

2
2

0780503519

BACKGROUND INFORMATION
1. How old are you?

3. This question is about your overall health.
Would you say your health in general is:
Excellent
Very Good
Good
Fair
Poor

years old
2. What is your sex?
Male
Female

EMOTIONS AND MOOD
The next questions are about emotional difficulties you might have experienced at some time in the
past year.
4. Almost everyone has times when they feel sad, depressed, or discouraged about how things are
going in their life. Think about a time in the past 12 months lasting 2 weeks or longer when you
had the strongest feelings of this sort. During those 2 weeks, how often did you have each of the
following feelings?
If you are one of the few people that never had such times, mark “None of the time” to all the following
questions.
All or
almost all Most of
Some of A little of
None of
the time
the time
the time
the time
the time
a. Felt sad or depressed
b. Felt discouraged about how things
were going in your life
c. Took little or no interest or pleasure in
things
d. Felt down on yourself, no good, or
worthless
5. Think about a time lasting 6 months or longer in the past 12 months when you had the strongest
feelings of worry and anxiety. During those 6 months, how often did you have each of the
following feelings?
Less than
Just about More days 1-3 days a 1 day a
every day than not
week
Never
week
a. You felt worried or anxious
b. You worried about a number of
different things in your life, such as
your work, family, health, or finances
c. You felt more worried than other
people in your same situation
d. You had trouble controlling your
worry

3

5910503519

6. The next question is about whether you ever in your life had an episode lasting 4 days or longer
when your mood was either much higher than usual most of the day, much more irritable than
usual most of the day, or a mix of these things.
During these episodes, people are often much more excitable than usual or are extremely selfconfident or optimistic. They often do things they would normally not do. And this sometimes
gets them into trouble or puts them at risk of trouble.
With this definition in mind, did you ever in your life have an episode of this sort lasting 4 days or
longer?
Yes
No  Skip to question 8
7. What is the longest episode of this sort you ever had in your life?
4 to 7 days
8 to 14 days
More than 14 days
8. Many people have extremely stressful experiences that affect them psychologically for many
years. Think of a time lasting 1 month or longer in the past 12 months when you had the most
severe reactions to such an extremely stressful experience. During that month, how much were
you bothered by each of the following problems:
Extremely Quite a bit Moderately A little bit

Not at all

a. Suddenly feeling or acting as if the
stressful experience were actually
happening again – as if you were
actually back there reliving it?
b. Avoiding external reminders of the
stressful experience, for example,
people, places, conversations,
activities, objects, or situations?
c. Feeling emotionally distant or
depressed?
d. Irritable behavior, angry outbursts, or
acting aggressively?

4

8271503512

ALCOHOL AND DRUG USE
9. During the past 12 months, how often did you have a drink containing alcohol?
Never  Skip to question 11
Once a month or less often
2 to 4 times a month
2 to 3 times a week
4 times a week or more
10. During the past 12 months, how many drinks containing alcohol did you have on a typical day
when you drank?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
11. These next questions are about drug use. "Drug use" refers to:
• Use of marijuana or cannabis,
• illegal drug use,
• use of prescribed drugs without your own prescription, and
• use of prescribed drugs in greater amounts, more often, or longer
than you were told to take them.
The various classes of drugs include cannabis, which includes marijuana and hashish, cocaine,
methamphetamine, heroin, fentanyl, hallucinogens (such as LSD), and prescription medications
such as benzodiazepines (such as Xanax, Ativan), stimulants (such as Ritalin, Adderall) and
opioids (such as hydrocodone, oxycodone).
During the past 12 months, how often did you use drugs other than alcohol?
Never  Skip to question 13
Once a month or less often
2 to 4 times a month
2 to 3 times a week
4 times a week or more
12. During the past 12 months, how often were you influenced heavily by drugs other than
alcohol?
Never
Less often than once a month
Every month
Every week
Daily or almost daily

5

8087503517

UNUSUAL EXPERIENCES
13. This question asks about unusual experiences, like seeing visions or hearing voices. Recent
research suggests that they are common and may be normal, but we do not know exactly how
common because this is the first large-scale survey to ask about them comprehensively. So
please take your time and think carefully before answering the following questions.
Please do not count times you had these experiences when you were having a fever, dreaming,
half-asleep, or under the influence of alcohol or drugs.
Not counting those things, did you ever in your life have any of the following experiences?
Yes No
a. The first one is seeing a vision that other people said was not there like a face, an
animal, a figure, or colors. Remember not to count times when you were having a
fever, dreaming, half-asleep or under the influence of alcohol or drugs. Did you ever
see a vision at any other time?
b. Did you ever hear voices that other people did not hear like voices coming from inside
your head talking to you or about you, or voices coming out of the air when there was
no one around?
c. Did you ever believe that some mysterious force was inserting thoughts that were
definitely not your own thoughts, directly into your head by means of x-rays, laser
beams, or other methods?
d. Did you ever believe your thoughts were being stolen out of your mind by some force?
e. Did you ever think your mind was being taken over by forces with laser beams or other
methods that were making you do things you did not choose to do?
f. Did you ever think some force was trying to communicate directly with you by sending
special signs or signals, like through the radio or television, that you could understand
but that no one else could understand?
g. Did you ever believe there was a plot to harm you or to have people follow you, but
your friends or family did not think this was true?

HEALTH AND HEALTH CARE
14. Are you currently covered by any kind of
health insurance, that is, any policy or
program that provides or pays for medical
care?
Yes
No

17. Are you currently receiving disability benefits
for problems with emotions nerves, or mental
health?
Yes
No
 Skip to question 19

15. Are you currently receiving disability benefits
such as SSI (Supplemental Security Income),
SSDI (Social Security Disability Insurance), or
disability benefits from the VA (U.S.
Department of Veterans Affairs)?
Yes
No
 Skip to question 19

18. Which of the following mental health
problems are reasons for your disability:
Yes
No
a.

Depression

b.

Bipolar disorder

Post-traumatic stress
disorder
d. Schizophrenia or
schizoaffective disorder
e. Any other mental health
problem
c.

16. Are you currently receiving disability
benefits for problems with your physical
health?
Yes
No

6

9371503514

19. Below is a list of health conditions. Have you
ever been told by a doctor or other health
care professional that you had any of these
conditions?
Yes
No
a. Diabetes
b. Heart problems
c. Cancer
d. Any other life-threatening or
seriously impairing physical
health problem
e. Depression
f. Mania, manic-depression, or
bipolar disorder
g. Schizophrenia or
schizoaffective disorder
h. Any other seriously impairing
emotional health problem

23. How much, if at all, has the coronavirus
pandemic negatively affected your emotional
or mental health?
Not at all
A little
Some
Quite a bit
A lot
24. How much, if at all, has the coronavirus
pandemic affected the amount of alcohol you
drink?
I drink much less than I did before the
coronavirus pandemic began
I drink a little less than I did before the
coronavirus pandemic began
I drink about the same amount as I did
before the coronavirus pandemic began
I drink a little more than I did before the
coronavirus pandemic began
I drink much more than I did before the
coronavirus pandemic began

20. About how tall are you, without shoes?
Please enter your height in feet and inches.
feet

inch(es)

Not applicable - I do not drink alcohol

21. About how much do you weigh in pounds?
pounds

25. How much, if at all, has the coronavirus
pandemic affected your use of drugs other
than alcohol?
By drugs we mean various classes of drugs
including cannabis, which includes marijuana and
hashish, cocaine, methamphetamine, heroin,
fentanyl, hallucinogens (such as LSD), and use
of prescription medication that you took without
your own prescription or in greater amounts,
more often or for longer than you were told to
take them. These prescription medications
include benzodiazepines (such as Xanax,
Ativan), stimulants (such as Ritalin, Adderall) and
opioids (such as hydrocodone, oxycodone).
I use much less than I did before the
coronavirus pandemic began
I use a little less than I did before the
coronavirus pandemic began
I use about the same amount as I did before
the coronavirus pandemic began
I use a little more than I did before the
coronavirus pandemic began
I use much more than I did before the
coronavirus pandemic began

22. Next are a few questions about your personal
experiences with the Coronavirus Disease
2019 pandemic, also referred to as COVID-19.
Since the beginning of the COVID-19
pandemic, …
Does not
Yes No
apply
a. Did you think or know that
you had COVID-19?
b. At any time, did you test
positive for the COVID-19
virus or for COVID-19
antibodies?
c. Were you yourself
hospitalized due to
COVID-19?
d. Was someone in your
immediate family or close
friend(s) hospitalized due
to COVID-19?
e. Did someone in your
immediate family or close
friend(s) die due to
COVID-19?

Not applicable - I do not use drugs

7

4688503510

31. What is the highest grade or level of school
you have completed?

YOUR BACKGROUND
26. Are you now married, widowed, divorced,
separated, or have you never married?
Now married  Skip to question 28
Widowed
Divorced
Separated
Never married

If currently enrolled, mark the previous grade or
highest degree received.
Less than a high school diploma
High school degree or equivalent (for
example: GED)
Some college, no degree
Associate degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
Master’s degree (for example: MA, MS,
MEng, MEd, MSW, MBA)
Professional degree (for example: MD, DDS,
DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

27. Are you now living with a partner?
Yes
No
28. Are you of Hispanic, Latino or Spanish
origin? That is, do any of these groups
describe your national origin or ancestry—
Puerto Rican, Cuban, Cuban-American,
Mexican, Mexican-American, Chicano, Central
or South American, or origin in some other
Spanish-speaking country?
Yes
No  Skip to question 30

32. Are you currently attending a college,
university, or trade school either full-time or
part-time?
If you are on a holiday or break from school, such
as spring break or summer vacation, but plan to
return when the break is over, please answer
yes.
Yes
No  Skip to question 39

29. Do you speak Spanish only, mostly
Spanish with some English, Spanish and
English about the same, mostly English
with some Spanish, or English only?
Spanish only
Mostly Spanish, but some English
Spanish and English about the same
Mostly English, but some Spanish
English only

33. How long ago did you first enroll at this
college, university, or trade school?
If you transferred to your current institution
directly from another college or university,
please include that time.
Within the past 12 months
More than 12 months ago
34. Do you currently live in college-owned
housing on campus, such as a dorm or a
residence hall?
Yes  Skip to question 37
No

30. Are you White, Black or African American,
American Indian or Alaska Native, Native
Hawaiian or other Pacific Islander, or Asian?
Please mark all that apply.
White
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian

35. At any time during the past 12 months (or
if you are a recently new student, since
you enrolled) did you live in collegeowned housing on campus, such as a
dorm or a residence hall?
Yes  Skip to question 37
No

8

1178503511

36. In what type of off-campus housing did
you mostly live in during that time?
Off-campus housing, owned or managed
by the school
Off campus with relatives, such as
parents or guardians
Other off-campus housing

42. Last week, were you on layoff from a job?
Yes  Skip to question 46
No
43. Last week, were you temporarily absent
from a job or business, for example,
because of vacation, temporary illness,
maternity leave, other family or personal
reasons, or bad weather?
Yes  Skip to question 49
No

 Skip to question 39
37. During the past 12 months (or if you are a
recently new student, since you enrolled), did
you mostly live in college-owned housing on
campus, such as a dorm or a residence hall?
Yes  Skip to question 39
No

44. During the last 4 weeks, have you been
actively looking for work?
Yes
No  Skip to question 49

38. In what type of off-campus housing did
you mostly live in during that time?
Off campus housing, owned or managed
by the school
Off campus with relatives, such as
parents or guardians
Other off campus housing

45. Last week, could you have started a job if
you had been offered one, or returned to
work if you had been recalled?
Yes, you could have gone to work
No, you could not have gone to work
because of your own temporary illness
No, you could not have gone to work for
some other reason, such as being in
school or taking care of house or family

EMPLOYMENT
39. Are you currently serving on active duty in
the United States Armed Forces?
Yes
No

 Skip to question 49
46. Have you been informed that you will be
recalled to work within the next 6 months or
been given a date to return to work?
Yes  Skip to question 48
No

40. The next question is about working. Last
week, did you work for pay at a job or
business? By last week, this means the last full
week beginning on a Sunday and ending last
Saturday.
Please include
• unpaid work in a family farm or business if
you usually work more than 15 hours each
week, or
• personal labor you provide in exchange for
work done for you, rather than for pay.
Please do not include
• work done as part of a student stipend, or
• volunteer work.
Yes  Skip to question 49
No – Did not work or am retired

47. During the last 4 weeks, have you been
actively looking for work?
Yes
No  Skip to question 49
48. Last week, could you have started a job if
you had been offered one, or returned to
work if you had been recalled?
Yes, you could have gone to work
No, you could not have gone to work
because of your own temporary illness
No, you could not have gone to work for
some other reason, such as being in
school or taking care of house or family

41. Last week did you do any work for pay,
even for as little as one hour?
Yes  Skip to question 49
No

9

0405503513

54. During the past 12 months, have you
stayed overnight or longer in a state
psychiatric hospital?
State psychiatric hospitals are public
psychiatric hospitals operated by a state for
treatment of serious mental disorders.
Yes
No  Skip to question 56

OTHER HOUSING
49. During the past 12 months, have you stayed
overnight or longer in a jail? Please do not
count any time spent in prison.
Yes
No  Skip to question 51
50. During the past 12 months, how much
time have you spent in a jail? If you are not
sure, just make your best guess.
Please enter your answer and mark whether
that is in number of nights, weeks, or months.

55. During the past 12 months, how much
time have you spent in a state psychiatric
hospital? If you are not sure, just make your
best guess.
Please enter your answer and mark whether
that is in number of nights, weeks, or months.

Nights
Weeks
Months
51. During the past 12 months, have you stayed
overnight or longer in a prison?
Yes
No  Skip to question 53
52. During the past 12 months, how much
time have you spent in a prison? If you are
not sure, just make your best guess.
Please enter your answer and mark whether
that is in number of nights, weeks, or months.

Nights
Weeks
Months
56. During the past 12 months, have you been
homeless, even if just for a short period of
time?
Yes
No  Skip to question 59
57. The next question is about shelters that
provide a place for people who are homeless
to stay. These shelters may also serve meals.

Nights
Weeks
Months

Not counting living on the street, in a
vehicle, or in some type of makeshift
housing like a tent or empty building,
during the past 12 months, have you
stayed overnight or longer in a homeless
shelter?
Yes
No  Skip to question 59

53. During the past 12 months, have you stayed
overnight or longer in a psychiatric hospital?
Yes
No  Skip to question 56

58. During the past 12 months, how much
time have you spent in a homeless
shelter? If you are not sure, just make your
best guess.
Please enter your answer and mark whether
that is in number of nights, weeks, or months.
Nights
Weeks
Months

10

6364503513

CONTACT INFORMATION
59. Please record your first name, cell phone number and/or landline, and email address so that we
can contact you should you be eligible for the main interview in the study.
First Name:
Cell Phone
Number:

-

-

Landline Number:

-

-

Email Address:
60. Can you participate in a private video call, for example using a smartphone, tablet, or a computer?
Yes
No
61. How would you prefer that we reach out to you?
Via telephone
Via email
62. May we send text messages to your personal cell phone to contact you about the upcoming
interview?
Yes
No
I don’t have a cell phone
63. Generally, what would be good days and times in the next few weeks for an interviewer to contact
you to conduct the main interview, should you be eligible?
Please mark all that apply.
Morning Afternoon

Evening

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
64. Please specify any further notes about your availability:

11

6301503514

65. Is there another person who would know how to get in touch with you if we cannot reach you?
Yes
No  Skip to question 67
66. Please record their first name, their phone number, and their email address.
First Name:
Phone Number:

-

-

Email Address:
67. To show our appreciation for completing this short survey today, we would like to send you a $20
check. Please enter your first and last name to receive this check. Print in all CAPS.

Please allow up to 4 weeks for processing and delivery.
First Name:
Last Name:
68. Do you have any additional thoughts to share about this survey or the overall study?

Please return your questionnaire in the enclosed return envelope or mail it to:
NSMH
RTI International
ATTN: Data Capture
5265 Capital Boulevard
Raleigh, NC 27690

Thank you for your participation! We will reach
out to you soon to let you know whether you
are eligible for the main interview.
12

7867503512

Attachment E
Clinical Interview
1) MDPS Clinical Interview (non-SCID)
2) Medication Showcard for use with the MDPS Clinical Interview
3) Income Showcard for use with the MDPS Clinical Interview
4) Structured Clinical Interview for DSM-IV (SCID)
5) SCID for Prison Inmates
6) Short Blessed Test

MDPS Main Interview Instrument

MDPS Clinical Interview Specifications

Acronyms used:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

HH = household population
GQU = group quarters
NHH = non-household population (JA, PR, SH, HL unless specified otherwise)
JA = jail population
PR = prison population
SH = state psychiatric hospital population
HL = homeless population
SI = secondary interviewer (NA as of April 21; before: only in HH, JA, OR SH)
PO = proxy (only in HH, JA; NA for SH as of April 21)
GQU = group quarters
LAR = legally authorized representative
SBT = short blessed test

Symbols used:
- [] skips
- <> fills
- != not equal to
- = equal to
- | = or
PROGRAMMER: PLEASE ALWAYS DISPLAY DK/REF (WHERE APPLICABLE) IN INTERVIEWER
ADMINISTRATION
The routing through the instruments for the different populations will be based on a preloaded case ID
which differentiates the populations.
For the proxy interviews:
- Only for HH, JA (note April 2021: NA for SH) but not in PR OR HL
- The respondent interview should be reset before the proxy interview is conducted
- Those interviews will mostly be conducted by phone
- Protocol is triggered either via:
o SBT fail
o Informed Consent Knowledge quiz fail
o Respondent initiated
- The interviewer will complete a debriefing for proxy interviews
For the secondary informant interviews – note NA entirely as of April 21:
- Only for HH, JA, and SH but not in PR OR HL
- The secondary informant will answer a handful of questions regarding the relationship to the
respondent and contact information in Blaise, and add to the information in the NetSCID portion
1

-

of the interview that was provided by the respondent, not the Blaise portion of what the
respondent provided.
o As discussed, questions that should be part of the SI interview will be marked in the
Note(s) column of the overview with an SI
Triggered by Clinical interviewer as necessary at the end of the respondent interview (failed to
establish diagnosis)
In most instances this interview will be conducted AFTER completion of the respondent
interview; Sometimes a secondary informant may be present during the interview.
Those interviews will mostly be conducted by phone
There will be no separate debriefing for these interviews

Line #

Pop.

1
2

HH, JA
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH,
NHH,
PO, SI
HH,
NHH,
PO, SI

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Variabl
e
Name
Cpre
Cconf
C1

Variable Description / Original
Variable Name
Programmer preload instructions
Confirmation of correct
respondent
Confirmation of interview
language
Interview administration mode

Source

Note(s)

SI
NSDUH

SI

New

SI

Confirmation of phone # if
disconnected
Telephone number if
disconnected
Best phone number to reconnect

New

SI

New

SI

New

SI

Thank you

New

SI

Date of birth

SI

Age verification

NSDUH
Redesign
NSDUH
Redesign
NIS

CSD1b

Age verification

NIS

SI

CSD1c_
dob
CSD1c_
age
CSD1d

Date of birth proxy

Age verification proxy

NSDUH
Redesign
NSDUH
Redesign
NIS

CSD1e

Age verification proxy

NIS

C3a

Recording start

New

SI

C3

Informed consent for clinical
interview

New

SI

CFIID3
Cphon
Cphon2
Cphon
New
CphonE
nd
CSD1_d
ob
CSD1_a
ge
CSD1a

Age

Age proxy

SI
SI

2

19

C3_int

Interview consent

New

SI

C3_rec

Recording consent

New

SI

C4a

Non-consent interview end

New

SI

C4b

Interviewer note recording

New

SI

23

HH,
NHH
HH, JA,
SH, HL
HH,
NHH
HH,
NHH
NHH

Cknow1

New

SI

24

NHH

Cknow2

New

SI

25

NHH

Cknow3

New

SI

26

NHH

New

SI

27

NHH

New

SI

28

NHH

Cknow4
a
Cknow4
b
Cknow5

29

NHH

Cknow6

30

NHH

Cknow7

31

NHH

32

NHH

33

HH, JA,
SH

Cknow8
a
Cknow8
b

Consent knowledge question:
study topic
Consent knowledge question:
study duration
Consent knowledge question:
study participation
Consent knowledge question:
voluntary participation
Consent knowledge question:
refuse to answer
Repeat consent knowledge
question: study topic
Repeat consent knowledge
question: study duration
Repeat consent knowledge
question: study participation
Repeat consent knowledge
question: voluntary participation
Repeat consent knowledge
question: refuse to answer
Short Blessed Test

New

34

HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH

C5

PO/SI transition

New

Paper job aid
only,
administered at
any point of the
interview if
necessary
SI

C6

PO/SI/subject relationship

SI

C6a

PO/SI/subject relationship other

C6b

PO/SI/subject living together

Modified
ACS
Modified
ACS
New

C7a

PO/SI/subject frequency of inperson contact

New

SI

HH, JA,
SH

C7e

PO/SI/subject frequency of mail
contact

New

SI

HH, JA,
SH

C7f

PO/SI/subject/subject frequency
of other contact

New

SI

20
21
22

35
36
37
38
3940HH, JA, SH C7c PO/SI/subject
frequency of telephone contact
ew SI
41HH, JA, SH C7d PO/SI/subject
frequency of email contact New
SI42
43

SI
SI

3

44

HH, JA, C7f_oth PO/SI other contact
New
SH
er
45
PR, SH,
COL1
Date admitted to this facility
NIS
HL
46
PR, SH,
COL2
Estimate when admitted to
NIS
HL
facility
47
HH,
CSD2a
Sex at birth
NIS
NHH
48
HH,
CSD2b
Gender identity current
Modified
NHH
NIS
49
HH,
CSD2c
Confirm sex at birth
NIS
NHH
50
HH,
CSD2d
Sex at birth
NIS
NHH
51
HH,
CSD2e
Gender identity current
Modified
NHH
NIS
52
HH,
C18
Interviewer online/offline
New
NHH
53
HH,
C19
Prompt for paper SCID
New
NHH
SECTION 1: SCID OVERVIEW (See separate file. Adjusted based on First et al. (2016) SCID-5-CV.
STRUCTURED CLINICAL INTERVIEW FOR DSM-5® DISORDERS. CLINICIAN VERSION.)
SECTION 2: SCID DISORDERS (See separate file. Adjusted based on First et al. (2016) SCID-5-CV.
STRUCTURED CLINICAL INTERVIEW FOR DSM-5® DISORDERS. CLINICIAN VERSION.)

SI

SI
SI
SI
SI

1.
2.
3.
4.

MDD
Mania
Psychosis
Differential diagnosis (major depressive disorder, bipolar, schizophrenia or
schizoaffective disorder)
5. Alcohol use disorder
6. Non-alcohol substance use disorder
7. GAD
8. OCD
9. PTSD
10. Anorexia nervosa

SECTION 3: CIGARETTE AND E-CIGARETTE USE
54
HH,
C20,
NHH
C20SCI
D
55
HH,
CT1
NHH
56
HH,
CT2
NHH
(not in
PR)
57
HH,
CT3
NHH
(not in
PR)

Prompt for SCID complete

New

Ever smoked cigarette
Smoked cigarette past 12
months

Modified
NSDUH
Modified
NSDUH

# cigarettes per day past 12
months

Modified
NSDUH

SI

4

58

HH,
NHH
HH,
NHH
(not in
PR)
HH,
NHH
(not in
PR)

CT4

Ever vaped

CT5

Vaped past 12 months

CT6

Frequency vaped past 30 days

Modified
NSDUH
Redesign

HH,
NHH
HH,
NHH
(not in
SH)
HH,
NHH
HH,
NHH

CT7a

Intro to treatment module

New

CT7

Hospitalization inpatient past 12
months

NSDUH

CT9a

Transition mental health

New

CT9Intr
o

HH,
NHH
(not in
SH)
HH,
NHH
(not in
SH)
HH,
NHH

CT9

Counseling, medication,
treatment mental health,
emotions, behavior
Counseling, medication,
treatment mental health,
emotions, behavior ever

Modified
NSDUH
2025
Modified
NSDUH
2025

CT10

Inpatient: Counseling,
medication, treatment mental
health, emotions, behavior

Modified
NSDUH
Redesign

CT11

68

HH,
NHH

CT12

Modified
NSDUH
Redesign
Modified
NSDUH

69

HH,
NHH

CT13

70

HH,
NHH
HH,
NHH
HH,
NHH

CT14

Outpatient: Counseling,
medication, treatment mental
health, emotions, behavior
Outpatient: Counseling,
medication, treatment mental
health, emotions, behavior # of
visits all facilities
Medication mental health,
emotions, behavior past 12
months y/n
Medication mental health,
emotions, behavior current y/n
Medication ID current

CT16

Counseling, medication,
treatment alcohol/drug use ever

HH,
NHH

CT17

Inpatient: Alcohol/drugs

59

60

SECTION 4: TREATMENT MODULE
61
62

63
64
65

66

67

71
72
73

CT15

Modified
MTF
Modified
NSDUH
Redesign

NSDUH
Redesign
NSDUH
Redesign
Modified
NMHS
Modified
NSDUH
Redesign
Modified
NSDUH
Redesign

2-part translation
2-part translation
2-part translation
2-part translation

5

74

HH,
NHH

CT18

Outpatient: Alcohol/drugs

75

HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH

CT19

Outpatient: alcohol/drugs # of
visits all facilities
Medications used to reduce drug
use past 12 months y/n
Other medications used to
reduce drug use (specify)
Intro COVID-19

76
77
78
79

80
81
82
83

84
85
86
87

88
89
90
91
92
93
94

HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH

CT20
CT20SP
COV0
COV1a

Access to mental health
treatment

COV1c

… appointments moved to
telehealth
… delays/cancelations of
appointments
… delays in prescriptions

COV1d

… unable to access care

COV5a

Access to alcohol and drug use
treatment

COV1b

COV5c

… appointments moved to
telehealth
… delays/cancelations of
appointments
… delays in prescriptions

COV5d

… unable to access care

COV2a

Access to medical care

COV2b
COV2c

… appointments moved to
telehealth
… delays/cancelations of
appointments
… delays in prescriptions

COV2d

… unable to access care

CT21A

Medicare

CT21B

Medicaid

CT21C

Military Tricare et al.

CT21D

Private health insurance

HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH

COV5b

HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH

Modified
NSDUH
Redesign
Modified
NSDUH
Modified
NSDUH
Modified
NMHS
Modified
PhenX
Modified
PhenX

2-part translation
2-part translation
2-part translation
2-part translation

Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX

Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
PhenX
Modified
NSDUH
Modified
NSDUH
Modified
NSDUH
Modified
NSDUH

2-part translation

6

95

CT21E

Any health insurance

CT22

Disability benefits

CT23

New

CT8

Reasons for disability mental or
physical health
Reasons for disability mental
health follow-up
Housing assistance

SECTION 5: SOCIO-DEMOGRAPHICS
100
PR, SH,
HL

CSD4

Marital status

Modified
ACS

101

PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL

CSD5

Living with partner

CSD6

Ethnicity

NSDUH
2025
NSDUH

C2

Speaking English/Spanish

NLAAS

CSD7

Race

NSDUH

CSD8

Highest educational degree

Modified
ACS

106

PR, SH,
HL

CSD9

Student status

Modified
B&B:08/18

107

PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL
PR, SH,
HL, HH

CSD9a

First enrollment (in months)

New

Adapted to “you”
instead of this
person and
aggregated
categories
Wording
adjusted to
current,
irrespective of
degree seeking or
not, full time or
part time or not.
Added
instruction to
answer yes if on
break.
Maps to NPSAS

CSD9b

On campus housing current y/n

New

Maps to NPSAS

CSD9e

On campus housing any time
past 12 months y/n
On campus housing mostly past
12 months y/n
Off campus housing type past 12
months
Veteran status

New

Maps to NPSAS

New

Maps to NPSAS

New

Maps to NPSAS

96
97
98
99

102
103
104
105

108
109
110
111
112

HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH
HH,
NHH

CT24

CSD9c
CSD9d
CSD10

Modified
NSDUH
New

New
New

Adapted to “you”
instead of this
person, and
adapted for
mixed-mode

asked in English

NIS
7

113
114
115
116
117

PR, SH,
HL
HH,
NHH
HH,
NHH
HH,
NHH
PR, SH,
HL

CSD11

Active duty

CSD12

Arrested

CSD13

Probation

CSD14

Parole

CSD15

Paid work

118

PR, SH,
CSD15a
HL
119
PR, SH,
CSD15b
HL
120
PR, SH,
CSD15c
HL
121
PR, SH,
CSD15d
HL
122
PR, SH,
CSD15e
HL
123
PR, SH,
CSD15f
HL
124
HH,
INTROF
NHH
I1
125
HH,
CSD16
NHH
126
HH,
CSD17a
NHH
127
HH,
CSD17b
NHH
128
HH,
COV3
NHH
129
HH,
COV4
NHH
SECTION 6: OVERLAP WITH (NON-)HH POPULATION
130
PR
COL3
131
132
133
134

PR

COL4

PR

COL5

PR, HL,
SH

COL6

PR, HL,
SH

COL7

Modified
ACS
NSDUH
NSDUH
Redesign
NSDUH
Redesign
Modified
ACS

Paid work any

ACS

Layoff

ACS

Temporary absence
Recalled to work

Modified
ACS
ACS

Actively looking for work

ACS

Could have started work

Modified
ACS
Modified
NSDUH
Modified
NSDUH
Modified
NSDUH
Modified
NSDUH
Modified
PhenX
New

Household income
Household income
Household income
Household income
COVID-19 financial strain
COVID-19 housing stability

State and county lived in most
prior to incarceration
State lived in most prior to
incarceration
County lived in most prior to
incarceration
Prison/homeless/state
psychiatric hospital more than
once
House/apartment lived

Added
introduction,
exact reference
period, and
unpaid
instructions

New
New
New
New
New

8

135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
SECTION 7: CONCLUSION
161
162

PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
HL, SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL
PR, HL
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, SH
PR, SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
PR, HL,
SH
SH
HH, JA

New

COL8N

House/apartment length of stay
reporting unit
House/apartment stay in nights

COL8W

House/apartment stay in weeks

New

COL8M

House/apartment stay in months

New

Jail stay

New

COL10

Jail length of stay reporting unit

New

COL10N

Jail stay in nights

New

COL10
W
COL10
M
COL11
COL12

Jail stay in weeks

New

Jail stay in months

New

Prison stay
Prison length of stay reporting
unit
Prison stay in nights

New
New

Prison stay in weeks

New

Prison stay in months

New

Psychiatric hospital stay
State psychiatric hospital stay
State psychiatric hospital length
of stay reporting unit
State psychiatric hospital stay in
nights
State psychiatric hospital stay in
weeks
State psychiatric hospital stay in
months
Homeless stay
Homeless shelter stay
Homeless shelter length of stay
reporting unit
Homeless shelter stay in nights

New
New
New

COL16
W
COL16
M

Homeless shelter stay in weeks

New

Homeless shelter stay in months

New

C8
C9

Administrative data linkage
Email confirmation

New
New

COL8

COL9

COL12N
COL12
W
COL12
M
COL13
COL13a
COL14
COL14N
COL14
W
COL14
M
COL15
COL15a
COL16
COL16N

New

New

New

If multiple:
overall

If multiple:
overall

New
New
New
New
New
New

If multiple:
overall

9

163

HH,
NHH
HH, JA,
SH
HH,
NHH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH
HH, JA,
SH, HL

C9a

New

C10

Contact information for possible
follow-up
Contact PO/SI

C21

Recontact consent

New

C11a

Interviewer SI necessary y/n

New

C11b

SI y/n

New

C11c

SI Name

New

C12

Relationship SI

New

C12a

SI /subject living together

New

C13

Contact SI

New

C14

New

C16

Respondent comfort with
current interview
mode/alternative preference
Respondent comfort with virtual
interviewing software
Respondent feedback general

HH, JA,
SH, HL
174
HH,
NHH
175
HH, JA,
PO, SI
176
HH, JA,
PO, SI
177
HH, JA,
PO, SI
178
HH, JA,
PO, SI
179
HH, JA,
PO, SI
180
HH, JA,
PO, SI
181
HH,
NHH
SECTION 8: INTERVIEWER DEBRIEFING
182
183
184

C15

New

SI

C17a

Incentive information

New

SI

C17b1

Email incentive payment

New

SI

C17b2

Email incentive payment

New

SI

C17c

Name incentive payment

New

SI

C17d

Address incentive payment

New

SI

C17e

Address new incentive payment

New

SI

C17

Incentive information and end

New

SI

CIDB0
GAF1
CIDB1

Complete or breakoff
Global assessment functioning
Mode of completion

185

CIDB1a

Technical difficulties

186
187
188
189
190

CIDB1b
CIDB2
CIDB3
CIDB4a
CIDB4b

Disconnected
Audio quality
See the respondent
Video quality
Respondent observation

New
DSM
Modified
NSFG
Modified
NSFG
New
New
New
New
New

164
165
166
167
168
169
170
171
172
173

New

SI

New

Virtual only
Virtual only
Virtual only
Virtual only
Virtual only
10

191

CIDB4c

192
193
194
195
196
197
198
199

CIDB5
CIDB6
CIDB7
CIDB7a
CIDB8
CIDB8a
CIDB9
CIDB10

200
201

!=PO/SI

202

PO/SI

203
204
205
206
207
208
209
210
211
212
213

CIDB11
CIDB11
a
CIDB11
b
CIDB12
CIDB13
CIDB14
CIDB15
a
CIDB15
b
CIDB16
C19n
C20n
CIDBBR
1
CIDBBR
2a
CIDBBR
2b

Usefulness of observation for
diagnosis
At home
Where
Privacy
Secondary informant presence
Who observed
Influence of observer
Interview atmosphere
Type of
distractions/interruptions
Attentiveness of respondent
Recall aids

New

Proxy/secondary informant
confidence in answers
Upset respondent
Trouble completing the interview
and which
Comments interview length
SBT administration

New

SBT pass

New

Anything else
Entering paper SCID data
Completion entering paper SCID
data
Breakoff codes

NSDUH
New
New

Virtual only

NSDUH
NSDUH
NSDUH
New
NSDUH
NSFG
NSFG
NSFG
NSFG
New

NSFG
Modified
NBS
NSDUH
New

SBT administration

Modified
NBS
New

SBT pass

New

11

Cpre PROGRAMMER, PLEASE PRELOAD
CATI = YES/NO FROM SYSTEMS
VIRTUAL = YES/NO FROM SYSTEMS
F2F = YES/NO FROM SYSTEMS
SCREENERCOMPLETE = YES/NO
SCREENER MAIL COMPLETE = YES/NO FROM SCREENER
SCREENER F2F COMPLETE = YES/NO FROM SCREENER
SCREENER CATI COMPLETE = YES/NO FROM SCREENER
JA = YES/NO FROM SAMPLING
HH = YES/NO FROM SAMPLING
SH = YES/NO FROM SAMPLING
PR = YES/NO FROM SAMPLING
HL = YES/NO FROM SAMPLING
PROXY = YES/NO FROM PROXY ASSENT
SECONDARY = YES/NO FROM SYSTEMS
LAR = YES/NO FROM SH
YOB = YEAR OF BIRTH FROM SH
HOSPITAL NAME = STATE HOSPITAL NAME FROM SH
SH_PERMISSION_REQ = YES/NO FROM SH
RESPONDENT = YES/NO FROM CLINICAL INTERVIEW
CKNOWLEDGEPASS2 FROM CLINICAL INTERVIEW
BREAKOFF = YES/NO FROM CLINICAL INTERVIEW
SBT = FAIL/PASS FROM CLINICAL INTERVIEW INTERVIEWER DEBRIEFING
NAMEFILL = RESPONDENT NAME FROM CLINICAL INTERVIEW
NAMEFILL2 = SECONDARY OR PROXY NAME
NAMEFILLLAR = LAR NAME
IF PROXY = YES NAMEFILL
PRISON = YES/NO FROM SAMPLING
STATE = FROM SAMPLING FOR PR ONLY
COUNTY = FROM SAMPLING FOR PR ONLY
AGE FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R OR LISTS FOR
PR, SH, OR HL (AS APPLICABLE)
NAME FROM ROSTER OR SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R
OR IF SCREENERCOMPLETE = NO LISTS FOR PR, SH, OR HL (AS APPLICABLE)
PHONE NUMBER FROM CATI SYSTEMS
GQU FROM ROSTER
SEX FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R
SH3a & b FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R
R7 FROM ROSTER
SH2 FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R
LANGUAGE FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R
SKNOWLEDGEPASS FROM SCREENER
CIINCENTIVE = YES/NO. IF CLINICAL INTERVIEW INCENTIVE WAS ALREADY PAID AT THE SCREENER
= YES; ELSE = NO
INCENTIVE $ ALREADY PAID BY INSTRUMENT IF SCREENERCOMPLETE = YES AND SCREENER R =
CLINICAL R
SCR = CIDI FROM SCREENER
SCR = CAT-MH FROM SCREENER
12

-

-

UNBLINDMDE YES/NO FROM SCREENER
UNBLINDMANIA YES/NO FROM SCREENER
UNBLINDPSYCHOS1 YES/NO FROM SCREENER
UNBLINDPSYCHOS2 YES/NO FROM SCREENER
UNBLINDPSYCHOS3 YES/NO FROM SCREENER
UNBLINDGAD YES/NO FROM SCREENER
UNBLINDPTSD YES/NO FROM SCREENER
EMAIL1 FROM SCREENER IF SCREENERCOMPLETE = YES AND SCREENER R = CLINICAL R; ELSE
FROM ROSTER IF MISSING IN SCREENER INCENTIVES.
ADDRESS FILL FROM SYSTEMS/ROSTER/SCREENER
INCENTIVE PRELOADS:
o CLINICALINC = $30
o SHINC = “INTERVIEWER: PLEASE CHECK LOGISTICS PLAN FOR THIS [HOSPITAL]”
o PRINC = “INTERVIEWER: PLEASE CHECK LOGISTICS PLAN FOR THIS [PRISON]”
o HLINC = “INTERVIEWER: PLEASE CHECK LOGISTICS PLAN FOR THIS [SHELTER]”
o PROXYINC = “$30”
o SIINC = “$10”

PROGRAMMER: SPANISH IS HERE:
\\rtpnfil02\mdps\Instrumentation\ClinicalInterview\ClinicalContent_20210310_PostAdvarra_ToProgram
mingTranslation_SPA.docx
PROGRAMMER TIME STAMP SET: START
Cconf

 (AGE:
, SEX: ).>
Before I review information about the study, I need to confirm I’m talking to the right
person. 
, AGE: , SEX: ) SHOULD BE COMPLETING THE CLINICAL INTERVIEW>
) SHOULD BE
COMPLETING THE CLINICAL INTERVIEW>
1
2

YES – CORRECT RESPONDENT, CONTINUE
NO
13

PROGRAMMER: IF Cconf = YES CONTINUE;
ELSE DISPLAY “INTERVIEWER, PLEASE IDENTIFY THE CORRECT RESPONDENT, AGE: , SEX: )>)>. IF THAT IS NOT
POSSIBLE END THE INTERVIEW AND ASSIGN THE CORRESPONDING STATUS CODE.”
PROGRAMMER: INCLUDE FOR EVERY NEW SESSION THAT IS STARTED IN CASE OF
INTERRUPTIONS
C1

[IF SCREENER RESPONDENT = CLINICAL INTERVIEW RESPONDENT] INTERVIEWER:
CONFIRM/SELECT THE LANGUAGE TO BE USED FOR THIS INTERVIEW. THE SCREENER WAS
COMPLETED IN .
[IF SCREENER RESPONDENT != CLINICAL INTERVIEW RESPONDENT] INTERVIEWER: SELECT
THE LANGUAGE TO BE USED FOR THIS INTERVIEW ESTABLISHED DURING THE INITIAL
CONTACT.
1
ENGLISH
2
SPANISH

CFIID3

INTERVIEWER: PLEASE ENTER THE INTERVIEW ADMINISTRATION MODE
1
ZOOM AUDIO ONLY (TELEPHONE)
2
VIRTUAL (ZOOM VIDEO)
3
IN-PERSON
PROGRAMMER: GENERATE CATI Y/N, VIRTUAL Y/N, F2F = Y/N
PROGRAMMER: INCLUDE FOR EVERY NEW SESSION THAT IS STARTED IN CASE OF
INTERRUPTIONS

Cphon

[IF ((CFIID3 = 1 & PHONE NUMBER = YES)) & ((HH | JA | HL = YES) | (PROXY | SECONDARY
= YES))]
Should you get disconnected please sign back into the call. Should I get disconnected
from this call, please remain on the line and I will dial back in.
Just to confirm, is  a good number to reach you in case there is a
Zoom outage?
1
YES
2
NO
DK/REF

Cphon2

[IF ((CFIID3 = 1 & PHONE NUMBER = MISSING) | CFIID3 = 2) & (HH | JA | HL | SH = YES) |
(PROXY | SECONDARY = YES))]:
Should you get disconnected please sign back into the  call. Should
I get disconnected from this  call, please remain   and I will .
14

Just in case of a ZOOM outage, is there a good phone number to reach you?
1
YES
2
NO
DK/REF
CphonNew

[IF Cphon = NO | Cphon2 = YES] Would you please give me a phone number so that I can
contact you in case there is a ZOOM outage?
______________
DK/REF

CphonEnd

[IF Cphon = YES/NO/DK/REF | Cphon2 = YES/NO/DK/REF | PR = YES]


contact the person who assisted you starting this  call.>

CSD1_dob

What is your date of birth?
DOB:

_____ _____ ______
MONTH

DAY

YEAR

DK/REF
PROGRAMMER PLEASE DISPLAY ERROR MESSAGE IF THE DATE OVERALL OR THE
INDIVIDUAL FIELDS ARE OUT OF RANGE: YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A
NUMBER BETWEEN .
PROGRAMMER IF DAY = DK/REF ASSUME 28TH AS DAY.
PROGRAMMER GENERATE AGE IN YEARS
CSD1_age

[IF CSD1_dob = DK/REF MONTH AND/OR YEAR] And what is your age?
AGE: ___ ___
DK/REF

CSD1a

[IF PROXY = NO & (CSD1_dob | CSD1_age < 18 |CSD1_age > 66)] Thank you for your
willingness to participate, but we cannot interview anyone who is  66: older than 66> for this
study.
[PROGRAMMER: THIS CONCLUDES THE INTERVIEW]
[IF PROXY = YES & (CSD1_dob | CSD1_age < 18)] Thank you for your willingness to
participate, but we cannot interview anyone who is younger than 18 for this study.
[PROGRAMMER: THIS CONCLUDES THE INTERVIEW]
15

CSD1b

[IF CSD1_dob | CSD1_age = DK/REF] Thank you for your willingness to participate, but we
cannot interview you if we don’t know how old you are.
[PROGRAMMER: THIS CONCLUDES THE INTERVIEW]

CSD1c_dob

[IF PROXY = YES] What is ’s date of birth?
DOB:

_____ _____ ______
MONTH

DAY

YEAR

DK/REF
PROGRAMMER PLEASE DISPLAY ERROR MESSAGE IF THE DATE OVERALL OR THE
INDIVIDUAL FIELDS ARE OUT OF RANGE: YOUR ENTRY IS OUT OF RANGE. PLEASE ENTER A
NUMBER BETWEEN .
PROGRAMMER GENERATE AGE IN YEARS
CSD1c_age

[IF PROXY = YES & CSD1c_dob = DK/REF MONTH AND/OR YEAR] And what is
’s age?
AGE: ___ ___
DK/REF

CSD1d

[IF CSD1c_dob | CSD1c_age < 18 | CSD1c_dob | CSD1c_age > 66] Thank you for your
willingness to participate on ’s behalf, but we cannot interview you about
anyone who is  66: older than 66> for this study.
[PROGRAMMER: THIS CONCLUDES THE INTERVIEW]

CSD1e

[IF CSD1c_dob | CSD1c_age = DK/REF] Thank you for your willingness to participate on
’s behalf, but we cannot interview you about anyone if we don’t know how
old they are.
[PROGRAMMER: THIS CONCLUDES THE INTERVIEW]

C3a



1

CONTINUE 

2



PROGRAMMER: PLEASE GENERATE RECALLOW = YES IF C3a = 1. IF RECALLOW != YES DO
NOT START RECORDING AND DO NOT ASK C3_rec.
16

C3

PROGRAMMER NOTE PLEASE INCLUDE AS FOLLOWS:
-

[IF HH = YES & SKNOWLEDGEPASS = 1 & SCREENER MAIL COMPLETE = NO & PROXY =
NO & SECONDARY = NO: RECAP HH CONSENT FORM + CONSENT FOR RECORDING]
PROGRAMMER PLEASE DISPLAY RECAP ABBREVIATED INFORMED CONSENT TEXT
FROM “3a Household Clinical Interview Informed Consent Recap” & “3b Recording
Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE HOUSEHOLDS:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_SPA_Jan0721_clean.pdf

-

[IF HH = YES & SKNOWLEDGEPASS = 0 & SCREENER MAIL COMPLETE = NO & PROXY =
NO & SECONDARY = NO: INFORMED HH CONSENT FORM + CONSENT FOR
RECORDING + KNOWLEDGE TEST] PROGRAMMER PLEASE ABBREVIATED DISPLAY
INFORMED CONSENT TEXT FROM “3 Household Clinical Interview Informed Consent”
& “3b Recording Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE HOUSEHOLDS:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_SPA_Jan0721_clean.pdf

-

[IF ((HH = YES & SKNOWLEDGEPASS = MISSING) | JA = YES) & PROXY = NO &
SECONDARY = NO: INFORMED HH CONSENT FORM + CONSENT FOR RECORDING +
KNOWLEDGE TEST] PROGRAMMER PLEASE DISPLAY ABBREVIATED INFORMED
CONSENT TEXT FROM “3 Household Clinical Interview Informed Consent” & “3b
Recording Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
17

PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE HOUSEHOLDS/
JAILS:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\Ringeisen Household ICF Pro00042170
Aug1320_v4_SPA_Jan0721_clean.pdf
-

[IF PR = YES & PROXY = NO & SECONDARY = NO: FULL INFORMED PR CONSENT FORM
+ (RECORDING CONSENT +) KNOWLEDGE TEST] PROGRAMMER PLEASE DISPLAY
ABBREVIATED INFORMED CONSENT TEXT FROM “4 Prison Clinical Interview Informed
Consent” HERE: \\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH
Consent Statements 073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER THIS WILL BE A JOB AID FOR THE FULL CONSENT FORM FOR THE
PRISONS:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Prison ICF Pro00042170 Aug1320_v4.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Prison ICF Pro00042170 Aug1320_v4_SPA.docx

-

[IF HL = YES & PROXY = NO & SECONDARY = NO: FULL INFORMED HL CONSENT FORM
+ (RECORDING CONSENT +) KNOWLEDGE TEST] PROGRAMMER PLEASE DISPLAY
ABBREVIATED INFORMED CONSENT TEXT FROM “6 Shelter Clinical Interview
Informed Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER THIS WILL BE A JOB AID FOR THE FULL CONSENT FORM FOR THE
SHELTERS:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Shelter ICF Pro00042170 Aug1320_ts_v4.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Shelter ICF Pro00042170 Aug1320_ts_v4_SPA.docx

-

[IF SH = YES & PROXY = NO & SECONDARY = NO: FULL INFORMED SH CONSENT FORM
+ (RECORDING CONSENT +) KNOWLEDGE TEST] PROGRAMMER PLEASE DISPLAY
ABBREVIATED INFORMED CONSENT TEXT FROM “5 Hospital Clinical Interview
Informed Consent” HERE:
\\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
18

PROGRAMMER THIS WILL BE A JOB AID FOR THE FULL CONSENT FORM FOR THE
HOSPITALS:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Hospital ICF Pro00042170 Aug1320_v4.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\Ringeisen
Hospital ICF Pro00042170 Aug1320_v4_SPA.docx
-

[IF PROXY = YES & SECONDARY = NO: FULL INFORMED PROXY CONSENT FORM +
RECORDING CONSENT + KNOWLEDGE TEST] PROGRAMMER PLEASE DISPLAY
ABBREVIATED INFORMED CONSENT TEXT FROM “7 Proxy Consent” & “3b Recording
Consent” HERE: \\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH
Consent Statements 073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE PROXY:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\NSMH Proxy Consent_Auf1320_v5_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\NSMH Proxy Consent_Aug1320_v5_SPA_Jan0721_clean.pdf

-

[IF SECONDARY = YES & PROXY = NO: FULL INFORMED SECONDARY INFORMANT
CONSENT FORM + RECORDING CONSENT]
PROGRAMMER PLEASE DISPLAY ABBREVIATED INFORMED CONSENT TEXT FROM
CONSENT TEXT FROM “8 Secondary Informant Consent” & “3b Recording Consent”
HERE: \\RTPNFIL02\mdps\Instrumentation\Screening\Consent\NSMH Consent
Statements 073120_revised111720_ToProgrammingTranslation.docx
\\rtpnfil02\mdps\Instrumentation\Screening\Consent\NSMH Consent Statements
073120_revised111720_ToProgrammingTranslation_SPA.docx
PROGRAMMER PLEASE LINK TO THIS FULL CONSENT FORM FOR THE SECONDARY
INFORMANTS:
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\NSMH Secondary Informant
Consent_Aug1320_v5_Jan0721_clean.pdf
\\rtpnfil02\MDPS\Data_Collection_Household\Informed Consent\Programmed
Versions\January2021\NSMH Secondary Informant Consent_Aug1320_v5_SPAJan0721_clean.pdf

PROGRAMMER: C3_rec SHOULD ONLY BE ASKED IF RESPONDENTS CONSENTED TO
PARTICIPATE IN THE INTERVIEW.
C4a

[IF C3_int = NO] Thank you for your willingness to participate ’s behalf>, but we cannot interview you without your consent.
PROGRAMMER: THIS CONCLUDES THE INTERVIEW
19

C4b

[IF C3_rec = NO] INTERVIEWER, THE RESPONDENT DOES NOT WISH TO BE RECORDED;
PLEASE TURN OFF THE ZOOM RECORDING NOW

Cknow1

[IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO & JA
= NO & PROXY = NO] To ensure you understand your rights as a NSMH respondent, I
need to ask you a few questions about the information we just discussed. You are being
asked to participate in the National Study of Mental Health – the NSMH. Would you say
the NSMH is about:
a.
b.
c.
d.

a. How pets improve our mental health
b. Mental health and other health issues
c. The health of kids in schools
d. Public transportation

PROGRAMMER NOTE: IF PR | SH | HL = YES PLEASE ONLY DISPLAY THE INTRODUCTORY
SENTENCE BUT REMOVE THE “YOU ARE BEING ASKED …” AND THE RESPONSE OPTIONS
ENTIRELY; THEN SET CKnow1 = b TO ENSURE Cknow5 IS NEVER DISPLAYED (DATE:
06/15/2021).
NOTE: THE KNOWLEDGE CHECK WAS NO LONGER ADMINISTERED FOR HH AND JA (INCL.
PROXY) AS OF DATE: 06/15/2021.
Cknow2

[IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO & JA
= NO & PROXY = NO] Your participation in the NSMH interview will take about:
a.
a. 15 minutes
b.
b. 6 hours
c.

d.
c. 3 days
NOTE: THE KNOWLEDGE CHECK WAS NO LONGER ADMINISTERED FOR HH AND JA (INCL.
PROXY) AS OF DATE: 06/15/2021.

Cknow3

[IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO & JA
= NO & PROXY = NO] You have been asked to:
a.
b.
c.
d.

a. Take part in a group discussion with 10 to 12 other people
b. Call your local health department to participate
c. Participate in an interview with an interviewer
d. Send a letter with information about your health

PROGRAMMER NOTE: NEVER DISPLAY THIS QUESTION TO ANY POPULATION; SET
CKnow3 = c TO ENSURE Cknow7 IS NEVER DISPLAYED (DATE: 06/15/2021).
NOTE: THE KNOWLEDGE CHECK WAS NO LONGER ADMINISTERED FOR HH AND JA (INCL.
PROXY) AS OF DATE: 06/15/2021.
20

Cknow4a

[IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO & JA
= NO & PROXY = NO] True or False: Your participation is voluntary.
1
TRUE
2
FALSE
DK/REF
NOTE: THE KNOWLEDGE CHECK WAS NO LONGER ADMINISTERED FOR HH AND JA (INCL.
PROXY) AS OF DATE: 06/15/2021.

Cknow4b

[IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO & JA
= NO & PROXY = NO] True or False: You can refuse to answer any questions.
1
TRUE
2
FALSE
DK/REF
PROGRAMMER: GENERATE CKNOWLEDGEPASS IF (HH = NO | (HH = YES &
SKNOWLEDGEPASS = 0 | MISSING)) & SECONDARY = NO
REPLACE CKNOWLEDGEPASS = 1 IF Cknow1 = b & Cknow2 = c & Cknow3 = c &
Cknow4a = 1 & Cknow4b = 1
ELSE CKNOWLEDGEPASS = 0 IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0 |
MISSING)) & SECONDARY = NO
IF CKNOWLEDGEPASS = 0 & (PROXY = YES) SKIP TO C17a.
ELSE CONTINUE

Cknow5

[IF Cknow1 != b & (PROXY = NO & SECONDARY = NO)] INTERVIEWER PLEASE REVIEW THE
FOLLOWING STUDY INFORMATION WITH THE RESPONDENT: I may have covered the
consent to participate information too quickly. Let me reread some of the relevant
details about the study:



You are being asked to participate in the National Study of Mental Health – the NSMH.
Would you say the NSMH is about:
a.

How pets improve our mental health
21

b.
c.
d.

Mental health and other health issues
The health of kids in schools
Public transportation

PROGRAMMER GENERATE Cknow5_admin YES/NO IF ADMINISTERED
Cknow6

[IF Cknow2 != c & (PROXY = NO & SECONDARY = NO)] INTERVIEWER PLEASE REVIEW THE
FOLLOWING STUDY INFORMATION WITH THE RESPONDENT: 
< IF CFIID3 = 3: $30 cash if you agree to participate.>>
 for agreeing to
participate in this interview.>
: IF INCENTIVES ARE ALLOWED IN THIS FACILITY
READ: AND YOU WILL RECEIVE “FILL INCENTIVE” IF YOU AGREE TO PARTICIPATE].>
: IF INCENTIVES ARE
ALLOWED IN THIS FACILITY READ: AND YOU WILL RECEIVE “FILL INCENTIVE” IF YOU
AGREE TO PARTICIPATE].>
: IF INCENTIVES ARE ALLOWED IN
THIS FACILITY READ: AND YOU WILL RECEIVE “FILL INCENTIVE” IF YOU AGREE TO
PARTICIPATE].>
Your participation in the NSMH interview will take about:
a.
b.
c.
d.

15 minutes
6 hours

3 days

PROGRAMMER GENERATE Cknow6_admin YES/NO IF ADMINISTERED
Cknow7

[IF Cknow3 != c & (PROXY = NO & SECONDARY = NO)] INTERVIEWER PLEASE REVIEW THE
FOLLOWING STUDY INFORMATION WITH THE RESPONDENT: 
22



 to talk with you privately.>
You have been asked to:
a.
b.
c.
d.

Take part in a group discussion with 10 to 12 other people
Call your local health department to participate
Participate in an interview with an interviewer
Send a letter with information about your health

PROGRAMMER GENERATE Cknow7_admin YES/NO IF ADMINISTERED
Cknow8a

[IF Cknow4a != 1 & (PROXY = NO & SECONDARY = NO)] INTERVIEWER PLEASE REVIEW
THE FOLLOWING STUDY INFORMATION WITH THE RESPONDENT: 



True or False: Your participation is voluntary.
1
TRUE
2
FALSE
DK/REF
PROGRAMMER GENERATE Cknow8a_admin YES/NO IF ADMINISTERED

23

Cknow8b

[IF Cknow4a != 1 & (PROXY = NO & SECONDARY = NO)] INTERVIEWER PLEASE REVIEW
THE FOLLOWING STUDY INFORMATION WITH THE RESPONDENT: 






True or False: You can refuse to answer any questions.
1
TRUE
2
FALSE
DK/REF
PROGRAMMER GENERATE Cknow8b_admin YES/NO IF ADMINISTERED
PROGRAMMER: GENERATE CKNOWLEDGEPASS2 IF (HH = NO | (HH = YES &
SKNOWLEDGEPASS = 0)) & (PROXY | SECONDARY = NO)
REPLACE CKNOWLEDGEPASS2 = 1 IF
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
NO & Cknow8a_admin = NO & Cknow8b_admin = NO) |
(Cknow6_admin = YES & Cknow6 = c & Cknow5_admin = NO & Cknow7_admin =
NO & Cknow8a_admin = NO & Cknow8b_admin = NO) |
24

(Cknow7_admin = YES & Cknow7 = c & Cknow5_admin = NO & Cknow6_admin =
NO & Cknow8a_admin = NO & Cknow8b_admin = NO) |
(Cknow8a_admin = YES & Cknow8a = 1 & Cknow5_admin = NO & Cknow6_admin
= NO & Cknow7_admin = NO & Cknow8b_admin = NO) |
(Cknow8b_admin = YES & Cknow8b = 1 & Cknow5_admin = NO & Cknow6_admin
= NO & Cknow7_admin = NO & Cknow8a_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = NO Cknow8a_admin = NO & Cknow8b_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = NO & Cknow8b_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
NO & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
NO & Cknow8b_admin = YES & Cknow8b = 1 & Cknow8a_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = NO & Cknow8b_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
NO & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
NO & Cknow8b_admin = YES & Cknow8b = 1 & Cknow8a_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = NO & Cknow7_admin = YES & Cknow7
= c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = NO & Cknow7_admin = YES & Cknow7
= c & Cknow8b_admin = YES & Cknow8b = 1 & Cknow8a_admin = NO) |
(Cknow5_admin = NO & Cknow6_admin = NO & Cknow7_admin = NO &
Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin = YES & Cknow8b = 1)
|
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = YES & Cknow7 = c & Cknow8a_admin = NO & Cknow8b_admin
= NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = NO & Cknow8a_admin = YES & Cknow8a = 1 &
Cknow8b_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = NO & Cknow8b_admin = YES & Cknow8b = 1 &
Cknow8a_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin =
NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
YES & Cknow7 = c & Cknow8b_admin = YES & Cknow8b = 1 & Cknow8a_admin =
NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
NO & Cknow8a_admin = YES & Cknow8a = 1 &Cknow8b_admin = YES & Cknow8b
= 1) |
25

(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin =
NO) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
YES & Cknow7 = c & Cknow8b_admin = YES & Cknow8b = 1 & Cknow8a_admin =
NO) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
NO & Cknow8a_admin = YES & Cknow8a = 1 &Cknow8b_admin = YES & Cknow8b
= 1) |
(Cknow5_admin = NO & Cknow6_admin = NO & & Cknow7_admin = YES &
Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin = YES &
Cknow8b = 1) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 &
Cknow8b_admin = NO) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = YES & Cknow7 = c & Cknow8a_admin = NO & Cknow8b_admin
= YES & Cknow8b = 1) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = NO & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin =
YES & Cknow8b = 1) |
(Cknow5_admin = NO & Cknow6_admin = YES & Cknow6 = c & Cknow7_admin =
YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 & Cknow8b_admin =
YES & Cknow8b = 1) |
(Cknow5_admin = YES & Cknow5 = b & Cknow6_admin = YES & Cknow6 = c &
Cknow7_admin = YES & Cknow7 = c & Cknow8a_admin = YES & Cknow8a = 1 &
Cknow8b_admin = YES & Cknow8b = 1) |
ELSE CKNOWLEDGEPASS2 = 0 IF (HH = NO | (HH = YES & SKNOWLEDGEPASS = 0))
& (PROXY | SECONDARY = NO)
PROGRAMMER:
- IF HH = YES & SKNOWLEDGEPASS = 1 CONTINUE
- IF HH = YES & SKNOWLEDGEPASS = 0 & (CKNOWLEDGEPASS = 1) CONTINUE
- IF HH = YES & SKNOWLEDGEPASS = 0 & (CKNOWLEDGEPASS = 0 &
CKNOWLEDGEPASS2 = 1) CONTINUE
- IF HH = YES & SKNOWLEDGEPASS = 0 & (CKNOWLEDGEPASS = 0 &
CKNOWLEDGEPASS2 = 0) TRIGGER PROXY PROTOCOL AND SKIP TO C17a:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20210201_ToProgrammingTranslation.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20201214_ToProgramminTranslation_SPA.docx
-

IF SH = YES & CKNOWLEDGEPASS = 1 CONTINUE
26

-

IF SH = YES & (CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 1) CONTINUE
IF SH = YES & (CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 0) & (LAR = YES &
SH_PERMISSION_REQ = YES) DO NOT TRIGGER PROXY PROTOCOL AND SKIP DIRECTLY
TO C17
IF SH = YES & (CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 0) & (LAR = YES &
SH_PERMISSION_REQ = NO) TRIGGER PROXY PROTOCOL AND SKIP TO C17:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20210201_ToProgrammingTranslation.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20201214_ToProgramminTranslation_SPA.docx

-

IF JA = YES & CKNOWLEDGEPASS = 1 CONTINUE
IF JA = YES & CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 1) CONTINUE
IF JA = YES & CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 0) TRIGGER PROXY
PROTOCOL AND SKIP TO C17a:
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20210201_ToProgrammingTranslation.docx
\\RTPNFIL02\mdps\Instrumentation\ClinicalInterview\Spanish Translation\NSMH
LAR Permission, Proxy Transition & Proxy
Assent_20201214_ToProgramminTranslation_SPA.docx

-

IF PR | HL = YES & CKNOWLEDGEPASS = 1 CONTINUE
IF PR | HL = YES & CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 1) CONTINUE
IF PR | HL = YES & CKNOWLEDGEPASS = 0 & CKNOWLEDGEPASS2 = 0) SKIP TO C17

-

IF PROXY = YES & CKNOWLEDGEPASS = 1 CONTINUE
IF SECONDARY = YES CONTINUE

PROGRAMMER NOTE: INTERVIEWER ASSESSMENT OF CAPACITY TO BE INTERVIEWED – SHORT BLESSED
TEST WILL NOT BE PART OF THE INTERVIEW BUT A JOB AID; IF FAILED & HH | JA | SH = YES PROXY
ASSENT THEN SKIP TO C17a; IF FAILED & PR | HL = YES SKIP TO C17; IF PASS CONTINUE. – REMINDER. DO
NOT PROGRAM THIS TEXT INTO THE INSTRUMENT.
C5

[IF PROXY = YES | SECONDARY = YES] Before we begin the questions about ,
we have a few questions about your relationship with .

C6

[IF PROXY = YES | SECONDARY = YES] What is your relationship to ?
□ HUSBAND/WIFE/SPOUSE
□ UNMARRIED PARTNER
□ SON OR DAUGHTER (INCL. ADOPTIVE OR
STEP)

□ PARENT-IN-LAW
□ SON-IN-LAW OR DAUGHTER-INLAW
□ OTHER RELATIVE

27

□ BROTHER OR SISTER (INCL. ADOPTIVE OR
STEP)
□ FATHER OR MOTHER (INCL. ADOPTIVE OR
STEP)
□ GRANDCHILD
DK/REF
C6a

□ ROOMMATE OR HOUSEMATE
□ OTHER NONRELATIVE, SUCH AS A
MEDICAL OR HEALTH CARE
PROVIDER

[IF C6 = OTHER (NON)RELATIVE] [INTERVIEWER PLEASE ENTER THE RELATIONSHIP]
_______________________
DK/REF

C6b

[IF PROXY = YES | SECONDARY = YES] Do you and  usually live at the same
address?
1
YES
2
NO
DK/REF

C7

[(IF PROXY = YES | SECONDARY = YES) & C6b = NO] How often do you interact with
?
INTERVIEWER: READ RESPONSE OPTIONS FOR FIRST TWO CATEGORIES AND REPEAT
THEREAFTER AS NEEDED.
Daily or Every
Every
Less
UNSURE DOES
almost week
month
often
NOT
daily
than
APPLY
once a
month
a. In-person
b. Virtually
c. By telephone
d. By email
e. By mail
f. By some other mode
DK/REF
PROGRAMMER IF SECONDARY = YES & C7f = DOES NOT APPLY/DK/REF GO TO C18;
PROGRAMMER IF SECONDARY = YES & C7f != DOES NOT APPLY/DK/REF CONTINUE;
ELSE CONTINUE

C7f_other

[IF C7f != DOES NOT APPLY/DK/REF] INTERVIEWER PLEASE ENTER THE OTHER CONTACT
MODE
_______________________
DK/REF
PROGRAMMER IF SECONDARY = YES GO TO C18;
ELSE CONTINUE
28

COL1

[IF PR = YES OR SH = YES] When > admitted to this facility?
[IF HL = YES] When > enter
this shelter?
COL1a. 2-DIGIT MONTH: _________
[RANGE: 1 – 12] DK/REF
COL1b. 2-DIGIT DAY: ____________
[RANGE: 1 – 31] DK/REF
COL1c. 4-DIGIT YEAR: ___________
[RANGE: 1915 – current year]
DK/REF
[PROGRAMMER: CALCULATE LENGTH OF STAY; USE THE 15TH IF COL1b =
DK/REF]
PROGRAMMER IF (COL1c <= (CURRENT YEAR - CSD1_age)) PLEASE DISPLAY THE
FOLLOWING ERROR MESSAGE AND LEAD BACK TO QUESTION: Year  cannot
be earlier than year of birth.

COL2

[IF COL1a = DK/REF AND COL1c != DK/REF] What time of year was it? Was it
winter, spring, summer, or fall when  was> admitted to this facility?
1
WINTER
2
SPRING
3
SUMMER
4
FALL
DK/REF
[PROGRAMMER: CALCULATE LENGTH OF STAY IN MONTHS]
PROGRAMMER: CALCULATE LENGTH OF STAY. FOR WINTER USE JANUARY AS THE
MONTH; FOR SPRING APRIL, FOR SUMMER JULY, FOR FALL OCTOBER
PROGRAMMER: IF COL2 = DK/REF & (COL1c = CURRENT YEAR OR CURRENT YEAR – 1)
then “LENGTH OF STAY IN MONTHS” = 11 (Less than 12 months)
IF COL2 = DK/REF & (COL1c >= CURRENT YEAR -2) then “LENGTH OF STAY IN MONTHS” =
12* (CURRENT YEAR – COL1c) (More than 12 months)

CSD2a

What sex was recorded on 
original birth certificate?
1
MALE
2
FEMALE
DK/REF

29

CSD2b

What is ’s> current gender identity?
Please tell me which of the following apply to >.
YES NO
Male
Female
Transgender
I am not sure of ’s> gender identity
PROGRAMMER CHECKBOX: I DO NOT KNOW WHAT THIS QUESTION IS ASKING AND SET CSD2b to
DK
REF
a.
b.
c.
d.

PROGRAMMER DEFINE PRSEX1 & PRSEX2 & PRSEX3
IF CSD2ba = 1 & (CSD2bb & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX1 = he
IF CSD2ba = 1 & (CSD2bb & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX2 = his
IF CSD2ba = 1 & (CSD2bb & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX3 = him
IF CSD2bb = 1 & (CSD2ba & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX1 = she
IF CSD2bb = 1 & (CSD2ba & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX2 = her
IF CSD2bb = 1 & (CSD2ba & CSD2bc & CSD2bd = 2 & CSD2b != DK/REF) THEN PRSEX3 = her
ELSE PRSEX1 = they
ELSE PRSEX2 = their
ELSE PRSEX3 = them
PROGRAMMER DEFINE CURRSEX FILL
IF CSD2ba = 1 THEN CURRSEX FILL = “ as male”
IF CSD2bb = 1 THEN CURRSEX FILL = “ as female”
IF CSD2bc = 1 THEN CURRSEX FILL = “ as transgender”
IF CSD2bd = 1 THEN CURRSEX FILL = “> gender identity”
IF CSD2ba = 1 & CSD2bb = 1 THEN CURRSEX FILL = “ as male and female”
IF CSD2ba = 1 & CSD2bc = 1 THEN CURRSEX FILL = “ as male and transgender”
IF CSD2ba = 1 & CSD2bd = 1 THEN CURRSEX FILL = “ as male and not sure of > gender identity”
IF CSD2bb = 1 & CSD2bc = 1 THEN CURRSEX FILL = “ as female and transgender”

30

IF CSD2bb = 1 & CSD2bd = 1 THEN CURRSEX FILL = “ as female and not sure of > gender identity”
IF CSD2bc = 1 & CSD2bd = 1 THEN CURRSEX FILL = “ as transgender and not sure of > gender identity”
IF CSD2ba = 1 & CSD2bb = 1 & CSD2bc = 1 THEN CURRSEX FILL = “ as male, female, and transgender”
IF CSD2ba = 1 & CSD2bb= 1 & CSD2bd = 1 THEN CURRSEX FILL = “ as male, female, and not sure of > gender identity”
IF CSD2ba = 1 & CSD2bc = 1 & CSD2bd = 1 THEN CURRSEX FILL = “ as male, transgender, and not sure of > gender identity”
IF CSD2bb = 1 & CSD2bc = 1 & CSD2bd = 1 THEN CURRSEX FILL = “ as female, transgender, and not sure of > gender identity”
IF CSD2ba = 1 & CSD2bb = 1 & CSD2bc = 1 & CSD2bd = 1 THEN CURRSEX FILL = “ as male, female, transgender, and not
sure of > gender identity”
PROGRAMMER DEFINE BIRTHSEX
IF CSD2a = 1 THEN BIRTHSEX = male
IF CSD2a = 2 THEN BIRTHSEX = female
ELSE BIRTHSEX = BLANK
CSD2c

[IF (CSD2a = 1 AND (CSD2bb = 1 OR CSD2bc = 1 OR CSD2bd = 1)) OR (CSD2a = 2 AND
(CSD2ba = 1 OR CSD2bc = 1 OR CSD2bd = 1))] Just to confirm what you told me,
[BIRTHSEX] was recorded on ’s>
original birth certificate and now >
[CURRSEX FILL]. Is that correct?
1
YES
2
NO
DK/REF

CSD2d

[IF CSD2c = 2] Please answer this question again: What sex was recorded on ’s> original birth certificate?
1
MALE
2
FEMALE
DK/REF

CSD2e

[IF CSD2c = 2] What is ’s> current
gender identity? Please tell me which of the following apply to >.
31

a.
b.
c.
d.

YES NO
Male
Female
Transgender
I am not sure of ’s> gender identity
PROGRAMMER CHECKBOX: I DO NOT KNOW WHAT THIS QUESTION IS ASKING AND SET
CSD2e to DK
REF

PROGRAMMER REPLACE PRSEX1 & PRSEX2
IF CSD2ea = 1 & (CSD2eb & CSD2ec & CSD2ed = 2 & CSD2e != DK/REF) THEN PRSEX1 = he
IF CSD2ea = 1 & (CSD2eb & CSD2ec & CSD2ed = 2 & CSD2e != DK/REF) THEN PRSEX2 = his
IF CSD2ea = 1 & (CSD2eb & CSD2ec & CSD2ed = 2 & CSD2e != DK/REF) THEN PRSEX3 = him
IF CSD2eb = 1 & (CSD2ea & CSD2ec & CSD2ed = 2 & CSD2e != DK/REF) THEN PRSEX1 = she
IF CSD2eb = 1 & (CSD2ea & CSD2ec & CSD2ed = 2 & CSD2e != DK/REF) THEN PRSEX2 = her
IF CSD2eb = 1 & (CSD2ea & CSD2ec & CSD2ed = 2 & CSD2e != DK/REF) THEN PRSEX3 = her
ELSE PRSEX1 = they
ELSE PRSEX2 = their
ELSE PRSEX3 = them
PROGRAMMER DEFINE TRANSID
IF CSD2bc = 1 AND CSD2e = BLANK THEN TRANSID = 1
IF CSD2bc = 1 AND CSD2e = 3 THEN TRANSID = 1
IF CSD2ba = 1 AND CSD2e = 3 THEN TRANSID = 1
IF CSD2bb = 1 AND CSD2e = 3 THEN TRANSID = 1
IF CSD2bd = 1 AND CSD2e = 3 THEN TRANSID = 1
IF CSD2ba = 1 AND CSD2bb = 1 AND CSD2c = 1 THEN TRANSID =1
IF CSD2ea = 1 AND CSD2eb = 1 AND CSD2c = 2 THEN TRANSID =1
ELSE TRANSID = 2
C18

INTERVIEWER PLEASE INDICATE WHETHER YOU ARE ONLINE OR NOT
1
ONLINE
2
OFFLINE
[IF C18 = 2 & C19 = 1] IF YOU ARE OFFLINE NetSCID ONLINE CANNOT BE SELECTED.
PLEASE CHECK YOUR ANSWERS.

C19

INTERVIEWER PLEASE SELECT EITHER NetSCID ONLINE OR PAPER SCID TO CONTINUE.
ADMINISTER THE …
1
NetSCID ONLINE
2
PAPER SCID
32

PROGRAMMER: IF C19 = 1 LAUNCH NETSCID; IF C19 = 2 CONTINUE
[IF C18 = 2 & C19 = 1] IF YOU ARE OFFLINE NetSCID ONLINE CANNOT BE SELECTED.
PLEASE CHECK YOUR ANSWERS.
[IF C19 = 2] INTERVIEWER PLEASE ADMINISTER THE PAPER VERSION OF THE SCID. WHEN
COMPLETED PLEASE RETURN TO THE BLAISE INSTRUMENT TO CONTINUE WITH THE
INTERVIEW.
[IF C19 = 2] PROGRAMMER SKIP DIRECTLY TO CIGARETTE AND E-CIGARETTE USE
MODULE
PROGRAMMER TIME STAMP SET: SCID

SECTION 1: SCID OVERVIEW
SCID Overview: Adjusted based on First et al. (2016) SCID-5-CV. STRUCTURED CLINICAL INTERVIEW FOR DSM-5®
DISORDERS. CLINICIAN VERSION. (See separate file)

[NOTE INTERVIEWER REENTER DOB, SEX, AND GENDER IDENTITY WITHOUT REASKING.]

33

MEDICATION SHOWCARD 1 FOR TREATMENT HISTRORY

1 -- ABILIFY
2 -- ABILIFY MAINTENA
3 -- ALPRAZOLAM
4 -- AMITRIPTYLINE
5 -- ARIPIPRAZOLE
6 -- ASENAPINE
7 -- ATIVAN
8 – BRINTELLIX OR TRINTELLIX
9 -- BUDEPRION
10 -- BUPROPION
11 -- BUSPAR
12 -- BUSPIRONE
13 -- CARBAMAZEPINE
14 -- CARBATROL
15 -- CATAPRES
16 -- CELEXA
17 -- CHLORDIAZEPOZIDE

18 -- CHLORPROMAZINE
19 -- CITALOPRAM
20 -- CLONAZEPAM
21 -- CLONIDINE
22 -- CLOZAPINE
23 -- CLOZARIL
24 -- CYMBALTA
25 -- DEPAKENE
26 -- DEPAKOTE
27 -- DESVENLAFAXINE
28 -- DESYREL
29 -- DIAZEPAM
30 -- DIVALPROEX
31 -- DULOXETINE
32 -- EFFEXOR
33 -- ELAVIL
34 -- ESCITALOPRAM

35 -- ESKETAMINE
36 -- FANAPT
37 -- FETZIMA
38 -- FLUOXETINE
39 -- FLUPHENAZINE
40 -- GABAPENTIN
41 -- GEODON
42 -- HALDOL
43 -- HALOPERIDOL
44 -- ILOPERIDONE
45 -- INDERAL
46 -- INVEGA
47 -- INVEGA SUSTENNA
48 -- KETAMINE
49 -- KLONOPIN
50 -- LAMICTAL
51 -- LAMOTRIGINE

52 -- LATUDA
53 -- LEVOMILNACIPRAN
54 -- LEXAPRO
55 -- LIBRIUM
56 -- LITHIUM
57 -- LITHOBID
58 -- LORAZEPAM
59 -- LURASIDONE
60 -- LYRICA
61 -- MINIPRESS
62 -- MIRTAZAPINE
63 -- MODAFINIL
64 -- NEURONTIN
65 -- NUVIGIL
66 -- OLANZAPINE
67 -- OXCARBAZEPINE
68 -- PALIPERIDONE
69 -- PAROXETINE

70 -- PAXIL
71 -- PRAZOSIN
72 -- PREGABALIN
73 -- PRISTIQ
74 -- PROLIXIN
75 -- PROPRANOLOL
76 -- PROZAC
77 -- QUETIAPINE
78 -- REMERON
79 -- RESTORIL
80 -- RISPERDAL
81 -- RISPERIDONE
82 -- SAPHRIS
83 -- SEROQUEL
84 -- SERTRALINE
85 -- SPRAVATO
86 -- STRATTERA
87 -- TEGRETOL

88 -- TEMAZEPAM
89 -- THORAZINE
90 -- TOPAMAX
91 -- TOPIRAMATE
92 -- TRAZODONE
93 -- TRILEPTAL
94 -- VALIUM
95 -- VALPROIC ACID
96 -- VENLAFAXINE
97 -- VIIBRYD
98 -- VILAZODONE
99 -- VORTIOXETINE
100 -- WELLBUTRIN
101 -- XANAX
102 -- ZIPRASIDONE
103 -- ZOLOFT
104-- ZYPREXA

SECTION 2: SCID DISORDERS
SCID Disorder Modules: Adjusted based on First et al. (2016) SCID-5-CV. STRUCTURED CLINICAL INTERVIEW FOR
DSM-5® DISORDERS. CLINICIAN VERSION. (See Separate file.)

34

SECTION 3: CIGARRETE AND E-CIGARETTE USE

C20

[IF C19 = 1] JUST TO CONFIRM, DID YOU COMPLETE THE NetSCID INSTRUMENT?
1
YES, COMPLETED THE ENTIRE NetSCID
2
YES, COMPLETED A PARTIAL NetSCID
3
NO, DID NOT COMPLETE THE NetSCID
PROGRAMMER: IF C20 = 1 | 2 CONTINUE
ELSE PROMPT: PLEASE CONDUCT THE SCID INTERVIEW AND RETURN HERE TO CONTINUE
ONCE COMPLETED

C20SCID

[IF C19 = 2] JUST TO CONFIRM, DID YOU COMPLETE THE PAPER SCID INSTRUMENT?
1
YES, COMPLETED THE ENTIRE PAPER SCID
2
YES, COMPLETED A PARTIAL PAPER SCID
3
NO, DID NOT COMPLETE THE PAPER SCID
PROGRAMMER: IF C20SCID = 1 | 2 CONTINUE
ELSE PROMPT: PLEASE CONDUCT THE SCID INTERVIEW AND RETURN HERE TO CONTINUE
ONCE COMPLETED

PROGRAMMER TIME STAMP SET: CIGARETTE
CT1

These next questions are about ’s>
use of cigarettes. > ever
smoked part or all of a cigarette?
1
YES
2
NO
DK/REF

CT2

[IF (PR = NO) & CT1 = YES] Did >
smoke part or all of a cigarette during the past 12 months?
1
YES
2
NO
DK/REF

CT3

[IF (PR = NO) & CT2 = 1] On the day(s) > smoked cigarettes during the past 12 months, how many cigarettes did > smoke?
1
2
3
4
5
6
7

LESS THAN ONE CIGARETTE
1 CIGARETTE
2 TO 5 CIGARETTES
6 TO 15 CIGARETTES (ABOUT ½ PACK)
16 TO 25 CIGARETTES (ABOUT 1 PACK)
26 TO 35 CIGARETTES (ABOUT 1 ½ PACKS)
MORE THAN 35 CIGARETTES (ABOUT 2 PACKS OR MORE)
35

DK/REF
CT4

The next questions are about using e-cigarettes or other vaping devices. These devices
might also be called vapes, vape pens, e-hookah, e-vaporizer, or mods. When answering,
please include any device that is used to inhale a mist or vapor into the lungs.
> ever, even once, vaped
any of the following with an e-cigarette or other vaping device?
YES
a.

Nicotine

b.

Marijuana

c.

Just flavoring

d.

Some other substance

NO

DK/REF
CT5

[IF CT4a | CT4b | CT4c | CT4d = YES & PR = NO] How long has it been since > last vaped using an e-cigarette or other vaping
device?
1
Less than 30 days ago
2
More than 30 days ago but within the past 12 months
3
More than 12 months ago but within the past 3 years
4
More than 3 years ago
DK/REF

CT6

[IF CT5 = 1 & PR = NO] What is your best estimate of the number of days > vaped using an e-cigarette or other vaping device
during the past 30 days, that is since ?
1
1 OR 2 DAYS
2
3 TO 5 DAYS
3
6 TO 9 DAYS
4
10 TO 19 DAYS
5
20 TO 29 DAYS
6
ALL 30 DAYS
DK/REF
PROGRAMMER: SHOW 30 DAY CALENDAR

36

SECTION 4: TREATMENT

PROGRAMMER TIME STAMP SET: TREATMENT
CT7a

I would now like to know more about > health and health care. I know we have already covered some of these
questions earlier in the interview but for completeness I need to ask some of them again.

CT7

[IF SH = NO] During the past 12 months, > stayed overnight or longer as an inpatient in a hospital?
1
YES
2
NO
DK/REF

CT9a

The next set of questions are about > mental health treatment and I’ll be asking about alcohol and substance
use treatment separately.

CT9Intro

Now think about professional counseling, medication, or other treatment > may have received to help with > mental health, emotions, or behavior. These
treatment types can be received during an overnight stay, outpatient visit, or over the
phone or internet.

CT9

[IF SH = NO] > ever
received professional counseling, medication or other treatment to help with > mental health, emotions, or behavior?
1
YES
2
NO
DK/REF

CT10

[IF CT9 = 1 AND SH = NO] During the past 12 months, > received inpatient or residential treatment, that is > stayed overnight or longer to
receive professional counseling, medication, or other treatment for > mental health, emotions, or behavior at any of these
places?
•
•
•
•

a hospital,
a residential mental health treatment center,
a residential drug or alcohol treatment or rehab center,
or some other place

1
YES
2
NO
DK/REF
37

CT11

[IF CT9 = 1 | SH = YES] Treatment can  be provided without needing to
stay overnight. This type of care is called outpatient treatment.
= 12 MONTHS: Thinking about the 12 months
before ’s> stay in this facility,> > received outpatient
professional counseling, medication, or other treatment for > mental health, emotions, or behavior at any of these places?
•
•
•
•
•
•
•
•

a mental health treatment center;
a drug or alcohol treatment or rehab center;
the office of a therapist, psychologist, psychiatrist, mental health professional, or
doctor;
a school, college, or a university clinic;
a shelter for the homeless;
a jail, prison, or juvenile detention facility;
phone, text, video, telemedicine; or
some other place

1
YES
2
NO
DK/REF
CT12

[IF CT11 = YES] Think about all the facilities where > received outpatient professional counseling, medication, or other
treatment for > mental health,
emotions, or behavior = 12 MONTHS: during the 12
months before ’s> stay in this
facility>.
How many visits did > make?
________# OF VISITS: [RANGE: 1 - 366]
DK/REF
PROGRAMMER: SHOW 12 MONTH CALENDAR
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between .

CT13

[IF CT9 = 1 | SH = YES] During the past 12 months, did > take any medication that was prescribed by a doctor or health care
professional to help with > mental
health, emotions, behavior, energy, concentration, or ability to cope with stress?
38

1
YES
2
NO
DK/REF
CT14

[IF CT13 = YES] And > currently
taking any medication that was prescribed by a doctor or health care professional to help
with > mental health, emotions,
behavior, energy, concentration, or ability to cope with stress?
1
YES
2
NO
DK/REF

CT15

[IF CT14 = YES] And what prescription medication is that?  is> currently
taking, you can also look at ’s>
prescription bottles if necessary.> 
> currently taking …
INTERVIEWER: IF NECESSARY, SHOW SHOWCARD IF IN PERSON OR IF VIRTUAL SHARE
YOUR SCREEN AND/OR POINT TO WEBSITE.
Medicine
A prescription medicine for problems with ’s> emotions, nerves, mental
health, behavior, energy, concentration, or ability to cope with
stress:
Another prescription medicine  is> currently taking for any of those
problems?
Another?
Another?
Another?
Another?
Another?
Another prescription medicine  is> currently taking for problems with
> emotions,
nerves, mental health, behavior, energy, concentration, or ability
to cope with stress?
Another?
Another?
Another?
Another?
Another?
39

Another prescription medicine IF PROXY = NO: you are> is> currently taking for any of those problems?
Another?
Another?
Another?
Another?
Another?
Another?
NO MORE MEDICATIONS
DK/REF
CT16

The next questions ask about treatment such as professional counseling, medication, or
other treatment > may have received
for use of alcohol or drugs, not including cigarettes. These treatment types can be
received during an overnight stay, outpatient visit, or over the phone or internet.
> ever received
professional counseling, medication or other treatment for > alcohol or drug use?
1
YES
2
NO
DK/REF

CT17

[IF CT16 = 1] During the past 12 months, > received inpatient or residential treatment, that is > stayed overnight or longer to receive
professional counseling, medication, or other treatment for > alcohol or drug use at any of these places?
•
•
•
•

a residential drug or alcohol treatment or rehab center,
a hospital,
a residential mental health treatment center, or
some other place

1
YES
2
NO
DK/REF
CT18

[IF CT16 = 1] Treatment can  be provided without needing to stay
overnight. This type of care is called outpatient treatment.
= 12 MONTHS: Thinking about the 12 months
before ’s> stay in this facility,> > received outpatient
professional counseling, medication, or other treatment for > alcohol or drug use at any of these places?
•
•
•
•
•
•
•
•

a drug or alcohol treatment or rehab center;
a mental health treatment center;
the office of a therapist, psychologist, psychiatrist, mental health professional, or
doctor;
a school, college, or a university clinic;
a shelter for the homeless;
a jail, prison, or juvenile detention facility;
phone, text, video, telemedicine; or
some other place

1
YES
2
NO
DK/REF
CT19

[IF CT18 = YES] Think about all the facilities where > received outpatient professional counseling, medication, or other
treatment for > alcohol or drug use = 12 MONTHS: during the 12 months before ’s> stay in this facility>.
How many visits did > make?
________# OF VISITS: [RANGE: 1 - 366]
DK/REF
PROGRAMMER: SHOW 12 MONTH CALENDAR
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between .

CT20

[IF CT16 = 1] The next questions are about prescription medication > may have used to cut back or stop > alcohol or drug use. These medications are different
from medications given to stop an overdose.
During the past 12 months, did > use
any medication prescribed by a doctor or health care professional to help cut back or
stop > alcohol or drug use?
Please, answer ‘yes’ even if > took
them only once.  takes> currently, you can also look at ’s> prescription bottles if necessary.> 
41

Did > take any of the following…
YES

NO

a. Methadone
b. Buprenorphine or buprenorphine-naloxone pills or film taken by
mouth, also known as Suboxone, Zubsolv, Bunavail, or Subutex
c. Injectable Buprenorphine, also known as Sublocade
d. Buprenorphine implant placed under the skin, also known as
Probuphine
e. Naltrexone pills, also known as ReVia or Trexan
f.

Injectable naltrexone, also known as Vivitrol

g. Acamprosate, also known as Campral
h. Disulfiram, also known as Antabuse
i. Some other prescription medication that you used to cut back
or stop your alcohol or drug use
DK/REF
CT20SP

[IF CT20i = YES] Please tell me the name of another prescription medication > used to cut back or stop > alcohol or drug use during the past 12 months.
_______________________ OTHER PRESCRIPTION DRUG [ALLOW 50 CHARACTERS]
DK/REF

COV0

Now I have a few questions for you about ’s> experiences regarding the Coronavirus Disease 2019 pandemic, also
referred to as COVID-19, in the U.S.
Because of the COVID-19 pandemic in the U.S., did > experience any of the following in >

COV1

[IF CT9 = 1 | SH = YES] … access to mental health treatment?
YES

b.

Appointments moved from in-person to
telehealth?
Delays or cancellations in appointments?

c.

Delays in getting prescriptions?

a.

NO

DOES NOT
APPLY

Unable to access needed care resulting in
moderate to severe impact on health?
DK/REF
d.

42

COV5

BECAUSE OF THE COVID-19 PANDEMIC IN THE U.S., DID > EXPERIENCE ANY OF THE FOLLOWING IN >
[IF CT16 = 1] … access to treatment for alcohol or drug use?
YES

b.

Appointments moved from in-person to
telehealth?
Delays or cancellations in appointments?

c.

Delays in getting prescriptions?

a.

NO

DOES NOT
APPLY

Unable to access needed care resulting in
moderate to severe impact on health?
DK/REF
d.

COV2

BECAUSE OF THE COVID-19 PANDEMIC IN THE U.S., DID > EXPERIENCE ANY OF THE FOLLOWING IN >
… access to medical care?
YES
a.

Appointments moved from in-person to telehealth?

b.

Delays or cancellations in appointments or
preventive services?
Delays in getting prescriptions?

c.

NO

DOES NOT
APPLY

Unable to access needed care resulting in moderate
to severe impact on health?
DK/REF
d.

CT21A

These next questions are about ’s>
insurance coverage.
Several government programs provide medical care or help pay medical bills.
Medicare is a health insurance program for people aged 65 and older and for certain
people with disabilities. >
covered by Medicare?
1
YES
2
NO
DK/REF
43

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT 'NOT SURE' OR 'PREFER NOT TO ANSWER' AND CLICK 'NEXT' TO CONTINUE.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF IS SELECTED: “This question
is important for classification purposes. Please try to answer if you can. OTHERWISE SELECT ‘SKIP’ TO
CONTINUE.”

CT21B

Medicaid is a public assistance program that pays for medical care for people with low
income and people with disabilities. Medicaid may also be called Medical Assistance.
> covered by Medicaid?
1
YES
2
NO
DK/REF

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT 'NOT SURE' OR 'PREFER NOT TO ANSWER' AND CLICK 'NEXT' TO CONTINUE.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF IS SELECTED: “This question
is important for classification purposes. Please try to answer if you can. OTHERWISE SELECT ‘SKIP’ TO
CONTINUE.”
CT21C

There are certain programs that cover active duty and retired career military personnel
and their dependents and survivors and also disabled veterans and their dependents and
survivors.
> currently covered by
TRICARE, or CHAMPUS, CHAMPVA, the VA, or military health care?
INTERVIEWER NOTE, READ IF NECESSARY:
CHAMPUS stands for civilian health and medical program of the uniformed
services. It provides health care in private facilities for dependents of military
personnel on active duty or retired for reasons other than disability. In some areas,
this may be known as TRICARE.
CHAMPVA stands for civilian health and medical program of the department of
veterans affairs. It provides health care for the spouse, dependents, or survivors of
a veteran who has a total, permanent service-connected disability.
The VA provides medical assistance to veterans of the armed forces.
Military health care refers to health care available to active duty personnel and
44

their dependents.
1
YES
2
NO
DK/REF
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT 'NOT SURE' OR 'PREFER NOT TO ANSWER' AND CLICK 'NEXT' TO CONTINUE.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF IS SELECTED: “This question
is important for classification purposes. Please try to answer if you can. OTHERWISE SELECT ‘SKIP’ TO
CONTINUE.”
CT21D

Private health insurance can be obtained through work, such as through an employer,
union, or professional association, by paying premiums directly to a health insurance
company, or by purchasing a plan through the Health Insurance Marketplace. It includes
coverage by a health maintenance organization or HMO, fee for service plans, and single
service plans.
> currently covered by private
health insurance?
1
YES
2
NO
DK/REF

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT 'NOT SURE' OR 'PREFER NOT TO ANSWER' AND CLICK 'NEXT' TO CONTINUE.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF IS SELECTED: “This question
is important for classification purposes. Please try to answer if you can. OTHERWISE SELECT ‘SKIP’ TO
CONTINUE.”
IF NO TO ALL OF CT21A THROUGH CT21D, CONTINUE.
IF YES TO ANY OF CT21A THROUGH CT21D, GO TO CT22
CT21E

> currently covered by any kind
of health insurance, that is, any policy or program that provides or pays for medical care?
1
YES
2
NO
DK/REF
INTERVIEWER NOTE: IF THE RESPONDENT REPORTS INDIAN HEALTH INSURANCE, ENTER
45

“YES”.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT 'NOT SURE' OR 'PREFER NOT TO ANSWER' AND CLICK 'NEXT' TO CONTINUE.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF IS SELECTED: “This question
is important for classification purposes. Please try to answer if you can. OTHERWISE SELECT ‘SKIP’ TO
CONTINUE.”
CT22

> currently
receiving disability benefits such as Supplemental Security Income or SSI, Social Security
Disability Insurance or SSDI, or disability benefits from the U.S. Department of Veterans
Affairs or VA?>

1
YES
2
NO
DK/REF

CT23

[IF ((SH | HL | PR = YES) & CT22 = 1) | (SH2 = NO & CT22 = YES) | (HH | JA = YES & SH3a |
b = DK/REF & CT22 = YES)] > currently> receiving disability benefits for:
YES
a.

NO

Problems with emotions, nerves, or mental health?

Problems with ’s>
physical health?
DK/REF
b.

CT24

[IF CT23a = 1] Which of the following mental health problems  reasons for ’s> disability:
YES
a.

Depression

b.

Bipolar disorder

c.

Post-traumatic stress disorder

d.

Schizophrenia or schizoaffective disorder

e.

Any other mental health problem

NO

DK/REF

46

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT 'NOT SURE' OR 'PREFER NOT TO ANSWER' AND CLICK 'NEXT' TO CONTINUE.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF IS SELECTED: “This question
is important for classification purposes. Please try to answer if you can. OTHERWISE SELECT ‘SKIP’ TO
CONTINUE.”

CT8

[IF PR = YES AND LENGTH OF STAY < 12 MONTHS] During the past 12 months, did a case
manager or other treatment provider help you to obtain any of the following types of
housing assistance?
•
•
•

HUD
Section 8 Certificates
Other living programs provided by local, state, or federal government

1
YES
2
NO
DK/REF

47

SECTION 5: SOCIO-DEMOGRAPHICS

PROGRAMMER TIME STAMP SET: CDEMOGRAPHICS
We are almost at the end of the interview and I would now like to ask you some background questions.

CSD4

[IF PR | SH | HL = YES] > now
married, widowed, divorced, separated, or > never married?
1
NOW MARRIED
2
WIDOWED
3
DIVORCED
4
SEPARATED 
5
NEVER MARRIED
DK/REF

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT 'NOT SURE' OR 'PREFER NOT TO ANSWER' AND CLICK 'NEXT' TO CONTINUE.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF IS SELECTED: “This question
is important for classification purposes. Please try to answer if you can. OTHERWISE SELECT ‘SKIP’ TO
CONTINUE.”
CSD5

[IF CSD4 != 1 & (SH | HL = YES)] > now living with a partner?
1
YES
2
NO
DK/REF

CSD6

[IF PR | HL | SH = YES] > of
Hispanic, Latino or Spanish origin?
That is, do any of these groups describe ’s> national origin or ancestry—Puerto Rican, Cuban, Cuban-American,
Mexican, Mexican-American, Chicano, Central or South American, or origin in some other
Spanish-speaking country?
1
YES
2
NO
DK/REF

48

C2

[IF PR | SH | HL = YES & CSD6 = 1] > speak Spanish only, mostly Spanish with some English, Spanish and English
about the same, mostly English with some Spanish, or English only?
1
SPANISH ONLY
2
MOSTLY SPANISH, BUT SOME ENGLISH
3
SPANISH AND ENGLISH ABOUT THE SAME
4
MOSTLY ENGLISH, BUT SOME SPANISH
5
ENGLISH ONLY
DK/REF

CSD7

[IF PR | HL | SH = YES] > White,
Black or African American, American Indian or Alaska Native, Native Hawaiian or other
Pacific Islander, or Asian? Please mark all that apply.
□
WHITE
□
BLACK OR AFRICAN AMERICAN
□
AMERICAN INDIAN OR ALASKA NATIVE
□
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
□
ASIAN
DK/REF

CSD8

[IF PR | SH | HL = YES] What is the highest grade or level of school  has> completed?
If currently enrolled, please tell me ’s> previous grade or highest degree received.
1
Less than a high school diploma
2
High school degree or equivalent (for example: GED)
3
Some college, no degree
4
Associate degree (for example: AA, AS)
5
Bachelor’s degree (for example: BA, BS)
6
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
7
Professional degree (for example: MD, DDS, DVM, LLB, JD)
8
Doctorate degree (for example: PhD, EdD)
DK/REF

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT 'NOT SURE' OR 'PREFER NOT TO ANSWER' AND CLICK 'NEXT' TO CONTINUE.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF IS SELECTED: “This question
is important for classification purposes. Please try to answer if you can. OTHERWISE SELECT ‘SKIP’ TO
CONTINUE.”

49

CSD9

[IF PR | SH | HL = YES] >
currently attending a college, university, or trade school either full-time or part-time?
If  is> on a holiday or break from
school, such as spring break or summer vacation, but  to return when the break is over, please answer yes.
1
YES
2
NO
DK/REF

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT 'NOT SURE' OR 'PREFER NOT TO ANSWER' AND CLICK 'NEXT' TO CONTINUE.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF IS SELECTED: “This question
is important for classification purposes. Please try to answer if you can. OTHERWISE SELECT ‘SKIP’ TO
CONTINUE.”

CSD9a

[IF CSD9 = YES] How long ago did >
first enroll at this college, university, or trade school? If > transferred to >
current institution directly from another college or university, please include that time.
Was that …
1
Within the past 12 months, or
2
More than 12 months ago
DK/REF

CSD9b

[IF CSD9 = YES & PR = NO & HL = NO] > currently live in college-owned housing on campus, such as a dorm or a
residence hall?
1
YES
2
NO
DK/REF

CSD9e

[IF CSD9b = NO | (PR | HL = YES & LENGTH OF STAY < 12 MONTHS & CSD9 = YES)] At any
time > enrolled
as a student,> did > live in college-owned housing on campus, such as a dorm or
a residence hall?
1
YES
2
NO
DK/REF
50

CSD9c

[IF CSD9b = YES | SSD9e = YES] > enrolled as a student,> did
> mostly live in college-owned
housing on campus, such as a dorm or a residence hall?
1
YES
2
NO
DK/REF

CSD9d

[IF CSD9c = NO | CSD9e = NO] You said > did not live on campus >
enrolled>. In what type of off-campus housing
did > mostly live in during that
time? Is that …
1
Off-campus housing, owned or managed by the school,
2
Off campus with relatives, such as parents or guardians, or
3
Other off-campus housing?
DK/REF

CSD10

[IF PR | SH | HL = YES | SCREENER MAIL COMPLETE = YES] > ever served in the United States Armed Forces?
1
YES
2
NO
DK/REF

CSD11

[IF CSD10 = YES] > currently
serving on active duty in the United States Armed Forces?
1
YES
2
NO
DK/REF

CSD12

[IF (PR = YES & LENGTH OF STAY <12 MONTHS/DK/REF) | HH | HL | SH = YES] The next
question is about encounters with the police or the court system.
Not counting minor traffic violations, > been arrested or booked for breaking the law during the past 12 months?
Being ‘booked’ means that 
was> taken into custody and processed by the police or by someone connected with the
courts, even if  was> then
released.
1

YES
51

2
NO
DK/REF
CSD13

[IF PR = NO | (PR = YES & LENGTH OF STAY < 12 MONTHS/DK/REF] “Probation” is a
period of time when a person is supervised in the community after being convicted of a
crime by a judge.
> on probation at any
time during the past 12 months?
1
YES
2
NO
DK/REF

CSD14

[IF PR = NO | (PR = YES & LENGTH OF STAY < 12 MONTHS/DK/REF] “Parole,” which may
also be called “supervised release” or “other conditional release,” is a period of time
when a person is supervised in the community after being released from prison.
> on parole, supervised
release, or other conditional release from prison at any time during the past 12
months?
1
YES
2
NO
DK/REF

CSD15

[IF PR | SH | HL = YES] The next question is about working. Last week, did > work for pay at a job or business? By last week, I
mean the week beginning on Sunday,  and ending on Saturday,
. 
TO VIEW INFORMATION ABOUT UNPAID WORK PLEASE CLICK ON THE QUESTION MARK
OR PRESS F2.
1
YES
2
NO – DID NOT WORK OR ARE RETIRED
DK/REF
INTERVIEWER NOTE, READ AS NEEDED:
•
Please include
unpaid work in a family farm or business if  usually works> more
than 15 hours each week, or
personal labor  provides> in exchange for work done for , rather than for pay.
•

Please do not include
52

-

work done as part of a student stipend, or
volunteer work.

PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF LEFT BLANK INSTEAD OF OUR
GENERIC ONE: This question is important for classification purposes. Please try to answer if you can.
OTHERWISE SELECT 'NOT SURE' OR 'PREFER NOT TO ANSWER' AND CLICK 'NEXT' TO CONTINUE.
PROGRAMMER PLEASE DISPLAY THE FOLLOWING ERROR MESSAGE IF DK/REF IS SELECTED: “This question
is important for classification purposes. Please try to answer if you can. OTHERWISE SELECT ‘SKIP’ TO
CONTINUE.”

CSD15a

[IF CSD15 = NO] Last week, did > do
any work for pay, even for as little as one hour?
1
YES
2
NO
DK/REF

CSD15b

[IF CSD15a = NO] Last week, > on layoff from a job?
1
YES
2
NO
DK/REF

CSD15c

[IF CSD15b = NO] Last week, > temporarily absent from a job or business, for example, because of
vacation, temporary illness, maternity leave, other family or personal reasons, or bad
weather?
1
YES
2
NO
DK/REF

CSD15d

[IF CSD15b = YES] > been
informed that > will be recalled to work
within the next 6 months or been given a date to return to work?
1
YES
2
NO
DK/REF

CSD15e

[IF CSD15c = NO | CSD15d = NO] During the last 4 weeks, > been actively looking for work?
53

1
YES
2
NO
DK/REF
CSD15f

[IF CSD15d = YES | CSD15e = YES] Last week, could > have started a job if > had been offered one, or returned to work if > had been recalled? Would you say …
1
2
3

INTROFI1

Yes, > could have gone to
work,
No, > could not have gone to
work because of >
temporary illness, or
No,  could not have gone to
work for some other reason, such as, being in school or taking care of house or
family

[IF HH = YES & R7 = 1 OR GQU = YES] Next, we would like to know about ’s> total income from all sources during the year
[CURRENT YEAR - 1] before taxes and other deductions.
[IF PR = YES | (SH | HL = YES & (CSD4 != 1/DK/REF & CSD5 != 1/DK/REF))] Next, we would
like to know about ’s> total income
from all sources during the year [CURRENT YEAR - 1] before taxes and other deductions.
[IF (HH = YES AND R7>1) | JA = YES] Next, we would like to know about the total income
from everyone who lives > from all sources during the
year [CURRENT -1] before taxes and other deductions.
We would like you to combine everyone’s income – that is, ’s> and that of anyone else living >.
[IF SH | HL = YES & (CSD4 = 1/DK/REF | CSD5 = 1/DK/REF)] Next, we would like to know
about the total income from everyone in ’s>   from
all sources during the year [CURRENT -1] before taxes and other deductions.

’s> and
that of anyone who lives in ’s>
54

household.>
[IF F2F: HAND INCOME TYPE SHOWCARD TO RESPONDENT]

Please include all of the sources of income on this card.
INCOME TYPE SHOWCARD
•
•

•

•
•
•
•
•
•
•
•
•
•
•
CSD16

Social Security/Railroad Retirement payments – paid by the U.S. Government to
people who are retired, severely disabled, or dependents or survivors of workers
Supplemental Security Income, or SSI – a program administered by a government
agency that makes assistance payments to people with low income who are
aged, blind, or disabled
Supplemental Nutrition Assistance Program, or SNAP – formerly known as food
stamps, provides assistance for buying food; a special card is issued which can be
used to buy food in grocery stores; SNAP does not include WIC or free or reduced
school lunches
Cash assistance from a state or county/borough welfare program, sometimes
called Temporary Assistance for Needy Families, or TANF
Any other type of welfare or public assistance
Income earned at a job or business
Retirement, disability, or survivor pension
Unemployment or worker’s compensation
Veteran’s Administration payments
Child support
Alimony
Interest income
Dividends from stocks or mutual funds
Income from rental properties, royalties, estates, or trusts

Before taxes and other deductions, was ’s> total 1) | JA = YES) | (SH | HL = YES & (CSD4 = 1/DK/REF |
CSD5 = 1/DK/REF): combined family> income during the year [CURRENT YEAR - 1] more
or less than 20,000 dollars?
1
$20,000 OR MORE
2
LESS THAN $20,000
DK/REF
55

CSD17a

[IF CSD16 =LESS THAN $20,000]
Of the following income groups, which category best represents ’s> total 1) | JA = YES) | (SH | HL = YES
& (CSD4 = 1/DK/REF | CSD5 = 1/DK/REF): combined family> income during [CURRENT
YEAR – 1]
 1) | JA = YES: – that is, ’s> and that of > family
and anyone else living <>

’s> and that of > family and anyone else living in ’s> household>?
Would you say …
1
less than $1,000
2
$1,000 - $4,999
3
$5,000 - $9,999
4
$10,000 - $14,999
5
$15,000 - $19,999
DK/REF

CSD17b

[IF (CSD16=MORE THAN $20,000)]
Of the following income groups, which category best represents ’s> total 1) | JA = YES) | (SH | HL = YES
& (CSD4 = 1/DK/REF | CSD5 = 1/DK/REF): combined family> income during [CURRENT
YEAR – 1]
 1) | JA = YES: – that is, ’s> and that of > family
and anyone else living >>

’s> and that of > family and anyone else living in ’s> household>?
Would you say …
56

1
$20,000 - $29,999
2
$30,000 - $39,999
3
$40,000 - $49,999
4
$50,000 - $74,999
5
$75,000 - $99,999
6
$100,000 - $149,999
7
$150,000 or more
DK/REF
COV3

Now I have a few questions for you about ’s> experiences regarding the Coronavirus Disease 2019 pandemic, also
referred to as COVID-19, in the U.S.
How often > had serious
financial worries because of the COVID-19 pandemic?
1
All the time
2
Nearly all the time
3
Some of the time
4
Rarely
5
Never
DK/REF

COV4

[IF PR = NO | (PR = YES & COL1c > 2019)]
> homeless, living on the
street, in a vehicle, or in some type of makeshift housing like a tent or empty building at
any time because of the COVID-19 pandemic?
1
YES
2
NO
DK/REF

57

SECTION 6: OVERLAP WITH (NON-)HH POPULATION

PROGRAMMER TIME STAMP SET: COVERLAP
[IF PR = YES | (HL OR SH = YES & LENGTH OF STAY < 12 MONTHS/DK/REF)] The next few questions are
about ’s> stay at this facility and
other places.
COL3

[IF PR = YES] During the 12 months before your incarceration, did you live in 
in  for most of the time?
1
YES
2
NO
DK/REF

COL4

[IF PR = YES & COL3 = NO] During the 12 months before your current incarceration, in
which state did > live in for most of
the time?
__________ [STATE]
DK/REF
INTERVIEWER NOTE: IF RESPONDENT WAS OUT OF THE COUNTRY, ENTER “NU” AS THE
STATE.
PROGRAMMER: ALLOW FOR OUT OF COUNTRY CODE AND D.C.

COL5

[IF PR = YES & COL3 = NO & COL4 != OUTSIDE OF US | DK | REF] And what county was
that in?
__________ [COUNTY]
DK/REF

COL6

[IF PR = YES & LENGTH OF STAY < 12 MONTHS/DK/REF] Other than ’s> current incarceration, > stayed overnight or longer in a prison during the past 12
months?
1
YES
2
NO
DK/REF
[IF SH = YES & LENGTH OF STAY < 12 MONTHS/DK/REF] State psychiatric hospitals, like
this facility, are public psychiatric hospitals operated by a state for treatment of serious
mental disorders, such as major depressive disorder, schizophrenia and bipolar disorder.
Other than ’s> current stay in this
facility, > stayed overnight
or longer in a state psychiatric hospital during the past 12 months?
58

1
YES
2
NO
DK/REF
[IF HL = YES] Not counting living on the street, in a vehicle, or in some type of makeshift
housing like a tent or empty building, other than your current stay in this facility, > stayed overnight or longer in
a homeless shelter during the past 12 months?
1
YES
2
NO
DK/REF
COL7

[IF ((PR | SH = YES) & LENGTH OF STAY < 12 MONTHS/DK/REF) OR HL = YES] During the
past 12 months, > lived in a
house, an apartment, or a mobile home, even if just for a short period of time?
1
YES
2
NO
DK/REF

COL8

[IF COL7 = YES] During the past 12 months, how much time > spent in a house, an apartment, or a mobile
home? If you are not sure, just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
NIGHTS
2
WEEKS
3
MONTHS
DK/REF

COL8N

[IF COL8 = 1 OR DK/REF] During the past 12 months, how many nights > spent in a house, an apartment, or a
mobile home? Again, if you are not sure, just make your best guess.
_______NIGHT(S) [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.

COL8W

[IF COL8 = 2] During the past 12 months, how many weeks > spent in a house, an apartment, or a mobile home?
Again, if you are not sure, just make your best guess.
59

_______WEEK(S) [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.
COL8M

[IF COL8 = 3] During the past 12 months, how many months > spent in a house, an apartment, or a mobile
home? Again, if you are not sure, just make your best guess.
_______MONTH(S) [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.

COL9

[IF ((PR | SH = YES) & LENGTH OF STAY < 12 MONTHS/DK/REF) OR HL = YES] During the
past 12 months, > stayed
overnight or longer in a jail? Please do not count any time spent in prison.
1
YES
2
NO
DK/REF

COL10

[IF COL9 = YES] During the past 12 months, how much time > spent in a jail? If you are not sure, just make
your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
NIGHTS
2
WEEKS
3
MONTHS
DK/REF

COL10N

[IF COL10 = 1 OR DK/REF] During the past 12 months, how many nights > spent in a jail? Again, if you are not sure,
just make your best guess.
_______NIGHT(S) [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
60

COL10W

[IF COL10 = 2] During the past 12 months, how many weeks > spent in a jail? Again, if you are not sure, just
make your best guess.
_______WEEK(S) [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.

COL10M

[IF COL10 = 3] During the past 12 months, how many months > spent in a jail? Again, if you are not sure, just
make your best guess.
_______MONTH(S) [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.

COL11

[IF (SH = YES & LENGTH OF STAY < 12 MONTHS/DK/REF) OR HL = YES] During the past 12
months, > stayed overnight
or longer in a prison?
1
YES
2
NO
DK/REF

COL12

[IF COL11 = YES | (PR = YES & COL6 = YES/DK/REF)] During the past 12 months, how
much time  > spent in a prison? If you are not sure, just make your
best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
NIGHTS
2
WEEKS
3
MONTHS
DK/REF

COL12N

[IF COL12 = 1 OR DK/REF] During the past 12 months, how many nights  > spent in a prison? Again, if you are not sure, just make your best guess.
_______NIGHT(S) [RANGE 1-366]
DK/REF
61

PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.
COL12W

[IF COL12 = 2] During the past 12 months, how many weeks  >
spent in a prison? Again, if you are not sure, just make your best guess.
_______WEEK(S) [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.

COL12M

[IF COL12 = 3] During the past 12 months, how many months  >
spent in a prison? Again, if you are not sure, just make your best guess.
_______MONTH(S) [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.

COL13

[IF (PR = YES & LENGTH OF STAY < 12 MONTHS/DK/REF) OR HL = YES] During the past 12
months, > stayed overnight
or longer in a psychiatric hospital?
1
YES
2
NO
DK/REF

COL13a

[IF COL13=YES] During the past 12 months, > stayed overnight or longer in a state psychiatric hospital? State
psychiatric hospitals are public psychiatric hospitals operated by a state for treatment of
serious mental disorders.
1
YES
2
NO
DK/REF

COL14

[IF COL13a = YES | (SH = YES & COL6 = YES/DK/REF)] During the past 12 months, how
much time < IF SH = YES & COL6 = YES/DK/REF: altogether> > spent in a state psychiatric hospital? If you are
not sure, just make your best guess.
62

Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
NIGHTS
2
WEEKS
3
MONTHS
DK/REF
COL14N

[IF COL14 = 1 OR DK/REF] During the past 12 months, how many nights  spent in a state psychiatric hospital? Again, if you are not sure, just make
your best guess.
_______NIGHT(S) [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.

COL14W

[IF COL14 = 2] During the past 12 months, how many weeks  >
spent in a state psychiatric hospital? Again, if you are not sure, just make your best
guess.
_______WEEK(S) [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.

COL14M

[IF COL14 = 3] During the past 12 months, how many months  >
spent in a state psychiatric hospital? Again, if you are not sure, just make your best
guess.
_______MONTH(S) [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.

COL15

[IF (PR | SH = YES) & LENGTH OF STAY < 12 MONTHS/DK/REF] During the past 12 months,
> been homeless, even if
just for a short period of time?
63

1
YES
2
NO
DK/REF
COL15a

[IF COL15 = YES] The next question is about shelters that provide a place for people who
are homeless to stay. These shelters may also serve meals. Not counting living on the
street, in a vehicle, or in some type of makeshift housing like a tent or empty building,
during the past 12 months, > stayed overnight or longer in a homeless shelter?
1
YES
2
NO
DK/REF

COL16

[IF COL15a = YES | (HL = YES & COL6 = YES/DK/REF)] During the past 12 months, how
much time  > spent in a homeless shelter? If you are not sure,
just make your best guess.
Would it be easiest for you to give your answer in number of nights, weeks, or months?
1
NIGHTS
2
WEEKS
3
MONTHS
DK/REF

COL16N

[IF COL16 = 1 OR DK/REF] During the past 12 months, how many nights  > spent in a homeless shelter? Again, if you are not sure, just make your
best guess.
_______NIGHT(S) [RANGE 1-366]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 366.

COL16W

[IF COL16 = 2] During the past 12 months, how many weeks  >
spent in a homeless shelter? Again, if you are not sure, just make your best guess.
_______WEEK(S) [RANGE 1-52]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 52.
64

COL16M

[IF COL16 = 3] During the past 12 months, how many months  >
spent in a homeless shelter? Again, if you are not sure, just make your best guess.
_______MONTH(S) [RANGE 1-12]
DK/REF
PROGRAMMER IF OUTSIDE OF RANGE PLEASE DISPLAY THE FOLLOWING ERROR
MESSAGE AND LEAD BACK TO QUESTION: Your entry is out of range. Please enter a
number between 1 and 12.

65

SECTION 7: CONCLUSION
PROGRAMMER TIME STAMP SET: CONCLUSION

C8

[IF SH = YES & PROXY = NO] We also hope to learn if health records can help us better
understand the information you have already provided. With your consent we would like
to get a copy of your health records from this hospital – either the records from when
you are discharged or the records as of September 30 of this year, whichever comes first.
We will only use this information to produce statistics. Your information will be
combined with the information from all other people in the study. If you agree, I will ask
you to sign a records release form for this hospital.
Will you allow us to access your health records?
1
2

YES
NO

IF YES: PROMPT INTERVIEWER TO OBTAIN SIGNATURE ON THE HOSPITAL RELEASE FORM
C9

>, >
indicated that  is a good e-mail address for us to contact >. Is that still the case?>
1
CORRECT
2
INCORRECT
DK/REF

C9a

 Is there an additional e-mail address that  has> should we need to contact > again?>
 is> likely to have
should we need to contact > again?> If
 has> more than one e-mail
address, please provide those as well.
EMAIL ADDRESS 1:
OPEN ENDED RESPONSE OPTION
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
EMAIL ADDRESS 2:
OPEN ENDED RESPONSE OPTION
EMAIL ADDRESS 3:
OPEN ENDED RESPONSE OPTION
66

EMAIL ADDRESS 4:
OPEN ENDED RESPONSE OPTION
DK/REF
PROGRAMMER: PLEASE ADD CHECK BOX “I have no additional e-mail address.” IF C9 =
YES.
C10

[IF PROXY = YES | SECONDARY = YES] Could we also have your e-mail address should we
need to reach out again? If you have more than one e-mail address, please provide those
as well.
EMAIL ADDRESS 1:
OPEN ENDED RESPONSE OPTION
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
EMAIL ADDRESS 2:
OPEN ENDED RESPONSE OPTION
EMAIL ADDRESS 3:
OPEN ENDED RESPONSE OPTION
EMAIL ADDRESS 4:
OPEN ENDED RESPONSE OPTION
DK/REF

C21

[IF PROXY = NO & SECONDARY = NO] It is possible that in the future we will invite
individuals who participated in this study to take part in another study. Would you be
willing to be contacted about such a study?
HELPTEXT: THERE IS CURRENTLY NO CERTAINTY THAT A FUTURE STUDY WILL TAKE
PLACE. IF A RESPONDENT AGREES TO BE CONTACTED, THEY WILL HAVE AN
OPPORTUNITY TO DECIDE WHETHER THEY WANT TO PARTICIPATE IN THE FUTURE STUDY
ONCE THE DETAILS OF THE STUDY ARE SHARED WITH THEM.
1
YES
2
NO
DK/REF

C11a

[IF PROXY = NO & SECONDARY = NO & HH | JA | SH = YES] INTERVIEWER DO NOT READ:
IN YOUR CLINICAL OPINION, DO YOU NEED MORE INFORMATION TO:
1. MAKE A DIAGNOSIS OF SCHIZOPHRENIA/SCHIZOAFFECTIVE DISORDER (I.E. 2 OUT
OF 5 ‘A’ SYMPTOMS LASTING AT LEAST 1 MONTH AND DURATION OF AT LEAST 6
MONTHS), OR

67

2.
1
2
C11b

TO DIFFERENTIATE THE PATTERN OF MOOD EPISODES CHARACTERISTIC OF
MAJOR DEPRESSIVE DISORDER OR BIPOLAR DISORDER WITH PSYCHOTIC
FEATURES VS. SCHIZOPHRENIA/SCHIZOAFFECTIVE DISORDER?
YES
NO

[IF C11a = YES] Sometimes we find that it would be helpful to talk with someone else who
knows you well in addition to interviewing you. Ideally this would be a spouse or partner,
adult child, or parent with whom you have regular contact. 
Is there a   that we could talk with?
1
YES
2
NO
DK/REF

C11c

[IF C11b = YES] Who do you recommend we talk with about your health?
FIRST NAME: ____________________
LAST NAME: ____________________
OPEN-ENDED RESPONSE OPTION
PROGRAMMER: PLEASE GENERATE NAMEFILL2 FROM FIRST NAME; IF MISSING PLEASE
GENERATE ‘that person’ AS A NAMEFILL

C12

[IF C11b = YES] And what is your relationship to ?
□ HUSBAND/WIFE/SPOUSE
□ PARENT-IN-LAW
□ UNMARRIED PARTNER
□ SON-IN-LAW OR DAUGHTER-IN-LAW
□ SON OR DAUGHTER (INCL. ADOPTIVE OR □ OTHER RELATIVE
STEP)
□ BROTHER OR SISTER (INCL. ADOPTIVE OR □ ROOMMATE OR HOUSEMATE
STEP)
□ FATHER OR MOTHER (INCL. ADOPTIVE OR □ OTHER NONRELATIVE, SUCH AS A
STEP)
MEDICAL OR HEALTH CARE
PROVIDER
□ GRANDCHILD
DK/REF

C12a

[IF C11b = YES] Do you and  usually live at the same address?
1
YES
2
NO
DK/REF

C13

[IF C11b = YES] I will also need ’s phone number, and email address if
possible.
68

PHONE NUMBER:
OPEN-ENDED RESPONSE OPTION WITH FAINT PLACEHOLDER TEXT (XXX) XXX-XXXX TO
PROMPT USERS TO ENTER FULL PHONE NUMBER INCLUDING AREA CODE
EMAIL ADDRESS:
OPEN-ENDED RESPONSE OPTION
DK/REF
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
Thank you for that information.  to let them know we will be
contacting them I would greatly appreciate it.>
C14

[IF PR = NO] Before we conclude our interview, I would like to know whether you would
have preferred to conduct this interview , or
whether you were comfortable being interviewed < IF VIRTUAL = YES: virtually>?
1
2
3

C15

[IF VIRTUAL = YES] And on a scale from 1 to 5, where 1 is very comfortable and 5 is very
uncomfortable, overall, how comfortable were you using the ZOOM virtual interviewing
software?
1
2
3
4
5

C16


TELEPHONE INTERVIEW
 INPERSON INTERVIEW

VIRTUAL INTERVIEW
DK/REF

VERY COMFORTABLE
COMFORTABLE
NEITHER COMFORTABLE NOR UNCOMFORTABLE
UNCOMFORTABLE
VERY UNCOMFORTABLE
DK/REF

INTERVIEWER: IF YOU ARE CURRENTLY RECORDING THIS INTERVIEW, PLEASE STOP THE
RECORDING BEFORE YOU LEAVE THIS SCREEN.
Do you have any feedback you would like to share regarding this interview?
______________________________(Allow 500 characters)
PROGRAMMER CHECKBOX: NO FEEDBACK
69

C17a

[IF (PROXY = YES | SECONDARY = YES) & CFIID3 = 1 | 2 | 3] 
This concludes our interview, thank you for your time. To show our appreciation for
completing this interview today, we would like to send you , by either electronic pre-paid Visa or check .
You should allow 1 to 2 weeks to receive the electronic pre-paid Visa and about 4 weeks
to receive the check.

1
2
4

ELECTRONIC PRE-PAID VISA. PLEASE ALLOW 1 TO 2 WEEKS FOR
PROCESSING.
CHECK. PLEASE ALLOW UP TO 4 WEEKS FOR PROCESSING AND DELIVERY.


3
NO, THANKS. DECLINE THE INCENTIVE.
DK/REF
HELPTEXT: The electronic pre-paid Visa card can be used for online shopping only.
[IF HH | JA = YES & PROXY = NO & SECONDARY = NO & CIINCENTIVE = NO & CFIID3 = 1 | 2
| 3] This concludes our interview, thank you for your time. To show our appreciation for
completing this interview today, we would like to send you , by either
electronic pre-paid Visa or check .
You should allow 1 to 2 weeks to receive the electronic pre-paid visa and about 4 weeks
to receive the check.

1
2
4

ELECTRONIC PRE-PAID VISA. PLEASE ALLOW 1 TO 2 WEEKS FOR
PROCESSING.
CHECK. PLEASE ALLOW UP TO 4 WEEKS FOR PROCESSING AND DELIVERY.


3
NO, THANKS. DECLINE THE INCENTIVE.
DK/REF
70

HELPTEXT: The electronic pre-paid Visa card can be used for online shopping only.
C17b1

[IF (CFIID3 = 1 | 2 | 3) & C17a = 1 & ((C9 = NO & C9a = BLANK | DK/REF) | (C9 = DK/REF) |
(C10 = BLANK | DK/REF))] Please provide your email address to receive the electronic
pre-paid Visa.
________________[OPEN-ENDED, FORMAT CHECK FOR VALID EMAIL ADDRESS]
DK/REF
PROGRAMMER: PLEASE CONFIRM EMAIL ADDRESS
PROGRAMMER NOTE: IF C17b1 = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO
ANSWER IF YOU CAN.

C17b2

[IF (CFIID3 = 1 | 2 | 3) & C17a = 1 & (C9 = YES | (C9a EMAIL != BLANK) | (C10 != BLANK))]
We will send your electronic pre-paid Visa to the email address .

C17c

[IF (CFIID3 = 1 | 2 | 3) & C17a = 2] Please provide your first and last name to receive your
check.
FIRST NAME:
OPEN-ENDED RESPONSE OPTION
LAST NAME:
OPEN-ENDED RESPONSE OPTION
DK/REF
PROGRAMMER NOTE: IF C17c = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO
ANSWER IF YOU CAN.

C17d

[IF (CFIID3 = 1 | 2 | 3) & C17a = 2 & ADDRESS FILL != .] Would you like us to mail your
check to [ADDRESS FILL] or to another address?
1
YES, MAIL TO [ADDRESS FILL]
2
NO, MAIL TO ANOTHER ADDRESS
DK/REF

C17e

[IF C17d = 2 | DK/REF | ADDRESS FILL = MISSING] What address do you want us to mail
the check to?
STREET: (NUMBER AND STREET NAME)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
DK/REF
PROGRAMMER NOTE: IF C17e = BLANK/DK/REF, SHOW ERROR MESSAGE: THIS
INFORMATION IS IMPORTANT SO WE CAN SEND YOU YOUR INCENTIVE. PLEASE TRY TO
ANSWER IF YOU CAN.
71

C17

[IF LAR = YES & PROXY = NO] This concludes our interview, thank you for your time.
[IF PR = YES] This concludes our interview, thank you for your time.
INTERVIEWER: PLEASE COLLECT FIRST AND LAST NAME OF THE RESPONDENT
FIRST NAME:
OPEN-ENDED RESPONSE OPTION
LAST NAME:
OPEN-ENDED RESPONSE OPTION
DK/REF
 AND THEN SELECT IF INCENTIVES ARE ALLOWED FOR THIS RESPONDENT
1 INCENTIVES ALLOWED
2 INCENTIVES NOT ALLOWED
INTERVIEWER IF INCENTIVES ARE ALLOWED AND ARE NONELECTRONIC PAYMENTS
PLEASE PROCEED HERE: IF YOU HAVEN’T ALREADY DONE SO, PLEASE HAND RESPONDENT
INCENTIVE OR TELL THE RESPONDENT THAT THE FACILITY WILL HAND OUT THE
INCENTIVE ().
1 INCENTIVE ACCEPTED / WILL ACCEPT INCENTIVE
2 INCENTIVE REFUSED
I HAVE CHECKED A BOX TO INDICATE THAT YOU  THE INCENTIVE FOR COMPLETING THIS INTERVIEW.
INTERVIEWER IF INCENTIVES ARE ALLOWED AND ARE ELECTRONIC PAYMENTS PLEASE
PROCEED HERE: PLEASE COLLECT NECESSARY INFORMATION TO MAKE INCENTIVE
PAYMENTS, E.G., TO COMMISSARY OR JPAY. PLEASE DOUBLE-KEY ALL PAYMENT-RELATED
INFORMATION.
______________________________(Allow 500 characters)
Thank you for your participation.
[IF SH = YES & PROXY = NO & SECONDARY = NO] This concludes our interview, thank you
for your time.
INTERVIEWER: PLEASE REENTER/COLLECT FIRST AND LAST NAME OF THE RESPONDENT
FIRST NAME:
OPEN-ENDED RESPONSE OPTION
LAST NAME:
OPEN-ENDED RESPONSE OPTION
DK/REF
 AND THEN SELECT IF INCENTIVES ARE ALLOWED FOR THIS RESPONDENT
72

1 INCENTIVES ALLOWED
2 INCENTIVES NOT ALLOWED
INTERVIEWER IF INCENTIVES ARE ALLOWED AND ARE NONELECTRONIC PAYMENTS
PLEASE PROCEED HERE: PLEASE HAND RESPONDENT INCENTIVE OR TELL THE
RESPONDENT THAT THE FACILITY WILL HAND OUT THE INCENTIVE ().
1 INCENTIVE ACCEPTED / WILL ACCEPT INCENTIVE
2 INCENTIVE REFUSED
I HAVE CHECKED A BOX TO INDICATE THAT YOU  THE INCENTIVE FOR COMPLETING THIS INTERVIEW.
INTERVIEWER IF INCENTIVES ARE ALLOWED AND ARE ELECTRONIC PAYMENTS PLEASE
PROCEED HERE: PLEASE COLLECT NECESSARY INFORMATION TO MAKE INCENTIVE
PAYMENT, E.G., INTO PATIENT ACCOUNT. PLEASE DOUBLE-KEY ALL PAYMENT-RELATED
INFORMATION.
______________________________(Allow 500 characters)
Thank you for your participation.
[IF HL = YES] This concludes our interview, thank you for your time.
INTERVIEWER: PLEASE COLLECT FIRST AND LAST NAME OF THE RESPONDENT
FIRST NAME:
OPEN-ENDED RESPONSE OPTION
LAST NAME:
OPEN-ENDED RESPONSE OPTION
DK/REF
 AND THEN SELECT IF INCENTIVES ARE ALLOWED FOR THIS RESPONDENT
1 INCENTIVES ALLOWED
2 INCENTIVES NOT ALLOWED
INTERVIEWER IF INCENTIVES ARE ALLOWED AND ARE NONELECTRONIC PAYMENTS
PLEASE PROCEED HERE: PLEASE HAND RESPONDENT INCENTIVE OR TELL THE
RESPONDENT THAT THE FACILITY WILL HAND OUT THE INCENTIVE ().
1 INCENTIVE ACCEPTED / WILL ACCEPT INCENTIVE
2 INCENTIVE REFUSED
I HAVE CHECKED A BOX TO INDICATE THAT YOU  THE INCENTIVE FOR COMPLETING THIS INTERVIEW.
INTERVIEWER IF INCENTIVES ARE ALLOWED AND ARE ELECTRONIC PAYMENTS PLEASE
PROCEED HERE: PLEASE COLLECT NECESSARY INFORMATION TO MAKE INCENTIVE
73

PAYMENT, E.G., INTO ACCOUNT. PLEASE DOUBLE-KEY ALL PAYMENT-RELATED
INFORMATION.
______________________________(Allow 500 characters)
Thank you for your participation.
[IF (PROXY = YES | SECONDARY = YES) & CFIID3 = 3 & C17a = 4] This concludes our
interview, thank you for your time. PLEASE HAND RESPONDENT  INCENTIVE.
1 INCENTIVE ACCEPTED
2 INCENTIVE REFUSED
I have checked a box to indicate that  the  incentive for completing this interview.
Thank you for your participation.
[IF (HH | JA | PROXY | SECONDARY = YES) & CFIID3 = 1 | 2 | 3 & C17a != 4] Again, thank
you for your time and participation.
[HH = YES & PROXY = NO & SECONDARY = NO & CIINCENTIVE = YES] This concludes our
interview. You likely already received your  for this main interview at the
time you completed your screening survey and if not you will in the next few days via the
payment method you provided in the screening survey. Again, thank you for your time
and participation.
[IF HH = YES & PROXY = NO & SECONDARY = NO & CIINCENTIVE = NO & CFIID3 = 3 & C17a
= 4] This concludes our interview, thank you for your time. PLEASE HAND RESPONDENT
 INCENTIVE.
1 INCENTIVE ACCEPTED
2 INCENTIVE REFUSED
I have checked a box to indicate that  the
 incentive for completing this interview. Thank you for your participation.
[IF JA = YES & PROXY = NO & SECONDARY = NO & CFIID3 = 3 & C17a == 4] This concludes
our interview, thank you for your time and participation. PLEASE HAND RESPONDENT
 INCENTIVE.
1 INCENTIVE ACCEPTED
2 INCENTIVE REFUSED
I have checked a box to indicate that  the
 incentive for completing this interview. Thank you for your participation.
PROGRAMMER TIME STAMP SET: CEND

74

SECTION 7: INTERVIEWER DEBRIEFING QUESTIONS

PROGRAMMER TIME STAMP SET: CDEBRIEF
THESE QUESTIONS ARE FOR THE INTERVIEWER TO ANSWER. DO NOT READ TO THE R.
CIDB0

Did the respondent complete the entire interview or is this an incomplete
interview/breakoff?
1. RESPONDENT COMPLETE INTERVIEW
2. INCOMPLETE INTERVIEW/BREAKOFF
[IF CIDB0 = 2 & INTERVIEW STATUS = COMPLETE] INTERVIEW IS COMPLETED BY
RESPONDENT. PLESE SELECT “Skip” TO CONFIRM YOUR ANSWER.
PROGRAMMER: GO TO CIDBBR1 IF CIDB0 = INCOMPLETE INTERVIEW/BREAKOFF
ELSE CONTINUE

GAF1

[IF SECONDARY = NO] Consider psychological, social, and occupational functioning on a
hypothetical continuum of mental health-illness. Do not include impairment in functioning due to
physical (or environmental) limitations.
__________ [RANGE]

NOTE: USE INTERMEDIATE CODES WHEN APPROPRIATE, E.G., 45, 68, 72.
100Superior functioning in a wide range of activities, life’s problems never seem to get out of
91
hand, is sought out by others because of his or her many positive qualities. No symptoms.
90-81 Absent of minimal symptoms (e.g., mild anxiety before an exam), good functioning in all
areas, interested and involved in a wide range of activities, socially effective, generally
satisfied with life, no more than everyday problems or concerns (e.g., an occasional
argument with family members).
80-71 If symptoms are present, they are transient and expectable reactions to psychosocial
stressors (e.g., difficulty concentrating after family argument); no more than slight
impairment in social, occupational, or school functioning (e.g., temporarily falling behind in
schoolwork).
70-61 Some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social,
occupational, or school functioning (e.g., occasional truancy, or theft within the household),
but generally functioning pretty well, has some meaningful interpersonal relationships.
60-51 Moderate symptoms (e.g., flat and circumstantial speech, occasional panic attacks) or
moderate difficulty in social occupational, or social functioning (e.g., few friends, conflicts
with co-workers).
50-41 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or
any serious impairment in social, occupational, or school functioning (e.g., no friends, unable
to keep a job).
40-31 Some impairment in reality testing or communication (e.g., speech is at times illogical,
obscure, or irrelevant) or major impairment in several areas, such as work or school, family
relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family,
and is unable to work, child frequently beats up younger children, is defiant at home, and is
failing at school).
75

30-21

20-11

10-1

Behavior is considerably influenced by delusions or hallucinations or serious impairment in
communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately,
suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day,
no job, home, or friends).
Some danger of hurting self or others (e.g., suicide attempts without clear expectation of
death, frequently violent, manic excitement) or occasionally fails to maintain minimal
personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely
incoherent or mute).
Persistent danger of severely hurting self or others (e.g., recurrent violence) or persistent
inability to maintain minimal personal hygiene or serious suicidal act with clear expectation
of death.

CIDB1

How did the respondent complete most of the clinical interview?
1. THE RESPONDENT COMPLETED THE INTERVIEW ON THE PHONE (ZOOM AUDIO)
2. THE RESPONDENT COMPLETED THE INTERVIEW VIRTUALLY
3. THE RESPONDENT COMPLETED THE INTERVIEW IN-PERSON

CIDB1a

[IF CIDB1 = 2] Did the respondent have any technical difficulties using ZOOM?
1. YES
2. NO

CIDB1b

[IF CIDB1 = 2] Did the respondent at any time get disconnected from the virtual
interview?
1. YES
2. NO

CIDB2

[IF CIDB1 = 1 | 2] Were you able to clearly hear what the respondent was saying and was
the respondent able to hear you for most of the interview?
1. YES
2. NO

CIDB3

[IF CIDB1 = 2] Did the respondent have their camera on ...
1. FOR THE ENTIRE INTERVIEW
2. FOR PART OF THE INTERVIEW
3. NOT AT ALL

CIDB4a

[IF CIDB1 = 2 & CIBD3 != 3] On a scale of 1 to 5, where 1 is extremely poor visual quality
and 5 is extremely good visual quality, how would you rate the overall visual quality of
the interview?
_____ [RANGE 1-5]

CIDB4b

[IF CIDB1 = 2 & CIDB3 != 3] How well were you able to observe the respondent during the
interview? Were you able to clearly observe the respondent’s …
Check all that apply.
1. ENTIRE UPPER BODY DURING THE ENTIRE INTERVIEW
2. ENTIRE UPPER BODY DURING PARTS OF THE INTERVIEW
3. FACE ONLY DURING THE ENTIRE INTERVIEW
4. FACE ONLY DURING PARTS OF THE INTERVIEW, OR

76

5. OTHER (SPECIFY:_______________)
CIDB4c

[(((CIDB1 = 2 & CIBD3 != 3) | CIDB1 = 3) & (PROXY | SECONDARY = NO))] How helpful, if at
all, was it to be able to see the respondent’s behavior or facial expressions to make a
diagnosis?
1. EXTREMELY HELPFUL
2. VERY HELPFUL
3. SOMEWHAT HELPFUL
4. NOT SO HELPFUL
5. NOT AT ALL HELPFUL
PROGRAMMER: INCLUDE CHECKBOX “I DID NOT USE VISUAL OBSERVATIONS TO
MAKE A DIAGNOSIS”

CIDB5

[IF (CIDB1 = 2 | 3) & (HH | JA | PO = YES)] 
1. YES
2. NO

CIDB6

[IF (CIDB5 = NO) | (HL | SH | PR = YES)] 
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
10. 
11. SOME OTHER PLACE (SPECIFY: _______________)

CIDB7

[IF CIDB1 = 2 | 3] Please indicate how private the interview was. If a secondary informant
was present during the interview, please count them as other people in the . Do not count yourself or a project observer
as another person (in the ).
1. COMPLETELY PRIVATE – NO ONE WAS IN THE  OR LISTENING
2. MOSTLY PRIVATE – PERSON(S) IN THE  OR LISTENING LESS THAN HALF OF THE TIME
3. SOMEWHAT PRIVATE – PERSON(S) IN THE  OR LISTENING ABOUT HALF OF THE TIME
4. NOT VERY PRIVATE – PERSON(S) IN THE  OR LISTENING MORE THAN HALF THE TIME
77

5. NOT AT ALL PRIVATE – CONSTANT PRESENCE OF OTHER PERSON(S) IN THE  OR LISTENING
CIDB7a

[IF CIDB7 != 1] Not including yourself or project observers, who were the people present
or listening to the interview?
Check all that apply.
1. SECONDARY INFORMANT
2. )>
3. OTHER PEOPLE

CIDB8

[IF CIDB7 != 1 & CIDB7A = 3] Not including , who were the other people present or listening
to the interview?
Check all that apply.
1. PARENT(S)
2. SPOUSE
3. LIVE-IN PARTNER/BOYFRIEND/GIRLFRIEND
4. OTHER ADULT RELATIVE(S)
5. 
6. 
7. CHILD(REN) UNDER 18
8. OTHER

CIDB8a

[IF CIDB7 != 1] In what ways did the other people’s presence influence the interview?
Check all that apply.
1. PERSON(S) CAME INTO THE  AND YOU PAUSED THE INTERVIEW UNTIL THEY LEFT
2. PERSON(S) CAME INTO THE , YOU OR R ANSWERED THEIR QUESTION OR EXPLAINED THAT
PRIVACY WAS NEEDED, AND THEY LEFT
3. PERSON(S) STAYED IN THE  BUT DID NOT PARTICIPATE IN INTERVIEW
4. PERSON(S) STAYED IN THE  AND HELPED R WITH ANSWERS RELEVANT TO THE DIAGNOSES
5. PERSONS(S) STAYED IN THE  AND HELPED R WITH ANSWERS NOT RELEVANT TO THE DIAGNOSES
6. PERSON(S) STAYED BUT WAS TOO YOUNG TO UNDERSTAND THE INTERVIEW
7. OTHER (SPECIFY: ___________________)

CIDB9

During the interview, was the atmosphere at the 
interview site:
1. EXTREMELY CHAOTIC AND NOISY; DISRUPTIVE TO INTERVIEW
2. SOME NOISE OR INTERRUPTIONS BUT INTERVIEW WENT REASONABLY
SMOOTHLY
3. VERY QUIET AND CALM, IDEAL FOR INTERVIEW
78

CIDB10

What types of distractions or interruptions were present during the interview?
Check all that apply.
□ TELEVISION ON DURING INTERVIEW BUT R NOT WATCHING
□ TELEVISION ON DURING INTERVIEW WITH R WATCHING AT LEAST SOME OF THE
TIME
□ R RECEIVED 1 OR 2 PHONE CALLS
□ R RECEIVED 3 OR MORE PHONE CALLS
□ CHILDREN PRESENT NEEDED ATTENTION
□ OTHER (SPECIFY: ___________________)
□ NO DISTRACTIONS OR INTERRUPTIONS PRESENT

CIDB11

How attentive was the respondent to the questions during the interview?
1. NOT AT ALL ATTENTIVE
2. SOMEWHAT ATTENTIVE
3. VERY ATTENTIVE

CIDB11a

[IF SECONDARY & PROXY = NO & CIDB1 = 2 | 3] Did the respondent reference any recall
aids such as records, diaries, or medication lists during the interview?
1. YES
2. NO

CIDB11b

[IF SECONDARY = YES] And how confident was the secondary informant about the
answers they gave?
[IF PROXY = YES] And how confident was the proxy respondent about the answers they
gave?
1. NOT AT ALL CONFIDENT
2. SOMEWHAT CONFIDENT
3. VERY CONFIDENT

CIDB12

Was the respondent upset during the interview?
1. YES, UPSET BECAUSE OF INTERVIEW CONTENT
2. YES UPSET, BUT NOT RELATED TO INTERVIEW CONTENT
3. NO, NOT UPSET

CIDB13

While completing the interview, did the respondent experience any of the following
difficulties?
Yes No
a. LANGUAGE/TRANSLATION PROBLEMS
b. READING OR VISION PROBLEMS
c. COMPREHENSION PROBLEMS
d. SUBSTANCE OF THE INTERVIEW (I.E., TOPICS WE
WERE ASKING ABOUT)
e. OTHER (SPECIFY: ___________________)

CIDB14

Did the respondent make any comments about the interview being too long?
79

1. YES
2. NO
CIDB15a

Did you administer the Short Blessed Test, also known as SBT, with this respondent?
1. YES
2. NO

CIDB15b

[IF CIDB15a = YES] Did the respondent pass the Short Blessed Test?
1. YES
2. NO

CIDB16

Please note anything else you think would be helpful for the interpretation and
understanding of this interview.
___________ALLOW 250 CHARACTERS
PROGRAMMER CHECKBOX: NO COMMENTS

PROGRAMMER TIME STAMP SET: CENDDB

C19n

[IF C19 = 2] Interviewer, do you wish to enter the paper SCID data into the NetSCID now?
1
YES, ENTER THE PAPER SCID DATA NOW
2
NO, ENTER THE PAPER SCID DATA LATER. PLEASE RETURN HERE WHEN
YOU ARE READY TO ENTER THE DATA
PROGRAMMER: IF C19n = 1 LAUNCH NETSCID; IF C19n = 2 CLOSE INTERVIEW
AND SET STATUS CODE PENDING

C20n

[IF C19n = 1] Just to confirm, did you finish entering the paper SCID data into the NetSCID
instrument?
1
YES, FINISHED ENTERING THE PAPER SCID
2
NO, ONLY ENTERED A PARTIAL PAPER SCID AND WILL CONTINUE LATER

PROGRAMMER TIME STAMP SET: CBEGINDBBR

CIDBBR1

[IF BREAKOFF = YES] Please indicate if any of the following contributed to the interview
termination.

a. DISTRESSED RESPONDENT PROTOCOL INITIATED
b. RESPONDENT NOTED THE INTERVIEW WAS TOO
LONG AND DID NOT WISH TO CONTINUE
c. RESPONDENT DID NOT HAVE TIME TO COMPLETE
THE INTERVIEW BUT IS WILLING TO COMPLETE AT
A LATER TIME
d. RESPONDENT DOES NOT WISH TO CONTINUE THE
INTERVIEW ALONE
e. RESPONDENT WAS STRESSED ABOUT THE
CONTENT OF THE INTERVIEW

Yes

No

80

f. EQUIPMENT/ZOOM PROBLEM
g. ABRUPT END, RESPONDENT DIDN’T GIVE A
REASON
h. RESPONDENT FAILED THE KNOWLEDGE QUIZ OR
THE SBT
i. OTHER (SPECIFY: ___________________)
PROGRAMMER CHECKBOX: NA (INTERVIEW WAS COMPLETED)
PROGRAMMER: IF CIDBBR1 = NA GO TO CIDB1
CIDBBR2a

[IF BREAKOFF = YES] Did you administer the Short Blessed Test, also known as SBT, with
this respondent?
1. YES
2. NO

CIDBBR2b

[IF BREAKOFF = YES & CIDBBR2a] Did the respondent pass the Short Blessed Test?
1. YES
2. NO
PROGRAMMER PLEASE GENERATE SBT FAIL Y/N

PROGRAMMER TIME STAMP SET: CENDDBBR
XXX

INTERVIEWER REMINDER: IMPLEMENT THE DISTRESSED RESPONDENT PROTOCOL FOR THIS
INTERVIEW IF NECESSARY.
INTERVIEWER: YOU HAVE REACHED THE END OF THE INTERVIEW. TOUCH THE SUBMIT BUTTON
BELOW TO FINALIZE CASE AND RETURN TO THE CASE MANAGEMENT SYSTEM.

81

Showcard 1 – Medications
1 – Abilify
2 – Abilify Maintena
3 – Alprazolam
4 – Amitriptyline
5 – Aripiprazole
6 – Asenapine
7 – Ativan
8 – Brintellix Or Trintellix
9 – Budeprion
10 – Bupropion
11 – Buspar
12 – Buspirone
13 – Carbamazepine
14 – Carbatrol
15 – Catapres
16 – Celexa
17 – Chlordiazepozide
18 – Chlorpromazine
19 – Citalopram
20 – Clonazepam
21 – Clonidine
22 – Clozapine
23 – Clozaril
24 – Cymbalta
25 – Depakene
26 – Depakote
27 – Desvenlafaxine
28 – Desyrel
29 – Diazepam
30 – Divalproex
31 – Duloxetine
32 – Effexor
33 – Elavil
34 – Escitalopram
35 – Esketamine

36 – Fanapt
37 – Fetzima
38 – Fluoxetine
39 – Fluphenazine
40 – Gabapentin
41 – Geodon
42 – Haldol
43 – Haloperidol
44 – Iloperidone
45 – Inderal
46 – Invega
47 – Invega Sustenna
48 – Ketamine
49 – Klonopin
50 – Lamictal
51 – Lamotrigine
52 – Latuda
53 – Levomilnacipran
54 – Lexapro
55 – Librium
56 – Lithium
57 – Lithobid
58 – Lorazepam
59 – Lurasidone
60 – Lyrica
61 – Minipress
62 – Mirtazapine
63 – Modafinil
64 – Neurontin
65 – Nuvigil
66 – Olanzapine
67 – Oxcarbazepine
68 – Paliperidone
69 – Paroxetine
70 – Paxil

71 – Prazosin
72 – Pregabalin
73 – Pristiq
74 – Prolixin
75 – Propranolol
76 – Prozac
77 – Quetiapine
78 – Remeron
79 – Restoril
80 – Risperdal
81 – Risperidone
82 – Saphris
83 – Seroquel
84 – Sertraline
85 – Spravato
86 – Strattera
87 – Tegretol
88 – Temazepam
89 – Thorazine
90 – Topamax
91 – Topiramate
92 – Trazodone
93 – Trileptal
94 – Valium
95 – Valproic Acid
96 – Venlafaxine
97 – Viibryd
98 – Vilazodone
99 – Vortioxetine
100 – Wellbutrin
101 – Xanax
102 – Ziprasidone
103 – Zoloft
104 – Zyprexa

Showcard 2 – Income Type
• Social Security/Railroad Retirement payments — paid by the U.S.
Government to people who are retired, severely disabled, or
dependents or survivors of workers
• Supplemental Security Income, or SSI — a program administered by a
government agency that makes assistance payments to people with low
income who are aged, blind, or disabled
• Supplemental Nutrition Assistance Program, or SNAP — formerly known
as food stamps, provides assistance for buying food; a special card is
issued which can be used to buy food in grocery stores; SNAP does not
include WIC or free or reduced school lunches
• Cash assistance from a state or county/borough welfare program,
sometimes called Temporary Assistance for Needy Families, or TANF
• Any other type of welfare or public assistance
• Income earned at a job or business
• Retirement, disability, or survivor pension
• Unemployment or worker’s compensation
• Veteran’s Administration payments
• Child support
• Alimony
• Interest income
• Dividends from stocks or mutual funds
• Income from rental properties, royalties, estates, or trusts

SCID-5-NSMH
STRUCTURED CLINICAL INTERVIEW FOR DSM-5® DISORDERS
Modified for National Study of Mental Health

03-01-2021
Michael B. First, M.D.
Professor of Clinical Psychiatry, Columbia University, and Research Psychiatrist,
Division of Clinical Phenomenology, New York State Psychiatric Institute,
New York, New York

Janet B. W. Williams, Ph.D.
Professor Emerita of Clinical Psychiatric Social Work (in Psychiatry and in
Neurology), Columbia University, and Research Scientist and Deputy Chief,
Biometrics Research Department (Retired), New York State Psychiatric Institute,
New York, New York; and Senior Vice President of Global Science,
MedAvante, Inc., Hamilton, New Jersey

Rhonda S. Karg, Ph.D.
Research Psychologist, Division of Behavioral Health and
Criminal Justice Research, RTI International, Durham, North Carolina

Robert L. Spitzer, M.D.
Professor Emeritus of Psychiatry, Columbia University, and
Research Scientist and Chief, Biometrics Research Department (Retired),
New York State Psychiatric Institute, New York, New York

Patient: ______________________________________________

Clinician: _____________________________________________

Date of
Interview:

_____
month

______
day

______
year

Note: The authors have worked to ensure that all information in this publication is accurate at the time of publication and
consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes
of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration
and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may
change. Moreover, specific situations may require a specific therapeutic response not included in this publication. For these
reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians
directly involved in their care or the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the findings, conclusions, and views of the individual
authors and do not necessarily represent the policies and opinions of American Psychiatric Association Publishing or the American
Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/specialdiscounts for more information.
Copyright © 2016 American Psychiatric Association
ALL RIGHTS RESERVED
DSM and DSM-5 are registered trademarks of the American Psychiatric Association. Use of these terms is prohibited without
permission of the American Psychiatric Association.
DSM-5® diagnostic criteria are reprinted or adapted with permission from American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright © 2013
American Psychiatric Association. Used with permission.
Unless authorized in writing by the American Psychiatric Association (APA), no part of the DSM-5® criteria may be reproduced or
used in a manner inconsistent with the APA’s copyright. This prohibition applies to unauthorized uses or reproductions in any
form, including electronic applications. Correspondence regarding copyright permission for DSM-5 criteria should be directed to
DSM Permissions, American Psychiatric Association Publishing, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901.
ICD-10-CM codes are periodically updated by the Cooperating Parties for the ICD-10-CM. For important updates to any listed
codes, see the DSM-5 Update on www.PsychiatryOnline.org
The Structured Clinical Interview for DSM-5® Disorders—Clinician Version (SCID-5-CV) comprises the User’s Guide for the SCID-5CV and this SCID-5-CV interview booklet (each sold separately). No part of these publications may be photocopied, reproduced,
stored in a retrieval system, or transmitted, in any form or by any means, without obtaining permission in writing from American
Psychiatric Association Publishing, or as expressly permitted by law, by license, or by terms agreed with the appropriate
reproduction rights organization. All such inquiries, including those concerning reproduction outside the scope of the above,
should be sent to Rights Department, American Psychiatric Association Publishing, 1000 Wilson Blvd., Suite 1825, Arlington, VA
22209-3901 or via the online permissions form at: http://www.appi.org/permissions. For more information, please visit the SCID
products page on www.appi.org.
For citation: First MB, Williams JBW, Karg RS, Spitzer RL: Structured Clinical Interview for DSM-5 Disorders—Clinician Version
(SCID-5-CV). Arlington, VA, American Psychiatric Association, 2016
Manufactured in the United States of America on acid-free paper
19 18 17 16 15 5 4 3 2 1
American Psychiatric Association Publishing
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org

SCID-5-NSMH

Overview

Page 3

SCID-5-NSMH DIAGNOSTIC SUMMARY SCORE SHEET
Psychotic Disorders (past 12 months and prior to past 12 months)
Past 12 months (and possibly
prior)

Likelihood
of coronavirus
causality
(see page
69)

Not in
past 12
months
but
prior to
past 12
months



____





____



Disorder

Schizophrenia or Schizoaffective Disorder with duration > 6
months (p.35/C6)
Schizophreniform or schizoaffective with duration < 6 months
(p.35/C8)

Mood Disorders (past 12 months)




____
____
____

Major Depressive Disorder (bipolar II not ruled out) (p. 36/D13)
Bipolar I Disorder. Manic in past year) (p. 37/D17)
Bipolar I Disorder, Depressed but no manic in past year (p.37/ D18)

Substance Use Disorders (past 12 months)
Past 12
Months

Coronavirus
causality
(see page
69)

Disorder

Alcohol Use Disorder (p. 41/E13)
Mild
Moderate
Severe
Sedative, Hypnotic, or Anxiolytic Use Disorder (p. 48/E36)
Mild
Moderate
Severe
Cannabis Use Disorder (p. 48/E36)
Mild
Moderate
Severe
Stimulant Use Disorder (p. 48/E36)
Mild
Moderate
Severe
Opioid Use Disorder (p.48/E36)
Mild
Moderate
Severe

















Other Disorders
Past 12
months





Coronavirus
causality

Disorder
Generalized Anxiety Disorder (past 12 months) (p. 53/F55)
Obsessive-Compulsive Disorder (past 12 months) (p. 55/G7)
Posttraumatic Stress Disorder (p. 66/G41)
Anorexia Nervosa (past 12 months) (p. 67/H3)

Specific drug used: ______________

Specific drug used: _______________

Specific drug used: _______________

Specific drug used: _______________

SCID-5-NSMH

Overview

OVERVIEW
I’m going to be asking you about problems or difficulties you may have had, and I’ll be making some notes as we go along.
Do you have any questions before we begin?
How old are you?

Are you currently in a relationship with a partner?
IF YES: What is the nature of that relationship, for
example, are you married or living together? How
long have you been (RELATIONSHIP STATUS)?
Have you ever been separated/divorced or widowed?
IF YES: How many times?
Do you have any children?
IF YES: How many? (What are their ages?)

In what city, town, or community do you live?
In what kind of place do you currently live? (A house, an
apartment, a shelter, a halfway house, or some other
living arrangement? Are you homeless?)

What is your highest completed level of education?
Did you ever not complete a degree or program?

Why?
I would like to now ask you about your cultural background
or identity. By background or identity, I mean, for example,
the communities you belong to, the languages you speak,
where you or your family are from, your race or ethnic
background, your gender or sexual orientation, or your faith
or religion.
For you, what are the most important aspects of your
background or identity?

In the past year, have you done work for which you were
paid?
IF YES: Tell me about that. What kind of jobs have
you had?

IF HAS NOT WORKED IN PAST YEAR OR HAS WORKED TOO
FEW HOURS TO BE SELF-SUPPORTING: How have you
supported yourself during the past year?

Page 4

SCID-5-NSMH

Overview

In the past year, have you (also) been in school or
enrolled in on-line classes? What kind of program was
it?
Have there been any times during the past year when
you were on leave for illness or disability?
IF YES: What was the illness/disability?
IF UNCLEAR: Are you currently retired?

IF UNKNOWN: During the past year, have there been any
periods of time when you were unable to work or go to
school?
IF YES: Why was that?

Have you ever been involved with the legal system
(Have you ever been arrested??)

Psychological Difficulties Past Year
In the past year, have you seen a doctor, a therapist, or
a counselor for any kind of psychological problem?
IF YES: Tell me about it. (What was the reason for
your seeking help?) (What kinds of symptoms [have
you been/were you experiencing?) (When did these
symptoms begin?) (Was anything going on in your
life when they began?) (Since they began, when have
you felt the worst?)
What kind of help did you receive? (Counselling or
psychotherapy?) (Medication—what kind?) (For how
long have you been getting that help?)
What about (also) getting help during the past year from
outside the health system, like from a self-help group
like Alcoholics Anonymous, or from a faith healer or
pastoral counselor?

→ IF HAS SOUGHT HELP IN THE PAST YEAR: Besides
[PROBLEMS ALREADY DISCUSSED], have you had any
other problems that you considered getting help for
but didn’t?
→ IF HAS NOT SOUGHT HELP IN PAST YEAR: What about
having a problem during the past year that you
considered getting help for? Have other people
mentioned that you ought to seek help for a
psychological problem? Tell me about that.
In the past year, have you gotten any help for problems
with drugs or alcohol? Tell me about that.

Page 5

SCID-5-NSMH

Overview

Most Stressful Situation/Event In
Past Year
Most people have experienced situations, other people,
or events that they have found to be upsetting,
challenging, or stressful.
What has been the most challenging or stressful
experience that you experienced in the past year? Tell
me about that. How did it affect you?

Hospitalization History
Have you ever been hospitalized for psychological
problems or a drug or alcohol problem?
IF YES: What was that for?
IF AN INADEQUATE ANSWER IS GIVEN, CHALLENGE
GENTLY: e.g., Wasn't there something else? People
don't usually go to psychiatric hospitals just because
they are tired or nervous.
Have you ever been hospitalized for treatment of a
medical problem?
IF YES: What was that for?

Page 6

SCID-5-NSMH

Overview

Suicidal Ideation and Behavior
CHECK FOR THOUGHTS: In the past year, since [ONE YEAR
AOG], have you had any thoughts about taking your own
life or just going to sleep and not waking up, or thinking
that you would be better off dead? (Tell me about that.)

CHECK FOR ATTEMPT: In the past year, have you done
anything to try to end your life?

Page 7

SUICIDAL IDEATION PAST YEAR:
1.

Yes

2.

No

SUICIDAL ATTEMPT PAST YEAR:

IF YES: Tell me about that. What did you do?

1.

Yes

NOTE: IF PAST YEAR IDEATION OR ATTEMPT, ASSESS
FOR CURRENT SUICIDE RISK AND ACT ACCORDINGLY.
Ask: In the past week have you had any thoughts
about taking your own life?

2.

No

IF YES, Tell me more about that. Do you intend to
hurt yourself or take your own life?
IF YES, Have you thought about a specific
method for attempting suicide? What has
prevented you from acting on this plan?
IF CURRENT, ACTIVE SUICIDAL IDEATION AND
INTENT IS CONFIRMED, STOP THE INTERVIEW AND
GO TO DRP SCENARIO 1B

Other Problems in Past Year
Have you had any problems in the past year other than
what we’ve talked about so far?
IF UNKNOWN: How were you affected by the
coronavirus pandemic? (Did you or someone close to
you need to be hospitalized for treatment? Did you
lose someone whom you were close to? How about
the financial implications of the crisis?)

How has your physical health been during the past year,
since [ONE YEAR AGO]? Have you been getting help for
any medical problems? (What kind of problems are you
getting help for? Are you taking any medicines or getting
any other kind of treatment for the problem?)
In the past year, have you taken any medication
(including over the counter medications, vitamins,
nutritional supplements, or natural or traditional health
remedies) for your emotions or nerves or to help you
sleep (other than those you’ve already told me about?)
IF YES: What medication are you taking (did you
take)?

SCID-5-NSMH

Overview

Page 8

Screening for Alcohol Use Disorder in
Past Year
Have you drunk any alcohol in the past year, that is, since
(ONE YEAR AGO)?
IF UNKNOWN: Have you drunk alcohol at least six times in the
past 12 months?

MALES: ALCOHOL DRUNK AT LEAST SIX TIMES IN PAST
TWELVE MONTHS AND HAVE HAD AT LEAST FOUR DRINKS
AT ONE TIME AT LEAST ONCE IN PAST YEAR:
Yes
No
FEMALES: ALCOHOL DRUNK AT LEAST SIX TIMES IN PAST
TWELVE MONTHS AND HAVE HAD AT LEAST THREE
DRINKS AT ONE TIME IN THE PAST YEAR:
Yes
No

IF UNKOWN: What are the most drinks you have had at one time
in the past 12 months?

Screening for Nonsubstance Use Disorder in Past Year
Now I’d like to ask you about your use of drugs or medicines over the past 12 months, since (ONE YEAR AGO).
At or Above
Screening
Threshold

Below
Scteening
Threshold

E15

Sedatives, Hypnotics, or Anxiolytics: In the past 12 months, have you taken any pills to calm you
down, help you relax, or help you sleep? (Drugs like Valium, Xanax, Ativan, Klonopin, Ambien,
Sonata, or Lunesta?)
IF YES, specific drug(s) used ______________________________________________________

YES

NO

E15

E16

Cannabis: In the past 12 months, have you used marijuana (“pot,” “grass,” “weed,” “flower”),
hashish ("hash"), THC, “wax,” “sauce,” or “shatter,”K2, or “spice?”
IF YES, specific drug(s) used: ______________________________________________________

YES

NO

E16

E17

Stimulants: In the past 12 months, have you used any stimulants or “uppers” to give you more
energy, keep you alert, lose weight, or help you focus? (Drugs like speed, methamphetamine, crystal
meth, “crank,” Ritalin or methylphenidate, Dexedrine, Adderall or amphetamine, or prescription diet
pills?) How about cocaine or “crack”?
IF YES, specific drug(s) used: ______________________________________________________

YES

NO

E17

E18

Opioids: In the past 12 months, have you ever used heroin or methadone? How about prescription
pain killers? (Drugs like morphine, codeine, Percocet, Percodan, Oxycontin, Tylox or oxycodone,
Vicodin, Lortab, Lorcet or hydrocodone, Suboxone or buprenorphine?)
IF YES, specific drug(s) used: ______________________________________________________

YES

NO

E18

FOR EACH DRUG CLASS THAT RESPONDANT ACKNOWLEDGES USING IN THE PAST YEAR, FOLLOW UP WITH THESE QUESTIONS TO
DETERMINE WHETHER USE IS AT OR ABOVE THRESHOLD FOR ASSESSMENT OF SUBSTANCE USE DISORDER:
→ IF ILLICIT OR RECREATIONAL DRUG: Have you used (SUBSTANCE) at least six times during the past 12 months?

→IF PRESCRIBED MEDICATION: Over the past 12 months, did you get hooked or become dependent on (PRESCRIBED MEDICATION)?
Did you ever take more of it than was prescribed or run out of your prescription early? Did you ever have to go to more than one
doctor to make sure you didn’t run out?
→IF OVER-THE-COUNTER (OTC) Over the past 12 months, did you get hooked or become dependent on (OTC MEDICATION)? Did you
ever take more of it than was recommended on the bottle? How much more?
THE TREATMENT TIMELINE (BELOW) MAY BE USED AT ANY POINT IN THE OVERVIEW TO RECORD THE DETAILS OF A COMPLICATED
HISTORY.

SCID-5-NSMH

Overview

Page 9

TREATMENT TIMELINE
Age (or date)

Description (symptoms, triggering events)

Treatment

SCID-5 for MSMH

Major Depressive Episode Past Year

Page 10

A. MOOD EPISODES
MAJOR DEPRESSIVE EPISODE PAST YEAR

[IF UNBLINDMDE = YES] In your earlier interview you
mentioned that you have had times in the past year
when you felt depressed or down or lost interest in
things that you used to enjoy. I’d like to ask you some
more questions about those times.

MAJOR DEPRESSIVE EPISODE CRITERIA

A. Five (or more) of the following symptoms have
been present during the same 2-week period and
represent a change from previous functioning; at
least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.

[ELSE] Now I am going to ask you some more questions
about your mood.
A1

During the past 12 months, since (ONE YEAR AGO), has
there been a period of time when you were feeling
depressed or down most of the day, nearly every day? (Has
anyone said that you look sad, down, or depressed?)

1. Depressed mood most of the day, nearly every
day, as indicated by either subjective report (e.g.,
feels sad, empty, hopeless) or observation made by
others (e.g., appears tearful).

—

+

2. Markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every day
(as indicated by either subjective account or
observation).

—

+

A1

IF NO: How about feeling sad, empty, or hopeless, most
of the day, nearly every day?
IF YES TO EITHER OF ABOVE: What has it been like? For
how long have you felt like that for most of the day, nearly
every day? (As long as 2 weeks?)

A2

IF PREVIOUS ITEM RATED “+”: During that time, did you
have less interest or pleasure in things you usually
enjoyed? (What has that been like?)
IF PREVIOUS ITEM RATED “—”: What about a time since
(ONE YEAR AGO) when you lost interest or pleasure in
things you usually enjoyed? (What has that been like?)
IF YES: Has it been nearly every day? How long has
it lasted? (As long as 2 weeks?)

IF BOTH A1 AND A2 ARE RATED AS “—” FOR THE PAST YEAR, Continue with A29 (Manic Episode Past Year), page 15.

Have you had more than one time like that during the past
12 months? (Which time was the worst?)

NOTE: If more than one episode in the past 12
months is likely, select the “worst” one for your
inquiry about a Major Depressive Episode in the past
12 months.

A2

SCID-5 for MSMH

A3

Major Depressive Episode Past Year

Page 11

FOR THE FOLLOWING QUESTIONS, FOCUS ON THE WORST
2-WEEK PERIOD OF THE WORST EPISODE IN THE PAST YEAR:
Thinking about (WORST EPISODE IN PAST YEAR), during
which 2-week period would you say you have been feeling
the worst or functioning the worst?

During (2-WEEK PERIOD)…
...how was your appetite? (What about compared to your
usual appetite? Did you have to force yourself to eat? Eat
[less/more] than usual? Was that nearly every day? Did
you lose or gain any weight?)

3. Significant weight loss when not dieting or weight
gain (e.g., a change of more than 5% of body weight
in a month), or decrease or increase in appetite
nearly every day.

—

+
A3

IF YES: How much? (Had you been trying to [lose/gain]
weight?)

A4

…how had you been sleeping? (Trouble falling asleep,
waking frequently, trouble staying asleep, waking too
early, OR sleeping too much?)

4. Insomnia or hypersomnia nearly every day.

—

+

5. Psychomotor agitation or retardation nearly every
day (observable by others, not merely subjective
feelings of restlessness or being slowed down).

—

+

A5

A4

How many hours of sleep (including naps) have you been
getting? How many hours of sleep did you typically get
before you got (depressed/OWN WORDS)? Had it been
nearly every night?

(During [2-WEEK PERIOD]…)
A5

…were you so fidgety or restless that you were unable to
sit still?
What about the opposite—talking more slowly, or moving
more slowly than was normal for you, as if you’re moving
through molasses or mud?

NOTE: CONSIDER BEHAVIOR DURING THE
INTERVIEW.

(IN EITHER INSTANCE, has it been so bad that other people
noticed it? What did they notice? Was that nearly every
day?)

A6

A7

...what was your energy like? (Tired all the time? Nearly
every day?)

6. Fatigue or loss of energy nearly every day.

—

+

A6

(During [2-WEEK PERIOD]…)

7. Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about
being sick).

—

+

A7

…were you feeling worthless?
What about feeling guilty about things you had done or
not done?
IF YES: What kinds of things? (Was this only because
you couldn’t take care of things because you had been
sick?)
IF YES TO EITHER OF ABOVE: Was that Nearly every day?

SCID-5 for MSMH
A8

Major Depressive Episode Past Year

…Did you have trouble thinking or concentrating? Had it
been hard to make decisions about everyday things?
(What kinds of things had it been interfering with? Nearly
every day?)

(During [2-WEEK PERIOD]…)
A9

…Had things been so bad that you thought a lot about
death or that you would be better off dead? Did you think
about taking your own life?
IF YES: Had you done something about it? (What did
you do? Had you made a specific plan? Did you take
any action to prepare for it? Did you actually make a
suicide attempt?)

Page 12

8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others).

9. Recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for
committing suicide.

—

+

—

+

A8

A9

Note: ANY CURRENT SUICIDAL THOUGHTS, PLANS,
OR ACTIONS SHOULD BE THOROUGHLY ASSESSED BY
THE CLINICIAN AND ACTION TAKEN IF NECESSARY.

A10

A10

AT LEAST FIVE OF THE ABOVE CRITERION A SXS
(A1-A9) ARE RATED “+”.

NO

IF FEWER THAN FIVE ITEMS: Has there been any other time when you were (depressed/OWN WORDS) during the past
year and had even more of the symptoms than I just asked about?
IF YES: Go back to A1, page 10, and assess symptoms for that episode.
IF NO: Continue with A29 (Manic Episode Past Year), page 15

YES

Continue
with A11
(Criterion B),
next page.

SCID-5 for MSMH

A11

Major Depressive Episode Past Year

IF UNKNOWN: Are you taking any medications or other
health remedies because of (DEPRESSIVE SXS)? Tell me
about that.

B. The symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.

IF UNKNOWN: Are you seeing a doctor, a therapist, or a
counselor for (DEPRESSIVE SXS)? Tell me about that.

Treatment for sxs: Code “+” if “YES” to any of the
first three questions.

IF UNKNOWN: Have other people suggested that you
ought to seek help for (DEPRESSIVE SXS)? Tell me about
that.

Impairment due to sxs: Code “+” if judged to be
moderate or greater
Distress: Code “+” if judged to be moderate or
greater

IF UNCLEAR: What effect did (DEPRESSIVE SXS) have on
your life?
ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How did (DEPRESSIVE SXS) affect your relationships or
your interactions with other people? (Did [DEPRESSIVE
SXS] cause you any problems in your relationships with
your family, romantic partner, or friends?)
How did (DEPRESSIVE SXS) affect your work/school?
(How about your attendance at work/school? Did
[DEPRESSIVE SXS] make it more difficult to do your
work/schoolwork? Did [DEPRESSIVE SXS] affect the
quality of your work/schoolwork?)
How did (DEPRESSIVE SXS) affect your ability to take
care of things at home? How about doing simple
everyday things, like getting dressed, bathing, or
brushing your teeth? What about doing other things
that were important to you, like religious activities,
physical exercise, or hobbies?
Did you avoid doing anything because you felt like you
weren’t up to it?
Did (DEPRESSIVE SXS) affect any other important part
of your life?
IF DEPRESSIVE SXS DO NOT INTERFERE WITH LIFE: How
much were you bothered or upset by having (DEPRESSIVE
SXS)?
IF EPISODE DOES NOT CAUSE DISTRESS OR IMPARIMAENT, ASK: Has there been any other time during the past year
when you were (depressed/OWN WORDS) and it caused even more problems than the time I just asked about?
IF YES: Go back to A1, page 10, and assess symptoms for that episode.
IF NO: Continue with A29 (Manic Episode Prior To Past Year), page 15

Page 13

—

+

Continue
with A12,
next page

A11

SCID-5 for MSMH

Major Depressive Episode Past Year

THIS PAGE INTENTIONALLY
LEFT BLANK

Page 14

SCID-5MSMH

Manic Episode Past Year

MANIC EPISODE PAST YEAR

A29a

[IF UNBLINDMANIA = YES] In your earlier interview you
mentioned that you have had times in the past year when
you felt so full of energy or in such a good mood for at
least four days that other people thought you were not
yourself. Or, you may have mentioned that you were
much more irritable for at least four days. I’d like to ask
you some more questions about those times.

Page 15

MANIC EPISODE CRITERIA

—

A29a

+

PERIOD OF ELEVATED MOOD?
A. A distinct period [lasting at least several
days] of abnormally and persistently elevated,
expansive, or irritable mood and abnormally Go to
and persistently increased activity or energy. A29c.

[ALL] During the past 12 months, since (12 MONTHS AGO),
has there been a period of time when you were feeling so
good, “high,” excited, or “on top of the world” that other
people thought you were not your normal self?
—
A29b

A29c

A29d

A30

Have you also been feeling like you were “hyper” or
“wired” and had an unusual amount of energy? Have you
been much more active than is typical for you? (Have
other people commented on how much you have been
doing?) What has it been like?

A29b
PLUS INCREASED ENERGY OR ACTIVITY?
A29 has been prepopulated
“+”. Go to A30
PERIOD OF IRRITATED MOOD?

Since (12 MONTHS AGO), have you had a period of time
when you were feeling irritable, angry, or short-tempered
for most of the day, for at least several days? (Was that
different from the way you usually are?)

+

—

+
A29c

A29 has been prepopulated “-“.
Go to A53, page 20.
PLUS INCREASED ENERGY OR ACTIVITY?

IF UNKNOWN: Have you also been feeling like you were
“hyper” or “wired” and had an unusual amount of energy?
Were you much more active than was typical for you? (Did
other people comment on how much you were doing?)
What has it been like?

How long did this last? (As long as 1 week?)
IF LESS THAN 1 WEEK: Did you need to go into the
hospital to protect you from hurting yourself or
someone else, or from doing something that could
have caused serious financial or legal problems?
Were you feeing (high/irritable/OWN WORDS) for most of
the day, nearly every day, during this time?

—

A29 has been
prepopulated “-“. Go to
A53, page 20.

...lasting at least 1 week and present most of
the day, nearly every day (or any duration if
hospitalization is necessary).
NOTE: IF ELEVATED MOOD LASTS LESS THAN 1
WEEK, CHECK WHETHER THERE HAS BEEN A
PERIOD OF IRRITABLE MOOD LASTING AT
LEAST 1 WEEK BEFORE SKIPPING TO A53.

—

+

A29d

A29 has been
prepopulated “+”. Go
to A30

+

Continue
with A53
(Consider
Assessment
of Manic
Episodes
prior to
past year)
page 20.

A30

SCID-5MSMH

Manic Episode Past Year

Have you had more than one time like that during the past
year? (Which time was the most intense or caused the
most problems?)
FOR A31–A37, FOCUS ON THE MOST SEVERE PERIOD OF THE
WORST EPISODE DURING THE PAST YEAR THAT YOU ARE
INQUIRING ABOUT.

Page 16

B. During the period of mood disturbance and
increased energy or activity, three (or more) of the
following symptoms (four if the mood is only
irritable) are present to a significant degree and
represent a noticeable change from usual behavior:

IF UNKNOWN: During (EPISODE), when were you the most
(high/irritable/OWN WORDS)?
1. Inflated self-esteem or grandiosity.

—

+

A31

2. Decreased need for sleep (e.g., feels rested after
only 3 hours of sleep).

—

+

A32

A33

(During that time…)
…were you much more talkative than usual?
(Did people have trouble stopping you or understanding
you? Did people have trouble getting a word in edgewise?)

3. More talkative than usual or pressure to keep
talking.

—

+

A34

…were your thoughts racing through your head?
(What was that like?)

4. Flight of ideas or subjective experience that
thoughts are racing.

—

+

A34

A35

…were you so easily distracted by things around you that
you had trouble concentrating or staying on one track?
(Give me an example of that.)

5. Distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external stimuli), as
reported or observed.

—

+

A35

6. Increase in goal-directed activity (either socially, at
work or school, or sexually) or psychomotor agitation
(i.e., purposeless non-goal-directed activity).

—

+

During that time…
A31

…how did you feel about yourself? (More self-confident
than usual? Did you feel much smarter or better than
everyone else? Did you feel like you had any special
powers or abilities?)

A32

…did you need less sleep than usual?
(How much sleep did you get?)
IF YES: Did you still feel rested?

A33

(During that time…)
A36

…how did you spend your time? (Work, friends, hobbies?
Were you especially busy during that time?)
(Did you find yourself more enthusiastic at work or working
harder at your job? Did you find yourself more engaged in
school activities or studying harder?)
(Were you more sociable during that time, such as calling
on friends, going out with them more than you usually do,
or making a lot of new friends?)
(Were you spending more time thinking about sex or
involved in doing something sexual, by yourself or with
others? Was that a big change for you?)
Were you physically restless during this time, doing things
like pacing a lot, or being unable to sit still?
(How bad was it?)

A36

SCID-5MSMH

Manic Episode Past Year

Page 17

(During that time…)
A37

…were you doing anything that could have caused trouble
for you or your family?

7. Excessive involvement in activities that have a high
potential for painful consequences (e.g., engaging in
unrestrained buying sprees, sexual indiscretions, or
foolish business investments).

—

+

AT LEAST THREE OF THE ABOVE CRITERION B SXS (A31–
A37) ARE RATED “+” (FOUR IF MOOD ONLY IRRITABLE).

NO

YES

A37

(Spending money on things you didn’t need or couldn’t
afford? How about giving away money or valuable things?
Gambling with money you couldn’t afford to lose?)
(Anything sexual that was likely to get you in trouble?
Driving recklessly?)
(Did you make any risky or impulsive business investments
or get involved in a business scheme that you wouldn’t
normally have done?)

A38

A38

Continue
with A39,
CRITERION C,
below.

IF FEWER THAN THREE (FOUR IF MOOD ONLY IRRITABLE) AND NOT ALREADY ASKED: Have there been any other times in the
past year when you were (high/irritable/OWN WORDS) and had even more of the symptoms that I just asked you about?
IF YES: Go back to A29, page 15, and ask about that episode.
IF NO: Continue with A53, page 20 (Consider Assessment of Manic Episodes prior to past year)

A39

IF UNCLEAR: What effect did (MANIC SXS) have on your
life?
IF UNKNOWN: Did you need to go into the hospital to
protect you from hurting yourself or someone else, or
from doing something that could have caused serious
financial or legal problems?

C. The mood disturbance is sufficiently severe to cause
marked impairment in social or occupational functioning
or to necessitate hospitalization to prevent harm to self
or others, or there are psychotic features.

ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How did (MANIC SXS) affect your relationships or your
interactions with other people? (Did [MANIC SXS] cause
you any problems in your relationships with your family,
romantic partner, or friends?)
How did (MANIC SXS) affect your work/school? (How
about your attendance at work/school? Did [MANIC SXS]
make it more difficult to do your work/schoolwork? Did
[MANIC SXS] affect the quality of your work/schoolwork?)
How have (MANIC SXS) affected your ability to take care of
things at home?
IF NOT ALREAD ASKED: IF MOOD DISTURBANCE WAS NOT SEVERE ENOUGH TO CAUSE MARKED IMPARIMENT OR TO
NECESSITATE HOSPITALIZATION AND NOT ALREADY ASKED: Has there been any other time in the past year when you were
(high/irritable/OWN WORDS) and had (ACKNOWLEDGED MANIC SXS) and you got into trouble with people or were
hospitalized?
IF YES: Go back to A29, page 15, and ask about that episode.
IF NO: Continue with A53 (Consider assessment of Manic Episodes prior to past year), page 20.

—

+

Continue
with A40,
next page

A39

SCID-5MSMH
A40

Manic Episode Past Year

IF UNKNOWN: When did this period of being
(high/irritable/OWN WORDS) begin?
Just before this began, were you physically ill?
IF YES: What did the doctor say?

A40a

Just before this began, were you taking any medications?
IF ALREADY ON MEDICATION WHEN EPISODE BEGAN:
Any change in the amount you were taking?
Just before this began, were you drinking or using any
street drugs?
IF ALREADY DRINKING OR USING DRUGS WHEN
EPISODE BEGAN: Any change in the amount you were
taking?
IF TAKING SUBSTANCE THAT CAN CAUSE MANIC-LIKE SXS
DURING WITHDRAWAL: Had you recently cut down or
stopped taking (drug)?

D. [Primary Manic Episode] The episode is not
attributable to the physiological effects of another
medical condition…
Refer to page 71 for a list of possibly etiological medical
conditions
NOTE: Code “NO” only if episode is due to a GMC

Page 18

NO

YES

A40

PRIMARY

D. [Primary Manic Episode] The episode is not
attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication, other treatment)
Refer to page 71 for a list of possibly etiological
substances/medications.
Note: A full Manic Episode that emerges during
antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a fully
syndromal level beyond the physiological effect of that
treatment is sufficient evidence for a Manic Episode and,
therefore, a Bipolar I [Disorder] diagnosis.
NOTE: Code “NO” only if episode is due to a
substance/medication.

DETERMINE WHETHER AMOUNT AND DURATION OF USE IS
SUFFICIENT TO CAUSE MANIC SYMPTOMS:

1) Amount or duration is insufficient to cause
manic symptoms:

IF UNKNOWN: How much (SUBSTANCE/MEDICATION) were you
using/taking at the time you began to have (MANIC SXS)?

YES (PRIMARY) [Answer “YES” to A40a]

IF UNKNOWN: For how long had you been [using (SUBSTANCE)/
taking (MEDICATION)?
DETERMINE WHETHER THERE WAS BEEN A PERIOD OF TIME OF
MANIC SXS WHEN NOT USING/TAKING SUBSTANCE/
MEDICATION:
IF UNKNOWN: Were you (high/excited/OWN WORDS) before
you started [using (SUBSTANCE)/taking (MEDICATION)]?
IF UNKNOWN: Have you had a period of time when you
stopped [using (SUBSTANCE]/taking (MEDICATION)]?
IF YES: After you stopped [using (SUBSTANCE)/taking
(MEDICATION)] did the (MANIC SXS) go away or get
better?
IF YES: How long did it take for them to get better? Did
they go away within a month of stopping?
CHECK FOR POSSIBILITY THAT A PRIMARY MANIC EPISODE IS
MORE LIKELY BASED ON PAST HX
IF UNKNOWN: Have you had other episodes of (MANIC SXS)?
IF YES: How many? Were you [using (SUBSTANCE)/ taking
MEDICATION)] at those times?

NO (SUFFICIENT, POSSIBLY SUBSTANCEINDUCED)
2) Determine if manic symptoms prior to
substance/medication use or manic symptoms
persist after stopping substance/medication
YES (PRIMARY) [Answer “YES” to A40a]
NO (MANIA CONFINED TO SUBSTANCE USE),
POSSIBLY SUBSTANCE-INDUCED

3) Check for prior non-substance-induced
manic episodes:
YES (POSSIBLY PRIMARY) [APPLY CLINICAL
JUDGEMENT]
NO (ALL EPISODES SUBSTANCE-RELATED)
[Answer “NO” to A40a]

MANIC EPISODE
PAST YEAR
Continue with
A53, page 20.

SCID-5MSMH

Manic Episode Past Year

IF DUE TO A MEDICAL CONDIITON OR SUBSTANCE: Has there been any other time during the past year when you were
(high/irritable/OWN WORDS) and had (ACKNOWLEDGED MANIC SXS) and you were not (ill with GMC/using SUBSTANCE)?
IF YES: Go back to A29, page 15, and ask about that episode
IF NO: Continue with A53, page 20 (Consider Assessment of Manic Episodes prior to past year)

Page 19

SCID-5MSMH

A53

Manic Episode Prior to Past Year

Page 20

CONSIDER ASSESSMENT OF MANIC EPISODES PRIOR TO PAST YEAR (ONLY IF MAJOR DEPRESSIVE EPISODES IN PAST YEAR
ONE OR MORE MAJOR DEPRESSIVE EPISODES IN PAST YEAR

NO

YES

Continue
with B1,
Page 26.

MANIC EPISODE PRIOR TO PAST YEAR

A54a

A54b

Prior to the past year, before (ONE YEAR AGO), have you
ever had a period of time when you were feeling so good,
“high,” excited, or “on top of the world” that other people
thought you were not your normal self?

A53

Continue with
A54 (Manic
prior to past
year), below.

MANIC EPISODE CRITERIA
—
PERIOD OF ELEVATED MOOD?
A. A distinct period [lasting at least several days]
of abnormally and persistently elevated,
expansive, or irritable mood and abnormally and
Go to
persistently increased activity or energy.
A54c.

+

—

+

A54a

PLUS INCREASED ENERGY OR ACTIVITY?

A54b

Did you also feel like you were “hyper” or “wired” and had
an unusual amount of energy? Were you much more
active than is typical for you? (Did other people comment
on how much you were doing?) What has it been like?

A54 has been
prepopulated “+”.
Go to A55
—

A54c

A54d

A55

Prior to the past year, have you ever had a period of time
when you were feeling irritable, angry, or short-tempered
for most of the day, for at least several days? (Was that
different from the way you usually are?)

+
A54c

PERIOD OF IRRITATED MOOD?
A54 has been prepopulated
“-“. Go to B1, page 26.

—

+

IF UNKNOWN: Did you also feel like you were “hyper” or
“wired” and had an unusual amount of energy? Were you
much more active than is typical for you? (Did other
people comment on how much you were doing?) What has
it been like?

PLUS INCREASED ENERGY OR ACTIVITY?

How long did this last? (As long as 1 week?)

...lasting at least 1 week and present most of the
day, nearly every day (or any duration if
hospitalization is necessary).

—

NOTE: IF ELEVATED MOOD LASTED LESS THAN
1 WEEK, CHECK WHETHER THERE HAS BEEN A
PERIOD OF IRRITABLE MOOD LASTING AT LEAST
1 WEEK BEFORE SKIPPING TO B1.

Continue
with B1
(psychotic
sxs) page 26.

IF LESS THAN ONE WEEK: Did you need to go into the
hospital to protect you from hurting yourself or
someone else, or from doing something that could have
caused serious financial or legal problems?
Did you feel (high/irritable/OWN WORDS) for most of the
day, nearly every day, during this time?

A54 has been
prepopulated “-“. Go to
B1, page 26.

A54d

A54 has been
prepopulated “+“. Go
to A55.

+

A55

SCID-5MSMH

Manic Episode Prior to Past Year

Have you had more than one time like that prior to the
past year? (Which time was the most intense or caused the
most problems?)

NOTE: If there is evidence for more than one past
episode prior to the past year, select the one with the
most impairment for your inquiry about past Manic
Episode.

FOR A56–A62, FOCUS ON THE MOST SEVERE PERIOD OF THE
WORST EPISODE PRIOR TO THE PAST YEATR THAT YOU ARE
INQUIRING ABOUT.

B. During the period of mood disturbance and
increased energy or activity, three (or more) of the
following symptoms (four if the mood is only
irritable) are present to a significant degree and
represent a noticeable change from usual behavior:

IF UNKNOWN: During (EPISODE), when were you the most
(high/irritable/OWN WORDS)?
A56

A57

Page 21

During that time…
…how did you feel about yourself? (More self-confident
than usual? Did you feel much smarter or better than
everyone else? Did you feel like you had any special
powers or abilities?)

1. Inflated self-esteem or grandiosity.

—

+

A56

…did you need less sleep than usual?
(How much sleep did you get?)

2. Decreased need for sleep (e.g., feels rested after
only 3 hours of sleep).

—

+

A57

3. More talkative than usual or pressure to keep
talking.

—

+

A58

IF YES: Did you still feel rested?
(During the past 12 months)
A58

…were you much more talkative than usual? (Did people
have trouble stopping you or understanding you? Did
people have trouble getting a word in edgewise?)

A59

…were your thoughts racing through your head?
(What was that like?)

4. Flight of ideas or subjective experience that
thoughts are racing.

—

+

A59

A60

…were you so easily distracted by things around you that
you had trouble concentrating or staying on one track?
(Give me an example of that.)

5. Distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external stimuli), as
reported or observed.

—

+

A60

SCID-5MSMH

Manic Episode Prior to Past Year

Page 22

(During the past 12 months)
A61

...how did you spend your time? (Work, friends, hobbies?
Were you especially busy during that time?)

6. Increase in goal-directed activity (either socially, at
work or school, or sexually) or psychomotor agitation
(i.e., purposeless non-goal-directed activity).

—

+

A61

7. Excessive involvement in activities that have a high
potential for painful consequences (e.g., engaging in
unrestrained buying sprees, sexual indiscretions, or
foolish business investments).

—

+

A62

NO

YES

A63

(Did you find yourself more enthusiastic at work or working
harder at your job? Did you find yourself more engaged in
school activities or studying harder?)
(Were you more sociable during that time, such as calling
on friends or going out with them more than you usually do
or making a lot of new friends?)
(Were you spending more time thinking about sex or
involved in doing something sexual, by yourself or with
others? Was that a big change for you?)
Were you physically restless during this time, doing things
like pacing a lot, or being unable to sit still?
(How bad was it?)
(During the past 12 months)
A62

...did you do anything that could have caused trouble for
you or your family?
(Spending money on things you didn’t need or couldn’t
afford? How about giving away money or valuable things?
Gambling with money you couldn’t afford to lose?)
(Anything sexual that was likely to get you in trouble?
Driving recklessly?)
(Did you make any risky or impulsive business investments
or get involved in a business scheme that you wouldn’t
normally have done?)

AT LEAST THREE OF THE ABOVE CRITERION B SXS
(A56–A62) ARE RATED “+” (FOUR IF MOOD ONLY
IRRITABLE).

A63

IF FEWER THAN THREE (FOUR IF MOOD ONLY IRRITABLE) AND NOT ALREADY ASKED: Have there been any other times prior
to the past year when you were (high/irritable/OWN WORDS) and had even more of the symptoms that I just asked you
about?
IF YES: Go back to A54, page 20, and ask about that episode.
IF NO: Continue with B1 (Psychotic sxs), page 26

Continue
with A64
(Criterion C),
next page.

SCID-5MSMH
A64

Manic Episode Prior to Past Year

IF UNCLEAR: What effect did (MANIC SXS) have on your life?
IF UNKNOWN: Did you need to go into the hospital to
protect you from hurting yourself or someone else, or from
doing something that could have caused serious financial
or legal problems?

C. The mood disturbance is sufficiently severe to
cause marked impairment in social or occupational
functioning or to necessitate hospitalization to
prevent harm to self or others, or there are psychotic
features.

ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How did (MANIC SXS) affect your relationships or your
interactions with other people? (Did [MANIC SXS] cause
you any problems in your relationships with your family,
romantic partner, or friends?)

Page 23

—

+

Continue
with A65,
next page.

How did (MANIC SXS) affect your work/school? (How about
your attendance at work/school? Did [MANIC SXS] make it
more difficult to do your work/schoolwork)? Did [MANIC
SXS] affect the quality of your work/schoolwork?)
How did (MANIC SXS) affect your ability to take care of
things at home?
IF MOOD DISTURBANCE WAS NOT SEVERE ENOUGH TO CAUSE MARKED IMPARIMENT OR NECESSITATE HOSPITALIZATION AND NOT
ALREADY ASKED: Has there been any other time prior to the past year when you were (high/irritable/OWN WORDS) and had
(ACKNOWLEDGED MANIC SXS) and you got into trouble with people or were hospitalized?
IF YES: Go back to A54, page 20, and ask about that episode.
IF NO: Continue with B1 (Psychotic sxs), page 26

A64

SCID-5MSMH
A65

Manic Episode Prior to Past Year

IF UNKNOWN: When did this period of being
(high/irritable/OWN WORDS) begin?
Just before this began, were you physically ill?

D. [Primary Manic Episode] The episode is not
attributable to the physiological effects of another
medical condition…
Refer to page 71 for a list of possibly etiological
medical conditions
NOTE: Code “NO” only if episode is due to a GMC

Page 24

NO

YES

A65

PRIMARY

IF YES: What did the doctor say?
Just before this began, were you taking any medications?
A65a
IF ALREADY ON MEDICATION WHEN EPISODE BEGAN:
Any change in the amount you were taking?
Just before this began, were you drinking or using any
street drugs?
IF ALREADY DRINKING OR USING DRUGS WHEN EPISODE
BEGAN: Any change in the amount you were taking?
IF TAKING SUBSTANCE THAT CAN CAUSE MANIC-LIKE SXS
DURING WITHDRAWAL: Had you recently cut down or
stopped taking (drug)?

D. [Primary Manic Episode] The episode is not
attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication, other
treatment)
Refer to page 71 for a list of possibly etiological
substances/medications.
Note: A full Manic Episode that emerges during
antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a fully
syndromal level beyond the physiological effect of
that treatment is sufficient evidence for a Manic
Episode and, therefore, a Bipolar I [Disorder]
diagnosis.
NOTE: Code “NO” only if episode is due to a
substance/medication.

DETERMINE WHETHER AMOUNT AND DURATION OF USE IS
SUFFICIENT TO CAUSE MANIC SYMPTOMS:

1) Amount or duration is insufficient to cause
manic symptoms:

IF UNKNOWN: How much (SUBSTANCE/MEDICATION) were you
using/taking at the time you began to have (MANIC SXS)?

YES (PRIMARY) [Answer “YES” to A65]

IF: UNKNOWN: For how long had you been [using
(SUBSTANCE)/ taking (MEDICATION)?
DETERMINE WHETHER THERE WAS BEEN A PERIOD OF TIME OF
MANIC SXS WHEN NOT USING/TAKING SUBSTANCE/
MEDICATION:
IF UNKNOWN: Were you (high/excited/OWN WORDS) before
you started [using (SUBSTANCE)/taking (MEDICATION)]?
IF UNKNOWN: Have you had a period of time when you
stopped [using (SUBSTANCE}/taking (MEDICATION)]?
IF YES: After you stopped [using (SUBSTANCE)/taking
(MEDICATION)] did the (MANIC SXS) go away or get
better?
IF YES: How long did it take for them to get better? Did
they go away within a month of stopping?
CHECK FOR POSSIBILITY THAT A PRIMARY MANIC EPISODE IS
MORE LIKELY BASED ON PAST HX
IF UNKNOWN: Have you had other episodes of (MANIC SXS)?
IF YES: How many? Were you [using (SUBSTANCE)/ taking
MEDICATION)] at those times?

NO (SUFFICIENT, POSSIBLY SUBSTANCEINDUCED)
2) Determine if manic symptoms prior to
substance/medication use or manic symptoms
persist after stopping substance/medication
YES (PRIMARY) [Answer “YES” to A65]
NO (MANIA CONFINED TO SUBSTANCE USE),
POSSIBLY SUBSTANCE-INDUCED

3) Check for prior non-substance-induced
manic episodes:
YES (POSSIBLY PRIMARY) [APPLY CLINICAL
JUDGEMENT[
NO (ALL EPISODES SUBSTANCE-RELATD)
[Answer “NO” to A65]

MANIC EPISODE
PRIOR TO THE
PAST YEAR
Continue with
A66, next page.

SCID-5MSMH
A66

Manic Episode Prior to Past Year

IF DUE TO MEDICAL CONIDITON OR SUBSTANCE: Has there been any other time during the past year when you were
(high/irritable/OWN WORDS) and had (ACKNOWLEDGED MANIC SXS) and you were not (ill with GMC/using SUBSTANCE)?
IF YES: Go back to A54, page 20, and ask about that episode
IF NO: Continue with B1 (Psychotic sxs), page 26.

Page 25

SCID-5MSMH

Psychotic and Associated Symptoms

Page 26

B. PSYCHOTIC AND ASSOCIATED SYMPTOMS
FOR ANY PSYCHOTIC AND ASSOCIATED SYMPTOMS THAT ARE PRESENT, DETERMINE WHETHER THE SYMPTOM IS DEFINITELY
“PRIMARY” (I.E., DUE TO A PSYCHOTIC DISORDER) OR WHETHER THERE IS A POSSIBLE OR DEFINITE ETIOLOGICAL GMC OR
SUBSTANCE/MEDICATION. (REFER TO PAGE 71 FOR A LIST OF ETIOLOGICAL GMCs OR SUBSTANCES/MEDICATIONS.) THIS
INFORMATION WILL BE USEFUL IN DIFFERENTIATING A PRIMARY PSYCHOTIC DISORDER FROM A PSYCHOTIC DISORDER DUE TO AMC
OR SUBSTANCE/MEDICATION-INDUCED PSYCHOTIC DISORDER IN MODULE C.
THE FOLLOWING QUESTIONS MAY BE USEFUL FOR THIS DETERMINATION IF THE OVERVIEW HAS NOT ALREADY PROVIDED THE
INFORMATION:
Just before (PSYCHOTIC SXS) began, were you using drugs? IF YES: What were you using?
...On any medications? IF YES: What were you taking?
...Did you drink much more than usual or stop drinking after you had been drinking a lot for a while?
...Were you physically ill?
IF YES TO ANY: Has there been a time when you had (PSYCHOTIC SXS) and were not (using [DRUG]/taking [MEDICATION]/changing
your drinking habits/physically ill)?
[IF UNBLINDPSYCHOS1 = YES] In your earlier interview you mentioned that a health professional said you had schizophrenia or
schizoaffective disorder, I’d like to ask you some more questions about this.
[IF UNBLINDPSYCHOS2 = YES] In your earlier interview you mentioned that you received disability payments because of a
schizophrenia or schizoaffective disorder diagnosis, I’d like to ask you some more questions about this.
[IF UNBLINDPSYCHOS3 = YES] In your earlier interview you mentioned having one or more unusual experiences in your life. I’d like to
ask you some more questions about those experiences.
[ELSE] Now I am going to ask you about unusual experiences that people sometimes have.
DELUSIONS
A false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and
despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by
other members of the person’s culture or subculture (i.e., it is not an article of religious faith). When a false belief involves a value
judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility.
NOTE: Code overvalued ideas (unreasonable and sustained beliefs that are maintained with less than delusional intensity) as “—”.

B1

Has it ever seemed like people were talking about you or
taking special notice of you? (What do you think they were
saying about you?)
IF YES: Were you convinced they were talking about
you or did you think it might have been your
imagination?
Did you ever have the feeling that something on the radio,
TV, or in a movie was meant especially for you? (Not just
that it was particularly relevant to you, but that it was
specifically meant for you.)
Did you ever have the feeling that the words in a popular
song were meant to send you a special message?
Did you ever have the feeling that what people were
wearing was intended to send you a special message?
Did you ever have the feeling that street signs or billboards
had a special meaning for you?

Delusion of reference (i.e., a belief that events,
objects, or other people in the individual’s immediate
environment have a particular or unusual
significance)
DESCRIBE:

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B1

B1a

SCID-5MSMH

B2

Psychotic and Associated Symptoms

What about anyone going out of their way to give you a
hard time, or trying to hurt you? (Tell me about that.)
Have you ever had the feeling that you were being
followed, spied on, manipulated, or plotted against?

Persecutory delusion (i.e., a belief that the individual
[or his or her group] is being attacked, harassed,
cheated, persecuted, or conspired against)
DESCRIBE:

Did you ever have the feeling that you were being poisoned
or that your food had been tampered with?
B3

B4

Have you ever thought that you were especially important
in some way, or that you had special powers or
knowledge? (Tell me about that.)

Grandiose delusion (i.e., content involves
exaggerated power, knowledge or importance, or a
special relationship to a deity or famous person)

Did you ever believe that you had a special or close
relationship with a celebrity or someone else famous?

DESCRIBE:

Have you ever been convinced that something was very
wrong with your physical health even though your doctor
said nothing was wrong...like you had cancer or some other
disease? (Tell me about that.)

Somatic delusion (i.e., content involves change or
disturbance in body appearance or functioning)
DESCRIBE:

Have you ever felt that something strange was happening
to parts of your body?

B5

Have you ever felt that you had committed a crime or done
something terrible for which you should be punished? (Tell
me about that.)
Have you ever felt that something you did, or should have
done but did not do, caused serious harm to your parents,
children, other family members, or friends? (Tell me about
that.)

Delusion of guilt (i.e., a belief that a minor error in
the past will lead to disaster, or that he or she has
committed a horrible crime and should be punished
severely, or that he or she is responsible for a
disaster [e.g., an earthquake or fire] with which there
can be no possible connection)

Page 27

—

+

Code “+” if
primary, “-“
otherwise:
—
+

—

+

Code “+” if
primary, “-“
otherwise:
—
+
—

+

Code “+” if
primary, “-“
otherwise:
—
+

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B2

B2a

B3

B3a

B4

B4a

B5

B5a

DESCRIBE:

What about feeling responsible for a disaster such as a fire,
flood, or earthquake? (Tell me about that.)

B6

Have you ever been convinced that your spouse or partner
was being unfaithful to you?

Jealous delusion (i.e., a belief that one’s sexual
partner is unfaithful)

IF YES: How did you know he/she was being unfaithful?
(What clued you into this?)

DESCRIBE:
LEAVE ITEM BLANK IF NO SPOUSE OR PARTNER

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B6

B6a

SCID-5MSMH

B7

Psychotic and Associated Symptoms

Are you a religious or spiritual person?
IF YES: Have you ever had any religious or spiritual
experiences that the other people in your religious or
spiritual community have not experienced?

Religious delusion (i.e., a delusion with a religious or
spiritual content)

DESCRIBE:

IF YES: Tell me about your experiences. (What did
they think about these experiences of yours?)

Page 28

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B7

B7a

IF NO: Have you ever felt that God, the devil, or
some other spiritual being or higher power has
communicated directly with you? (Tell me about
that. Do others in your religious or spiritual
community also have such experiences?)
IF NO: Have you ever felt that God, or the devil or
some other spiritual being or higher power has
communicated directly with you? (Tell me about that.
Do others in your religious or spiritual community also
have such experiences?)

B8

B9

Did you ever have a “secret admirer” who, when you tried
to contact them, denied that they were in love with you?
(Tell me about that.)

Erotomaniac delusion (i.e., a belief that another
person, usually of higher status, is in love with the
individual)

Were you ever romantically involved with someone
famous? (Tell me about that.)

DESCRIBE:

Did you ever feel that someone or something outside
yourself was controlling your thoughts or actions against
your will? (Tell me about that.)

Delusion of being controlled (i.e., feelings, impulses,
thoughts, or actions are experienced as being under
the control of some external force rather than under
one’s own control)
DESCRIBE:

B10

Did you ever feel that certain thoughts that were not your
own were put into your head? (Tell me about that.)

Thought insertion (i.e., a belief that certain thoughts
are not one’s own, but rather are inserted into one’s
mind)
DESCRIBE:

B11

What about thoughts being taken out of your head? (Tell
me about that.)

Thought withdrawal (i.e., a belief that one’s
thoughts have been “removed” by some outside
force)
DESCRIBE:

B12

Did you ever feel as if your thoughts were being broadcast
out loud so that other people could actually hear what you
were thinking? (Tell me about that.)

Thought broadcasting (i.e., a delusion that one’s
thoughts are being broadcast out loud so that others
can perceive them)
DESCRIBE:

—

+

Code “+” if
primary, “-“
otherwise:
—
+
—

+

Code “+” if
primary, “-“
otherwise:
—
+
—

+

Code “+”if
primary, “-“
otherwise:
—
+
—

+

Code “+” if
primary, “-“
otherwise:
—
+
—

+

Code “+” if
primary, “-“
otherwise:
—
+

B8

B8a

B9

B9a

B10

B10a

B11

B11a

B12

B12a

SCID-5MSMH

B13

Psychotic and Associated Symptoms

Did you ever believe that someone could read your mind?
(Tell me about that.)

Other delusions (e.g., a belief that others can read
the person’s mind, a delusion that one has died
several years ago)
DESCRIBE:

Page 29

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B13

B13a

HALLUCINATIONS
A perception-like experience with the clarity and impact of a true perception, but without the external stimulation of the relevant
sensory organ. The person may or may not have insight into the nonveridical nature of the hallucination (i.e., one hallucinating person
may recognize the false sensory experience, whereas another may be convinced that the experience is grounded in reality).
NOTE: Code “—” for hallucinations that are so transient as to be without diagnostic significance.
Code “—” for hypnagogic or hypnopompic hallucinations occurring only when falling asleep or upon awakening, respectively.

B14

Did you ever hear things that other people couldn’t, such
as noises, or the voices of people whispering or talking?
(Were you awake at the time?)

Auditory hallucinations (i.e., a hallucination involving
the perception of sound, most commonly of voice,
when fully awake, heard either inside or outside of
one’s head)

IF YES: What did you hear? How often did you hear it?
DESCRIBE:
B15

Did you have visions or see things that other people
couldn’t see? (Tell me about that. Were you awake at the
time?)

Visual hallucinations (i.e., a hallucination involving
sight, which may consist of formed images, such as of
people, or of unformed images, such as flashes of
light)
NOTE: Distinguish from an illusion (i.e., a
misperception of a real external stimulus).
DESCRIBE:

—

+

Code “+” if
primary, “-“
otherwise:
—
+
—

+

Code “+” if
primary, “-“
otherwise:
—
+

B14

B14a

B15

B15a

SCID-5MSMH

Psychotic and Associated Symptoms

Page 30

DISORGANIZED SPEECH AND BEHAVIOR AND CATATONIA
(Let me stop for a minute while I make a few notes...)

ARE YOU CURRENTLY INTERVIEWING A SECONDARY INFORMANT OR HAVE YOU CODED ANY PSYCHOTIC AND ASSOCIATED SYMPTOMS
POSITIVELY DURING THE INTERVIEW WITH THE PRIMARY RESPONDENT?”
Yes→ continue
No→ IF NO go to B23, page 33

IF NOT INTERVIEWING SECONDARY INFORMANT, THEN SCORE BASED ON OBSERVATIONS DURING INTERVIEW WITH PRIMARY
RESPONDENT.
IF INTERVIEWING SECONDARY INFORMANT, THEN ASK:
Just before (PSYCHOTIC SXS) began, was (PRIMARY RESPONDENT) using drugs? IF YES: What was (PRIMARY RESPONDENT) using?
...on any medications? IF YES: What was (PRIMARY RESPONDENT) taking?
...did (PRIMARY RESPONDENT) drink much more than usual or stop drinking after they had been drinking a lot for a while?
... was (PRIMARY RESPONDENT) physically ill?
IF YES TO ANY: Has there been a time when (PRIMARY RESPONDENT) had (PSYCHOTIC SXS) and was not (using [DRUG]/taking
[MEDICATION]/changing their drinking habits/physically ill)?

B20

Note: The ratings of lifetime disorganized speech will almost
always be based on the observations by untrained secondary
informants.
IF NOT INTERVIEWING SECONDARY INFORMANT, THEN
SCORE BASED ON OBSERVATIONS DURING INTERVIEW WITH
PRIMARY RESPONDENT.
IF INTERVIEWING SECONDARY INFORMANT, THEN ASK: Has
(PRIMARY RESPONDENT) ever had periods in which his /her
speech was very difficult to follow because he/she would
jump from one topic to a completely unrelated topic or
because it consisted of words strung together and that did
not make any sense? Tell me about this. Did you have a lot
of trouble understanding him/her because of this?

B21

Note: The ratings of lifetime disorganized speech will almost
always be based on the observations of untrained secondary
informants.
IF NOT INTERVIEWING SECONDARY INFORMANT, THEN
SCORE BASED ON OBSERVATIONS DURING INTERVIEW WITH
PRIMARY RESPONDENT.
IF INTERVIEWING SECONDARY INFORMANT, THEN ASK: Has
(PRIMARY RESPONDENT) ever had periods in which he/she
would become agitated and repeatedly shout or swear for
no apparent reason? How about periods in which
(RESPONDENT) appeared very disheveled or was dressed in
an unusual manner, like wearing multiple overcoats,
scarves and gloves on a hot day?

DISORGANIZED SPEECH: The individual may switch
from one topic to another (derailment or loose
associations). Answers to questions may be
obliquely related or completely unrelated
(tangentiality). Rarely, speech may be so severely
disorganized that it is nearly incomprehensible and
resembles receptive aphasia in its linguistic
disorganization (incoherence or “word salad”).
Because mildly disorganized speech is common and
nonspecific, the symptom must be severe enough to
substantially impair effective communication.

—

+

B20

Code “+” if
primary, “-“
otherwise:
—
+

DESCRIBE:

GROSSLY DISORGANIZED BEHAVIOR: May range
from childlike silliness to unpredictable agitation. The
person may appear markedly disheveled, may dress
in an unusual manner (e.g., wearing multiple
overcoats, scarves, and gloves on a hot day), or may
display clearly inappropriate sexual behavior
(e.g., public masturbation) or unpredictable and
untriggered agitation (e.g., shouting or swearing).
DESCRIBE:

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B21

B21a

SCID-5MSMH

B22

Psychotic and Associated Symptoms

Note: The ratings of lifetime catatonia items will almost
always be based on the observations by untrained secondary
informants whose ability to describe them in sufficient detail
so as to allow the rater to accurately differentiate among
them is likely to be quite limited. Consequently, these
symptoms have been grouped together by similar
phenomenology, with suggested questions provided for
inquiry.

CATATONIC BEHAVIOR

IF NOT INTERVIEWING SECONDARY INFORMANT, THEN
SCORE BASED ON OBSERVATIONS DURING INTERVIEW WITH
PRIMARY RESPONDENT.

Little or no psychomotor activity or verbal
responses

IF INTERVIEWING SECONDARY INFORMANT, THEN ASK: Has
(PRIMARY RESPONDENT) ever had periods in which he/she
completely stopped moving or talking or would not
respond to anything you said to him/her? Tell me about
that.

—

Code “+” if
primary, “-“
otherwise:

Stupor (i.e., no psychomotor activity; not actively
relating to environment)
Mutism (i.e., no, or very little, verbal response
[exclude if known aphasia])

Maintenance of Unusual postures against gravity
Posturing (i.e., spontaneous, and active
maintenance of a posture against gravity)
Catalepsy (i.e., passive induction of a posture held
against gravity)
Waxy flexibility (i.e., slight, even resistance to
positioning by examiner)

Excessive movement or behavior
Has (PRIMARY RESPONDANT) ever had periods in which
(he/she) would become and stay agitated for a long period
of time for no apparent reason?
Has (PRIMARY RESPONDANT) ever had periods in which
(he/she) would repeat the same action again and again for
no apparent reason? Has (PRIMARY RESPONDANT) ever had
periods in which (he/she) would make exaggerated facial
expressions of disgust for no good reason?
Has (PRIMARY RESPONDANT) ever had periods in which
(he/she) would carry out normal actions but in an
exaggerated way?

+

B22

Code ‘+ if at least two of the below symptoms are
present

Negativism (i.e., opposition or no response to
instructions or external stimuli)

Has (PRIMARY RESPONDANT) ever had periods in which
(he/she) would assume a rigid pose or hold up an arm or
leg against gravity for a long period of time? Tell me about
that.

Page 31

Agitation, not influenced by external stimuli
Stereotypy (i.e., repetitive, abnormally frequent,
non-goal-directed movements)
Odd facial expressions or movements
Grimacing (i.e., odd and inappropriate facial
expressions unrelated to situation)
Mannerism (i.e., odd, circumstantial caricature of
normal actions)

—

+

B22a

SCID-5MSMH

Psychotic and Associated Symptoms

Mimicking speech or actions
Has (PRIMARY RESPONDANT) ever had periods in which
(he/she) would mimic other people’s speech or
movements?

Echolalia (i.e., mimicking another’s speech)
Echopraxia (i.e., mimicking another’s movements)
DESCRIBE:

Page 32

SCID-5MSMH

Psychotic and Associated Symptoms

Page 33

NEGATIVE SYMPTOMS
For any negative symptoms rated “+”, determine whether the symptom is definitely primary (i.e., due to a Psychotic Disorder) or
whether it is possibly or definitely secondary—i.e., related to another mental disorder (e.g., depression), a substance or a GMC (e.g.,
medication-induced akinesia), or a psychotic symptom (e.g., command hallucinations not to move).

B23

RATE THIS ITEM BASED ON INFORMATION OBTAINED FROM
THE OVERVIEW.
IF UNKNOWN: Has there been a period of time lasting at
least several months when you were not working, not in
school, or doing much of anything?

Avolition: An inability to initiate and persist in goaldirected activities. When severe enough to be
considered pathological, avolition is pervasive and
prevents the person from completing many different
types of activities (e.g., work, intellectual pursuits,
self-care).

IF UNKNOWN: How about a period of time when you were
unable to take care of basic everyday things, like brushing
your teeth or bathing?

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B23

B23a

IF NO: Did anyone ever say that you were not taking
care of these or other basic everyday things?

B24

Diminished Emotional Expressiveness: Includes
reductions in the expression of emotions in the face,
eye contact, intonation of speech (prosody), and
movements of the hand, head, and face that
normally give an emotional emphasis to speech.

—

+

Code “+” if
primary, “-“
otherwise:
—
+

Continue with C1
(Differential Diagnosis
of Psychotic Disorders),
next page.

B24

B24a

SCID-5MSMH

Differential Diagnosis of Psychotic Disorders

Page 34

C. DIFFERENTIAL DIAGNOSIS OF PSYCHOTIC DISORDERS
If no primary psychotic items from Module B have ever been present, skip to D1 (Differential Diagnosis of Mood Disorders), page 36.
C1

Note: for the following items, only include psychotic symptoms in Module B that have been rated to be primary.

Psychotic symptoms occur at times other than during Major Depressive or Manic Episodes
IF A MAJOR DEPRESSIVE OR MANIC EPISODE HAS EVER BEEN PRESENT:
Has there ever been a time when you had (PSYCHOTIC SXS) and you were not
(depressed/high/irritable/OWN WORDS)?
That is, have you only had (PSYCHOTIC SXS) during times when you have been
(depressed/high/irritable/OWN WORDS)?

YES

NO

SCHIZOPHRENIA CRITERION A
C2

Psychotic Mood Disorder
Go to D1 (Differential Diagnosis of
Mood Disorders), page 36.

C1

Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
At least one of these must be (1), (2), or (3):
1. Delusions [B1–B13].
2. Hallucinations [B14–B15].
3. Disorganized speech (e.g., frequent derailment or incoherence) [B20].
4. Grossly disorganized or catatonic behavior [B21–B22].
5. Negative symptoms (i.e., diminished emotional expression or avolition) [B23–B24].
NO: Consider rating “NO” if the only symptoms are delusions accompanied by tactile and/or olfactory hallucinations that are
thematically related to the content of the delusions (which is consistent with a diagnosis of Delusional Disorder).
YES

NO

SCHIZOPHRENIA CRITERION C
C4

Go to D1 (Differential
Diagnosis of Mood Disorders),
page 36.

C2

Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms
(or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or
residual symptoms.
Prodromal/residual symptoms include:
- Unusual or odd beliefs that are not of delusional proportions (e.g., ideas of reference or magical thinking);
- Unusual perceptual experiences (e.g., sensing the presence of an unseen person);
- Speech that is generally understandable but digressive, vague, or overelaborate
- Behavior that is unusual but not grossly disorganized (e.g., collecting garbage, talking to self in public, hoarding food)
- Negative symptoms (e.g., marked impairment in personal hygiene and grooming; marked lack of initiative, interests, or energy)
- Blunted or inappropriate affect
- Marked social isolation or withdrawal

YES

NO

Go to C8 (Assessment of
Schizophreniform/ Schizoaffective
Disorder), next page

C4

SCID-5MSMH

Differential Diagnosis of Psychotic Disorders

Page 35

Active-phase criteria (except duration) met at some
point in the past year,

C6
IF UNCLEAR: During the past year, since (ONE YEAR AGO),
have you had (PSYCHOTIC SXS)?

NO

YES
C6

Past Hx

Past yr

OR A major mood episode (Major Depressive or
Manic) concurrent with Criterion A of
Schizophrenia at some point in past year
Diagnose: Schizophrenia or Schizoaffective Disorder.
Check here ___ if onset after January 2020. Continue
with D1 (Differential Diagnosis of Mood Disorders), page
36

Active-phase criteria (except duration) met at some
point in the past year,

C8
IF UNCLEAR: During the past year, since (ONE YEAR AGO),
have you had (PSYCHOTIC SXS)?

NO

Past Hx

C6a

YES
C8
Past yr

OR A major mood episode (Major Depressive or
Manic) concurrent with Criterion A of
Schizophrenia at some point in past year
Diagnose: Schizophreniform or Schizoaffective Disorder.
Check here ___ if onset after January 2020. Continue
with D1 (Differential Diagnosis of Mood Disorders), next
page.

C8a

SCID-5MSMH

Differential Diagnosis of Mood Disorders

Page 36

D. DIFFERENTIAL DIAGNOSIS OF MOOD DISORDERS
D1

If there have never been any clinically significant mood symptoms go to E1 (Substance Use Disorders), page 38 Otherwise continue
with D2.

D1

CRITERIA FOR BIPOLAR I DISORDER
D2

A. Criteria have been met for at least one Manic Episode either during the past year or prior to the past year [A40/A65].

YES

D3

NO

Go to D11 (Criteria for MDD)

B. At least one Manic Episode(s) is not better explained by, and is not superimposed on, Schizophrenia/Schizoaffective Disorder.

YES

NO

D2

D3

Go to D11 (Criteria for MDD)

BIPOLAR I DISORDER
Continue with D17 (Bipolar I Chronology), next page.

CRITERIA FOR MAJOR DEPRESSIVE DISORDER
D11

A.–C. At least one Major Depressive Episode (A12) in the past year.

YES

D11

NO
Go to E1 (Substance Use Disorder) page 38.

D12

D. The Major Depressive Episode is not better explained by, and is not superimposed on, Schizophrenia/Schizoaffective Disorder.

YES

NO

D12

Go to E1 (Substance Use Disorders) page 38.

E. There has never been a Manic Episode. [Note: DSM-5 also requires that there has never been a hypomanic episode as well]
D13

D13
Note: This exclusion does not apply if all of the manic-like episodes are substance/medication-induced or are attributable to the
physiological effects of another medical condition.

YES

NO
MAJOR DEPRESSIVE DISORDER
Check here ____ if onset after January 2020
Continue with D24 (Depressive Chronology), next page

Bipolar I Disorder should have been previously
diagnosed. Go back to D2 (Criteria for Bipolar I
Disorder), above.

D13a

SCID-5MSMH

Differential Diagnosis of Mood Disorders

Page 37

MOOD CHRONOLOGY
D17

For BIPOLAR I DISORDER,

Has met symptomatic criteria for a Manic Episode in the
past year

NO

YES
D17

Diagnose: Bipolar I Disorder, manic. Check here ___ if onset after January 2020
Continue with E1 (Substance Use Disorders), next page.
Has met symptomatic criteria for a Major Depressive
Episode in the past year and for a Manic Episode prior to
the past year (bipolar depression)

D17a
NO

YES

D18

Diagnose: Bipolar I Disorder, depressed / Check here ___ if onset after January 2020
Continue with E1 (Substance Use Disorders), next page.

D18a

D24

For MAJOR DEPRESSIVE DISORDER:

Has met symptomatic criteria for a Major Depressive
Episode in the past year.

Diagnose: Major Depressive Disorder Check here ___ if onset after January 2020
Continue with E1 (Substance Use Disorders), next page.

NO

YES

D24

D24a

SCID-5MSMH

Alcohol Use Disorder

Page 38

E. SUBSTANCE USE DISORDERS
Alcohol Use Disorder (Past 12 Months)
IF E1 in Overview is coded “YES” i.e., at least six drinking events in past year), continue with E2. Otherwise, continue
with E23 (Nonsubstance User Disorder), page 42.
PAST-12-MONTH ALCOHOL USE DISORDER

I’d now like to ask you some more questions about your
drinking habits over the past 12 months, since
(ONE YEAR AGO)….
When were you drinking the most? During
that time, how much were you drinking?
What were you drinking? Beer? Wine? Hard
liquor? How often were you drinking that
much?

E2

E1

ALCOHOL USE DISORDER CRITERIA

A. A problematic pattern of alcohol use leading to
clinically significant impairment or distress, as
manifested by at least two of the following occurring
within a 12-month period:

During the past 12 months…
…have you found that once you started drinking you ended
up drinking much more than you intended to? For example,
you planned to have only one or two drinks but you ended
up having many more. (Tell me about that. How often did
this happen?)

1. Alcohol is often taken in larger amounts OR over a
longer period than was intended.

—

+

E2

2. There is a persistent desire OR unsuccessful efforts
to cut down or control alcohol use.

—

+

E3

3. A great deal of time is spent in activities necessary
to obtain alcohol, use alcohol, or recover from its
effects.

—

+

E4

4. Craving, or a strong desire or urge to use alcohol.

—

+

E5

IF NO: What about drinking for a much longer period of
time than you were intending to?
(During the past 12 months)
E3

…have you wanted to stop, cut down, or control your
drinking?
IF YES: How long did this desire to stop, cut down, or
control your drinking last?
IF NO: During the past 12 months, did you ever try to
cut down, stop, or control your drinking? How
successful were you? (Did you make more than one
attempt to stop, cut down, or control your drinking?)

E4

…have you spent a lot of time drinking, being drunk, or
hung over? (How much time?)

(During the past 12 months)
E5

…have you had a strong desire or urge to drink In between
those times when you were drinking? (Has there been a
time when you had such strong urges to have a drink that
you had trouble thinking about anything else?)
IF NO: How about having a strong desire or urge to
drink when you were around bars or around people
with whom you go drinking?

SCID-5MSMH

E6

Alcohol Use Disorder

Page 39

During the past 12 months, since (ONE YEAR AGO)…
…have you missed work or school or often arrived late
because you were intoxicated, high, or very hung over?
IF NO: How about doing a bad job at work or school, or
failing courses or getting kicked out of school because
of your drinking?

E6
5. Recurrent alcohol use resulting in a failure to fulfill
major role obligations at work, school, or home [e.g.,
repeated absences or poor work performance
related to alcohol use; alcohol-related absences,
suspensions, or expulsions from school; neglect of
children or household].

—

+

6. Continued alcohol use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of alcohol [e.g.,
arguments with spouse about consequences of
intoxication, physical fights].

—

+

E7

7. Important social, occupational, or recreational
activities are given up or reduced because of alcohol
use.

—

+

E8

8. Recurrent alcohol use in situations in which it is
physically hazardous [e.g., driving an automobile or
operating a machine when impaired by alcohol use].

—

+

E9

9. Alcohol use is continued despite knowledge of
having a persistent or recurrent physical or
psychological problem that is likely to have been
caused or exacerbated by alcohol [e.g., continued
drinking despite recognition that an ulcer was made
worse by alcohol consumption].

—

+

E10

IF NO: How about getting into trouble at work or
school because of your use of alcohol?
IF NO: How about not taking care of things at
home because of your drinking, like making
sure there are food and clean clothes for your
family and making sure your children go to
school and get medical care? How about not
paying your bills?
IF YES TO ANY: How often?
(During the past 12 months)
E7

…has your drinking caused problems with other people,
such as family members, friends, or people at work? (Have
you found yourself regularly getting into arguments about
what happens when you drink too much? Have you gotten
into physical fights when you were drunk?)
IF YES: Did you keep on drinking anyway? (Over what
period of time?)

E8

…have you had to give up or reduce the time you spent at
work or school, with family or friends, or on things you like
to do (like sports, cooking, other hobbies) because you
were drinking or hungover?
(During the past 12 months)

E9

…have you ever had a few drinks right before doing
something that requires coordination and concentration
like driving, boating, climbing on a ladder, or operating
heavy machinery?
IF YES: Would you say that the amount you had to drink
affected your coordination or concentration so that it
was more likely that you or someone else could have
been hurt?
IF YES AND UNKNOWN: How many times? (When?)
(During the past 12 months)

E10

…has your drinking caused you any problems like making
you very depressed or anxious? How about putting you in
a “mental fog,” making it difficult for you to sleep, or
making it so you couldn’t recall what happened while you
were drinking?

SCID-5MSMH

Alcohol Use Disorder

Page 40

Has your drinking caused significant physical problems or
made a physical problem worse, like stomach ulcers, liver
disease, or pancreatitis?
IF YES TO EITHER OF ABOVE: Did you keep on drinking
anyway?
E11

During the past 12 months, since (ONE YEAR AGO)…
…have you ever found that you needed to drink much more
in order to get the feeling you wanted than you did when
you first started drinking?

10. Tolerance, as defined by either of the following:

—

+

—

+

E11

a. A need for markedly increased amounts of
alcohol to achieve intoxication or desired effect.

IF YES: How much more?
IF NO: What about finding that when you drank the
same amount, it had much less effect than before?
(How much less?)

b. A markedly diminished effect with continued
use of the same amount of alcohol.

(during the past 12 months…)
E12

…have you ever had any withdrawal symptoms, in other
words felt sick when you cut down or stopped drinking?
IF YES: What symptoms did you have?
(Sweating or a racing heart? Your hand[s] shaking?
Trouble sleeping? Feeling nauseated or vomiting?
Feeling agitated? Feeling anxious? How about having a
seizure or seeing, feeling, or hearing things that weren’t
really there?)
IF NO: Have you ever started the day with a drink, or
did you often drink or take some other drug or
medication to keep yourself from getting the shakes or
becoming sick?

11. Withdrawal, as manifested by either of the
following:
a. [At least TWO] of the following, developing
within several hours to a few days after the
cessation of (or reduction in) alcohol use that has
been heavy and prolonged:
1. Autonomic hyperactivity (e.g., sweating or
pulse rate greater than 100 bpm)
2. Increased hand tremor
3. Insomnia
4. Nausea or vomiting
5. Transient visual, tactile, or auditory
hallucinations or illusions
6. Psychomotor agitation
7. Anxiety
8. Generalized tonic-clonic seizures
b. Alcohol (or a closely related substance, such as
a benzodiazepine) is taken to relieve or avoid
withdrawal symptoms.

E12

SCID-5MSMH
E13

Alcohol Use Disorder

IF UNCLEAR: When did (ABOVE CRITERION A SXS [E2–E12]
RATED “+”) occur? (Did they all happen within the past
12 months?)

Page 41

AT LEAST TWO OF THE ABOVE ALCOHOL USE
CRITERION A SXS (E2–E12) ARE RATED “+” AND SXS
OCCURRED WITHIN THE PAST 12 MONTHS.

NO

YES

E13

Go to E23
(Nonalcohol
Substance Use
Disorder), next
page
E13a

IF UNKNOWN: Are you taking any medications or other
health remedies because of your drinking problem? Tell
me about that.
IF UNKNOWN: Are you seeing a doctor, a therapist, or a
counselor because of your drinking problem? Tell me
about that.
IF UNKNOWN: Have other people suggested that you ought
to seek help for your drinking problem? Tell me about
that.

The problematic pattern of alcohol use has causes
clinically significant impairment or distress
Treatment for sxs: Code “+” if “YES” to any of the
first three questions.
Impairment due to sxs: Code “+” if judged to be
moderate or greater
Distress: Code “+” if judged to be moderate or
greater

—

+

E13a

Go to E23
(Nonalcohol
Substance
Use Disorder),
next page

IF UNCLEAR: What effect has your drinking had on your life
in the past year, since (12 MONTHS AGO)?
ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How has your drinking affected your relationships or
your interactions with other people? (Has your drinking
caused you any problems in your relationships with
your family, romantic partner, or friends?)
How has your drinking affected your work/schoolwork?
(How about your attendance at work/school? Has your
drinking made it more difficult to do your
work/schoolwork? Has your drinking affected the
quality of your work/schoolwork?)
How how has yur drinking affected your ability to take
care of things at home? How about doing other things
that are important to you, like religious activities,
physical exercise, or hobbies? Have you avoided doing
anything because you felt like you weren’t up to it?
Has your drinking affected any other important part of
your life overe ther past year?
IF DOES NOT INTERFERE WITH LIFE: In the past year, how
much have you been bothered or upset by your drinking or
aobut the problems associated with your drinking?

Diagnose: Alcohol Use Disorder Check here ___ if onset after
January 2020
Mild: If 2–3 symptoms.
Moderate: If 4–5 symptoms.
Severe: If 6 or more symptoms.
Continue with E23 (Nonalcohol Substance Use Disorder), next page.

E13b

SCID-5MSMH

Nonalcohol Substance Use Disorder

Page 42

Nonalcohol Substance Use Disorder (Past 12 Months)
IF ANY CLASS OF ILLEGAL OR RECREATIONAL DRUGS WAS USED AT LEAST SIX TIMES WITHIN THE PAST 12 MONTHS OR
PRESCRIBED/OTC MEDICATIONS WERE ABUSED OVER THE PAST 12 MONTHS (E.G., TAKING MORE THAN PRESCRIBED OR
RECOMMENDED, DOCTOR SHOPPING TO GET PRESCRIPTIONS), I.E., ON PAGE 8 OF THE OVERVEIW, ANY OF E15, E16, E17, or E18
ARE CODED “YES”, Continue with E23 (Past-12-Month Nonalcohol Substance Use Disorder), below.
OTHERWISE (I.E., NO DRUG USED AT LEAST SIX TIMES AND NO EVIDENCE OF PRESCRIPTION/OTC MEDICATION ABUSE),
GO TO F42 (GAD), page 50.

E23

PAST-12-MONTH NONALCOHOL SUBSTANCE USE DISORDER

SUBSTANCE USE DISORDER CRITERIA

I’d now like to ask you some more questions about your
use of (DRUG CLASS[ES] AT SCREENING THRESHOLD) in the
past 12 months.

A. A problematic pattern of substance use leading to
clinically significant impairment or distress, as
manifested by at least two of the following occurring
within a 12-month period:

FOR EACH DRUG CLASS AT THRESHOLD: During the past 12
months, when were you taking (SUBSTANCE) the most?
How long did that period last? How much were you
using? How often?
E24

During the past 12 months…
…have you found that once you started using (DRUG) you
ended up using much more than you intended to?
For example, you planned to have (SMALL AMOUNT OF
DRUG) but you ended up having much more. (Tell me about
that. How often did that happen?)

1. The substance is often taken in larger amounts OR
over a longer period than was intended.

IF NO: What about using (DRUG) for a much longer
period of time than you were intending to?
SEDATIVE/
HYPNOTIC/ANX

CANNABIS

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E24

(During the past 12 months)
E25

…have you wanted to stop or cut down using (DRUG), or
control your use of (DRUG)?

2. There is a persistent desire OR unsuccessful efforts
to cut down or control substance use.

IF YES: How long did this desire to stop, cut down, or
control your use of (DRUG) last?
IF NO: During the past year, did you ever try to cut
down, stop, or control your use of (DRUG)? How
successful were you? (Did you make more than one
attempt to stop, cut down, or control your use of
(DRUG)?)
SEDATIVE/
HYPNOTIC/ANX

CANNABIS

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E25

SCID-5MSMH

Nonalcohol Substance Use Disorder

Page 43

(During the past 12 months)
E26

…have you spent a lot of time getting (DRUG) or using
(DRUG) or has it taken a lot of time for you to get over the
effects of (DRUG)? (How much time?)
SEDATIVE/
HYPNOTIC/ANX

CANNABIS

3. A great deal of time is spent in activities necessary
to obtain the substance, use the substance, or
recover from its effects.

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E26

(During the past 12 months)
E27

…have you had a strong desire or urge to use (DRUG) In
between those times when you were using (DRUG)? (Has
there been a time when you had such strong urges to use
(DRUG) that you had trouble thinking about anything else?)

4. Craving, or a strong desire or urge to use the
substance.

IF NO: How about having a strong desire or urge to use
(DRUG) when you were around people with whom you
have used (DRUG)?
SEDATIVE/
HYPNOTIC/ANX

E28

CANNABIS

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E27

During the past 12 months, since (ONE YEAR AGO)…
…have you missed work or school or often arrived late
because you were intoxicated, high, or recovering from the
night before?
IF NO: How about doing a bad job at work or school, or
failing courses or getting kicked out of school because
of your use of (DRUG)?

5. Recurrent substance use resulting in a failure to
fulfill major role obligations at work, school, or home
(e.g., repeated absences or poor work performance
related to substance use; substance-related
absences, suspensions, or expulsions from school;
neglect of children or household).

IF NO: How about getting into trouble at work or
school because of your use of (DRUG)?
IF NO: How about not taking care of things at
home because of your use of (DRUG), like
making sure there is food and clean clothes for
your family and making sure your children go to
school and get medical care? How about not
paying your bills?
IF YES TO ANY: How often?
SEDATIVE/
HYPNOTIC/ANX

CANNABIS

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E28

SCID-5MSMH

Nonalcohol Substance Use Disorder

Page 44

(During the past 12 months)

E29

…has your use of (DRUG) caused problems with other
people, such as with family members, friends, or people at
work? (Have you found yourself regularly getting into
arguments about your [DRUG] use? Have you gotten into
physical fights when you were taking [DRUG]?)

6. Continued substance use despite having persistent
or recurrent social or interpersonal problems caused
or exacerbated by the effects of the substance (e.g.,
arguments with spouse about consequences of
intoxication, physical fights).

IF YES: Did you keep on using (DRUG) anyway? (Over
what period of time?)
SEDATIVE/
HYPNOTIC/ANX

CANNABIS

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E29

(During the past 12 months)
E30

…have you had to give up or reduce the time you spent at
work, with family or friends, or on your hobbies because
you were using (DRUG) instead?
SEDATIVE/
HYPNOTIC/ANX

CANNABIS

7. Important social, occupational, or recreational
activities given up or reduced because of substance
use.

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E30

(During the past 12 months)
E31

…have you ever gotten high before doing something that
requires coordination and concentration like driving,
boating, climbing on a ladder, or operating heavy
machinery?

8. Recurrent substance use in situations in which it is
physically hazardous (e.g., driving an automobile or
operating a machine when impaired by substance
use).

IF YES (FOR SUBSTANCES OTHER THAN STIMULANTS):
Would you say that your use of (DRUG) affected your
coordination or concentration so that it was more likely
that you or someone else could have been hurt?
IF YES (FOR STIMULANTS ONLY): Would you say that
your being high on (STIMULANT DRUG) made you drive
recklessly like driving very fast or taking unnecessary
risks?
IF YES TO EITHER OF ABOVE AND IF UNKNOWN:
How many times?
SEDATIVE/
HYPNOTIC/ANX

STIMULANTS

OPIOIDS

+

CANNABIS
+

+

+

-

-

-

-

E31

SCID-5MSMH

E32
vvv
vvv

Nonalcohol Substance Use Disorder

Page 45

During the past 12 months, since (ONE YEAR AGO)…
…has your use of (DRUG) caused you any problems like
making you very depressed, anxious, paranoid, very
irritable, or extremely agitated? What about triggering
panic attacks, making it difficult for you to sleep, putting
you into a “mental fog,” or making it so you couldn’t recall
what happened while you were using (DRUG)?

9. Substance use is continued despite knowledge of
having a persistent or recurrent physical or
psychological problem that is likely to have been
caused or exacerbated by the substance (e.g.,
recurrent cocaine use despite recognition of cocainerelated depression).

Has your use of (DRUG) ever caused physical problems, like
heart palpitations, coughing or trouble breathing,
constipation, or skin infections?
IF YES TO EITHER OF ABOVE: Did you keep on using (DRUG)
anyway?
SEDATIVE/
HYPNOTIC/ANX

CANNABIS

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E32

(During the past 12 months)
10. Tolerance, as defined by either of the following:
E33

…have you found that you needed to use much more
(DRUG) in order to get the feeling you wanted than when
you first started using it?

a. A need for markedly increased amounts of the
substance to achieve intoxication or desired
effect.

IF YES: How much more?
IF NO: What about finding that when you used the
same amount, it had much less effect than before?

b. Markedly diminished effect with continued use
of the same amount of the substance.

IF PRESCRIBED MEDICATION: Were you taking (DRUG)
exactly as your doctor told you to? (Did you ever take
more of it than was prescribed or run out of your
prescription early? Did you ever go to more than one
doctor in order to get the amount of medication you
wanted?)
SEDATIVE/
HYPNOTIC/ANX

CANNABIS

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E33

SCID-5MSMH

E34

Nonalcohol Substance Use Disorder

Have you ever had any withdrawal symptoms, in other
words felt sick when you cut down or stopped using
(DRUG)?
IF YES: What symptoms did you have? (Refer to List of
Withdrawal Symptoms on page 49.)
IF NO: After not using (DRUG) for a few hours or more,
did you sometimes use it or something like it to keep
yourself from getting sick with (WITHDRAWAL
SYMPTOMS)?
IF PRESCRIBED MEDICATION: Were you taking this exactly
as your doctor told you to? (Did you ever take more of it
than was prescribed or run out of your prescription early?
Did you ever have to go to more than one doctor to make
sure you didn’t run out?)
SEDATIVE/
HYPNOTIC/ANX

CANNABIS

Page 46

11. Withdrawal, as manifested by either of the
following:
a. The characteristic withdrawal syndrome for
the substance [see page 49].
b. The same (or a closely related) substance is
taken to relieve or avoid withdrawal symptoms.
NOTE: This criterion applies to use of the following:
sedatives, hypnotics, or anxiolytics; cannabis;
stimulants/cocaine; and opioids.
NOTE: This criterion is not considered met for
individuals taking opioids; sedatives, hypnotics, or
anxiolytics; or stimulant medications solely under
medical supervision.
STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E34

FOR EACH SUBSTANCE CLASS, CODE ‘+” IF AT LEAST TWO OF THE SUBSTANCE USE DISORDER CRITERIA A SXS (E24–E34) ARE RATED “+” AND SXS
OCCURRED WITHIN THE PAST 12 MONTHS.
SEDATIVE/
HYPNOTIC/ANX

E35

CANNABIS

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E35

IF ANY OF THE DRUG CLASSES ARE CODED “+,” GO TO E35a ON THE NEXT PAGE. OTHERWISE, GO TO F42 (GAD), page 50.

SCID-5MSMH

E35a

Nonalcohol Substance Use Disorder

IF UNKNOWN: Are you taking any medications or other
health remedies because of your (DRUG) problem? Tell me
about that.
IF UNKNOWN: Are you seeing a doctor, a therapist, or a
counselor because of your (DRUG) problem? Tell me about
that.
IF UNKNOWN: Have other people suggested that you ought
to seek help for your (DRUG) problem? Tell me about that.

Page 47

The problematic pattern of substance use causes
clinically significant impairment or distress.

—

Treatment for sxs: Code “+” if “YES” to any of the
first three questions.
Impairment due to sxs: Code “+” if judged to be
moderate or greater
Distress: Code “+” if judged to be moderate or
greater

IF UNCLEAR: What effect has your use of (DRUG) had on
your life? In the past year, since (12 MONTHS AGO)?
ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How has your use of (DRUG) affected your relationships
or your interactions with other people? (Has your use
of (DRUG) caused you any problems in your
relationships with your family, romantic partner, or
friends?)
How has your use of (DRUG) affected your
work/schoolwork? (How about your attendance at
work/school? Has yor use of [DRUG] made it more
difficult to do your work/schoolwork? Has your use of
[DRUG] affected the quality of your work/schoolwork?)
How has your use of (DRUG) affected your ability to
take care of things at home? How about doing other
things that are important to you, like religious
activities, physical exercise, or hobbies? Have you
avoided doing anything because you felt like you
weren’t up to it?
Has your use of (DRUG) affected any other important
part of your life?
IF DOES NOT INTERFERE WITH LIFE: During the past 12
months, since (12 MONTHS AGO), how much have you been
bothered or upset by your use of (DRUG)?
SEDATIVE/
HYPNOTIC/ANX

CANNABIS

STIMULANTS

OPIOIDS

+

+

+

+

-

-

-

-

E35a

+

SCID-5MSMH

Nonalcohol Substance Use Disorder

E36a_1
Diagnose based on drug class and number of symptoms; indicating the diagnosis by checking the specific substance use
disorder(s) box(es) and severity level(s) below:
E36

□ Sedative, Hypnotic, or Anxiolytic Use Disorder
Check here ___ if onset after January 2020

E36a

Specific drug used: ____________________________
□ Mild: If 2–3 symptoms
□ Moderate: If 4–5 symptoms
□ Severe: If 6 or more symptoms

E37

□ Cannabis Use Disorder
Check here ___ if onset after January 2020

E37a

Specific drug used: ____________________________
□ Mild: If 2–3 symptoms
□ Moderate: If 4–5 symptoms
□ Severe: If 6 or more symptoms

E38

□ Stimulant Use Disorder (including amphetamines, cocaine, and other stimulants)
Check here ___ if onset after January 2020
Specific drug used: ____________________________

E38a
□ Mild: If 2–3 symptoms
□ Moderate: If 4–5 symptoms
□ Severe: If 6 or more symptoms
E39
E39a

□ Opioid Use Disorder
Check here ___ if onset after January 2020
Specific drug used: ____________________________
□ Mild: If 2–3 symptoms
□ Moderate: If 4–5 symptoms
□ Severe: If 6 or more symptoms

Continue with F42 (Generalized
Anxiety Disorder), page 50.

Page 48

SCID-5MSMH

Substance Use Disorder

List of Withdrawal Symptoms (from DSM-5 criteria for specific substance withdrawal diagnoses)
Listed below are the characteristic withdrawal syndromes for those classes of psychoactive substances for which a withdrawal
syndrome has been identified. (NOTE: A specific withdrawal syndrome has not been identified for PCP, HALLUCINOGENS, and
INHALANTS.) Withdrawal symptoms may occur following the cessation of prolonged moderate or heavy use of a psychoactive
substance or a reduction in the amount used.
SEDATIVES, HYPNOTICS, OR ANXIOLYTICS
Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in)
sedative, hypnotic, or anxiolytic use that has been heavy and prolonged:
1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
2. Hand tremor.
3. Insomnia.
4. Nausea or vomiting.
5. Transient visual, tactile, or auditory hallucinations or illusions.
6. Psychomotor agitation.
7. Anxiety.
8. Grand mal seizures.

CANNABIS
Three (or more) of the following signs and symptoms developing within approximately 1 week after cessation of cannabis
use that has been heavy and prolonged (i.e., usually daily or almost daily use over a period of at least a few months):
1. Irritability, anger, or aggression.
2. Nervousness or anxiety.
3. Sleep difficulty (e.g., insomnia, disturbing dreams).
4. Decreased appetite or weight loss.
5. Restlessness.
6. Depressed mood.
7. At least one of the following physical symptoms causing significant discomfort: abdominal pain, shakiness/tremors,
sweating, fever, chills, or headache.

STIMULANTS/COCAINE
Dysphoric mood AND two (or more) of the following physiological changes, developing within a few hours to several days
after cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or other stimulant use:
1. Fatigue.
2. Vivid, unpleasant dreams.
3. Insomnia or hypersomnia.
4. Increased appetite.
5. Psychomotor retardation or agitation.

OPIOIDS
Three (or more) of the following, developing within minutes to several days after cessation of (or reduction in) opioid use
that has been heavy and prolonged (i.e., several weeks or longer) or after administration of an opioid antagonist after a
period of opioid use:
1. Dysphoric mood.
2. Nausea or vomiting.
3. Muscle aches.
4. Lacrimation or rhinorrhea (runny nose).
5. Pupillary dilation, piloerection [(“goose bumps”)], or sweating.
6. Diarrhea.
7. Yawning.
8. Fever.
9. Insomnia.

Page 49

SCID-5MSMH

Generalized Anxiety Disorder

GENERALIZED ANXIETY DISORDER
(PAST YEAR)

[IF UNBLINDGAD = YES] In your earlier interview you
mentioned that you have had times in the past year when
you felt worried, nervous or anxious for a lot of the time. I’d
like to ask you some more questions about those times.
F42

Page 50

GENERALIZED ANXIETY DISORDER CRITERIA

A. Excessive anxiety and worry (apprehensive
expectation), occurring more days than not for at
least 6 months, about a number of events or
activities (such as work or school performance).

—

+

F42

Go to G1 (OCD),
page 54.

[ALL] Over the past 12 months, since (12 MONTHS AGO),
have you been feeling anxious and worried for a lot of the
time?
(Tell me about that.)
What kinds of things have you worried about? (What about
your job, your health, your family members, your finances,
or other smaller things like being late for appointments?)
How much did you worry about (EVENTS OR ACTIVITIES)?
What else have you worried about?
Have you worried about (EVENTS OR ACTIVITIES) even
when there was no reason? (Have you worried more than
most people would in your circumstances? Has anyone else
thought you worried too much? Have you worried more
than you should have given your actual circumstances?)
During the last 12 months, has there been a period of time
lasting at least 6 months in which you have been worrying
more days than not?

F43

When you’re worrying this way, have you found that it’s
hard to stop yourself or to think about anything else?

B. The individual finds it difficult to control the worry.

—

+

F43

Go to G1 (OCD),
page 54.

F44

Now I am going to ask you some questions about
symptoms that often go along with being nervous or
worried.

C. The anxiety and worry are associated with three
(or more) of the following six symptoms (with at least
some symptoms present for more days than not for
the past 6 months):

F44

Thinking about those periods in the past 12 months when
you have been feeling nervous, anxious, or worried…
F45

F46

F47

F48

...have you often felt physically restless, like you couldn’t
sit still?

1. Restlessness or feeling keyed up or on edge.

—

+

(Thinking about those periods in the past 12 months when
you have been feeling nervous, anxious, or worried...)
...have you often felt keyed up or on edge?

...have you often tired easily?
(Thinking about those periods in the past 12 months when
you have been feeling nervous, anxious, or worried...)
...have you often had trouble concentrating or has your
mind often gone blank?

F45

F46

2. Being easily fatigued.

—

+

F47

3. Difficulty concentrating or mind going blank.

—

+

F48

SCID-5MSMH

Generalized Anxiety Disorder

Page 51

F49

...have you often been irritable?

4. Irritability.

—

+

F49

F50

...have your muscles often been tense?

5. Muscle tension.

—

+

F50

F51

…have you often had trouble falling or staying asleep?
How about often feeling tired when you woke up because
you didn’t get a good night’s sleep?

6. Sleep disturbance (difficulty falling or staying
asleep, or restless unsatisfying sleep).

—

+

AT LEAST THREE OF THE ABOVE CRITERION C SXS
—
+
(F45–F51) ARE RATED “+”.
Go to G1 (OCD), page 54.

F52

F53

IF UNKNOWN: Are you taking any medications or other
health remedies because of (GAD SXS)? Tell me about that.
IF UNKNOWN: Are you seeing a doctor, a therapist, or a
counselor for (GAD SXS)? Tell me about that.

D. The anxiety, worry, or physical symptoms cause
clinically significant distress or impairment in social,
occupational, or other important areas of
functioning.

Treatment for sxs: Code “+” if “YES” to any of the
first three questions.

IF NO TO ALL OF ABOVE AND UNCLEAR: What effect have
(GAD SXS) had on your life?

Impairment due to sxs: Code “+” if judged to be
moderate or greater

How have (GAD SXS) affected your relationships or your
interactions with other people? (Have [GAD SXS]
caused you any problems in your relationships with
your family, romantic partner, or friends?)
How have (GAD SXS) affected your work/schoolwork?
(How about your attendance at work/school? Have
[GAD SXS] made it more difficult to do your
work/schoolwork? Have [GAD SXS] affected the quality
of your work/schoolwork?)
How have (GAD SXS) affected your ability to take care
of things at home? How about doing other things that
are important to you, like religious activities, physical
exercise, or hobbies? Have you avoided doing anything
because you felt like you weren’t up to it?
Has your anxiety or worry affected any other important
part of your life?
IF IMPAIRMENT JUDGED TO BE MILD OR LESS: How much
have you been bothered or upset by having (GAD SXS)?

+

Go to G1 (OCD), page 54.

IF UNKNOWN: Have other people suggested that you ought
to seek help for (GAD SXS)? Tell me about that.

ASK THE FOLLOWING QUESTIONS ONLY IF NEEDED:

—

Distress: Code “+” if judged to be moderate or
greater

F51

F52

F53

SCID-5MSMH

Generalized Anxiety Disorder

THIS PAGE INTENTIONALLY
LEFT BLANK

Page 52

SCID-5MSMH
F55

Generalized Anxiety Disorder

Page 53

F. The disturbance is not better explained by another
NO
YES
mental disorder (e.g., anxiety or worry about having
panic attacks in Panic Disorder, negative evaluation
in Social Anxiety Disorder, contamination or other
Go to G1
obsessions in Obsessive-Compulsive Disorder,
(OCD), next
separation from attachment figures in Separation
page.
Anxiety Disorder, reminders of traumatic events in
Posttraumatic Stress Disorder, gaining weight in
Anorexia Nervosa, physical complaints in Somatic
Symptom Disorder, perceived appearance flaws in
Body Dysmorphic Disorder, having a serious illness in
Illness Anxiety Disorder, or the content of delusional
beliefs in Schizophrenia or Delusional Disorder).
Diagnose: Generalized Anxiety Disorder, Past 12 Months.
Check here ___ if onset after January 2020
Continue with G1 (Obsessive-Compulsive Disorder), next page.

F55

F55a

SCID-5MSMH

Obsessive-Compulsive Disorder

OBSESSIVE-COMPULSIVE DISORDER (PAST YEAR)

Page 54

OBSESSIVE-COMPULSIVE DISORDER CRITERIA

A. Presence of obsessions, compulsions, or both:

G1

In the past year, since (12 MONTHS AGO)…

Obsessions are defined by (1) and (2):

…have you been bothered by thoughts that kept coming
back to you even when you didn’t want them to, like being
exposed to germs or dirt or needing everything to be lined
up in a certain way? (What were they?)

1. Recurrent and persistent thoughts, urges, or
images that are experienced, at some time during the
disturbance, as intrusive and unwanted, and that in
most individuals cause marked anxiety or distress.

—

+

G1

Go to G3
(Compulsions),
below.

How about having urges to do something that kept coming
back to you even though you didn’t want them to, like an
urge to harm a loved one? (What were they?)
How about having images popping into your head that you
didn’t want, like violent or horrible scenes or something of
a sexual nature? (What were they?)
IF YES TO ANY OF ABOVE: Have these (THOUGHTS/URGES/
IMAGES) made you very anxious or upset?

G2

When you had these (THOUGHTS/URGES/IMAGES) did you
try hard to get them out of your head? (What would you
try to do?)

2. The individual attempts to ignore or suppress such
thoughts, urges, or images, or to neutralize them
with some other thought or action (i.e., by
performing a compulsion).

—

+

G2

OBSESSIONS

Go to G3
(Compulsions),
below.

Compulsions are defined by (1) and (2):

G3

In the past year since (12 MONTHS AGO), was there
anything that you had to do over and over again and was
hard to resist doing, like washing your hands again and
again, repeating something over and over again until it
“felt right,” counting up to a certain number, or checking
something many times to make sure that you‘d done it
right?

1. Repetitive behaviors (e. g., hand washing,
ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) that the individual
feels driven to perform in response to an obsession
or according to rules that must be applied rigidly.

—

+

G3

+

G4

Go to G5,
next page.

Tell me about that. (What did you have to do?)

G4

IF UNCLEAR: Why did you have to do (COMPULSIVE ACT)?
What would happen if you didn’t do it?
IF UNCLEAR: How many times would you do (COMPULSIVE
ACT)? Are you doing (COMPULSIVE ACT) more than really
makes sense?

2. The behaviors or mental acts are aimed at
preventing or reducing anxiety or distress, or
preventing some dreaded event or situation;
however, these behaviors or mental acts either are
not connected in a realistic way with what they are
designed to neutralize or prevent, or are clearly
excessive.

—

COMPULSIONS
Go to G5,
next page.

SCID-5MSMH

G5

Obsessive-Compulsive Disorder

CHECK FOR OBSESSIONS AND/OR COMPULSIONS

PRESENCE OF OBSESSIONS (G2 RATED “+”) OR
COMPULSIONS (G4 RATED “+”)

Page 55

NO

YES

G5

Go to
G9 (PTSD),
page 56.

G6

IF UNCLEAR: How much time have you spent on
(OBSESSION OR COMPULSION)?
IF UNKNOWN: Are you taking any medications or other
health remedies because of (OBSESSION OR COMPULSION)?
Tell me about that.
IF UNKNOWN: Are you seeing a doctor, a therapist, or a
counselor for (OBSESSION OR COMPULSION)? Tell me about
that.
IF UNKNOWN: Have other people suggested that you ought
to seek help for (OBSESSION OR COMPULSION)? Tell me
about that.

B. The obsessions or compulsions are timeconsuming (e.g., take more than 1 hour per day) or
cause clinically significant distress or impairment in
social, occupational, or other important areas of
functioning
Treatment for sxs: Code “+” if “YES” to any of the
first three questions.

—

+

G6

Go to
G9
(PTSD)
page 56.

Impairment due to sxs: Code “+” if judged to be
moderate or greater
Distress: Code “+” if judged to be moderate or
greater

IF UNCLEAR: What effect did these (OBSESSIONS OR
COMPULSIONS) have on your life?
ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How have (OBSESSIONS OR COMPULSIONS) affected
your relationships or your interactions with other
people? (Have [OBSESSIONS OR COMPULSIONS] caused
you any problems in your relationships with your
family, romantic partner, roommates, or friends?)
How have (OBSESSIONS OR COMPULSIONS) affected
your work/school? (How about your attendance at
work/school? Have [OBSESSIONS OR COMPULSIONS]
made it more difficult to do your work/schoolwork?
Have [OBSESSIONS OR COMPULSIONS] affected the
quality of your work/schoolwork?)
How have (OBSESSIONS OR COMPULSIONS) affected
your ability to take care of things at home? How about
doing other things that are important to you, like
religious activities, physical exercise, or hobbies?
Have (OBSESSIONS OR COMPULSIONS) affected any
other important part of your life?
G7a

IF HAVE NOT INTERFERED WITH LIFE: How much have
you been bothered by having (OBSESSIONS OR
COMPULSIONS)?

Diagnose Obsessive Compulsive Disorder, Past 12
Months. Check here ___ if onset after January 2020.
Continue with G9 (PTSD), next page

SCID-5MSMH

Posttraumatic Stress Disorder

Page 56

POSTTRAUMATIC STRESS DISORDER
[IF UNBLINDPTSD = YES] In your earlier interview you mentioned having one or more highly stressful experiences in your
life. I’d like to ask you some more questions about those experiences.
[ALL]
G9

I’d now like to ask about some things that may have happened to you that may have been extremely upsetting. People
often find that talking about these experiences can be helpful. I’ll start by asking if these experiences apply to you, and if
so, I’ll ask you to briefly describe what happened and how you felt at the time.

G9a

SCREEN FOR EACH TYPE OF TRAUMA. IF EVENT HAPPENED WITHIN THE PAST MONTH, INQUIRE IF THERE WAS ANOTHER
EVENT OF THIS TYPE THAT HAPPENED PRIOR TO THE LAST MONTH.
Have you ever been in a life-threatening situation like a
major disaster or fire, in combat, or a serious car or workrelated accident?

INTERVIEWER CODE: NO

YES

What about being physically assaulted or abused, or
threatened with physical assault?

INTERVIEWER CODE: NO

YES

G9c

What about being sexually assaulted or abused, or
threatened with sexual assault?

INTERVIEWER CODE: NO

YES

G9d

How about seeing another person being physically or
sexually assaulted or abused, or threatened with physical
or sexual assault?

INTERVIEWER CODE: NO

YES

Have you ever seen another person killed or dead, or badly
hurt?

INTERVIEWER CODE: NO

YES

G9f

How about learning that one of these things happened to
someone you are close to?

INTERVIEWER CODE: NO

YES

G9g

IF UNKNOWN: Have you ever been the victim of a serious
crime?

INTERVIEWER CODE: NO

YES

G9h

IF NO EVENTS ENDORSED: What would you say has been
the most stressful or traumatic experience you have had
over your life?

IF NO EVENTS ACKNOWLEDGED, CONTINUE WITH H1
(Anorexia Nervosa), page 67.

G9b

G9e

SCID-5MSMH

G10

Posttraumatic Stress Disorder

IF MORE THAN ONE EVENT REPORTED: Which of (EVENTS
REPORTED ABOVE) would you say has affected you the
most or caused you the most problems during the past
12 months, since (12 MONTHS AGO)?

A. Exposure to actual or threatened death,
serious injury, or sexual violence in one (or more)
of the following ways:

ASK AS MANY QUESTIONS AS NEEDED TO DETERMINE
WHETHER TRAUMA MEETS CRITERION A REQUIREMENTS

1. Directly experiencing the traumatic event(s).

IF DIRECT EXPOSURE TO TRAUMA:

2. Witnessing, in person, the event(s) as it
occurred to others.

What happened? Were you afraid of dying or being
seriously hurt? Were you seriously hurt?
IF WITNESSED TRAUMATIC EVENT HAPPENING TO
OTHERS:
What happened? What did you see? How close were
you to (TRAUMATIC EVENT)? Were you concerned about
your own safety?
IF LEARNED ABOUT TRAUMATIC EVENT:
What happened? Who did it involve? (How close
[emotionally] were you to them? Did it involve violence,
suicide, or a bad accident?)
IF EVENT DOES NOT MEET CRITERION A, THEN EVALUATE
NEXT MOST IMPACTFUL EVENT UNTIL AN EVENT MEETS
CRITERION A. IF NO EVENTS MEET CRITERION A, THEN
CODE “-“ AND SKIP TO NEXT SECTION PAGE 67.

Page 57

—

+
G10

3. Learning that the traumatic event(s) occurred
to a close family member or close friend. In cases
of actual or threatened death of a family member
or friend, the event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to
aversive details of the traumatic event(s) (e.g., first
responders collecting human remains; police
officers repeatedly exposed to details of child
abuse).

Continue with
questions on
Page 58 for this
traumatic event.

Note: Criterion A4 does not apply to exposure
through electronic media, television, movies, or
pictures, unless this exposure is work related.
INDICATE EVENT THAT AFFECTED RESPONDENT
THE MOST AND MEETS CRITERION A, THEN
CONTINUE WITH NEXT PAGE:
CRITERION A EVENT #1:
__________________________________
IF NEEDED TO REPEAT QUESTIONS, RECORD
APPLICABLE TRAUMATIC EVENTS BELOW, THEN
CONTINUE WITH QUESTIONS ON NEXT PAGE:
CRITERTION A EVENT #2:
__________________________________
CRITERTION A EVENT #3:
__________________________________

Skip to next
section, Page 67

SCID-5MSMH

Posttraumatic Stress Disorder

Page 58

G13_2
DETERMINE WORST MONTH WITIHN THE PAST YEAR IN TERMS OF SEVERITY OF THE REACTION
SEPARATELY FOR EACH SELECTED TRAUMA:

—

→ IF SELECTED TRAUMATIC EVENT OCCURRED PRIOR TO THE PAST YEAR:
In the past year, since (12 MONTHS AGO), have you had thoughts about (SELECTED TRAUMATIC EVENT) that kept
coming back to you even when you didn’t want to think about them?

+

→ IF SELECTED TRAUMATIC EVENT OCCURRED DURING THE PAST YEAR:
Since (TRAUMATIC EVENT), have you had thoughts about (SELECTED EVENT) that kept coming back to you even
when you didn’t want to think about them?

Continue with
questions
below for this
traumatic
event.

How about bad dreams about (TRAUMATIC EVENT[S]) or the feeling that you were back in the situation again?

4.

What about getting physical symptoms—like breaking out in a sweat, or your heart pounding or racing-- or feeling
very upset when something or someone reminded you of (TRAUMATIC EVENT)?
NOTE: IF RESPONDENT HAS EXPERIENCED NO PTSD ISSUES OR SXS FOR THE PAST 12 MONTHS, CODE “-“ TO SKIP TO
THE NEXT MODULE.
HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?
IF YES: Go back to G10, page 57, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 67
G13_3
DETERMINE WORST MONTH WITIHN THE PAST YEAR IN TERMS OF REACTION TO THE TRAUMA
IF YES TO ANY G13_1: During the past year, during which month would you say that (ACKNOWLEDGED PTSD SXS) happened the most
often or were the most upsetting to you?
REFER TO THAT PARTICULAR MONTH FOR THE FOLLOWING QUESTIONS. IF NO ONE PARTICULAR MONTH STANDS OUT AS MOST SEVERE,
USE INSTEAD PAST MONTH FOR THE FOLLOWING QUESTIONS.
Indicate month chosen: __________

G13
Now I’d like to ask a few questions about specific ways that
(TRAUMATIC EVENT) may have affected you during
[MONTH SELECTED ABOVE).

B. Presence of one (or more) of the following
intrusion symptoms associated with the traumatic
event(s), beginning after the traumatic event(s)
occurred:

For example, during that month…

G14
…did you had memories of (TRAUMATIC EVENT), including
feelings, physical sensations, sounds, smells, or images,
when you didn’t expect to or want to? How often did that
happen during (MONTH)?

1. Recurrent, involuntary, and intrusive distressing
memories of the traumatic event(s).

—

+

…what about repeatedly having upsetting dreams that
reminded you of (TRAUMATIC EVENT)? Tell me about that.
How often did this happen during (MONTH)?

2. Recurrent distressing dreams in which the content
and/or effect of the dream are related to the
traumatic events.

—

+

G14

G15
G15

SCID-5MSMH

G16

Posttraumatic Stress Disorder

…what about have found yourself acting or feeling as if you
were back in the situation? (Have you had “flashbacks” of
[TRAUMATIC EVENT]?)

3. Dissociative reactions (e.g., flashbacks) in which
the individual feels or acts as if the traumatic event(s)
were recurring. (Such reactions may occur on a
continuum, with the most extreme expression being
a complete loss of awareness of present
surroundings.)

Page 59

—

+
G16

During (MONTH SELECTED ABOVE)…
…did you have a strong emotional or physical reaction
when something reminded you of (TRAUMATIC EVENT)?
Give me some examples of the kinds of things that would
have triggered this reaction. (Things like…seeing a person
who resembles the person who attacked you, hearing the
screech of brakes if you were in a car accident, hearing the
sound of helicopters if you were in combat, any kind of
physically intimacy if you were raped?)
NOTE: IF DENIES EMOTIONAL OR PHYSICAL REACTION TO
REMINDERS, CODE “—” FOR BOTH G17 (EMOTIONAL
REACTION) AND G18 (PHYSICAL REACTION).

G17

G17
IF ACKNOWLEDGES STRONG EMOTIONAL OR PHYSICAL
REACTION: What kind of reaction did you have? Did you
get very upset or stay upset for a while, even after the
reminder had gone away? (For how long do the symptoms
last?)

4. Intense or prolonged psychological distress at
exposure to internal or external cues that symbolize
or resemble an aspect of the traumatic event(s).

—

+

IF ACKNOWLEDGES STRONG EMOTIONAL OR PHYSICAL
REACTION: What about having physical symptoms—like
breaking out in a sweat, breathing heavily or irregularly, or
feeling your heart pound or race when something
reminded you of (TRAUMATIC EVENT)? How about feeling
tense or shaky?

5. Marked physiological reactions to internal or
external cues that symbolize or resemble an aspect
of the traumatic event(s).

—

+

AT LEAST ONE OF THE ABOVE CRITERION B SXS (G14–
G18) IS RATED “+”.

NO

G18

G18

G19

G19

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

YES

Continue with
questions on
Page 60 for this
traumatic event.

IF YES: Go back to G10, page 57, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 67

SCID-5MSMH

Posttraumatic Stress Disorder

Page 60

During (MONTH SELECTED ABOVE)…

C. Persistent avoidance of stimuli associated with
the traumatic event(s), beginning after the traumatic
event(s) occurred, as evidenced by one or both of the
following:

…did you do things to avoid remembering or thinking
about (TRAUMATIC EVENT), like keeping yourself busy,
distracting yourself by playing computer or video games or
watching TV, or using drugs or alcohol to “numb” yourself
or try to forget what happened? How long did this go on?
(Did this happen for almost all the time during (MONTH
SELECTED ABOVE)?

1. Avoidance of, or efforts to avoid distressing
memories, thoughts, or feelings about or closely
associated with the traumatic event(s).

—

+

2. Avoidance of or efforts to avoid external
reminders (people, places, conversations, activities,
objects, situations), that arouse distressing
memories, thoughts, or feelings about or closely
associated with the traumatic event(s).

—

+

AT LEAST ONE OF THE ABOVE CRITERION C SXS (G20–
G21) IS RATED “+”.

NO

YES

G20

G20

IF NO: How about doing things to avoid having feelings
similar to those you had during (TRAUMATIC EVENT)?
(Has this happened for almost all the time during
(MONTH SELECTED ABOVE)?

G21

…were there things, places, or people that you tried to
avoid because they brought up upsetting memories,
thoughts, or feelings about (TRAUMATIC EVENT)? (Was this
for almost all the time during (MONTH SELECTED ABOVE)?

G21

IF NO: How about avoiding certain activities, situations,
or topics of conversation? (Did this happen for almost
all the time during (MONTH SELECTED ABOVE)?

G22
G22

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

Continue with
questions on
Page 61 for this
traumatic event.

IF YES: Go back to G10, page 57, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 67

SCID-5MSMH

G23

Posttraumatic Stress Disorder

Page 61

During (MONTH SELECTED ABOVE)…

D. Negative alterations in cognitions and mood
associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:

…Were you unable to remember some important part of
what happened? (Tell me about that.) How many times
did this happened?

1. Inability to remember an important aspect of the
traumatic event(s) (typically due to dissociative
amnesia and not to other factors such as head injury,
alcohol, or drugs).

—

+

G23

2. Persistent and exaggerated negative beliefs or
expectations about oneself, others, or the world
(e.g., “I am bad,” “No one can be trusted,” “The
world is completely dangerous,” “My whole nervous
system is permanently ruined”).

—

+

G24

3. Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead the
individual to blame himself/herself or others.

—

+

IF YES: Did you get a head injury during (TRAUMATIC
EVENT)? Were you drinking a lot or were taking any
drugs at the time of (TRAUMATIC EVENT)?

G24

……was there a change in how you thought about yourself?
(Like feeling you were “bad,” or permanently damaged or
“broken”?) Tell me about that. How long did ou feel this
way about yourself? (Did you feel this way almost all of
the time during (MONTH SELECTED)?)
IF NO: Was there been a change in how you see other
people or the way the world works? Like you couldn’t
trust anyone anymore? Like the world was a
completely dangerous place? Tell me about that. How
long did you think this way? Did you feel this way
almost all of the time during (MONTH SELECTED)?)

G25

…did you blame yourself for the (TRAUMATIC EVENT) or
how it affected your life? (Like thinking that [TRAUMATIC
EVENT] was your fault or that you should have done
something to prevent it? Like thinking that you should
have gotten over it by now?)
IF YES: Tell me about it. Did you think this way about
yourself almost all of the time during (MONTH
SELECTED)?
IF NO: Did you blame someone else for (TRAUMATIC
EVENT)? Tell me about that. (What did they have to do
with [TRAUMATIC EVENT]?) Did you think this way
almost all of the time during (MONTH SELECTED)?

G25

SCID-5MSMH

Posttraumatic Stress Disorder

Page 62

G26
During (MONTH SELECTED ABOVE)…
…did you have bad feelings a lot of the time, like feeling
sad, angry, afraid, guilty, ashamed, or numb? (Tell me
about that.) Did you feel this way almost all of the time
during (MONTH SELECTED)?

4. Persistent negative emotional state (e.g., fear,
horror, anger, guilt, or shame).

—

+

5. Markedly diminished interest or participation in
significant activities.

—

+

6. Feelings of detachment or estrangement from
others.

—

+

7. Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction,
or loving feelings).

—

+

G26

IF YES: Was this different from the way you were
before (TRAUMATIC EVENT)?

G27
…were you a lot less interested in things that you were
interested in before (TRAUMATIC EVENT), like spending
time with family or friends, reading books, watching TV,
cooking, or sports? (Tell me about that.) Did you feel this
way almost all of the time during (MONTH SELECTED)?

G27

IF NO LOSS OF INTEREST: Were you still doing as many
activities as you were before (TRAUMATIC EVENT)?
(Were you involved in fewer activities almost all of the
time during (MONTH SELECTED)?

G28

G28
…did you feel distant or disconnected from others or did
you close yourself off from other people almost all of the
time during (MONTH SELECTED)? (Tell me about that.)
IF YES: Was this different from the way you were
before (TRAUMATIC EVENT)?
Did you feel this way almost all of the time during (MONTH
SELECTED)?

G29

…were you unable to experience good feelings, like feeling
happy, joyful, satisfied, loving, or tender toward other
people? (Tell me about that.) How long were you unable
to experience good feelings? (Were you unable to
experience good feelings almost all of the time during
(MONTH SELECTED?)
IF YES: Was this different from the way you were
before (TRAUMATIC EVENT)?

G29

SCID-5MSMH

Posttraumatic Stress Disorder

Page 63

G30

G30

AT LEAST TWO OF THE ABOVE CRITERION D SXS
(G23–G29) ARE RATED “+”.

NO

YES

Continue with
questions below
for this traumatic
event.

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

IF YES: Go back to G10, page 57, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 67

During (MONTH SELECTED ABOVE)…

E. Marked alterations in arousal and reactivity
associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:

G31

G31
…did you lose control of your anger, so that you threatened
or hurt someone or damaged something? Tell me what
happened. (Was it over something little or even nothing at
all?) How often did this happen during (SELECTED
MONTH)?

1. Irritable behavior and angry outbursts (with little
or no provocation) typically expressed as verbal or
physical aggression toward people or objects.

—

+

2. Reckless or self-destructive behavior.

—

+

IF NO: Since (TRAUMATIC EVENT), were you more quicktempered or have a shorter “fuse” than before? How
often did this happened during (SELECTED MONTH)?
IF YES TO EITHER: How different was this from the way you
were before (TRAUMATIC EVENT)?

G32

…did you do reckless things, like drive dangerously, or drink
or use drugs without caring about the consequences? How
often did this happen during (SELECTED MONTH)?
IF NO: How about hurting yourself on purpose or trying
to kill yourself? (What did you do?) How often did this
happened during (SELECTED MONTH)?
IF YES TO ETIHER: How different was this from the way you
were before (TRAUMATIC EVENT)?

Note: ANY CURRENT SUICIDAL THOUGHTS, PLANS,
OR ACTIONS SHOULD BE THOROUGHLY ASSESSED BY
THE CLINICIAN AND ACTION TAKEN IF NECESSARY.

G32

SCID-5MSMH

G33

Posttraumatic Stress Disorder

During (MONTH SELECTED ABOVE)…

Page 64

G33

3. Hypervigilance.

—

+

…were you jumpy or easily startled, like by sudden
noises? (Was this a change from before [TRAUMATIC
EVENT]?) Did you feel this way most of the time during
(MONTH SELECTED)

4. Exaggerated startle response.

—

+

…did you have trouble concentrating? (What are some
examples? (Was this a change from before [TRAUMATIC
EVENT]?) Did you feel this way most of the time during
(MONTH SELECTED)?

5. Problems with concentration.

—

+

…how were you sleeping during (MONTH SELECTED)? (Was
this a change from before [TRAUMATIC EVENT]?) Did you
have trouble for most of the time during (MONTH
SELECTED)?

6. Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).

—

+

G36

AT LEAST TWO OF THE ABOVE CRITERION E SXS
(G31–G36) ARE RATED “+”.

NO

YES

G37

…did you notice that you were more watchful or on
guard? (Give me some examples.) Did you feel this way
almost all of the time during (MONTH SELECTED)?
IF NO: Were you extra aware of your surroundings and
your environment? Did you feel this way most of the
time during (MONTH SELECTED)?
IF YES TO ETIHER: How different was this from the way you
were before (TRAUMATIC EVENT)?

G34

G34

G35

G36

G35

G37

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

Continue with
questions on
page 65 for this
traumatic event.

IF YES: Go back to G10, page 57, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 67

SCID-5MSMH

G38

Posttraumatic Stress Disorder

IF UNCLEAR: About how long did these (PTSD SXS RATED
“+”) last altogether?

F. Duration of the disturbance [symptoms in
Criteria B (G19), C (G22), D (G30), and E (G37)] is
more than 1 month.

Page 65

—

+

G38

Continue with
questions below
for this traumatic
event.

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

IF YES: Go back to G10, page 57, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 67
IF UNKNOWN: Are you taking any medications or other
health remedies because of (PTSD SXS)? Tell me about
that.
IF UNKNOWN: Are you seeing a doctor, a therapist, or a
counselor for (PTSD SXS)? Tell me about that.
IF UNKNOWN: Have other people suggested that you ought
to seek help for (PTSD SXS)? Tell me about that.
G39

IF UNCLEAR: What effect did (PTSD SXS DURING MONTH
SELECTED) have on your life?
ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How did (PTSD SXS) affect your relationships or your
interactions with other people? (Did [PTSD SXS] cause you
any problems in your relationships with your family,
romantic partner, or friends?)

G39
G. The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.

Treatment for sxs: Code “+” if “YES” to any of the
first three questions.
Impairment due to sxs: Code “+” if judged to be
moderate or greater

—

+

Continue with
questions on
page 66 for this
traumatic event.

Distress: Code “+” if judged to be moderate or
greater

How did (PTSD SXS) affect your work/school? (How about
your attendance at work/school? Did [PTSD SXS] make it
more difficult to do your work/schoolwork? Did [PTSD SXS]
affect the quality of your work/schoolwork?)
How did [PTSD SXS] affect your ability to take care of things
at home? What about being involved in things that were
important to you, like religious activities, physical exercise,
or hobbies?
Did (PTSD SXS) affect any other important part of your life?
IF HAVE NOT INTERFERED WITH LIFE: How much were you
bothered or upset by (PTSD SXS)?
HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?
IF YES: Go back to G10, page 57, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 67

SCID-5MSMH

G40

Posttraumatic Stress Disorder

Were you drinking a lot or using a lot of drugs during
(MONTH SELECTED)? Tell me about that.

H. The disturbance is not attributable to the
physiological effects of a substance (e.g., medication,
alcohol) or another medical condition.

Page 66

NO

YES
G40

How much were you (drinking/using [DRUGS])? (Do you
think your problems during [SELECTED MONTH] were more
due to your [drinking/(DRUG) use] rather than to your
reaction to [TRAUMATIC EVENT] itself?)

Continue with
question below
for this traumatic
event.

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?
IF YES: Go back to G10, page 57, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 67

G41

G41
CRITERIA B (G19), C (G22), D (G30), and E (G37) ARE
RATED “YES” AND CRITERION G (G39) (CLINICAL
SIGNIFICANCE) IS RATED “+”

NO

Diagnose: Posttraumatic Stress Disorder (past year).
Check here ___ if onset after January 2020
Go to H1 (Anorexia Nervosa), next page.

YES

G41a

SCID-5MSMH

H1

Anorexia Nervosa

ANOREXIA NERVOSA PAST YEAR

ANOREXIA NERVOSA CRITERIA

Have you had a time over the past 12 months when you
weighed much less than other people thought you ought to
weigh?

Restriction of energy intake relative to requirements,
leading to a significantly low body weight in the
context of age, sex, developmental trajectory, and
physical health. Significantly low weight is defined as
a weight that is less than minimally normal or, for
children and adolescents, less than minimally
expected.

IF YES: Why was that? How much did you weigh? How
old were you then? How tall were you?

H2

Page 67

At that time, were you very afraid that you could become
fat?

B. Intense fear of gaining weight or of becoming fat,
or persistent behavior that interferes with weight
gain, even though underweight.

IF NO: Tell me about your eating habits. (Have you
avoided high calorie foods or high fat foods? How strict
are you about it? Have you ever thrown up after you
eaten? How often? Do you exercise a lot after you
eat?)

At your lowest weight, did you still feel too fat or that part
of your body was too fat?
H3
IF NO: Did you need to be very thin in order to feel
better about yourself?
IF NO AND LOW WEIGHT IS MEDICALLY SERIOUS:
When you were that thin, did anybody tell you it
could be dangerous to your health to be that thin?
(What did you think?)

C. Disturbance in the way in which one’s body
weight or shape is experienced; undue influence of
body weight or shape on self-evaluation, or
persistent lack of recognition of the seriousness of
the current low body weight.

—

+

H1

Go to
Possible
Association
with COVID,
page 69

—

+

H2

+

H3

Go to
Possible
Association
with COVID,
page 69

—

Go to
Possible
Association
with COVID,
page 69

Diagnose: Anorexia Nervosa, Past
12 Months Check here ___ if onset
after January 2020
Continue with Possible Association
with COVID, page 69

H3a

SCID-5MSMH

Etiologies

Page 68

Possible Etiologies for Manic Episodes:
Possibly etiological GMCs include Alzheimer’s disease, vascular dementia, HIV-induced dementia, Huntington’s disease, Lewy body disease,
Wernicke-Korsakoff syndrome, Cushing’s disease, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson’s disease, Pick’s disease,
Creutzfeldt-Jakob disease, stroke, traumatic brain injuries, and hyperthyroidism.
Possibly etiological substance include alcohol (I/W); phencyclidine (I); hallucinogens (I); sedatives, hypnotics, and anxiolytics (I/W);
amphetamines (I/W); cocaine (I/W);
Possibly etiological medications include corticosteroids; androgens; isoniazid; levodopa; interferon-alpha; varenicline; procarbazine;
clarithromycin; and ciprofloxacin.
Possible Etiologies for Psychotic Symptoms:
Possibly etiological GMCs include neurological conditions (e.g., neoplasms, cerebrovascular disease, Huntington's disease, multiple sclerosis,
epilepsy, auditory or visual nerve injury or impairment, deafness, migraine, central nervous system infections), endocrine conditions (e.g., hyperand hypothyroidism, hyper- and hypoparathyroidism, hyper- and hypoadrenocorticism), metabolic conditions
(e.g., hypoxia, hypercarbia, hypoglycemia), fluid or electrolyte imbalances, hepatic or renal diseases, and autoimmune disorders with central
nervous system involvement (e.g., systemic lupus erythematosus).
Possibly etiological substances include alcohol (I/W); cannabis (I); hallucinogens (I), phencyclidine and related substances (I); inhalants (I);
sedatives, hypnotics, and anxiolytics (I/W); stimulants (including cocaine) (I);
Possibly etiological medications include anesthetics and analgesics; anticholinergic agents; anticonvulsants; antihistamines; antihypertensive and
cardiovascular medications; antimicrobial medications; antiparkinsonian medications; chemotherapeutic agents (e.g., cyclosporine,
procarbazine); corticosteroids; gastrointestinal medications; muscle relaxants; nonsteroidal anti-inflammatory medications; other over-thecounter medications (e.g., phenylephrine, pseudoephedrine); antidepressant medication; and disulfiram. ]
Possibly etiological toxins include anticholinesterase, organophosphate insecticides, sarin and other nerve gases, carbon monoxide, carbon
dioxide, and volatile substances such as fuel or paint.

SCID-5MSMH

Coronavirus Casualty

Page 69

THIS ITEM HAS ALREADY BEEN ASKED AS PART OF THE OVERVIEW AND HAS BEEN
PREPOPULATED BASED ON INFORMATION PREVIOULSY OBTAINED:
IF UNKNOWN: How were you affected by the coronavirus pandemic? (Did you or someone close to
you need to be hospitalized for treatment? Did you lose someone whom you were close to? How
about the financial implications of the crisis?)

QUESTIONS TO DETERMINE POSSIBLE ASSOCIATION OF EACH PAST 12 MONTH DIAGNOSIS WITH
CORONAVIUS AND ASSOCIATED STRESSORS:
(FILL OUT THIS PAGE SEPARATELY FOR EACH PAST 12 MONTH DIAGNOSIS)
FOR EACH DISORDER DIAGNOSED IN PAST 12
MONTHS:
IF UNKNOWN: When did [SXS OF DIAGNOSED
DISORDER] start?

IF ONSET SINCE START OF CORONAVIRUS
PANDEMIC IN JANUARY 2020:
IF UNKNOWN: What was going on in your
life when (SXS) started?
Do you think (SXS) were due to the effects
of the coronavirus pandemic on your life?
IF ONSET PRIOR TO START OF CORONAVISU
PANDEMIC IN JANUARY 2020: Did (SXS)
become worse since the start of the
pandemic?
IF YES: When did they get worse? How
much worse? Do you think they got
worse because of the effects of the
coronavirus pandemic on your life?

BASED ON ALL AVAILABLE INFORMATION, INDICATE FOR EACH 12-MONTH DIAGNOSIS THE
LIKELIHOOD THAT DISORDER OCCURRING IN PAST 12 MONTHS WAS DUE TO THE EFFECTS OF
CORONAVIRUS PANDEMIC: (INCLUDING ECONOMIC EFFECTS)
1

Not at all likely

2

3

4

5

6

Somewhat likely

7

8

9

10

Very likely

SCID-5-NSMH
STRUCTURED CLINICAL INTERVIEW FOR DSM-5® DISORDERS
(Prison Population)
Modified for National Study of Mental Health

03-01-2021
Edits for Prison Population

Michael B. First, M.D.
Professor of Clinical Psychiatry, Columbia University, and Research Psychiatrist,
Division of Clinical Phenomenology, New York State Psychiatric Institute,
New York, New York

Janet B. W. Williams, Ph.D.
Professor Emerita of Clinical Psychiatric Social Work (in Psychiatry and in
Neurology), Columbia University, and Research Scientist and Deputy Chief,
Biometrics Research Department (Retired), New York State Psychiatric Institute,
New York, New York; and Senior Vice President of Global Science,
MedAvante, Inc., Hamilton, New Jersey

Rhonda S. Karg, Ph.D.
Research Psychologist, Division of Behavioral Health and
Criminal Justice Research, RTI International, Durham, North Carolina

Robert L. Spitzer, M.D.
Professor Emeritus of Psychiatry, Columbia University, and
Research Scientist and Chief, Biometrics Research Department (Retired),
New York State Psychiatric Institute, New York, New York

Patient: ______________________________________________

Date of
Interview:

_____
month

______
day

______
year

Clinician: _____________________________________________
Note: The authors have worked to ensure that all information in this publication is accurate at the time of publication and
consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes
of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration
and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may
change. Moreover, specific situations may require a specific therapeutic response not included in this publication. For these
reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians
directly involved in their care or the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the findings, conclusions, and views of the individual
authors and do not necessarily represent the policies and opinions of American Psychiatric Association Publishing or the American
Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/specialdiscounts for more information.
Copyright © 2016 American Psychiatric Association
ALL RIGHTS RESERVED
DSM and DSM-5 are registered trademarks of the American Psychiatric Association. Use of these terms is prohibited without
permission of the American Psychiatric Association.
DSM-5® diagnostic criteria are reprinted or adapted with permission from American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright © 2013
American Psychiatric Association. Used with permission.
Unless authorized in writing by the American Psychiatric Association (APA), no part of the DSM-5® criteria may be reproduced or
used in a manner inconsistent with the APA’s copyright. This prohibition applies to unauthorized uses or reproductions in any
form, including electronic applications. Correspondence regarding copyright permission for DSM-5 criteria should be directed to
DSM Permissions, American Psychiatric Association Publishing, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901.
ICD-10-CM codes are periodically updated by the Cooperating Parties for the ICD-10-CM. For important updates to any listed
codes, see the DSM-5 Update on www.PsychiatryOnline.org
The Structured Clinical Interview for DSM-5® Disorders—Clinician Version (SCID-5-CV) comprises the User’s Guide for the SCID-5CV and this SCID-5-CV interview booklet (each sold separately). No part of these publications may be photocopied, reproduced,
stored in a retrieval system, or transmitted, in any form or by any means, without obtaining permission in writing from American
Psychiatric Association Publishing, or as expressly permitted by law, by license, or by terms agreed with the appropriate
reproduction rights organization. All such inquiries, including those concerning reproduction outside the scope of the above,
should be sent to Rights Department, American Psychiatric Association Publishing, 1000 Wilson Blvd., Suite 1825, Arlington, VA
22209-3901 or via the online permissions form at: http://www.appi.org/permissions. For more information, please visit the SCID
products page on www.appi.org.
For citation: First MB, Williams JBW, Karg RS, Spitzer RL: Structured Clinical Interview for DSM-5 Disorders—Clinician Version
(SCID-5-CV). Arlington, VA, American Psychiatric Association, 2016
Manufactured in the United States of America on acid-free paper
19 18 17 16 15 5 4 3 2 1
American Psychiatric Association Publishing
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org

SCID-5NSMH

Overview

Page 3

SCID-5-NSMH DIAGNOSTIC SUMMARY SCORE SHEET
Psychotic Disorders (past 12 months and prior to past 12 months)
Past 12 months (and possibly
prior)

Likelihood
of coronavirus
causality
(see page
52)

Not in
past 12
months
but
prior to
past 12
months



____





____



Disorder

Schizophrenia or Schizoaffective Disorder with duration > 6
months (p.31/C6)
Schizophreniform or schizoaffective with duration < 6 months
(p.31/C8)

Mood Disorders (past 12 months)




____
____
____

Major Depressive Disorder (bipolar II not ruled out) (p. 32/D13)
Bipolar I Disorder. Manic in past year) (p. 33/D17)
Bipolar I Disorder, Depressed but no manic in past year (p.33/ D18)

Other Disorders
Past 12
months





Coronavirus
causality

Disorder
Generalized Anxiety Disorder (past 12 months) (p. 36/F55)
Obsessive-Compulsive Disorder (past 12 months) (p. 36/G7)
Posttraumatic Stress Disorder (p. 49/G41)
Anorexia Nervosa (past 12 months) (p. 50/H3)

SCID-5NSMH

Overview

Page 4

OVERVIEW
I’m going to be asking you about problems or difficulties you may have had, and I’ll be making some notes as we go along.
Do you have any questions before we begin?
How old are you?

Are you currently in a relationship with a partner?
IF YES: What is the nature of that relationship, for
example, are you married? How long have you been
(RELATIONSHIP STATUS)?
Have you ever been separated/divorced or widowed?
IF YES: How many times?
Do you have any children?
IF YES: How many? (What are their ages?)

What is your highest completed level of education?
Did you ever not complete a degree or program?

Why?
I would like to now ask you about your cultural background
or identity. By background or identity, I mean, for example,
the communities you belong to, the languages you speak,
where you or your family are from, your race or ethnic
background, your gender or sexual orientation, or your faith
or religion.
For you, what are the most important aspects of your
background or identity?

Before you were in prison what kinds of work did you
do?

In the past year, have you been in school or enrolled in
on-line classes? What kind of program was it?

SCID-5NSMH

Overview

Psychological Difficulties Past Year
In the past year, have you seen a doctor, a therapist, or
a counselor for any kind of psychological problem?
IF YES: Tell me about it. (What was the reason for
your seeking help?) (What kinds of symptoms [have
you been/were you experiencing?) (When did these
symptoms begin?) (Was anything going on in your
life when they began?) (Since they began, when have
you felt the worst?)
What kind of help did you receive? (Counselling or
psychotherapy?) (Medication—what kind?) (For how
long have you been getting that help?)

What about (also) getting help during the past year from
outside the health system, like from a self-help group
like Alcoholics Anonymous, or from a faith healer or
pastoral counselor?

→ IF HAS SOUGHT HELP IN THE PAST YEAR: Besides
[PROBLEMS ALREADY DISCUSSED], have you had any
other problems that you considered getting help for
but didn’t?
→ IF HAS NOT SOUGHT HELP IN PAST YEAR: What about
having a problem during the past year that you
considered getting help for? Have other people
mentioned that you ought to seek help for a
psychological problem? Tell me about that.

Page 5

SCID-5NSMH

Overview

Most Stressful Situation/Event In
Past Year
Most people have experienced situations, other people,
or events that they have found to be upsetting,
challenging, or stressful.
What has been the most challenging or stressful
experience that you experienced in the past year? Tell
me about that. How did it affect you?

Hospitalization History
Have you ever been hospitalized for psychological
problems?
IF YES: What was that for?
IF AN INADEQUATE ANSWER IS GIVEN, CHALLENGE
GENTLY: e.g., Wasn't there something else? People
don't usually go to psychiatric hospitals just because
they are tired or nervous.
Have you ever been hospitalized for treatment of a
medical problem?
IF YES: What was that for?

Page 6

SCID-5NSMH

Overview

Suicidal Ideation and Behavior
CHECK FOR THOUGHTS: In the past year, since [ONE YEAR
AOG], have you had any thoughts about taking your own
life or just going to sleep and not waking up, or thinking
that you would be better off dead? (Tell me about that.)

CHECK FOR ATTEMPT: In the past year, have you done
anything to try to end your life?

Page 7

SUICIDAL IDEATION PAST YEAR:
1.

Yes

2.

No

SUICIDAL ATTEMPT PAST YEAR:

IF YES: Tell me about that. What did you do?

1.

Yes

NOTE: IF PAST YEAR IDEATION OR ATTEMPT, ASSESS
FOR CURRENT SUICIDE RISK AND ACT ACCORDINGLY.
Ask: In the past week have you had any thoughts
about taking your own life?

2.

No

IF YES, Tell me more about that. Do you intend to
hurt yourself or take your own life?
IF YES, Have you thought about a specific
method for attempting suicide? What has
prevented you from acting on this plan?
IF CURRENT, ACTIVE SUICIDAL IDEATION AND
INTENT IS CONFIRMED, STOP THE INTERVIEW AND
GO TO DRP SCENARIO 1B

Other Problems in Past Year
Have you had any problems in the past year other than
what we’ve talked about so far?
IF UNKNOWN: How were you affected by the
coronavirus pandemic? (Did you or someone close to
you need to be hospitalized for treatment? Did you
lose someone whom you were close to? How about
the financial implications for people close to you
related to the crisis?)

How has your physical health been during the past year,
since [ONE YEAR AGO]? Have you been getting help for
any medical problems? (What kind of problems are you
getting help for? Are you taking any medicines or getting
any other kind of treatment for the problem?)
In the past year, have you taken any medication
(including over the counter medications, vitamins,
nutritional supplements, or natural or traditional health
remedies) for your emotions or nerves or to help you
sleep (other than those you’ve already told me about?)
IF YES: What medication are you taking (did you
take)?

SCID-5NSMH

Overview

Page 8

THE TREATMENT TIMELINE (BELOW) MAY BE USED AT ANY POINT IN THE OVERVIEW TO RECORD THE DETAILS OF A COMPLICATED
HISTORY.

TREATMENT TIMELINE
Age (or date)

Description (symptoms, triggering events)

Treatment

SCID-5MSMH

Major Depressive Episode Past Year

Page 9

A. MOOD EPISODES
MAJOR DEPRESSIVE EPISODE PAST YEAR

[IF UNBLINDMDE = YES] In your earlier interview you
mentioned that you have had times in the past year
when you felt depressed or down or lost interest in
things that you used to enjoy. I’d like to ask you some
more questions about those times.

MAJOR DEPRESSIVE EPISODE CRITERIA

A. Five (or more) of the following symptoms have
been present during the same 2-week period and
represent a change from previous functioning; at
least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.

[ELSE] Now I am going to ask you some more questions
about your mood.
A1

During the past 12 months, since (ONE YEAR AGO), has
there been a period of time when you were feeling
depressed or down most of the day, nearly every day? (Has
anyone said that you look sad, down, or depressed?)

1. Depressed mood most of the day, nearly every
day, as indicated by either subjective report (e.g.,
feels sad, empty, hopeless) or observation made by
others (e.g., appears tearful).

—

+

2. Markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every day
(as indicated by either subjective account or
observation).

—

+

A1

IF NO: How about feeling sad, empty, or hopeless, most
of the day, nearly every day?
IF YES TO EITHER OF ABOVE: What has it been like? For
how long have you felt like that for most of the day, nearly
every day? (As long as 2 weeks?)

A2

IF PREVIOUS ITEM RATED “+”: During that time, did you
have less interest or pleasure in things you usually
enjoyed? (What has that been like?)
IF PREVIOUS ITEM RATED “—”: What about a time since
(ONE YEAR AGO) when you lost interest or pleasure in
things you usually enjoyed? (What has that been like?)
IF YES: Has it been nearly every day? How long has
it lasted? (As long as 2 weeks?)

IF BOTH A1 AND A2 ARE RATED AS “—” FOR THE PAST YEAR, Continue with A29 (Manic Episode Past Year), page 13.

Have you had more than one time like that during the past
12 months? (Which time was the worst?)

NOTE: If more than one episode in the past 12
months is likely, select the “worst” one for your
inquiry about a Major Depressive Episode in the past
12 months.

A2

SCID-5MSMH

A3

Major Depressive Episode Past Year

Page 10

FOR THE FOLLOWING QUESTIONS, FOCUS ON THE WORST
2-WEEK PERIOD OF THE WORST EPISODE IN THE PAST YEAR:
Thinking about (WORST EPISODE IN PAST YEAR), during
which 2-week period would you say you have been feeling
the worst or functioning the worst?

During (2-WEEK PERIOD)…
...how was your appetite? (What about compared to your
usual appetite? Did you have to force yourself to eat? Eat
[less/more] than usual? Was that nearly every day? Did
you lose or gain any weight?)

3. Significant weight loss when not dieting or weight
gain (e.g., a change of more than 5% of body weight
in a month), or decrease or increase in appetite
nearly every day.

—

+
A3

IF YES: How much? (Had you been trying to [lose/gain]
weight?)

A4

…how had you been sleeping? (Trouble falling asleep,
waking frequently, trouble staying asleep, waking too
early, OR sleeping too much?)

4. Insomnia or hypersomnia nearly every day.

—

+

5. Psychomotor agitation or retardation nearly every
day (observable by others, not merely subjective
feelings of restlessness or being slowed down).

—

+

A5

A4

How many hours of sleep (including naps) have you been
getting? How many hours of sleep did you typically get
before you got (depressed/OWN WORDS)? Had it been
nearly every night?

(During [2-WEEK PERIOD]…)
A5

…were you so fidgety or restless that you were unable to
sit still?
What about the opposite—talking more slowly, or moving
more slowly than was normal for you, as if you’re moving
through molasses or mud?

NOTE: CONSIDER BEHAVIOR DURING THE
INTERVIEW.

(IN EITHER INSTANCE, has it been so bad that other people
noticed it? What did they notice? Was that nearly every
day?)

A6

A7

...what was your energy like? (Tired all the time? Nearly
every day?)

6. Fatigue or loss of energy nearly every day.

—

+

A6

(During [2-WEEK PERIOD]…)

7. Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about
being sick).

—

+

A7

…were you feeling worthless?
What about feeling guilty about things you had done or
not done?
IF YES: What kinds of things? (Was this only because
you couldn’t take care of things because you had been
sick?)
IF YES TO EITHER OF ABOVE: Was that Nearly every day?

SCID-5MSMH
A8

Major Depressive Episode Past Year

…Did you have trouble thinking or concentrating? Had it
been hard to make decisions about everyday things?
(What kinds of things had it been interfering with? Nearly
every day?)

(During [2-WEEK PERIOD]…)
A9

…Had things been so bad that you thought a lot about
death or that you would be better off dead? Did you think
about taking your own life?
IF YES: Had you done something about it? (What did
you do? Had you made a specific plan? Did you take
any action to prepare for it? Did you actually make a
suicide attempt?)

Page 11

8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others).

9. Recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for
committing suicide.

—

+

—

+

A8

A9

Note: ANY CURRENT SUICIDAL THOUGHTS, PLANS,
OR ACTIONS SHOULD BE THOROUGHLY ASSESSED BY
THE CLINICIAN AND ACTION TAKEN IF NECESSARY.

A10

A10

AT LEAST FIVE OF THE ABOVE CRITERION A SXS
(A1-A9) ARE RATED “+”.

NO

IF FEWER THAN FIVE ITEMS: Has there been any other time when you were (depressed/OWN WORDS) during the past
year and had even more of the symptoms than I just asked about?
IF YES: Go back to A1, page 9, and assess symptoms for that episode.
IF NO: Continue with A29 (Manic Episode Past Year), page 13.

YES

Continue
with A11
(Criterion B),
next page.

SCID-5MSMH

A11

Major Depressive Episode Past Year

Page 12

IF UNKNOWN: Are you taking any medications or other
health remedies because of (DEPRESSIVE SXS)? Tell me
about that.

B. The symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.

IF UNKNOWN: Are you seeing a doctor, a therapist, or a
counselor for (DEPRESSIVE SXS)? Tell me about that.

Treatment for sxs: Code “+” if “YES” to any of the
first three questions.

IF UNKNOWN: Have other people suggested that you
ought to seek help for (DEPRESSIVE SXS)? Tell me about
that.

Impairment due to sxs: Code “+” if judged to be
moderate or greater

—

Distress: Code “+” if judged to be moderate or
greater
IF UNCLEAR: What effect did (DEPRESSIVE SXS) have on
your life?
ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How did (DEPRESSIVE SXS) affect your relationships or
your interactions with other people? (Did [DEPRESSIVE
SXS] cause you any problems in your relationships with
your family, friends, other inmates, or with
correctional staff?)
How did (DEPRESSIVE SXS) affect your work/school?
(How about your attendance at work/school? Did
[DEPRESSIVE SXS] make it more difficult to do your
work/schoolwork? Did [DEPRESSIVE SXS] affect the
quality of your work/schoolwork?)
How did (DEPRESSIVE SXS) affect your ability to follow
the prison schedule? How about doing simple everyday
things, like getting dressed, bathing, or brushing your
teeth? What about doing other things that were
important to you, like religious activities, physical
exercise, hobbies, or keeping in touch with family?
Did you avoid doing anything because you felt like you
weren’t up to it?
Did (DEPRESSIVE SXS) affect any other important part
of your life?
IF DEPRESSIVE SXS DO NOT INTERFERE WITH LIFE: How
much were you bothered or upset by having (DEPRESSIVE
SXS)?

IF EPISODE DOES NOT CAUSE DISTRESS OR IMPARIMAENT, ASK: Has there been any other time during the past year
when you were (depressed/OWN WORDS) and it caused even more problems than the time I just asked about?
IF YES: Go back to A1, page 9, and assess symptoms for that episode.
IF NO: Continue with A29 (Manic Episode Prior To Past Year), page 13.

+

Continue
with A12,
next page

A11

SCID-5MSMH

Manic Episode Past Year

MANIC EPISODE PAST YEAR

A29a

[IF UNBLINDMANIA = YES] In your earlier interview you
mentioned that you have had times in the past year when
you felt so full of energy or in such a good mood for at
least four days that other people thought you were not
yourself. Or, you may have mentioned that you were
much more irritable for at least four days. I’d like to ask
you some more questions about those times.

Page 13

MANIC EPISODE CRITERIA

—

A29a

+

PERIOD OF ELEVATED MOOD?
A. A distinct period [lasting at least several
days] of abnormally and persistently elevated,
expansive, or irritable mood and abnormally Go to
and persistently increased activity or energy. A29c.

[ALL] During the past 12 months, since (12 MONTHS AGO),
has there been a period of time when you were feeling so
good, “high,” excited, or “on top of the world” that other
people thought you were not your normal self?
—
A29b

A29c

A29d

A30

Have you also been feeling like you were “hyper” or
“wired” and had an unusual amount of energy? Have you
been much more active than is typical for you? (Have
other people commented on how much you have been
doing?) What has it been like?

A29b
PLUS INCREASED ENERGY OR ACTIVITY?
A29 has been prepopulated
“+”. Go to A30
—

PERIOD OF IRRITATED MOOD?
Since (12 MONTHS AGO), have you had a period of time
when you were feeling irritable, angry, or short-tempered
for most of the day, for at least several days? (Was that
different from the way you usually are?)

+

+
A29c

A29 has been prepopulated “-“.
Go to A53, page 17.
PLUS INCREASED ENERGY OR ACTIVITY?

IF UNKNOWN: Have you also been feeling like you were
“hyper” or “wired” and had an unusual amount of energy?
Were you much more active than was typical for you? (Did
other people comment on how much you were doing?)
What has it been like?

How long did this last? (As long as 1 week?)
IF LESS THAN 1 WEEK: Did you need to go into the
hospital, or medical or psychiatric ward to protect you
from hurting yourself or someone else, or from doing
something that could have caused serious legal
problems?
Were you feeing (high/irritable/OWN WORDS) for most of
the day, nearly every day, during this time?

—

A29 has been
prepopulated “-“. Go to
A53, page 17.

...lasting at least 1 week and present most of
the day, nearly every day (or any duration if
hospitalization is necessary).
NOTE: IF ELEVATED MOOD LASTS LESS THAN 1
WEEK, CHECK WHETHER THERE HAS BEEN A
PERIOD OF IRRITABLE MOOD LASTING AT
LEAST 1 WEEK BEFORE SKIPPING TO A53.

—

+

A29d

A29 has been
prepopulated “+”. Go
to A30

+

Continue
with A53
(Consider
Assessment
of Manic
Episodes
prior to
past year)
page 17.

A30

SCID-5MSMH

Manic Episode Past Year

Have you had more than one time like that during the past
year? (Which time was the most intense or caused the
most problems?)
FOR A31–A37, FOCUS ON THE MOST SEVERE PERIOD OF THE
WORST EPISODE DURING THE PAST YEAR THAT YOU ARE
INQUIRING ABOUT.

Page 14

B. During the period of mood disturbance and
increased energy or activity, three (or more) of the
following symptoms (four if the mood is only
irritable) are present to a significant degree and
represent a noticeable change from usual behavior:

IF UNKNOWN: During (EPISODE), when were you the most
(high/irritable/OWN WORDS)?
1. Inflated self-esteem or grandiosity.

—

+

A31

2. Decreased need for sleep (e.g., feels rested after
only 3 hours of sleep).

—

+

A32

A33

(During that time…)
…were you much more talkative than usual?
(Did people have trouble stopping you or understanding
you? Did people have trouble getting a word in edgewise?)

3. More talkative than usual or pressure to keep
talking.

—

+

A34

…were your thoughts racing through your head?
(What was that like?)

4. Flight of ideas or subjective experience that
thoughts are racing.

—

+

A34

A35

…were you so easily distracted by things around you that
you had trouble concentrating or staying on one track?
(Give me an example of that.)

5. Distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external stimuli), as
reported or observed.

—

+

A35

6. Increase in goal-directed activity (either socially, at
work or school, or sexually) or psychomotor agitation
(i.e., purposeless non-goal-directed activity).

—

+

During that time…
A31

…how did you feel about yourself? (More self-confident
than usual? Did you feel much smarter or better than
everyone else? Did you feel like you had any special
powers or abilities?)

A32

…did you need less sleep than usual?
(How much sleep did you get?)
IF YES: Did you still feel rested?

A33

(During that time…)
A36

…how did you spend your time? (Work, friends, hobbies?
Were you especially busy during that time?)
(Did you find yourself more enthusiastic at work or working
harder at your job? Did you find yourself more engaged in
school activities or studying harder?)
(Were you more sociable during that time, such as hanging
out with friends, participating in prison activities more than
you usually do, finding opportunities to interact with
people you didn’t already know in the prison?)
(Were you spending more time thinking about sex? Was
that a big change for you?)
Were you physically restless during this time, doing things
like pacing a lot, or being unable to sit still?
(How bad was it?)

A36

SCID-5MSMH

Manic Episode Past Year

Page 15

(During that time…)
A37

…were you doing anything that could have caused trouble
for you or your family?

7. Excessive involvement in activities that have a high
potential for painful consequences (e.g., engaging in
unrestrained buying sprees, sexual indiscretions, or
foolish business investments).

—

+

AT LEAST THREE OF THE ABOVE CRITERION B SXS (A31–
A37) ARE RATED “+” (FOUR IF MOOD ONLY IRRITABLE).

NO

YES

A37

(Spending money on things you didn’t need or couldn’t
afford? How about giving away money or valuable things?
Gambling with money you couldn’t afford to lose?)
(Did you make any risky or impulsive decisions that you
wouldn’t normally have done?)
(Were you less likely to obey prison rules? Were you more
likely to say things that could get you in trouble?)

A38

A38

Continue
with A39,
CRITERION C,
below.

IF FEWER THAN THREE (FOUR IF MOOD ONLY IRRITABLE) AND NOT ALREADY ASKED: Have there been any other times in the
past year when you were (high/irritable/OWN WORDS) and had even more of the symptoms that I just asked you about?
IF YES: Go back to A29, page 13, and ask about that episode.
IF NO: Continue with A53, page 17 (Consider Assessment of Manic Episodes prior to past year)

A39

IF UNCLEAR: What effect did (MANIC SXS) have on your
life?
IF UNKNOWN: Did you need to go into the hospital, or
medical or psychiatric ward to protect you from hurting
yourself or someone else, or from doing something that
could have caused serious legal problems?

C. The mood disturbance is sufficiently severe to cause
marked impairment in social or occupational functioning
or to necessitate hospitalization to prevent harm to self
or others, or there are psychotic features.

ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How did (MANIC SXS) affect your relationships or your
interactions with other people? (Did [MANIC SXS] cause
you any problems in your relationships with your family,
friends, other inmates, or correctional staff?)
How did (MANIC SXS) affect your work/school? (How
about your attendance at work/school? Did [MANIC SXS]
make it more difficult to do your work/schoolwork? Did
[MANIC SXS] affect the quality of your work/schoolwork?)
How have (MANIC SXS) affected your ability to follow the
prison schedule?
IF NOT ALREAD ASKED: IF MOOD DISTURBANCE WAS NOT SEVERE ENOUGH TO CAUSE MARKED IMPARIMENT OR TO
NECESSITATE HOSPITALIZATION AND NOT ALREADY ASKED: Has there been any other time in the past year when you were
(high/irritable/OWN WORDS) and had (ACKNOWLEDGED MANIC SXS) and you got into trouble with people or were
hospitalized?
IF YES: Go back to A29, page 13, and ask about that episode.
IF NO: Continue with A53 (Consider assessment of Manic Episodes prior to past year), page 17.

—

+

Continue
with A40,
next page

A39

SCID-5MSMH
A40

Manic Episode Past Year

IF UNKNOWN: When did this period of being
(high/irritable/OWN WORDS) begin?
Just before this began, were you physically ill?
IF YES: What did the doctor say?

A40a

Just before this began, were you taking any medications?
IF ALREADY ON MEDICATION WHEN EPISODE BEGAN:
Any change in the amount you were taking?

Page 16

D. [Primary Manic Episode] The episode is not
attributable to the physiological effects of another
medical condition…
Refer to page 51 for a list of possibly etiological medical
conditions
NOTE: Code “NO” only if episode is due to a GMC

NO

YES

A40

PRIMARY

D. [Primary Manic Episode] The episode is not
attributable to the physiological effects of a medication
(e.g., a medication, other treatment)
Refer to page 51 for a list of possibly etiological
substances/medications.
Note: A full Manic Episode that emerges during
antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a fully
syndromal level beyond the physiological effect of that
treatment is sufficient evidence for a Manic Episode and,
therefore, a Bipolar I [Disorder] diagnosis.
NOTE: Code “NO” only if episode is due to a medication.

DETERMINE WHETHER AMOUNT AND DURATION OF USE IS
SUFFICIENT TO CAUSE MANIC SYMPTOMS:

1) Amount or duration is insufficient to cause
manic symptoms:

IF UNKNOWN: How much (MEDICATION) were you
using/taking at the time you began to have (MANIC SXS)?

YES (PRIMARY) [Answer “YES” to A40a]

IF UNKNOWN: For how long had you been taking
(MEDICATION)?
DETERMINE WHETHER THERE WAS BEEN A PERIOD OF TIME OF
MANIC SXS WHEN NOT TAKING MEDICATION:
IF UNKNOWN: Were you (high/excited/OWN WORDS) before
you started [taking (MEDICATION)]?

NO (SUFFICIENT, POSSIBLY SUBSTANCEINDUCED)
2) Determine if manic symptoms prior to
medication use or manic symptoms persist
after stopping medication
YES (PRIMARY) [Answer “YES” to A40a]

IF UNKNOWN: Have you had a period of time when you
stopped [taking (MEDICATION)]?
IF YES: After you stopped [taking (MEDICATION)] did the
(MANIC SXS) go away or get better?
IF YES: How long did it take for them to get better? Did
they go away within a month of stopping?
CHECK FOR POSSIBILITY THAT A PRIMARY MANIC EPISODE IS
MORE LIKELY BASED ON PAST HX

NO (MANIA CONFINED TO SUBSTANCE USE),
POSSIBLY SUBSTANCE-INDUCED

IF UNKNOWN: Have you had other episodes of (MANIC SXS)?
IF YES: How many? Were you [taking MEDICATION)] at
those times?

YES (POSSIBLY PRIMARY) [APPLY CLINICAL
JUDGEMENT]

3) Check for prior non-substance-induced
manic episodes:

NO (ALL EPISODES SUBSTANCE-RELATED)
[Answer “NO” to A40a]

IF DUE TO A MEDICAL CONDITION OR MEDICATION: Has there been any other time during the past year when you were
(high/irritable/OWN WORDS) and had (ACKNOWLEDGED MANIC SXS) and you were not (ill with GMC/taking MEDICATION)?
IF YES: Go back to A29, page 13, and ask about that episode
IF NO: Continue with A53, page 17 (Consider Assessment of Manic Episodes prior to past year)

MANIC EPISODE
PAST YEAR
Continue with
A53, page 17.

SCID-5MSMH

A53

Manic Episode Prior to Past Year

Page 17

CONSIDER ASSESSMENT OF MANIC EPISODES PRIOR TO PAST YEAR (ONLY IF MAJOR DEPRESSIVE EPISODES IN PAST YEAR
ONE OR MORE MAJOR DEPRESSIVE EPISODES IN PAST YEAR

NO

YES

Continue
with B1,
Page 23.

MANIC EPISODE PRIOR TO PAST YEAR

A54a

A54b

Prior to the past year, before (ONE YEAR AGO), have you
ever had a period of time when you were feeling so good,
“high,” excited, or “on top of the world” that other people
thought you were not your normal self?

A53

Continue with
A54 (Manic
prior to past
year), below.

MANIC EPISODE CRITERIA
—
PERIOD OF ELEVATED MOOD?
A. A distinct period [lasting at least several days]
of abnormally and persistently elevated,
expansive, or irritable mood and abnormally and
Go to
persistently increased activity or energy.
A54c.

+

—

+

A54a

PLUS INCREASED ENERGY OR ACTIVITY?

A54b

Did you also feel like you were “hyper” or “wired” and had
an unusual amount of energy? Were you much more
active than is typical for you? (Did other people comment
on how much you were doing?) What has it been like?

A54 has been
prepopulated “+”.
Go to A55
—

A54c

A54d

A55

Prior to the past year, have you ever had a period of time
when you were feeling irritable, angry, or short-tempered
for most of the day, for at least several days? (Was that
different from the way you usually are?)

+
A54c

PERIOD OF IRRITATED MOOD?
A54 has been prepopulated
“-“. Go to B1, page 23.

—

+

IF UNKNOWN: Did you also feel like you were “hyper” or
“wired” and had an unusual amount of energy? Were you
much more active than is typical for you? (Did other
people comment on how much you were doing?) What has
it been like?

PLUS INCREASED ENERGY OR ACTIVITY?

How long did this last? (As long as 1 week?)

...lasting at least 1 week and present most of the
day, nearly every day (or any duration if
hospitalization is necessary).

—

NOTE: IF ELEVATED MOOD LASTED LESS THAN
1 WEEK, CHECK WHETHER THERE HAS BEEN A
PERIOD OF IRRITABLE MOOD LASTING AT LEAST
1 WEEK BEFORE SKIPPING TO B1.

Continue
with B1
(psychotic
sxs) page 23.

IF LESS THAN ONE WEEK: Did you need to go into the
hospital, or medical or psychiatric ward to protect you
from hurting yourself or someone else, or from doing
something that could have caused serious legal
problems?
Did you feel (high/irritable/OWN WORDS) for most of the
day, nearly every day, during this time?

A54 has been
prepopulated “-“. Go to
B1, page 23.

A54d

A54 has been
prepopulated “+“. Go
to A55.

+

A55

SCID-5MSMH

Manic Episode Prior to Past Year

Have you had more than one time like that prior to the
past year? (Which time was the most intense or caused the
most problems?)

NOTE: If there is evidence for more than one past
episode prior to the past year, select the one with the
most impairment for your inquiry about past Manic
Episode.

FOR A56–A62, FOCUS ON THE MOST SEVERE PERIOD OF THE
WORST EPISODE PRIOR TO THE PAST YEATR THAT YOU ARE
INQUIRING ABOUT.

B. During the period of mood disturbance and
increased energy or activity, three (or more) of the
following symptoms (four if the mood is only
irritable) are present to a significant degree and
represent a noticeable change from usual behavior:

IF UNKNOWN: During (EPISODE), when were you the most
(high/irritable/OWN WORDS)?
A56

A57

Page 18

During that time…
…how did you feel about yourself? (More self-confident
than usual? Did you feel much smarter or better than
everyone else? Did you feel like you had any special
powers or abilities?)

1. Inflated self-esteem or grandiosity.

—

+

A56

…did you need less sleep than usual?
(How much sleep did you get?)

2. Decreased need for sleep (e.g., feels rested after
only 3 hours of sleep).

—

+

A57

3. More talkative than usual or pressure to keep
talking.

—

+

A58

IF YES: Did you still feel rested?
(During the past 12 months)
A58

…were you much more talkative than usual? (Did people
have trouble stopping you or understanding you? Did
people have trouble getting a word in edgewise?)

A59

…were your thoughts racing through your head?
(What was that like?)

4. Flight of ideas or subjective experience that
thoughts are racing.

—

+

A59

A60

…were you so easily distracted by things around you that
you had trouble concentrating or staying on one track?
(Give me an example of that.)

5. Distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external stimuli), as
reported or observed.

—

+

A60

SCID-5MSMH

Manic Episode Prior to Past Year

Page 19

(During the past 12 months)
A61

...how did you spend your time? (Work, friends, hobbies?
Were you especially busy during that time?)

6. Increase in goal-directed activity (either socially, at
work or school, or sexually) or psychomotor agitation
(i.e., purposeless non-goal-directed activity).

—

+

A61

7. Excessive involvement in activities that have a high
potential for painful consequences (e.g., engaging in
unrestrained buying sprees, sexual indiscretions, or
foolish business investments).

—

+

A62

NO

YES

A63

(Did you find yourself more enthusiastic at work or working
harder at your job? Did you find yourself more engaged in
school activities or studying harder?)
(Were you more sociable during that time, such as hanging
out with friends, participating in prison activities more than
you usually do, finding opportunities to interact with
people you didn’t already know in the prison?)
(Were you spending more time thinking about sex? Was
that a big change for you?)
Were you physically restless during this time, doing things
like pacing a lot, or being unable to sit still?
(How bad was it?)
(During the past 12 months)
A62

...did you do anything that could have caused trouble for
you or your family?
(Spending money on things you didn’t need or couldn’t
afford? How about giving away money or valuable things?
Gambling with money you couldn’t afford to lose?)
(Did you make any risky or impulsive decisions that you
wouldn’t normally have done?)
(Were you less likely to obey prison rules? Were you more
likely to say things that could get you in trouble?)

A63

AT LEAST THREE OF THE ABOVE CRITERION B SXS
(A56–A62) ARE RATED “+” (FOUR IF MOOD ONLY
IRRITABLE).

IF FEWER THAN THREE (FOUR IF MOOD ONLY IRRITABLE) AND NOT ALREADY ASKED: Have there been any other times prior
to the past year when you were (high/irritable/OWN WORDS) and had even more of the symptoms that I just asked you
about?
IF YES: Go back to A54, page 17, and ask about that episode.
IF NO: Continue with B1 (Psychotic sxs), page 23.

Continue
with A64
(Criterion C),
next page.

SCID-5MSMH
A64

Manic Episode Prior to Past Year

IF UNCLEAR: What effect did (MANIC SXS) have on your life?
IF UNKNOWN: Did you need to go into the hospital, or
medical or psychiatric ward to protect you from hurting
yourself or someone else, or from doing something that
could have caused serious financial or legal problems?

C. The mood disturbance is sufficiently severe to
cause marked impairment in social or occupational
functioning or to necessitate hospitalization to
prevent harm to self or others, or there are psychotic
features.

ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:

Page 20

—

+

Continue
with A65,
next page.

How did (MANIC SXS) affect your relationships or your
interactions with other people? (Did [MANIC SXS] cause
you any problems in your relationships with your family,
friends, other inmates, or correctional staff?)
How did (MANIC SXS) affect your work/school? (How about
your attendance at work/school? Did [MANIC SXS] make it
more difficult to do your work/schoolwork)? Did [MANIC
SXS] affect the quality of your work/schoolwork?)
How did (MANIC SXS) affect your ability to follow the prison
schedule?
IF MOOD DISTURBANCE WAS NOT SEVERE ENOUGH TO CAUSE MARKED IMPARIMENT OR NECESSITATE HOSPITALIZATION AND NOT
ALREADY ASKED: Has there been any other time prior to the past year when you were (high/irritable/OWN WORDS) and had
(ACKNOWLEDGED MANIC SXS) and you got into trouble with people or were hospitalized?
IF YES: Go back to A54, page 17, and ask about that episode.
IF NO: Continue with B1 (Psychotic sxs), page 23.

A64

SCID-5MSMH
A65

Manic Episode Prior to Past Year

IF UNKNOWN: When did this period of being
(high/irritable/OWN WORDS) begin?
Just before this began, were you physically ill?

D. [Primary Manic Episode] The episode is not
attributable to the physiological effects of another
medical condition…
Refer to page 51 for a list of possibly etiological
medical conditions
NOTE: Code “NO” only if episode is due to a GMC

Page 21

NO

YES

A65

PRIMARY

IF YES: What did the doctor say?
Just before this began, were you taking any medications?
A65a
IF ALREADY ON MEDICATION WHEN EPISODE BEGAN:
Any change in the amount you were taking?

D. [Primary Manic Episode] The episode is not
attributable to the physiological effects of a
medication (e.g., a medication, other treatment)
Refer to page 51 for a list of possibly etiological
medications.
Note: A full Manic Episode that emerges during
antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a fully
syndromal level beyond the physiological effect of
that treatment is sufficient evidence for a Manic
Episode and, therefore, a Bipolar I [Disorder]
diagnosis.
NOTE: Code “NO” only if episode is due to a
substance/medication.

DETERMINE WHETHER AMOUNT AND DURATION OF USE IS
SUFFICIENT TO CAUSE MANIC SYMPTOMS:

1) Amount or duration is insufficient to cause
manic symptoms:

IF UNKNOWN: How much (MEDICATION) were you taking at
the time you began to have (MANIC SXS)?

YES (PRIMARY) [Answer “YES” to A65]

IF: UNKNOWN: For how long had you been taking
(MEDICATION)?
DETERMINE WHETHER THERE WAS BEEN A PERIOD OF TIME OF
MANIC SXS WHEN NOT TAKING MEDICATION:
IF UNKNOWN: Were you (high/excited/OWN WORDS) before
you started [taking (MEDICATION)]?

NO (SUFFICIENT, POSSIBLY SUBSTANCEINDUCED)
2) Determine if manic symptoms prior to
medication use or manic symptoms persist
after stopping medication
YES (PRIMARY) [Answer “YES” to A65]

IF UNKNOWN: Have you had a period of time when you
stopped [taking (MEDICATION)]?
IF YES: After you stopped [taking (MEDICATION)] did the
(MANIC SXS) go away or get better?
IF YES: How long did it take for them to get better? Did
they go away within a month of stopping?
CHECK FOR POSSIBILITY THAT A PRIMARY MANIC EPISODE IS
MORE LIKELY BASED ON PAST HX

NO (MANIA CONFINED TO SUBSTANCE USE),
POSSIBLY SUBSTANCE-INDUCED

IF UNKNOWN: Have you had other episodes of (MANIC SXS)?
IF YES: How many? Were you [taking MEDICATION)] at
those times?

YES (POSSIBLY PRIMARY) [APPLY CLINICAL
JUDGEMENT]

3) Check for prior non-substance-induced
manic episodes:

NO (ALL EPISODES SUBSTANCE-RELATD)
[Answer “NO” to A65]

MANIC EPISODE
PRIOR TO THE
PAST YEAR
Continue with
A66, next page.

SCID-5MSMH
A66

Manic Episode Prior to Past Year

IF DUE TO MEDICAL CONIDITON OR MEDICATION: Has there been any other time during the past year when you were
(high/irritable/OWN WORDS) and had (ACKNOWLEDGED MANIC SXS) and you were not (ill with GMC/taking MEDICATION)?
IF YES: Go back to A54, page 17, and ask about that episode
IF NO: Continue with B1 (Psychotic sxs), page 23.

Page 22

SCID-5MSMH

Psychotic and Associated Symptoms

Page 23

B. PSYCHOTIC AND ASSOCIATED SYMPTOMS
FOR ANY PSYCHOTIC AND ASSOCIATED SYMPTOMS THAT ARE PRESENT, DETERMINE WHETHER THE SYMPTOM IS DEFINITELY
“PRIMARY” (I.E., DUE TO A PSYCHOTIC DISORDER) OR WHETHER THERE IS A POSSIBLE OR DEFINITE ETIOLOGICAL GMC OR
MEDICATION. (REFER TO PAGE 51 FOR A LIST OF ETIOLOGICAL GMCs OR MEDICATIONS.) THIS INFORMATION WILL BE USEFUL IN
DIFFERENTIATING A PRIMARY PSYCHOTIC DISORDER FROM A PSYCHOTIC DISORDER DUE TO AMC OR MEDICATION-INDUCED
PSYCHOTIC DISORDER IN MODULE C.
THE FOLLOWING QUESTIONS MAY BE USEFUL FOR THIS DETERMINATION IF THE OVERVIEW HAS NOT ALREADY PROVIDED THE
INFORMATION:
Just before (PSYCHOTIC SXS) began, were you
...On any medications? IF YES: What were you taking?
...Were you physically ill?
IF YES TO ANY: Has there been a time when you had (PSYCHOTIC SXS) and were not (taking [MEDICATION]/ill)?

[IF UNBLINDPSYCHOS1 = YES] In your earlier interview you mentioned that a health professional said you had schizophrenia or
schizoaffective disorder, I’d like to ask you some more questions about this.
[IF UNBLINDPSYCHOS2 = YES] In your earlier interview you mentioned that you received disability payments because of a
schizophrenia or schizoaffective disorder diagnosis, I’d like to ask you some more questions about this.
[IF UNBLINDPSYCHOS3 = YES] In your earlier interview you mentioned having one or more unusual experiences in your life. I’d like to
ask you some more questions about those experiences.
[ELSE] Now I am going to ask you about unusual experiences that people sometimes have.
DELUSIONS
A false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and
despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by
other members of the person’s culture or subculture (i.e., it is not an article of religious faith). When a false belief involves a value
judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility.
NOTE: Code overvalued ideas (unreasonable and sustained beliefs that are maintained with less than delusional intensity) as “—”.

B1

Has it ever seemed like people were talking about you or
taking special notice of you? (What do you think they were
saying about you?)
IF YES: Were you convinced they were talking about
you or did you think it might have been your
imagination?
Did you ever have the feeling that something on the radio,
TV, or in a movie was meant especially for you? (Not just
that it was particularly relevant to you, but that it was
specifically meant for you.)
Did you ever have the feeling that the words in a popular
song were meant to send you a special message?
Did you ever have the feeling that what people were
wearing was intended to send you a special message?
Did you ever have the feeling that street signs or billboards
had a special meaning for you?

Delusion of reference (i.e., a belief that events,
objects, or other people in the individual’s immediate
environment have a particular or unusual
significance)
DESCRIBE:

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B1

B1a

SCID-5MSMH

B2

Psychotic and Associated Symptoms

What about anyone going out of their way to give you a
hard time, or trying to hurt you? (Tell me about that.)
Have you ever had the feeling that you were being
followed, spied on, manipulated, or plotted against?

Page 24

Persecutory delusion (i.e., a belief that the individual
[or his or her group] is being attacked, harassed,
cheated, persecuted, or conspired against)
DESCRIBE:

—

+

Code “+” if
primary, “-“
otherwise:
—
+

Did you ever have the feeling that you were being poisoned
or that your food had been tampered with?
B3

B4

B2a

Have you ever thought that you were especially important
in some way, or that you had special powers or
knowledge? (Tell me about that.)

Grandiose delusion (i.e., content involves
exaggerated power, knowledge or importance, or a
special relationship to a deity or famous person)

Did you ever believe that you had a special or close
relationship with a celebrity or someone else famous?

DESCRIBE:

Have you ever been convinced that something was very
wrong with your physical health even though your doctor
said nothing was wrong...like you had cancer or some other
disease? (Tell me about that.)

Somatic delusion (i.e., content involves change or
disturbance in body appearance or functioning)
DESCRIBE:

Have you ever felt that something strange was happening
to parts of your body?

B5

Have you ever felt that you had committed a crime or done
something terrible for which you should be punished? (Tell
me about that.)
Have you ever felt that something you did, or should have
done but did not do, caused serious harm to your parents,
children, other family members, or friends? (Tell me about
that.)

B2

Delusion of guilt (i.e., a belief that a minor error in
the past will lead to disaster, or that he or she has
committed a horrible crime and should be punished
severely, or that he or she is responsible for a
disaster [e.g., an earthquake or fire] with which there
can be no possible connection)

—

+

B3

Code “+” if
primary, “-“
otherwise:
—
+
—

+

B3a
B4

Code “+” if
primary, “-“
otherwise:
—
+

—

+

B4a
B5

Code “+” if
primary, “-“
otherwise:
—
+

DESCRIBE:

B5a

What about feeling responsible for a disaster such as a fire,
flood, or earthquake? (Tell me about that.)

B6

Have you ever been convinced that your spouse or partner
was being unfaithful to you?

Jealous delusion (i.e., a belief that one’s sexual
partner is unfaithful)

IF YES: How did you know he/she was being unfaithful?
(What clued you into this?)

DESCRIBE:
LEAVE ITEM BLANK IF NO SPOUSE OR PARTNER

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B6

B6a

SCID-5MSMH

B7

Psychotic and Associated Symptoms

Are you a religious or spiritual person?
IF YES: Have you ever had any religious or spiritual
experiences that the other people in your religious or
spiritual community have not experienced?

Page 25

Religious delusion (i.e., a delusion with a religious or
spiritual content)

DESCRIBE:

IF YES: Tell me about your experiences. (What did
they think about these experiences of yours?)

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B7

B7a

IF NO: Have you ever felt that God, the devil, or
some other spiritual being or higher power has
communicated directly with you? (Tell me about
that. Do others in your religious or spiritual
community also have such experiences?)
IF NO: Have you ever felt that God, or the devil or
some other spiritual being or higher power has
communicated directly with you? (Tell me about that.
Do others in your religious or spiritual community also
have such experiences?)

B8

B9

Did you ever have a “secret admirer” who, when you tried
to contact them, denied that they were in love with you?
(Tell me about that.)

Erotomaniac delusion (i.e., a belief that another
person, usually of higher status, is in love with the
individual)

Were you ever romantically involved with someone
famous? (Tell me about that.)

DESCRIBE:

Did you ever feel that someone or something outside
yourself was controlling your thoughts or actions against
your will? (Tell me about that.)

Delusion of being controlled (i.e., feelings, impulses,
thoughts, or actions are experienced as being under
the control of some external force rather than under
one’s own control)
DESCRIBE:

B10

Did you ever feel that certain thoughts that were not your
own were put into your head? (Tell me about that.)

Thought insertion (i.e., a belief that certain thoughts
are not one’s own, but rather are inserted into one’s
mind)
DESCRIBE:

B11

What about thoughts being taken out of your head? (Tell
me about that.)

Thought withdrawal (i.e., a belief that one’s
thoughts have been “removed” by some outside
force)
DESCRIBE:

—

+

Code “+” if
primary, “-“
otherwise:
—
+

—

+

Code “+” if
primary, “-“
otherwise:
—
+

—

+

Code “+”if
primary, “-“
otherwise:
—
+

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B8

B8a

B9

B9a

B10

B10a

B11

B11a

SCID-5MSMH

B12

Psychotic and Associated Symptoms

Did you ever feel as if your thoughts were being broadcast
out loud so that other people could actually hear what you
were thinking? (Tell me about that.)

Page 26

Thought broadcasting (i.e., a delusion that one’s
thoughts are being broadcast out loud so that others
can perceive them)
DESCRIBE:

B13

Did you ever believe that someone could read your mind?
(Tell me about that.)

Other delusions (e.g., a belief that others can read
the person’s mind, a delusion that one has died
several years ago)
DESCRIBE:

—

+

Code “+” if
primary, “-“
otherwise:
—
+
—

+

Code “+” if
primary, “-“
otherwise:
—
+

B12

B12a

B13

B13a

HALLUCINATIONS
A perception-like experience with the clarity and impact of a true perception, but without the external stimulation of the relevant
sensory organ. The person may or may not have insight into the nonveridical nature of the hallucination (i.e., one hallucinating person
may recognize the false sensory experience, whereas another may be convinced that the experience is grounded in reality).
NOTE: Code “—” for hallucinations that are so transient as to be without diagnostic significance.
Code “—” for hypnagogic or hypnopompic hallucinations occurring only when falling asleep or upon awakening, respectively.

B14

Did you ever hear things that other people couldn’t, such
as noises, or the voices of people whispering or talking?
(Were you awake at the time?)

Auditory hallucinations (i.e., a hallucination involving
the perception of sound, most commonly of voice,
when fully awake, heard either inside or outside of
one’s head)

IF YES: What did you hear? How often did you hear it?
DESCRIBE:

B15

Did you have visions or see things that other people
couldn’t see? (Tell me about that. Were you awake at the
time?)

Visual hallucinations (i.e., a hallucination involving
sight, which may consist of formed images, such as of
people, or of unformed images, such as flashes of
light)
NOTE: Distinguish from an illusion (i.e., a
misperception of a real external stimulus).
DESCRIBE:

—

+

Code “+” if
primary, “-“
otherwise:
—
+

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B14

B14a

B15

B15a

SCID-5MSMH

Psychotic and Associated Symptoms

Page 27

DISORGANIZED SPEECH AND BEHAVIOR AND CATATONIA
(Let me stop for a minute while I make a few notes...)

HAVE YOU CODED ANY PSYCHOTIC AND ASSOCIATED SYMPTOMS POSITIVELY DURING THE INTERVIEW WITH THE PRIMARY
RESPONDENT?”
Yes continue
No IF NO go to B23, page 29

SCORE BASED ON OBSERVATIONS DURING INTERVIEW WITH PRIMARY RESPONDENT.

B20

Note: The ratings of lifetime disorganized speech will almost
always be based on the observations by untrained secondary
informants.
SCORE BASED ON OBSERVATIONS DURING INTERVIEW WITH
PRIMARY RESPONDENT.

DISORGANIZED SPEECH: The individual may switch
from one topic to another (derailment or loose
associations). Answers to questions may be
obliquely related or completely unrelated
(tangentiality). Rarely, speech may be so severely
disorganized that it is nearly incomprehensible and
resembles receptive aphasia in its linguistic
disorganization (incoherence or “word salad”).
Because mildly disorganized speech is common and
nonspecific, the symptom must be severe enough to
substantially impair effective communication.

—

+

B20

Code “+” if
primary, “-“
otherwise:
—
+

DESCRIBE:

B21

Note: The ratings of lifetime disorganized speech will almost
always be based on the observations of untrained secondary
informants.
SCORE BASED ON OBSERVATIONS DURING INTERVIEW WITH
PRIMARY RESPONDENT.

GROSSLY DISORGANIZED BEHAVIOR: May range
from childlike silliness to unpredictable agitation. The
person may appear markedly disheveled, may dress
in an unusual manner (e.g., wearing multiple
overcoats, scarves, and gloves on a hot day), or may
display clearly inappropriate sexual behavior
(e.g., public masturbation) or unpredictable and
untriggered agitation (e.g., shouting or swearing).
DESCRIBE:

B22

Note: The ratings of lifetime catatonia items will almost
always be based on the observations by untrained secondary
informants whose ability to describe them in sufficient detail
so as to allow the rater to accurately differentiate among
them is likely to be quite limited. Consequently, these
symptoms have been grouped together by similar
phenomenology, with suggested questions provided for
inquiry.

CATATONIC BEHAVIOR

SCORE BASED ON OBSERVATIONS DURING INTERVIEW WITH
PRIMARY RESPONDENT.

Little or no psychomotor activity or verbal
responses

—

+

Code “+” if
primary, “-“
otherwise:
—
+

—

+

B21

B21a

B22

Code ‘+ if at least two of the below symptoms are
present
Code “+” if
primary, “-“
otherwise:

Stupor (i.e., no psychomotor activity; not actively
relating to environment)

—

+

B22a

SCID-5MSMH

Psychotic and Associated Symptoms

Page 28

Mutism (i.e., no, or very little, verbal response
[exclude if known aphasia])
Negativism (i.e., opposition or no response to
instructions or external stimuli)

Maintenance of Unusual postures against gravity
Posturing (i.e., spontaneous, and active
maintenance of a posture against gravity)
Catalepsy (i.e., passive induction of a posture held
against gravity)
Waxy flexibility (i.e., slight, even resistance to
positioning by examiner)

Excessive movement or behavior
Agitation, not influenced by external stimuli
Stereotypy (i.e., repetitive, abnormally frequent,
non-goal-directed movements)
Odd facial expressions or movements
Grimacing (i.e., odd and inappropriate facial
expressions unrelated to situation)
Mannerism (i.e., odd, circumstantial caricature of
normal actions)
Mimicking speech or actions
Echolalia (i.e., mimicking another’s speech)
Echopraxia (i.e., mimicking another’s movements)
DESCRIBE:

SCID-5MSMH

Psychotic and Associated Symptoms

Page 29

NEGATIVE SYMPTOMS
For any negative symptoms rated “+”, determine whether the symptom is definitely primary (i.e., due to a Psychotic Disorder) or
whether it is possibly or definitely secondary—i.e., related to another mental disorder (e.g., depression), a medication or a GMC (e.g.,
medication-induced akinesia), or a psychotic symptom (e.g., command hallucinations not to move).

B23

RATE THIS ITEM BASED ON INFORMATION OBTAINED FROM
THE OVERVIEW.
IF UNKNOWN: Has there been a period of time lasting at
least several months when you were not working, not in
school, or doing much of anything?

Avolition: An inability to initiate and persist in goaldirected activities. When severe enough to be
considered pathological, avolition is pervasive and
prevents the person from completing many different
types of activities (e.g., work, intellectual pursuits,
self-care).

IF UNKNOWN: How about a period of time when you were
unable to take care of basic everyday things, like brushing
your teeth or bathing?

—

+

Code “+” if
primary, “-“
otherwise:
—
+

B23

B23a

IF NO: Did anyone ever say that you were not taking
care of these or other basic everyday things?

B24

Diminished Emotional Expressiveness: Includes
reductions in the expression of emotions in the face,
eye contact, intonation of speech (prosody), and
movements of the hand, head, and face that
normally give an emotional emphasis to speech.

—

+

Code “+” if
primary, “-“
otherwise:
—
+

Continue with C1
(Differential Diagnosis
of Psychotic Disorders),
next page.

B24

B24a

SCID-5MSMH

Differential Diagnosis of Psychotic Disorders

Page 30

C. DIFFERENTIAL DIAGNOSIS OF PSYCHOTIC DISORDERS
If no primary psychotic items from Module B have ever been present, skip to D1 (Differential Diagnosis of Mood Disorders), page 36.
C1

Note: for the following items, only include psychotic symptoms in Module B that have been rated to be primary.

Psychotic symptoms occur at times other than during Major Depressive or Manic Episodes
IF A MAJOR DEPRESSIVE OR MANIC EPISODE HAS EVER BEEN PRESENT:
Has there ever been a time when you had (PSYCHOTIC SXS) and you were not
(depressed/high/irritable/OWN WORDS)?
That is, have you only had (PSYCHOTIC SXS) during times when you have been
(depressed/high/irritable/OWN WORDS)?

YES

NO

SCHIZOPHRENIA CRITERION A
C2

Psychotic Mood Disorder
Go to D1 (Differential Diagnosis of
Mood Disorders), page 32.

C1

Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
At least one of these must be (1), (2), or (3):
1. Delusions [B1–B13].
2. Hallucinations [B14–B15].
3. Disorganized speech (e.g., frequent derailment or incoherence) [B20].
4. Grossly disorganized or catatonic behavior [B21–B22].
5. Negative symptoms (i.e., diminished emotional expression or avolition) [B23–B24].
NO: Consider rating “NO” if the only symptoms are delusions accompanied by tactile and/or olfactory hallucinations that are
thematically related to the content of the delusions (which is consistent with a diagnosis of Delusional Disorder).
YES

NO

SCHIZOPHRENIA CRITERION C
C4

Go to D1 (Differential
Diagnosis of Mood Disorders),
page 32.

C2

Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms
(or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or
residual symptoms.
Prodromal/residual symptoms include:
- Unusual or odd beliefs that are not of delusional proportions (e.g., ideas of reference or magical thinking);
- Unusual perceptual experiences (e.g., sensing the presence of an unseen person);
- Speech that is generally understandable but digressive, vague, or overelaborate
- Behavior that is unusual but not grossly disorganized (e.g., collecting garbage, talking to self in public, hoarding food)
- Negative symptoms (e.g., marked impairment in personal hygiene and grooming; marked lack of initiative, interests, or energy)
- Blunted or inappropriate affect
- Marked social isolation or withdrawal

YES

NO

Go to C8 (Assessment of
Schizophreniform/ Schizoaffective
Disorder), next page

C4

SCID-5MSMH

Differential Diagnosis of Psychotic Disorders

Page 31

Active-phase criteria (except duration) met at some
point in the past year,

C6
IF UNCLEAR: During the past year, since (ONE YEAR AGO),
have you had (PSYCHOTIC SXS)?

NO

YES
C6

Past Hx

Past yr

OR A major mood episode (Major Depressive or
Manic) concurrent with Criterion A of
Schizophrenia at some point in past year
Diagnose: Schizophrenia or Schizoaffective Disorder.
Check here ___ if onset after January 2020. Continue
with D1 (Differential Diagnosis of Mood Disorders), next
page.

Active-phase criteria (except duration) met at some
point in the past year,

C8
IF UNCLEAR: During the past year, since (ONE YEAR AGO),
have you had (PSYCHOTIC SXS)?

NO

Past Hx

C6a

YES
C8
Past yr

OR A major mood episode (Major Depressive or
Manic) concurrent with Criterion A of
Schizophrenia at some point in past year
Diagnose: Schizophreniform or Schizoaffective Disorder.
Check here ___ if onset after January 2020. Continue
with D1 (Differential Diagnosis of Mood Disorders), next
page.

C8a

Differential Diagnosis of Mood Disorders

SCID-5MSMH

Page 32

D. DIFFERENTIAL DIAGNOSIS OF MOOD DISORDERS
D1

If there have never been any clinically significant mood symptoms go to F42 (Generalized Anxiety Disorder), page 34 Otherwise
continue with D2.

D1

CRITERIA FOR BIPOLAR I DISORDER
D2

A. Criteria have been met for at least one Manic Episode either during the past year or prior to the past year [A40/A65].

YES

D3

NO

Go to D11 (Criteria for MDD)

B. At least one Manic Episode(s) is not better explained by, and is not superimposed on, Schizophrenia/Schizoaffective Disorder.

YES

NO

D2

D3

Go to D11 (Criteria for MDD)

BIPOLAR I DISORDER
Continue with D17 (Bipolar I Chronology), next page.

CRITERIA FOR MAJOR DEPRESSIVE DISORDER
D11

A.–C. At least one Major Depressive Episode (A12) in the past year.

YES

D11

NO
Go to F42 (Generalized Anxiety Disorder), page 34.

D12

D. The Major Depressive Episode is not better explained by, and is not superimposed on, Schizophrenia/Schizoaffective Disorder.

YES

NO

D12

Go to F42 (Generalized Anxiety Disorder), page 34.

E. There has never been a Manic Episode. [Note: DSM-5 also requires that there has never been a hypomanic episode as well]
D13

D13
Note: This exclusion does not apply if all of the manic-like episodes are substance/medication-induced or are attributable to the
physiological effects of another medical condition.

YES

NO
MAJOR DEPRESSIVE DISORDER
Check here ____ if onset after January 2020
Continue with D24 (Depressive Chronology), next page

Bipolar I Disorder should have been previously
diagnosed. Go back to D2 (Criteria for Bipolar I
Disorder), above.

D13a

SCID-5MSMH

Differential Diagnosis of Mood Disorders

Page 33

MOOD CHRONOLOGY
D17

For BIPOLAR I DISORDER,

Has met symptomatic criteria for a Manic Episode in the
past year

NO

YES

Diagnose: Bipolar I Disorder, manic. Check here ___ if onset after January 2020
Continue with F42 (Generalized Anxiety Disorder), next page.
Has met symptomatic criteria for a Major Depressive
Episode in the past year and for a Manic Episode prior to
the past year (bipolar depression)

D17a

NO

YES

Diagnose: Bipolar I Disorder, depressed / Check here ___ if onset after January 2020
Continue with F42 (Generalized Anxiety Disorder), next page.

D24

For MAJOR DEPRESSIVE DISORDER:

Has met symptomatic criteria for a Major Depressive
Episode in the past year.

Diagnose: Major Depressive Disorder Check here ___ if onset after January 2020
Continue with F42 (Generalized Anxiety Disorder), next page.

D17

D18

D18a

NO

YES

D24

D24a

SCID-5MSMH

Generalized Anxiety Disorder

GENERALIZED ANXIETY DISORDER
(PAST YEAR)

[IF UNBLINDGAD = YES] In your earlier interview you
mentioned that you have had times in the past year when
you felt worried, nervous or anxious for a lot of the time. I’d
like to ask you some more questions about those times.
F42

Page 34

GENERALIZED ANXIETY DISORDER CRITERIA

A. Excessive anxiety and worry (apprehensive
expectation), occurring more days than not for at
least 6 months, about a number of events or
activities (such as work or school performance).

—

+

F42

Go to G1 (OCD),
page 37.

[ALL] Over the past 12 months, since (12 MONTHS AGO),
have you been feeling anxious and worried for a lot of the
time?
(Tell me about that.)
What kinds of things have you worried about? (What about
your health, your family members, your finances, your
safety, or being written up?) How much did you worry
about (EVENTS OR ACTIVITIES)? What else have you worried
about?
Have you worried about (EVENTS OR ACTIVITIES) even
when there was no reason? (Have you worried more than
most people would in your circumstances? Has anyone else
thought you worried too much? Have you worried more
than you should have given your actual circumstances?)
During the last 12 months, has there been a period of time
lasting at least 6 months in which you have been worrying
more days than not?

F43

When you’re worrying this way, have you found that it’s
hard to stop yourself or to think about anything else?

B. The individual finds it difficult to control the worry.

—

+

F43

Go to G1 (OCD),
page 37.

F44

Now I am going to ask you some questions about
symptoms that often go along with being nervous or
worried.

C. The anxiety and worry are associated with three
(or more) of the following six symptoms (with at least
some symptoms present for more days than not for
the past 6 months):

F44

Thinking about those periods in the past 12 months when
you have been feeling nervous, anxious, or worried…
F45

...have you often felt physically restless, like you couldn’t
sit still?

F46

(Thinking about those periods in the past 12 months when
you have been feeling nervous, anxious, or worried...)
...have you often felt keyed up or on edge?

F47

...have you often tired easily?

F48

(Thinking about those periods in the past 12 months when
you have been feeling nervous, anxious, or worried...)
...have you often had trouble concentrating or has your
mind often gone blank?

1. Restlessness or feeling keyed up or on edge.

—

+

F45

F46

2. Being easily fatigued.

—

+

F47

3. Difficulty concentrating or mind going blank.

—

+

F48

SCID-5MSMH

Generalized Anxiety Disorder

Page 35

...have you often been irritable?

4. Irritability.

—

+

...have your muscles often been tense?

5. Muscle tension.

—

+

…have you often had trouble falling or staying asleep?
How about often feeling tired when you woke up because
you didn’t get a good night’s sleep?

6. Sleep disturbance (difficulty falling or staying
asleep, or restless unsatisfying sleep).

—

+

F49

F49

F50

F51

F50

AT LEAST THREE OF THE ABOVE CRITERION C SXS
—
+
(F45–F51) ARE RATED “+”.
Go to G1 (OCD), page 37.

F52
IF UNKNOWN: Are you taking any medications or other
health remedies because of (GAD SXS)? Tell me about that.
F53

F51

IF UNKNOWN: Are you seeing a doctor, a therapist, or a
counselor for (GAD SXS)? Tell me about that.

D. The anxiety, worry, or physical symptoms cause
clinically significant distress or impairment in social,
occupational, or other important areas of
functioning.

Treatment for sxs: Code “+” if “YES” to any of the
first three questions.

IF NO TO ALL OF ABOVE AND UNCLEAR: What effect have
(GAD SXS) had on your life?

Impairment due to sxs: Code “+” if judged to be
moderate or greater

How have (GAD SXS) affected your relationships or your
interactions with other people? (Have [GAD SXS]
caused you any problems in your relationships with
your family, friends, other inmates, or correctional
staff?)
How have (GAD SXS) affected your work/schoolwork?
(How about your attendance at work/school? Have
[GAD SXS] made it more difficult to do your
work/schoolwork? Have [GAD SXS] affected the quality
of your work/schoolwork?)
How have (GAD SXS) affected your ability to follow the
prison schedule? How about doing other things that are
important to you, like religious activities, physical
exercise, hobbies, or keeping in touch with family?
Have you avoided doing anything because you felt like
you weren’t up to it?
Has your anxiety or worry affected any other important
part of your life?
IF IMPAIRMENT JUDGED TO BE MILD OR LESS: How much
have you been bothered or upset by having (GAD SXS)?

+

Go to G1 (OCD), page 37.

IF UNKNOWN: Have other people suggested that you ought
to seek help for (GAD SXS)? Tell me about that.

ASK THE FOLLOWING QUESTIONS ONLY IF NEEDED:

—

Distress: Code “+” if judged to be moderate or
greater

F52

F53

SCID-5MSMH

F55

Generalized Anxiety Disorder

Page 36

NO
YES
F. The disturbance is not better explained by another
mental disorder (e.g., anxiety or worry about having
panic attacks in Panic Disorder, negative evaluation
in Social Anxiety Disorder, contamination or other
Go to G1
obsessions in Obsessive-Compulsive Disorder,
(OCD), next
separation from attachment figures in Separation
page.
Anxiety Disorder, reminders of traumatic events in
Posttraumatic Stress Disorder, gaining weight in
Anorexia Nervosa, physical complaints in Somatic
Symptom Disorder, perceived appearance flaws in
Body Dysmorphic Disorder, having a serious illness in
Illness Anxiety Disorder, or the content of delusional
beliefs in Schizophrenia or Delusional Disorder).
Diagnose: Generalized Anxiety Disorder, Past 12 Months.
Check here ___ if onset after January 2020
Continue with G1 (Obsessive-Compulsive Disorder), next page.

F55

F55a

SCID-5MSMH

Obsessive-Compulsive Disorder

OBSESSIVE-COMPULSIVE DISORDER (PAST YEAR)

Page 37

OBSESSIVE-COMPULSIVE DISORDER CRITERIA

A. Presence of obsessions, compulsions, or both:

G1

In the past year, since (12 MONTHS AGO)…

Obsessions are defined by (1) and (2):

…have you been bothered by thoughts that kept coming
back to you even when you didn’t want them to, like being
exposed to germs or dirt or needing everything to be lined
up in a certain way? (What were they?)

1. Recurrent and persistent thoughts, urges, or
images that are experienced, at some time during the
disturbance, as intrusive and unwanted, and that in
most individuals cause marked anxiety or distress.

—

+

G1

Go to G3
(Compulsions),
below.

How about having urges to do something that kept coming
back to you even though you didn’t want them to, like an
urge to harm a loved one? (What were they?)
How about having images popping into your head that you
didn’t want, like violent or horrible scenes or something of
a sexual nature? (What were they?)
IF YES TO ANY OF ABOVE: Have these (THOUGHTS/URGES/
IMAGES) made you very anxious or upset?

G2

When you had these (THOUGHTS/URGES/IMAGES) did you
try hard to get them out of your head? (What would you
try to do?)

2. The individual attempts to ignore or suppress such
thoughts, urges, or images, or to neutralize them
with some other thought or action (i.e., by
performing a compulsion).

—

+

G2

OBSESSIONS

Go to G3
(Compulsions),
below.

Compulsions are defined by (1) and (2):

G3

In the past year since (12 MONTHS AGO), was there
anything that you had to do over and over again and was
hard to resist doing, like washing your hands again and
again, repeating something over and over again until it
“felt right,” counting up to a certain number, or checking
something many times to make sure that you‘d done it
right?

1. Repetitive behaviors (e. g., hand washing,
ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) that the individual
feels driven to perform in response to an obsession
or according to rules that must be applied rigidly.

—

+

G3

+

G4

Go to G5,
next page.

Tell me about that. (What did you have to do?)

G4

IF UNCLEAR: Why did you have to do (COMPULSIVE ACT)?
What would happen if you didn’t do it?
IF UNCLEAR: How many times would you do (COMPULSIVE
ACT)? Are you doing (COMPULSIVE ACT) more than really
makes sense?

2. The behaviors or mental acts are aimed at
preventing or reducing anxiety or distress, or
preventing some dreaded event or situation;
however, these behaviors or mental acts either are
not connected in a realistic way with what they are
designed to neutralize or prevent, or are clearly
excessive.

—

COMPULSIONS
Go to G5,
next page.

SCID-5MSMH

G5

Obsessive-Compulsive Disorder

CHECK FOR OBSESSIONS AND/OR COMPULSIONS

Page 38

PRESENCE OF OBSESSIONS (G2 RATED “+”) OR
COMPULSIONS (G4 RATED “+”)

NO

YES

G5

Go to
G9 (PTSD),
page 39.

G6

IF UNCLEAR: How much time have you spent on
(OBSESSION OR COMPULSION)?
IF UNKNOWN: Are you taking any medications or other
health remedies because of (OBSESSION OR COMPULSION)?
Tell me about that.
IF UNKNOWN: Are you seeing a doctor, a therapist, or a
counselor for (OBSESSION OR COMPULSION)? Tell me about
that.
IF UNKNOWN: Have other people suggested that you ought
to seek help for (OBSESSION OR COMPULSION)? Tell me
about that.

B. The obsessions or compulsions are timeconsuming (e.g., take more than 1 hour per day) or
cause clinically significant distress or impairment in
social, occupational, or other important areas of
functioning
Treatment for sxs: Code “+” if “YES” to any of the
first three questions.

—

+

G6

Go to
G9
(PTSD)
page 39.

Impairment due to sxs: Code “+” if judged to be
moderate or greater
Distress: Code “+” if judged to be moderate or
greater

IF UNCLEAR: What effect did these (OBSESSIONS OR
COMPULSIONS) have on your life?
ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How have (OBSESSIONS OR COMPULSIONS) affected
your relationships or your interactions with other
people? (Have [OBSESSIONS OR COMPULSIONS] caused
you any problems in your relationships with your
family, friends, other inmates, or correctional staff?)
How have (OBSESSIONS OR COMPULSIONS) affected
your work/school? (How about your attendance at
work/school? Have [OBSESSIONS OR COMPULSIONS]
made it more difficult to do your work/schoolwork?
Have [OBSESSIONS OR COMPULSIONS] affected the
quality of your work/schoolwork?)
How have (OBSESSIONS OR COMPULSIONS) affected
your ability to follow the prison schedule? How about
doing other things that are important to you, like
religious activities, physical exercise, hobbies, or
keeping in touch with family?
Have (OBSESSIONS OR COMPULSIONS) affected any
other important part of your life?
G7a

IF HAVE NOT INTERFERED WITH LIFE: How much have
you been bothered by having (OBSESSIONS OR
COMPULSIONS)?

Diagnose Obsessive Compulsive Disorder, Past 12
Months. Check here ___ if onset after January 2020.
Continue with G9 (PTSD), next page

SCID-5MSMH

Posttraumatic Stress Disorder

Page 39

POSTTRAUMATIC STRESS DISORDER
I’d now like to ask about some things that may have happened to you that may have been extremely upsetting. People
often find that talking about these experiences can be helpful. I’ll start by asking if these experiences apply to you, and
if so, I’ll ask you to briefly describe what happened and how you felt at the time.
SCREEN FOR EACH TYPE OF TRAUMA. IF EVENT HAPPENED WITHIN THE PAST MONTH, INQUIRE IF THERE WAS ANOTHER
EVENT OF THIS TYPE THAT HAPPENED PRIOR TO THE LAST MONTH.
Have you ever been in a life-threatening situation like a major
disaster or fire, in combat, or a serious car or work-related
accident?

INTERVIEWER CODE: NO

What about being physically assaulted or abused, or
threatened with physical assault?

INTERVIEWER CODE: NO

YES

What about being sexually assaulted or abused, or threatened
with sexual assault?

INTERVIEWER CODE: NO

YES

How about seeing another person being physically or sexually
assaulted or abused, or threatened with physical or sexual
assault?

INTERVIEWER CODE: NO

Have you ever seen another person killed or dead, or badly
hurt?

INTERVIEWER CODE: NO

How about learning that one of these things happened to
someone you are close to?

INTERVIEWER CODE: NO

IF UNKNOWN: Have you ever been the victim of a serious
crime?

INTERVIEWER CODE: NO

IF NO EVENTS ENDORSED: What would you say has been the
most stressful or traumatic experience you have had over your
life?

IF NO EVENTS ACKNOWLEDGED, CONTINUE WITH H1 (Anorexia
Nervosa), page 50.

YES
G9a

G9b

G9c

YES
G9d

YES
G9e

YES
G9f

YES
G9g

G9h

SCID-5MSMH

G10

Posttraumatic Stress Disorder

IF MORE THAN ONE EVENT REPORTED: Which of (EVENTS
REPORTED ABOVE) would you say has affected you the
most or caused you the most problems during the past
12 months, since (12 MONTHS AGO)?

Page 40

A. Exposure to actual or threatened death,
serious injury, or sexual violence in one (or more)
of the following ways:

ASK AS MANY QUESTIONS AS NEEDED TO DETERMINE
WHETHER TRAUMA MEETS CRITERION A REQUIREMENTS

1. Directly experiencing the traumatic event(s).

IF DIRECT EXPOSURE TO TRAUMA:

2. Witnessing, in person, the event(s) as it
occurred to others.

What happened? Were you afraid of dying or being
seriously hurt? Were you seriously hurt?
IF WITNESSED TRAUMATIC EVENT HAPPENING TO
OTHERS:
What happened? What did you see? How close were
you to (TRAUMATIC EVENT)? Were you concerned about
your own safety?
IF LEARNED ABOUT TRAUMATIC EVENT:
What happened? Who did it involve? (How close
[emotionally] were you to them? Did it involve violence,
suicide, or a bad accident?)
IF EVENT DOES NOT MEET CRITERION A, THEN EVALUATE
NEXT MOST IMPACTFUL EVENT UNTIL AN EVENT MEETS
CRITERION A. IF NO EVENTS MEET CRITERION A, THEN
CODE “-“ AND SKIP TO NEXT SECTION PAGE 50.

—

+

G10

3. Learning that the traumatic event(s) occurred
to a close family member or close friend. In cases
of actual or threatened death of a family member
or friend, the event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to
aversive details of the traumatic event(s) (e.g., first
responders collecting human remains; police
officers repeatedly exposed to details of child
abuse).

Continue with
questions on
Page 41 for this
traumatic event.

Note: Criterion A4 does not apply to exposure
through electronic media, television, movies, or
pictures, unless this exposure is work related.
INDICATE EVENT THAT AFFECTED RESPONDENT
THE MOST AND MEETS CRITERION A, THEN
CONTINUE WITH NEXT PAGE:
CRITERION A EVENT #1:
__________________________________
IF NEEDED TO REPEAT QUESTIONS, RECORD
APPLICABLE TRAUMATIC EVENTS BELOW, THEN
CONTINUE WITH QUESTIONS ON NEXT PAGE:
CRITERTION A EVENT #2:
__________________________________
CRITERTION A EVENT #3:
__________________________________

Skip to next
section, Page 50

SCID-5MSMH

Posttraumatic Stress Disorder

Page 41

G13_2
DETERMINE WORST MONTH WITIHN THE PAST YEAR IN TERMS OF SEVERITY OF THE
REACTION SEPARATELY FOR EACH SELECTED TRAUMA:

—

+

→ IF SELECTED TRAUMATIC EVENT OCCURRED PRIOR TO THE PAST YEAR:
In the past year, since (12 MONTHS AGO), have you had thoughts about (SELECTED TRAUMATIC EVENT)
that kept coming back to you even when you didn’t want to think about them?
→ IF SELECTED TRAUMATIC EVENT OCCURRED DURING THE PAST YEAR:
Since (TRAUMATIC EVENT), have you had thoughts about (SELECTED EVENT) that kept coming back to you
even when you didn’t want to think about them?

Continue with
questions
below for this
traumatic
event.

How about bad dreams about (TRAUMATIC EVENT[S]) or the feeling that you were back in the situation
again?
What about getting physical symptoms—like breaking out in a sweat, or your heart pounding or racing-- or
feeling very upset when something or someone reminded you of (TRAUMATIC EVENT)?
NOTE: IF RESPONDENT HAS EXPERIENCED NO PTSD ISSUES OR SXS FOR THE PAST 12 MONTHS, CODE “-“ TO
SKIP TO THE NEXT MODULE.
HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

IF YES: Go back to G10, page 40, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 50
G13_3
DETERMINE WORST MONTH WITIHN THE PAST YEAR IN TERMS OF REACTION TO THE TRAUMA
IF YES TO ANY G13_1: During the past year, during which month would you say that (ACKNOWLEDGED PTSD SXS) happened the most
often or were the most upsetting to you?
REFER TO THAT PARTICULAR MONTH FOR THE FOLLOWING QUESTIONS. IF NO ONE PARTICULAR MONTH STANDS OUT AS MOST
SEVERE, USE INSTEAD PAST MONTH FOR THE FOLLOWING QUESTIONS.
Indicate month chosen: __________

G13
Now I’d like to ask a few questions about specific ways that
(TRAUMATIC EVENT) may have affected you during
[MONTH SELECTED ABOVE).

B. Presence of one (or more) of the following
intrusion symptoms associated with the traumatic
event(s), beginning after the traumatic event(s)
occurred:

For example, during that month…

G14

G15

…did you have memories of (TRAUMATIC EVENT), including
feelings, physical sensations, sounds, smells, or images,
when you didn’t expect to or want to? How often did that
happen during (MONTH)?

1. Recurrent, involuntary, and intrusive distressing
memories of the traumatic event(s).

…what about repeatedly having upsetting dreams that
reminded you of (TRAUMATIC EVENT)? Tell me about that.
How often did this happen during (MONTH)?

2. Recurrent distressing dreams in which the content
and/or effect of the dream are related to the
traumatic events.

—

+

—

+

G14

G15

SCID-5MSMH

G16

Posttraumatic Stress Disorder

…what about finding yourself acting or feeling as if you
were back in the situation? (Have you had “flashbacks” of
[TRAUMATIC EVENT]?)

Page 42

3. Dissociative reactions (e.g., flashbacks) in which
the individual feels or acts as if the traumatic event(s)
were recurring. (Such reactions may occur on a
continuum, with the most extreme expression being
a complete loss of awareness of present
surroundings.)

G16
—

+

During (MONTH SELECTED ABOVE)…
…did you have a strong emotional or physical reaction
when something reminded you of (TRAUMATIC EVENT)?
Give me some examples of the kinds of things that would
have triggered this reaction. (Things like…seeing a person
who resembles the person who attacked you, being in the
place where you were attacked, hearing the screech of
brakes if you were in a car accident, hearing the sound of
helicopters if you were in combat?
NOTE: IF DENIES EMOTIONAL OR PHYSICAL REACTION TO
REMINDERS, CODE “—” FOR BOTH G17 (EMOTIONAL
REACTION) AND G18 (PHYSICAL REACTION).

G17

G17
IF ACKNOWLEDGES STRONG EMOTIONAL OR PHYSICAL
REACTION: What kind of reaction did you have? Did you
get very upset or stay upset for a while, even after the
reminder had gone away? (For how long do the symptoms
last?)

4. Intense or prolonged psychological distress at
exposure to internal or external cues that symbolize
or resemble an aspect of the traumatic event(s).

—

+

IF ACKNOWLEDGES STRONG EMOTIONAL OR PHYSICAL
REACTION: What about having physical symptoms—like
breaking out in a sweat, breathing heavily or irregularly, or
feeling your heart pound or race when something
reminded you of (TRAUMATIC EVENT)? How about feeling
tense or shaky?

5. Marked physiological reactions to internal or
external cues that symbolize or resemble an aspect
of the traumatic event(s).

—

+

AT LEAST ONE OF THE ABOVE CRITERION B SXS (G14–
G18) IS RATED “+”.

NO

YES

G18

G18

G19

G19

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

Continue with
questions on
Page 43 for this
traumatic event.

IF YES: Go back to G10, page 40, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 50

SCID-5MSMH

Posttraumatic Stress Disorder

Page 43

During (MONTH SELECTED ABOVE)…

C. Persistent avoidance of stimuli associated with
the traumatic event(s), beginning after the traumatic
event(s) occurred, as evidenced by one or both of the
following:

…did you do things to avoid remembering or thinking about
(TRAUMATIC EVENT), like keeping yourself busy, distracting
yourself by playing cards, reading, watching TV, playing
sports, or hanging out with others? How long did this go
on? (Did this happen for almost all the time during
(MONTH SELECTED ABOVE)?

1. Avoidance of, or efforts to avoid distressing
memories, thoughts, or feelings about or closely
associated with the traumatic event(s).

—

+

2. Avoidance of or efforts to avoid external
reminders (people, places, conversations, activities,
objects, situations), that arouse distressing
memories, thoughts, or feelings about or closely
associated with the traumatic event(s).

—

+

AT LEAST ONE OF THE ABOVE CRITERION C SXS (G20–
G21) IS RATED “+”.

NO

YES

G20

G20

IF NO: How about doing things to avoid having feelings
similar to those you had during (TRAUMATIC EVENT)?
(Has this happened for almost all the time during
(MONTH SELECTED ABOVE)?

G21
G21

…were there things, places, or people that you tried to
avoid because they brought up upsetting memories,
thoughts, or feelings about (TRAUMATIC EVENT)? (Was this
for almost all the time during (MONTH SELECTED ABOVE)?
IF NO: How about avoiding certain activities, situations,
or topics of conversation? (Did this happen for almost
all the time during (MONTH SELECTED ABOVE)?

G22
G22

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

Continue with
questions on
Page 44 for this
traumatic event.

IF YES: Go back to G10, page 40, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 50

SCID-5MSMH

G23

Posttraumatic Stress Disorder

Page 44

During (MONTH SELECTED ABOVE)…

D. Negative alterations in cognitions and mood
associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:

…Were you unable to remember some important part of
what happened? (Tell me about that.) How many times
did this happened?

1. Inability to remember an important aspect of the
traumatic event(s) (typically due to dissociative
amnesia and not to other factors such as head injury,
alcohol, or drugs).

—

+

G23

2. Persistent and exaggerated negative beliefs or
expectations about oneself, others, or the world
(e.g., “I am bad,” “No one can be trusted,” “The
world is completely dangerous,” “My whole nervous
system is permanently ruined”).

—

+

G24

3. Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead the
individual to blame himself/herself or others.

—

+

4. Persistent negative emotional state (e.g., fear,
horror, anger, guilt, or shame).

—

+

IF YES: Did you get a head injury during (TRAUMATIC
EVENT)?

G24

…was there a change in how you thought about yourself?
(Like feeling you were “bad,” or permanently damaged or
“broken”?) Tell me about that. How long did you feel this
way about yourself? (Did you feel this way almost all of the
time during (MONTH SELECTED)?)
IF NO: Was there been a change in how you see other
people or the way the world works? Like you couldn’t
trust anyone anymore? Like the world was a
completely dangerous place? Tell me about that. How
long did you think this way? Did you feel this way
almost all of the time during (MONTH SELECTED)?)
(During [MONTH SELECTED]...)

G25

…did you blame yourself for the (TRAUMATIC EVENT) or
how it affected your life? (Like thinking that [TRAUMATIC
EVENT] was your fault or that you should have done
something to prevent it? Like thinking that you should
have gotten over it by now?)

G25

IF YES: Tell me about it. Did you think this way about
yourself almost all of the time during (MONTH
SELECTED)?
IF NO: Did you blame someone else for (TRAUMATIC
EVENT)? Tell me about that. (What did they have to do
with [TRAUMATIC EVENT]?) Did you think this way
almost all of the time during (MONTH SELECTED)?

G26
During (MONTH SELECTED ABOVE)…
…did you have bad feelings a lot of the time, like feeling
sad, angry, afraid, guilty, ashamed, or numb? (Tell me

G26

SCID-5MSMH

Posttraumatic Stress Disorder

Page 45

about that.) Did you feel this way almost all of the time
during (MONTH SELECTED)?
IF YES: Was this different from the way you were
before (TRAUMATIC EVENT)?

(During [MONTH SELECTED]...)
G27
…were you a lot less interested in things that you were
interested in before (TRAUMATIC EVENT), like having visits
with family or friends, spending time with other inmates,
reading books, watching TV, or exercising? (Tell me about
that.) Did you feel this way almost all of the time during
(MONTH SELECTED)?

5. Markedly diminished interest or participation in
significant activities.

—

+

6. Feelings of detachment or estrangement from
others.

—

+

7. Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction,
or loving feelings).

—

+

G27

IF NO LOSS OF INTEREST: Were you still doing as many
activities as you were before (TRAUMATIC EVENT)?
(Were you involved in fewer activities almost all of the
time during (MONTH SELECTED)?
(During [MONTH SELECTED]...)

G28

G28
…did you feel distant or disconnected from others or did
you close yourself off from other people almost all of the
time during (MONTH SELECTED)? (Tell me about that.)
IF YES: Was this different from the way you were before
(TRAUMATIC EVENT)?
Did you feel this way almost all of the time during (MONTH
SELECTED)?

G29

…were you unable to experience good feelings, like feeling
happy, joyful, satisfied, loving, or tender toward other
people? (Tell me about that.) How long were you unable to
experience good feelings? (Were you unable to experience
good feelings almost all of the time during (MONTH
SELECTED?)
IF YES: Was this different from the way you were before
(TRAUMATIC EVENT)?

G29

SCID-5MSMH

Posttraumatic Stress Disorder

Page 46

G30

G30

AT LEAST THREE OF THE ABOVE CRITERION D SXS
(G23–G29) ARE RATED “+”.

NO

YES

Continue with
questions below
for this traumatic
event.

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

IF YES: Go back to G10, page 40, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 50

During (MONTH SELECTED ABOVE)…

E. Marked alterations in arousal and reactivity
associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:

G31

G31
…did you lose control of your anger, so that you threatened
or hurt someone or damaged something? Tell me what
happened. (Was it over something little or even nothing at
all?) How often did this happen during (SELECTED
MONTH)?

1. Irritable behavior and angry outbursts (with little
or no provocation) typically expressed as verbal or
physical aggression toward people or objects.

—

+

2. Reckless or self-destructive behavior.

—

+

IF NO: Since (TRAUMATIC EVENT), were you more quicktempered or have a shorter “fuse” than before? How
often did this happened during (SELECTED MONTH)?
IF YES TO EITHER: How different was this from the way you
were before (TRAUMATIC EVENT)?

G32

…did you do reckless things, like pick fights or ignore prison
rules without caring about the consequences? How often
did this happen during (SELECTED MONTH)?
IF NO: How about hurting yourself on purpose or trying
to kill yourself? (What did you do?) How often did this
happened during (SELECTED MONTH)?
IF YES TO ETIHER: How different was this from the way you
were before (TRAUMATIC EVENT)?

Note: ANY CURRENT SUICIDAL THOUGHTS, PLANS,
OR ACTIONS SHOULD BE THOROUGHLY ASSESSED BY
THE CLINICIAN AND ACTION TAKEN IF NECESSARY.

G32

SCID-5MSMH

G33

Posttraumatic Stress Disorder

During (MONTH SELECTED ABOVE)…

Page 47

G33

3. Hypervigilance.

—

+

…were you jumpy or easily startled, like by sudden
noises? (Was this a change from before [TRAUMATIC
EVENT]?) Did you feel this way most of the time during
(MONTH SELECTED)

4. Exaggerated startle response.

—

+

…did you have trouble concentrating? What are some
examples? (Was this a change from before [TRAUMATIC
EVENT]?) Did you feel this way most of the time during
(MONTH SELECTED)?

5. Problems with concentration.

—

+

…how were you sleeping during (MONTH SELECTED)? (Was
this a change from before [TRAUMATIC EVENT]?) Did you
have trouble for most of the time during (MONTH
SELECTED)?

6. Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).

—

+

G36

AT LEAST TWO OF THE ABOVE CRITERION E SXS
(G31–G36) ARE RATED “+”.

NO

YES

G37

…did you notice that you were more watchful or on guard?
(Give me some examples.) Did you feel this way almost all
of the time during (MONTH SELECTED)?
IF NO: Were you extra aware of your surroundings and
your environment? Did you feel this way most of the
time during (MONTH SELECTED)?
IF YES TO ETIHER: How different was this from the way you
were before (TRAUMATIC EVENT)?

G34

G34

G35

G36

G35

G37

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

Continue with
questions on
Page 48 for this
traumatic event.

IF YES: Go back to G10, page 40, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 50

SCID-5MSMH

G38

Posttraumatic Stress Disorder

IF UNCLEAR: About how long did these (PTSD SXS RATED
“+”) last altogether?

Page 48

F. Duration of the disturbance [symptoms in
Criteria B (G19), C (G22), D (G30), and E (G37)] is
more than 1 month.

—

+

G38

Continue with
questions below
for this traumatic
event.

HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?

IF YES: Go back to G10, page 40, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 50
IF UNKNOWN: Are you taking any medications or other
health remedies because of (PTSD SXS)? Tell me about
that.
IF UNKNOWN: Are you seeing a doctor, a therapist, or a
counselor for (PTSD SXS)? Tell me about that.

G39
G. The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.

—

+

IF UNKNOWN: Have other people suggested that you ought
to seek help for (PTSD SXS)? Tell me about that.
G39
IF UNCLEAR: What effect did (PTSD SXS DURING MONTH
SELECTED) have on your life?
ASK THE FOLLOWING QUESTIONS ONLY AS NEEDED:
How did (PTSD SXS) affect your relationships or your
interactions with other people? (Did [PTSD SXS] cause you
any problems in your relationships with your family,
friends, other inmates, or correctional staff?)

Treatment for sxs: Code “+” if “YES” to any of the
first three questions.
Impairment due to sxs: Code “+” if judged to be
moderate or greater
Distress: Code “+” if judged to be moderate or
greater

Continue with
questions on
Page 49 for this
traumatic event.

How did (PTSD SXS) affect your work/school? (How about
your attendance at work/school? Did [PTSD SXS] make it
more difficult to do your work/schoolwork? Did [PTSD SXS]
affect the quality of your work/schoolwork?)
How did [PTSD SXS] affect your ability to follow the prison
schedule? What about being involved in things that were
important to you, like religious activities, physical exercise,
hobbies, or keeping in touch with family?
Did (PTSD SXS) affect any other important part of your life?
IF HAVE NOT INTERFERED WITH LIFE: How much were you
bothered or upset by (PTSD SXS)?
HAVE ANY OTHER TRAUMATIC EVENTS BEEN REPORTED?
IF YES: Go back to G10, page 40, record next most traumatic event, and cycle again through items to determine if full criteria are
met.
IF NO: Skip to H1 (Anorexia Nervosa), p. 50

SCID-5MSMH

Posttraumatic Stress Disorder

Page 49

G41

G41
CRITERIA B (G19), C (G22), D (G30), and E (G37) ARE
RATED “YES” AND CRITERION G (G39) (CLINICAL
SIGNIFICANCE) IS RATED “+”

NO

YES

Diagnose: Posttraumatic Stress Disorder (past year).
Check here ___ if onset after January 2020
Go to H1 (Anorexia Nervosa), p. 50

G41a

SCID-5MSMH

H1

Anorexia Nervosa

ANOREXIA NERVOSA PAST YEAR

ANOREXIA NERVOSA CRITERIA

Have you had a time over the past 12 months when you
weighed much less than other people thought you ought to
weigh?

Restriction of energy intake relative to requirements,
leading to a significantly low body weight in the
context of age, sex, developmental trajectory, and
physical health. Significantly low weight is defined as
a weight that is less than minimally normal or, for
children and adolescents, less than minimally
expected.

IF YES: Why was that? How much did you weigh? How
old were you then? How tall were you?

H2

Page 50

At that time, were you very afraid that you could become
fat?

B. Intense fear of gaining weight or of becoming fat,
or persistent behavior that interferes with weight
gain, even though underweight.

IF NO: Tell me about your eating habits. (Have you
avoided high calorie foods or high fat foods? How strict
are you about it? Have you ever thrown up after you
eaten? How often? Do you exercise a lot after you
eat?)

At your lowest weight, did you still feel too fat or that part
of your body was too fat?
H3
IF NO: Did you need to be very thin in order to feel
better about yourself?
IF NO AND LOW WEIGHT IS MEDICALLY SERIOUS:
When you were that thin, did anybody tell you it
could be dangerous to your health to be that thin?
(What did you think?)

C. Disturbance in the way in which one’s body
weight or shape is experienced; undue influence of
body weight or shape on self-evaluation, or
persistent lack of recognition of the seriousness of
the current low body weight.

—

+

H1

Go to
Possible
Association
with COVID,
page 52

—

+

H2

+

H3

Go to
Possible
Association
with COVID,
page 52

—

Go to
Possible
Association
with COVID,
page 52

Diagnose: Anorexia Nervosa, Past
12 Months Check here ___ if onset
after January 2020
Continue with Possible Association
with COVID, page 52

H3a

SCID-5MSMH

Etiologies

Page 51

Possible Etiologies for Manic Episodes:
Possibly etiological GMCs include Alzheimer’s disease, vascular dementia, HIV-induced dementia, Huntington’s disease, Lewy body disease,
Wernicke-Korsakoff syndrome, Cushing’s disease, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson’s disease, Pick’s disease,
Creutzfeldt-Jakob disease, stroke, traumatic brain injuries, and hyperthyroidism.
Possibly etiological substance include alcohol (I/W); phencyclidine (I); hallucinogens (I); sedatives, hypnotics, and anxiolytics (I/W);
amphetamines (I/W); cocaine (I/W);
Possibly etiological medications include corticosteroids; androgens; isoniazid; levodopa; interferon-alpha; varenicline; procarbazine;
clarithromycin; and ciprofloxacin.
Possible Etiologies for Psychotic Symptoms:
Possibly etiological GMCs include neurological conditions (e.g., neoplasms, cerebrovascular disease, Huntington's disease, multiple sclerosis,
epilepsy, auditory or visual nerve injury or impairment, deafness, migraine, central nervous system infections), endocrine conditions (e.g., hyperand hypothyroidism, hyper- and hypoparathyroidism, hyper- and hypoadrenocorticism), metabolic conditions
(e.g., hypoxia, hypercarbia, hypoglycemia), fluid or electrolyte imbalances, hepatic or renal diseases, and autoimmune disorders with central
nervous system involvement (e.g., systemic lupus erythematosus).
Possibly etiological substances include alcohol (I/W); cannabis (I); hallucinogens (I), phencyclidine and related substances (I); inhalants (I);
sedatives, hypnotics, and anxiolytics (I/W); stimulants (including cocaine) (I);
Possibly etiological medications include anesthetics and analgesics; anticholinergic agents; anticonvulsants; antihistamines; antihypertensive and
cardiovascular medications; antimicrobial medications; antiparkinsonian medications; chemotherapeutic agents (e.g., cyclosporine,
procarbazine); corticosteroids; gastrointestinal medications; muscle relaxants; nonsteroidal anti-inflammatory medications; other over-thecounter medications (e.g., phenylephrine, pseudoephedrine); antidepressant medication; and disulfiram. ]
Possibly etiological toxins include anticholinesterase, organophosphate insecticides, sarin and other nerve gases, carbon monoxide, carbon
dioxide, and volatile substances such as fuel or paint.

SCID-5MSMH

Coronavirus Casualty

Page 52

THIS ITEM HAS ALREADY BEEN ASKED AS PART OF THE OVERVIEW AND HAS BEEN
PREPOPULATED BASED ON INFORMATION PREVIOULSY OBTAINED:
IF UNKNOWN: How were you affected by the coronavirus pandemic? (Did you or someone close to
you need to be hospitalized for treatment? Did you lose someone whom you were close to? How
about the financial implications for people close to you related to the crisis?)

QUESTIONS TO DETERMINE POSSIBLE ASSOCIATION OF EACH PAST 12 MONTH DIAGNOSIS WITH
CORONAVIUS AND ASSOCIATED STRESSORS:
(FILL OUT THIS PAGE SEPARATELY FOR EACH PAST 12 MONTH DIAGNOSIS)
FOR EACH DISORDER DIAGNOSED IN PAST 12
MONTHS:
IF UNKNOWN: When did [SXS OF DIAGNOSED
DISORDER] start?

IF ONSET SINCE START OF CORONAVIRUS
PANDEMIC IN JANUARY 2020:
IF UNKNOWN: What was going on in your
life when (SXS) started?
Do you think (SXS) were due to the effects
of the coronavirus pandemic on your life?
IF ONSET PRIOR TO START OF CORONAVISU
PANDEMIC IN JANUARY 2020: Did (SXS)
become worse since the start of the
pandemic?
IF YES: When did they get worse? How
much worse? Do you think they got
worse because of the effects of the
coronavirus pandemic on your life?

BASED ON ALL AVAILABLE INFORMATION, INDICATE FOR EACH 12-MONTH DIAGNOSIS THE
LIKELIHOOD THAT DISORDER OCCURRING IN PAST 12 MONTHS WAS DUE TO THE EFFECTS OF
CORONAVIRUS PANDEMIC: (INCLUDING ECONOMIC EFFECTS)
1

Not at all likely

2

3

4

5

6

Somewhat likely

7

8

9

10

Very likely

SHORT BLESSED TEST
THE SHORT BLESSED TEST IS TO BE COMPLETED AT ANY POINT DURING THE INTERVIEW IF THE
RESPONDENT APPEARS TO BE COGNITIVELY IMPAIRED.
ERROR SCORES

SB-1.

What year is it now? _____________
CIRCLE 4 FOR ANY ERROR.......................................................................... 0 4

SB-2.

What month is it now? _______________
CIRCLE 3 FOR ANY ERROR.......................................................................... 0 3
Please repeat this phrase after me: John Brown, 42 Market Street, Chicago.
NO SCORE – FOR ITEM SB-6.

SB-3.

About what time is it? _______________
CIRCLE 3 FOR ANY ERROR.......................................................................... 0 3

SB-4.

Please count backwards from 20 to 1.
[20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, 1]

2 PER ERROR .............................................................................................. 0 2 4

SB-5.

Please say the months of the year in reverse order.
[DEC, NOV, OCT, SEP, AUG, JUL, JUN, MAY, APR, MAR, FEB, JAN]

2 PER ERROR ............................................................................................. 0 2 4

SB-6.

Please repeat the phrase I asked you to repeat before.

[JOHN BROWN/ 42 MARKET STREET/ CHICAGO]

2 PER ERROR .............................................................................................. 0 2 4 6 8 10

TOTAL NUMBER OF ERRORS IN SB-1 TO SB-6: .................................... _______

IF THE TOTAL NUMBER OF ERRORS IS GREATER THAN 10, TERMINATE THE INTERVIEW.

Attachment G
Informed Consent Forms

1) Screening Survey Informed Consent
2) Household Consent to Participate
3) Hospital Volunteers Consent to Participate
4) Jail Volunteers Consent to Participate
5) Prisoner Volunteers Consent to Participate
6) Shelter Volunteers Consent to Participate
7) Proxy Consent to Participate

NSMH Screening Survey Informed Consent
Sponsor / Study Title:

RTI International / “National Study of Mental Health
(NSMH)”

Protocol Number:

FG00030 / 021786

Principal Investigator:
(Study Doctor)

Heather Ringeisen, PhD

Telephone:

(833) 947-2575 (24 Hours)

Address:

RTI, International
3040 E Cornwallis Rd, PO Box 12194
Research Triangle Park, NC 27709

Key Information
Your address was randomly chosen for the National Study of Mental Health. This is a
research study about mental health and tobacco, alcohol and drug use. If you choose to
take part in the study, you will be one of about 44,500 people to do so.
We would like to conduct a short screening survey with you to determine if you are
eligible to be interviewed for the overall study.
If you decide to participate you can complete the screening survey online or by
telephone, by mail, or a professional interviewer will come to your home to complete the
survey in person.
The screening survey should take about 15 minutes to complete and you will receive a
$20 electronic gift card or $20 cash if in person. This study is for research purposes only.
There is no direct benefit to you from your participation in the study. Information learned
from the study may help other people in the future. You might find some of the questions
we ask to be upsetting or stressful. Your participation is voluntary, and you can refuse to
answer any questions.. Although, you may not be able to skip, refuse, or answer ‘don’t
know’ to some questions depending on whether you are answering the questions over
video, phone, or in-person.
It is up to you whether or not to be in this study. The following information is meant to
help you decide.
General Information
This study, sponsored by the Substance Abuse and Mental Health Services
Administration (SAMHSA), collects information for research and program planning by
asking about:

Attachment G. Informed Consent Forms

1

•
•
•
•

Mental health;
Health behaviors;
Access to, and use of, medical care or treatment; and
Tobacco, alcohol, and drug use or non-use.

We will be asking questions about substance abuse and mental health. You cannot be
identified through any information you give us. Your name and address will never be
connected to your answers. In addition, federal law requires us to keep all your answers
confidential. Any answers you give will only be used by authorized researchers for
statistical purposes. Your participation is voluntary and you can stop at any time. Your
alternative is not to participate, and there is no expected benefit to you from your
participation in the study
This screening survey will take about 15 minutes and we will e-mail you a $20 electronic
gift card or give you $20 cash when you finish. We will request your email address at the
end of this survey. It will only be used to send you the gift card, and to contact you if you
are selected for the main interview. It will not be stored with your answers There will be
no additional costs to you for participating in this short survey, other than your normal
phone, internet or data plan charges if applicable.
If you are chosen for the main interview, it will be done on a different day that we will
schedule at your convenience. The interview takes about 80 minutes, on average.
Each person who is chosen and completes the interview will receive a $30 electronic
gift card or $30 cash if in person.
Protecting Your Confidentiality
To help keep information about you confidential, we have obtained a Certificate of
Confidentiality from the Department of Health and Human Services (DHHS). This adds
special protection for the research information about you because it protects the research
team from being forced, even under a court order or subpoena, to release information that
could identify you. However, there are some exceptions to this privacy rule. If you tell
me about the abuse of a child or that you plan to hurt yourself or others, we may need to
notify a mental health professional or other authorities.
Whom To Contact About This Study
During the study, if you have questions, concerns or complaints about the study, please contact
the Investigator at the contact information on the first page of this consent.
An institutional review board (IRB) is an independent committee established to help protect the
rights of research participants. If you have any questions about your rights as a research
participant, and/or concerns or complaints regarding this research study, contact:
•

By mail:
Study Subject Adviser

Attachment G. Informed Consent Forms

2

•
•

Advarra IRB
6940 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
or call toll free: 877-992-4724
or by email:
[email protected]

Please reference the following number when contacting the Study Subject Adviser:
Pro00042170.
Do you agree to participate in this study?
YES
NO
[IF MODE = IN PERSON FILL: I am recording part of this interview so my supervisor can
make sure I am following the correct procedures. The recording will be kept private and will be
deleted after my work has been reviewed. If you don’t want me to record the interview I will
stop the recording. We can still do the interview even if you don’t want it to be recorded.
May we record part of the interview?]
YES
NO
[IF MODE = PHONE FILL: This call may be recorded for quality assurance purposes.]

Attachment G. Informed Consent Forms

3

Consent to Participate in a Research Study
(Household)
Sponsor / Study Title:

RTI International / “National Study of Mental Health
(NSMH)”

Protocol Number:

FG00030 / 021786

Principal Investigator:
(Study Doctor)

Heather Ringeisen, PhD

Telephone:

(833) 947-2575 (24 Hours)

Address:

RTI, International
3040 E Cornwallis Rd, PO Box 12194
Research Triangle Park, NC 27709

[IF MODE = TELEPHONE OR IN PERSON FILL: First I need to share some key information
about the study.]
KEY INFORMATION
You are being invited to take part in the National Study of Mental Health. This is a research
study about mental health and tobacco, alcohol and drug use, and consists of one interview. If
you choose to take part in the study, you will be one of about 7,200 people to do so.
[IF SCREENER MODE = WEB OR TELEPHONE OR IN PERSON OR PRINTED VERSION
FILL: If you decide to participate, a trained interviewer will ask the questions either in person,
by video teleconference, or by telephone, using a laptop computer. You can be in your home,
office, or another private location when you complete the interview. You will be asked for
permission to record the interview to ensure the interviewer did it properly.] [IF SCREENER
MODE = MAIL OR JAIL FILL: If you decide to participate, I will ask you questions using a
laptop computer. I will ask for permission to record the interview to ensure I did it properly.]
You can still be interviewed even if you do not allow the interview to be recorded.
The interview should take about 80 minutes to complete and you will receive $30. Your
participation is voluntary, and you can refuse to answer any questions.
You cannot be identified through any information you give us. Your name and address will never
be connected to your answers. However, there are some exceptions to this privacy rule. If you
tell me about the abuse of a child or that you plan to hurt yourself or others, we may need to
notify a mental health professional or other authorities.

Attachment G. Informed Consent Forms

4

It is up to you whether or not to be in this study. The following information is meant to help you
decide.
WHO IS LEADING THE STUDY?
The person in charge of this study is the study investigator from RTI International, a nonprofit
research company in North Carolina. The study is sponsored by the Substance Abuse and
Mental Health Services Administration (SAMHSA), an agency in the U.S. Department of Health
and Human Services (DHHS).
[IF MODE = TELEPHONE OR IN PERSON FILL: Next I will share additional information
about the study.]
WHAT IS THIS STUDY ABOUT?
The study will look at how many people in the United States have experienced mental health
conditions like depression, anxiety, psychosis, and post-traumatic stress disorder. We are asking
people who take part in the study to answer questions about these conditions. We will also ask
about using tobacco, alcohol, and drugs.
For the study to be successful, we need to hear from people who have had these experiences and
from people who have never had these experiences.
The questions will also ask about your health in general and about healthcare and any mental
health or substance abuse treatment you may be getting. The last set of questions asks about
household income and involvement with the criminal justice system.
Your name will not be linked to your answers. Your answers will be combined with answers
from the other study participants and will be used to understand how many people experience
mental health and substance use conditions, and how these conditions impact their quality of life.
Also, this information may be used by local, state, and federal agencies to support education,
treatment and prevention programs.
[IF MODE = TELEPHONE OR IN PERSON FILL: Now I will share information about your
participation in this interview, possible risks or discomforts, as well as possible benefits.]
DO I HAVE TO TAKE PART IN THIS INTERVIEW?
It is your choice whether or not you take part in this study. Even if you decide to start the
interview, you may change your mind and stop at any time. If you decide to stop the interview
before finishing it, let the interviewer know.

Attachment G. Informed Consent Forms

5

The only alternative is to not participate in the study. If you decide not to take part or to stop the
interview, there will not be any penalty and you will not lose any benefits or rights you would
normally receive.
WHAT ARE THE POSSIBLE RISKS OR DISCOMFORTS?
The length of the interview might cause you to feel tired or stressed. Also, you might find some
of the questions we ask to be upsetting or stressful. If this happens, you can take a short break or
stop the interview and finish it another day. Your participation is voluntary, and you can refuse
to answer any of the questions.
WHAT ARE THE POSSIBLE BENEFITS?
This study is for research purposes only. There is no direct benefit to you from your participation
in the study. Information learned from the study may help other people in the future.
[IF MODE = TELEPHONE OR IN PERSON FILL: Next I will share if there are any costs
associated with your participation, and the payment you will receive for participating, as well as
information about confidentiality.]
WILL THERE BE ANY COSTS ASSOCIATED WITH MY PARTICIPATION?
There will be no charge to you for your participation in this study, other than your normal phone,
internet or data plan charges if applicable.
WILL I RECEIVE ANY PAYMENT FOR TAKING PART IN THIS STUDY?
Yes, you will receive $30 if you participate.
WILL MY RESPONSES BE KEPT CONFIDENTIAL?
You cannot be identified through any information you give us. Your name and address will never
be connected to your answers. Your answers will be combined with those from the other study
participants. The results of the study will come from the combined answers and it won’t be
possible to identify you. In addition, federal law requires us to keep all your answers
confidential. Any information you give us will only be used by authorized personnel for
statistical purposes.
To help keep information about you confidential, we have obtained a Certificate of
Confidentiality from the Department of Health and Human Services (DHHS). This adds special
protection for the research information about you because it protects the research team from
being forced, even under a court order or subpoena, to release information that could identify
you. However, there are some exceptions to this privacy rule. If you tell me about the abuse of a

Attachment G. Informed Consent Forms

6

child or that you plan to hurt yourself or others, we may need to notify a mental health
professional or other authorities.
[IF MODE = TELEPHONE OR IN PERSON FILL: Here is the information on whom you can
contact if you have questions, concerns or complaints about the study.]
WHOM TO CONTACT ABOUT THIS STUDY
During the study, if you have questions, concerns or complaints about the study, please contact
the Investigator at the telephone number listed on the first page of this consent document. .
An institutional review board (IRB) is an independent committee established to help protect the
rights of research participants. If you have any questions about your rights as a research
participant, and/or concerns or complaints regarding this research study, contact:
•

•
•

By mail:
Study Subject Adviser
Advarra IRB
6100 Merriweather Dr., Suite 600
Columbia, MD 21044
or call toll free: 877-992-4724
or by email:
[email protected]

Please reference the following number when contacting the Study Subject Adviser:
Pro00042170.
You are not giving up any of your legal rights by agreeing to be in this study.
Do you agree to participate in this study?
YES
NO
Interview Audio/Video Consent to be administered at the beginning of the Interview
I am [IF PHONE FILL: recording this phone interview;] [IF IN PERSON OR VIDEO: video
recording this interview] so my supervisor can make sure I am following the correct
procedures. The recording will be kept private and will be deleted after my work has been
reviewed. If you don’t want me to record the interview I will stop the recording You can still do
the interview even if you do not want it to be recorded.
May we record this interview?
YES
NO

Attachment G. Informed Consent Forms

7

Consent to Participate in a Research Study
Hospital Volunteers
Sponsor / Study Title:

RTI International / “National Study of Mental Health
(NSMH)”

Protocol Number:

FG00030 / 021786

Principal Investigator:
(Study Doctor)

Heather Ringeisen, PhD

Telephone:

(833) 947-2575 (24 Hours)

Address:

RTI, International
3040 E Cornwallis Rd, PO Box 12194
Research Triangle Park, NC 27709

KEY INFORMATION
You are being invited to take part in the National Study of Mental Health. This is a research
study about mental health, and tobacco, alcohol, and drug use. If you choose to take part in the
study, you will be one of about 7,200 people to do so.
If you decide to participate, I will ask you the questions using a laptop computer. We have
arranged with the hospital to talk with you privately. It should take about 90 minutes to complete
and you will receive a $30 deposit to your hospital account or voucher to be used in the hospital
store or cafeteria. [IF RECORDING IS ALLOWED IN FACILITY: I will ask for your
permission to record the interview to ensure I did it properly. You can still be interviewed even if
you do not allow the interview to be recorded.] There is no direct benefit to you from your
participation in the study. Information learned from the study may help other people in the
future. If you decide not to take part, there will not be any penalty and you will not lose any
benefits or rights you would normally receive. Your participation is voluntary, and you can
refuse to answer any questions.
You cannot be identified through any information you give us. Your name will not be connected
to your answers. However, there are some exceptions to this privacy rule. If you tell me about the
abuse of a child or that you plan to hurt yourself or others, we may need to notify a mental health
professional or other authorities.
It is up to you whether or not you are part of this study. The following information is meant to
help you decide.

Attachment G. Informed Consent Forms

8

WHO IS LEADING THE STUDY?
The person in charge of this study is the study investigator from RTI International, a nonprofit
research company in North Carolina. The study is sponsored by the Substance Abuse and Mental
Health Services Administration (SAMHSA), an agency in the U.S. Department of Health and
Human Services (DHHS).
WHAT IS THIS STUDY ABOUT?
The study will look at how many people in the United States have experienced mental health
conditions like depression, anxiety, psychosis, and post-traumatic stress disorder. We are asking
people who take part in the study to answer questions about these conditions. We will also ask
about using tobacco, alcohol, and drugs.
For the study to be successful, we need to hear from people who have had these experiences and
from people who have never had these experiences.
The questions will also ask about your health in general and about healthcare and any mental
health or substance abuse treatment you may be getting. The last set of questions asks about
household income and involvement with the criminal justice system.
Your name will not be linked to your answers. Your answers will be combined with answers
from the other study participants and will be used to understand how many people experience
mental health and substance use conditions, and how these conditions impact their quality of life.
Also, this information may be used by local, state, and federal agencies to support education,
treatment, and prevention programs.
If you participate in the interview, we would also like to receive a copy of your medical records
from this hospital. This is separate from this interview, and you will be asked to sign and date a
separate form for this. You can consent to the interview and to allow the study staff to receive
your medical records, or you can consent to just the interview, or you can choose not to take part
in either activity.
DO I HAVE TO TAKE PART IN THIS INTERVIEW?
It is your choice whether or not you take part in this study. Even if you decide to start the
interview, you may change your mind and stop at any time. If you decide to stop the interview
before finishing it, let me know. The only alternative is to not participate in the study. If you
decide not to take part or to stop the interview, there will not be any penalty and you will not lose
any benefits or rights you would normally receive.

Attachment G. Informed Consent Forms

9

WHERE IS THE INTERVIEW GOING TO TAKE PLACE, AND HOW LONG WILL IT
LAST?
We will do the interview here. It should take about 90 minutes to complete.
WHAT ARE THE POSSIBLE RISKS OR DISCOMFORTS?
The length of the interview might cause you to feel tired or stressed. Also, you might find some
of the questions I ask to be upsetting or stressful. If this happens, you can take a short break or
stop the interview and finish it another day, if that is an option. Your participation is voluntary,
and you can refuse to answer any of the questions.
WHAT ARE THE POSSIBLE BENEFITS?
This study is for research purposes only. There is no direct benefit to you from your participation
in the study. Information learned from the study may help other people in the future.
WILL THERE BE ANY COSTS ASSOCIATED WITH MY PARTICIPATION?
There will be no charge to you for your participation in this study.
WILL I RECEIVE ANY PAYMENT OR REWARD FOR TAKING PART IN THIS STUDY?
«Compensation»
Yes, you can get a $30 deposit to your hospital account or a voucher to be used in the hospital
store or cafeteria.
WILL MY RESPONSES BE KEPT CONFIDENTIAL?
You cannot be identified through any information you give us. Your name will never be
connected to your answers. Your answers will be combined with those from the other study
participants. The results of the study will come from the combined answers and it won’t be
possible to identify you. In addition, federal law requires us to keep all your answers
confidential. Any information you give us will only be used by authorized personnel for
statistical purposes.
To help keep information about you confidential, we have obtained a Certificate of
Confidentiality from the Department of Health and Human Services. This adds special protection
for the information about you because it protects the research team from being forced, even
under a court order or subpoena, to release information that could identify you. However, there
are some exceptions to this privacy rule. If you tell me about the abuse of a child or that you plan
to hurt yourself or others, we may need to notify a mental health professional or other authorities.

Attachment G. Informed Consent Forms

10

WHOM TO CONTACT ABOUT THIS STUDY
During the study, if you have questions, concerns or complaints about the study, please contact
the Investigator at the telephone number listed on the first page of this consent document.
An IRB is an independent committee established to help protect the rights of research
participants. If you have any questions about your rights as a research participant, and/or
concerns or complaints regarding this research study, contact:
•

•
•

By mail:
Study Subject Adviser
Advarra IRB
6940 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
or call toll free: 877-992-4724
or by email: [email protected]

Please include the following number when contacting the Study Subject Adviser: Pro00042170.
You are not giving up any of your legal rights by agreeing to be in this study.
Do you agree to participate in this study?
YES
NO
IF VIDEO RECORDING IS ALLOWED: I am video recording this interview so my supervisor
can make sure I am following the correct procedures. The recording will be kept private and will
be deleted after my work has been reviewed. If you don’t want me to record the interview I will
stop the recording. You can still do the interview even if you do not want it to be recorded.
May we record this interview?
YES
NO

Attachment G. Informed Consent Forms

11

Consent to Participate in a Research Study
Jail Volunteers
Sponsor / Study Title:

RTI International / “National Study of Mental Health (NSMH)”

Protocol Number:

FG00030 / 021786

Principal Investigator:
(Study Doctor)

Heather Ringeisen, PhD

Telephone:

(833) 947-2575 (24 Hours)

Address:

RTI, International
3040 E Cornwallis Rd, PO Box 12194
Research Triangle Park, NC 27709

KEY INFORMATION
You are being invited to take part in the National Study of Mental Health. This is a research study about
mental health, and tobacco, alcohol, and drug use. If you choose to take part in the study, you will be
one of about 44,500 people to do so.
Today, I would like to conduct a short screening survey with you to determine if you are eligible to be
interviewed for the overall study. If you are eligible, that interview would be done after you are released
from jail.
The screening survey should take about 15 minutes to complete [IF INCENTIVE IS ALLOWED IN FACILITY:
and you will receive (a snack/OTHER INCENTIVE) if you agree to participate]. This study is for research
purposes only. There is no direct benefit to you from your participation in the study. Information
learned from the study may help other people in the future. If you decide not to take part, there will not
be any penalty and you will not lose any benefits or rights you would normally receive. You might find
some of the questions we ask to be upsetting or stressful. Your participation is voluntary, and you can
refuse to answer any questions.
You cannot be identified through any information you give us. Your name will not be connected to your
answers.
However, there are some exceptions to this privacy rule. If you tell me about the abuse of a child or that
you plan to hurt yourself or others, we may need to notify a mental health professional or other
authorities. If you tell me that you have had sexual contact with another inmate or correctional staff, I
may need to inform officials at this jail or authorities outside of the jail who are responsible for
protecting jail inmates.

Attachment G. Informed Consent Forms

12

It is up to you whether or not to be in this study. The following information is meant to help you decide.
General Information
This study, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA),
collects information for research and program planning by asking about:

•
•
•
•

Mental health;
Health behaviors;
Access to, and use of, medical care or treatment; and
Tobacco, alcohol, and drug use or non-use.

Today, I will be asking questions about mental health. You cannot be identified through any information
you give us. Your name and address will never be connected to your answers. In addition, federal law
requires us to keep all your answers confidential. Any answers you give will only be used by authorized
researchers for statistical purposes. Your participation is voluntary, and you can stop at any time. Your
alternative is not to participate, and there is no expected benefit to you from your participation in the
study.
«Compensation»
This screening survey will take about 15 minutes [IF INCENTIVE IS ALLOWED IN FACILITY: and you will
receive (a snack/OTHER INCENTIVE) if you agree to participate]. There will be no costs to you for
participating in this short survey.
If you are chosen for the main interview, it will be done after you are released from jail. The
interview takes about 80 minutes, on average. I will give you information on how to reach the
study team so that you can contact us to schedule that interview at your convenience.
Each person who is chosen and completes the interview will receive a $30 electronic gift card or
$30 cash if in person.
Protecting Your Confidentiality
To help keep information about you confidential, we have obtained a Certificate of Confidentiality from
the Department of Health and Human Services (DHHS). This adds special protection for the research
information about you because it protects the research team from being forced, even under a court
order or subpoena, to release information that could identify you. However, there are some exceptions
to this privacy rule. If you tell me about the abuse of a child or that you plan to hurt yourself or others,
we may need to notify a mental health professional or other authorities. If you tell me that you have had
sexual contact with another inmate or correctional staff, I may need to inform officials at this jail or
authorities outside of the facility who are responsible for protecting jail inmates.
Whom To Contact About This Study

Attachment G. Informed Consent Forms

13

During the study, if you have questions, concerns or complaints about the study, please contact the
Investigator at the telephone number listed on the first page of this consent document.
An institutional review board (IRB) is an independent committee established to help protect the rights of
research participants. If you have any questions about your rights as a research participant, and/or
concerns or complaints regarding this research study, contact:
•

By mail:

•
•

Study Subject Adviser
Advarra IRB
6940 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
or call toll free: 877-992-4724
or by email: [email protected]

Please reference the following number when contacting the Study Subject Adviser: Pro00042170.
Do you agree to participate in this study?
YES
NO
IF RECORDING IS ALLOWED IN FACILITY: I am recording part of this interview so my supervisor can make
sure I am following the correct procedures. The recording will be kept private and will be deleted after
my work has been reviewed. If you don’t want me to record the interview, I will stop the recording. We
can still do the interview even if you don’t want it to be recorded.
May we record part of the interview?
YES
NO

Attachment G. Informed Consent Forms

14

Consent to Participate in a Research Study
Prisoner Volunteers
Sponsor / Study Title:

RTI International / “National Study of Mental Health
(NSMH)”

Protocol Number:

FG00030 / 021786

Principal Investigator:
(Study Doctor)

Heather Ringeisen, PhD

Telephone:

(833) 947-2575 (24 Hours)

Address:

RTI, International
3040 E Cornwallis Rd, PO Box 12194
Research Triangle Park, NC 27709

KEY INFORMATION
You are being invited to take part in the National Study of Mental Health. This is a research
study about mental health, and tobacco, alcohol, and drug use. If you choose to take part in the
study, you will be one of about 7,200 people to do so
If you decide to participate, I will ask you questions using a laptop computer. We have arranged
with the prison to talk with you privately. It should take about 90 minutes to complete [IF
INCENTIVE IS ALLOWED IN FACILITY: and you will receive (a snack/OTHER
INCENTIVE) if you agree to participate]. [IF RECORDING IS ALLOWED IN FACILITY: I
will ask you for permission to record the interview to ensure I did it properly. You can still be
interviewed even if you do not allow the interview to be recorded.] There is no direct benefit to
you from your participation in the study. Information learned from the study may help other
people in the future. If you decide not to take part, there will not be any penalty and you will not
lose any benefits or rights you would normally receive. Your participation is voluntary, and you
can refuse to answer any questions.
You cannot be identified through any information you give us. Your name will not be connected
to your answers. However, there are some exceptions to this privacy rule. If you tell me about the
abuse of a child or that you plan to hurt yourself or others, we may need to notify a mental health
professional or other authorities. If you tell me that you have had sexual contact with another
inmate or correctional staff, I may need to inform officials at this prison or authorities outside of
the prison who are responsible for protecting prison inmates.
It is up to you whether or not you are part of this study. The following information is meant to
help you decide.
Attachment G. Informed Consent Forms

15

WHO IS LEADING THE STUDY?
The person in charge of this study is the study investigator from RTI International, a nonprofit
research company in North Carolina. The study is sponsored by the Substance Abuse and Mental
Health Services Administration (SAMHSA), an agency in the U.S. Department of Health and
Human Services (DHHS).
WHAT IS THIS STUDY ABOUT?
The study will look at how many people in the United States have experienced mental health
conditions like depression, anxiety, psychosis, and post-traumatic stress disorder. We are asking
people who take part in the study to answer questions about these conditions. While the study
goals also address alcohol, drug, and tobacco use, we will not ask inmates about using alcohol or
drugs.
For the study to be successful, we need to hear from people who have had these experiences and
from people who have never had these experiences.
The questions will also ask about your health in general and about healthcare and any mental
health or substance abuse treatment you may be getting. The last set of questions asks about
involvement with the criminal justice system.
Your name will not be linked to your answers. Your answers will be combined with answers
from the other study participants and will be used to understand how many people experience
mental health and substance use conditions, and how these conditions impact their quality of life.
Also, this information may be used by local, state, and federal agencies to support education,
treatment and prevention programs.
DO I HAVE TO TAKE PART IN THIS INTERVIEW?
It is your choice whether or not you take part in this study. Even if you decide to start the
interview, you may change your mind and stop at any time. If you decide to stop the interview
before finishing it, let me know. The only alternative is to not participate in the study. If you
decide not to take part or to stop the interview, there will not be any penalty and you will not lose
any benefits or rights you would normally receive. If you agree to participate, or decline to
participate, in this study, your sentence, parole or probation will not be affected in any way.

WHERE IS THE INTERVIEW GOING TO TAKE PLACE, AND HOW LONG WILL IT
LAST?
We will do the interview here. It should take about 90 minutes to complete.

Attachment G. Informed Consent Forms

16

WHAT ARE THE POSSIBLE RISKS OR DISCOMFORTS?
The length of the interview might cause you to feel tired or stressed. Also, you might find some
of the questions I ask to be upsetting or stressful. If this happens, you can take a short break or
stop the interview and finish it another day, if that is an option. Your participation is voluntary,
and you can refuse to answer any of the questions.
WHAT ARE THE POSSIBLE BENEFITS?
This study is for research purposes only. There is no direct benefit to you from your participation
in the study. Information learned from the study may help other people in the future.
WILL THERE BE ANY COSTS ASSOCIATED WITH MY PARTICIPATION?
There will be no charge to you for your participation in this study.
WILL I RECEIVE ANY PAYMENT OR REWARD FOR TAKING PART IN THIS STUDY?
IF INCENTIVE APPROVED: To thank you for participating in the study, I will offer you [a
snack to eat before you leave this room/OTHER INCENTIVE].
IF INCENTIVE NOT APPROVED: No, we are not able to provide any payment or reward for
taking part in the study.
WILL MY RESPONSES BE KEPT CONFIDENTIAL?
You cannot be identified through any information you give us. Your name will never be
connected to your answers. Your answers will be combined with those from the other study
participants. The results of the study will come from the combined answers and it won’t be
possible to identify you. In addition, federal law requires us to keep all your answers
confidential. Any information you give us will only be used by authorized personnel for
statistical purposes.
To help keep information about you confidential, we have obtained a Certificate of
Confidentiality from the Department of Health and Human Services. This adds special protection
for the information about you because it protects the research team from being forced, even
under a court order or subpoena, to release information that could identify you. However, there
are some exceptions to this privacy rule. If you tell me about the abuse of a child or that you plan
to hurt yourself or others, we may need to notify a mental health professional or other authorities.
If you tell me that you have had sexual contact with another inmate or correctional staff, I may
need to inform officials at this prison or authorities outside of the prison who are responsible for
protecting prison inmates.

Attachment G. Informed Consent Forms

17

WHOM TO CONTACT ABOUT THIS STUDY
During the study, if you have questions, concerns, or complaints about the study, please contact
the Investigator at the telephone number listed on the first page of this consent document .
An IRB is an independent committee established to help protect the rights of research
participants. If you have any questions about your rights as a research participant, and/or
concerns or complaints regarding this research study, contact:
•

•
•

By mail:
Study Subject Adviser
Advarra IRB
6940 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
or call toll free: 877-992-4724
or by email: [email protected]

Please include the following number when contacting the Study Subject Adviser: Pro00042170.
Do you agree to participate in this study?
YES
NO
IF VIDEO RECORDING IS ALLOWED: I am video recording this interview so my supervisor
can make sure I am following the correct procedures. The recording will be kept private and will
be deleted after my work has been reviewed. If you don’t want me to record the interview, I will
stop the recording. You can still do the interview even if you do not want it to be recorded.
May we record this interview?
YES
NO

Attachment G. Informed Consent Forms

18

Consent to Participate in a Research Study
Shelter Resident Volunteers
Sponsor / Study Title:

RTI International / “National Study of Mental Health
(NSMH)”

Protocol Number:

FG00030 / 021786

Principal Investigator:
(Study Doctor)

Heather Ringeisen, PhD

Telephone:

(833) 947-2575 (24 Hours)

Address:

RTI, International
3040 E Cornwallis Rd, PO Box 12194
Research Triangle Park, NC 27709

KEY INFORMATION
You are being invited to take part in the National Study of Mental Health. This is a research
study about mental health, and tobacco, alcohol, and drug use. If you choose to take part in the
study, you will be one of about 7,200 people to do so.
If you decide to participate, I will ask you questions using a laptop computer. We have arranged
with the shelter to talk with you privately. It should take about 90 minutes to complete [IF
INCENTIVE IS ALLOWED IN FACILITY: and you will receive (INCENTIVE) if you agree to
participate.] [IF RECORDING IS ALLOWED IN FACILITY: I will ask for your permission to
record the interview to ensure I did it properly. You can still be interviewed even if you do not
allow the interview to be recorded.] There is no direct benefit to you from your participation in
the study. Information learned from the study may help other people in the future. If you decide
not to take part, there will not be any penalty and you will not lose any benefits or rights you
would normally receive. Your participation is voluntary, and you can refuse to answer any
questions.
You cannot be identified through any information you give us. Your name will not be connected
to your answers. However, there are some exceptions to this privacy rule. If you tell me about the
abuse of a child or that you plan to hurt yourself or others, we may need to notify a mental health
professional or other authorities.
It is up to you whether or not you are part of this study. The following information is meant to
help you decide.

Attachment G. Informed Consent Forms

19

WHO IS LEADING THE STUDY?
The person in charge of this study is the study investigator, from RTI International, a nonprofit
research company in North Carolina. The study is sponsored by the Substance Abuse and Mental
Health Services Administration (SAMHSA), an agency in the U.S. Department of Health and
Human Services (DHHS).
WHAT IS THIS STUDY ABOUT?
The study will look at how many people in the United States have experienced mental health
conditions like depression, anxiety, psychosis, and post-traumatic stress disorder. We are asking
people who take part in the study to answer questions about these conditions. We will also ask
about using tobacco, alcohol, and drugs.
For the study to be successful, we need to hear from people who have had these experiences and
from people who have never had these experiences.
The questions will also ask about your health in general and about healthcare and any mental
health or substance abuse treatment you may be getting. The last set of questions asks about
household income and involvement with the criminal justice system.
Your name will not be linked to your answers. Your answers will be combined with answers
from the other study participants and will be used to understand how many people experience
mental health and substance use conditions, and how these conditions impact their quality of life.
Also, this information may be used by local, state, and federal agencies to support education,
treatment, and prevention programs.
DO I HAVE TO TAKE PART IN THIS INTERVIEW?
It is your choice whether or not you take part in this study. Even if you decide to start the
interview, you may change your mind and stop at any time. If you decide to stop the interview
before finishing it, let me know. The only alternative is to not participate in the study. If you
decide not to take part or to stop the interview, there will not be any penalty and you will not lose
any benefits or rights you would normally receive.
WHERE IS THE INTERVIEW GOING TO TAKE PLACE, AND HOW LONG WILL IT
LAST?
We will do the interview here. It should take about 90 minutes to complete.

Attachment G. Informed Consent Forms

20

WHAT ARE THE POSSIBLE RISKS OR DISCOMFORTS?
The length of the interview might cause you to feel tired or stressed. Also, you might find some
of the questions I ask to be upsetting or stressful. If this happens, you can take a short break or
stop the interview and finish it another day, if that is an option. Your participation is voluntary,
and you can refuse to answer any of the questions.
WHAT ARE THE POSSIBLE BENEFITS?
This study is for research purposes only. There is no direct benefit to you from your participation
in the study. Information learned from the study may help other people in the future.
WILL THERE BE ANY COSTS ASSOCIATED WITH MY PARTICIPATION?
There will be no charge to you for your participation in this study.
WILL I RECEIVE ANY PAYMENT OR REWARD FOR TAKING PART IN THIS STUDY?
«Compensation»
To thank you for participating in the study, I will offer you [INCENTIVE].
IF INCENTIVE IS NOT APPROVED: No, we are not able to provide any payment or reward
for taking part in the study.
WILL MY RESPONSES BE KEPT CONFIDENTIAL?
You cannot be identified through any information you give us. Your name will never be
connected to your answers. Your answers will be combined with those from the other study
participants. The results of the study will come from the combined answers and it won’t be
possible to identify you. In addition, federal law requires us to keep all your answers
confidential. Any information you give us will only be used by authorized personnel for
statistical purposes.
To help keep information about you confidential, we have obtained a Certificate of
Confidentiality from the Department of Health and Human Services. This adds special protection
for the information about you because it protects the research team from being forced, even
under a court order or subpoena, to release information that could identify you. However, there
are some exceptions to this privacy rule. If you tell me about the abuse of a child or that you plan
to hurt yourself or others, we may need to notify a mental health professional or other authorities.
WHOM TO CONTACT ABOUT THIS STUDY
During the study, if you have questions, concerns or complaints about the study, please contact
the Investigator at the telephone number listed on the first page of this consent document .

Attachment G. Informed Consent Forms

21

An IRB is an independent committee established to help protect the rights of research
participants. If you have any questions about your rights as a research participant, and/or
concerns or complaints regarding this research study, contact:
•

•
•

By mail:
Study Subject Adviser
Advarra IRB
6940 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
or call toll free: 877-992-4724
or by email: [email protected]

Please include the following number when contacting the Study Subject Adviser: Pro00042170.

Do you agree to participate in this study?
YES
NO
IF VIDEO RECORDING IS ALLOWED: I am video recording this interview so my supervisor
can make sure I am following the correct procedures. The recording will be kept private and will
be deleted after my work has been reviewed. If you don’t want me to record the interview, I will
stop the recording. You can still do the interview even if you do not want it to be recorded.
May we record this interview?
YES
NO

Attachment G. Informed Consent Forms

22

Proxy Consent to Participate in a Research Study
Sponsor / Study Title:

RTI International / National Study of Mental Health
(NSMH)

Protocol Number:

FG00030 / 021786

Principal Investigator:
(Study Doctor)

Heather Ringeisen, PhD

Telephone:

(833) 947-2575 (24 Hours)

Address:

RTI, International
3040 E Cornwallis Rd, PO Box 12194
Research Triangle Park, NC 27709

KEY INFORMATION
You are being invited to take part in the National Study of Mental Health on behalf of the
participant. The participant was selected to participate in this study and provided permission for
you to participate on his/her behalf. This is a research study about mental health, tobacco,
alcohol and drug use, and consists of one interview. If you choose to take part in the study, you
will be one of about 7,200 people to do so.
If you decide to participate, a trained interviewer will ask the questions by phone, video
teleconference, or in person, using a laptop computer. You can be in your home, office or
another private location when you complete the interview. You will be asked for permission to
record the interview to ensure: the interviewer did it properly. You can still be interviewed even
if you do not allow the interview to be recorded.
The interview will include a few questions about your relationship with the participant, but will
mostly consist of questions about the participant’s health. The interview should take about 60 to
80 minutes to complete and you will receive a $30 electronic gift card or $30 cash if you agree to
participate. Your participation is voluntary, and you can refuse to answer any questions.
The following information is meant to help you decide whether or not to be in this study.
WHO IS LEADING THE STUDY?
The person in charge of this study is the study investigator from RTI International, a nonprofit
research company in North Carolina. The study is sponsored by the Substance Abuse and
Mental Health Services Administration (SAMHSA), an agency in the U.S. Department of Health
and Human Services (DHHS).

Attachment G. Informed Consent Forms

23

WHAT IS THIS STUDY ABOUT?
The study will look at how many people in the United States have experienced mental health
conditions like depression, anxiety, psychosis, and post-traumatic stress disorder. We are asking
you to answer questions about these conditions in regard to the participant. We will also ask
about the participant’s use of tobacco, alcohol, and drugs. We will also ask a few questions about
your relationship with the participant.
For the study to be successful, we need to hear about people who have had these experiences and
about people who have never had these experiences.
The questions will also ask about the participant’s health in general and about healthcare and any
mental health or substance abuse treatment s/he may be getting. The last set of questions asks
about household income and involvement with the criminal justice system.
Your name and the participant’s name will not be linked to your answers. Your answers
will be combined with answers from the other study participants and will be used to understand
how many people experience mental health and substance use conditions, and how these
conditions impact their quality of life. Also, this information may be used by local, state, and
federal agencies to support education, treatment and prevention programs.
DO I HAVE TO TAKE PART IN THIS INTERVIEW?
It is your choice whether or not you take part in this study. Even if you decide to start the
interview, you may change your mind and stop at any time. If you decide to stop the interview
before finishing it, let the interviewer know. The only alternative is to not participate in the
study. If you decide not to take part, or to stop the interview, there will not be any penalty and
neither you nor the participant will lose any benefits or rights you would normally receive.
WHAT ARE THE POSSIBLE RISKS OR DISCOMFORTS?
The length of the interview might cause you to feel tired or stressed. Also, you might find some
of the questions we ask to be upsetting or stressful. If this happens, you can take a short break or
stop the interview and finish it another day. Your participation is voluntary, and you can refuse
to answer any of the questions.
WHAT ARE THE POSSIBLE BENEFITS?
This study is for research purposes only. There is no direct benefit to you or the participant from
your participation in the study. Information learned from the study may help other people in the
future.

Attachment G. Informed Consent Forms

24

WILL THERE BE ANY COSTS ASSOCIATED WITH MY PARTICIPATION?
There will be no charge to you or the participant for your participation in this study, other than
your normal phone, internet, or data plan charges if applicable.
WILL I RECEIVE ANY PAYMENT FOR TAKING PART IN THIS STUDY?
Yes, you will receive a $30 electronic gift card or $30 cash if the interview is conducted in
person.
WILL MY RESPONSES BE KEPT CONFIDENTIAL?
You and the participant cannot be identified through any information you give us. Your name
and address and the participant’s name and address will never be connected to your answers.
Your answers will be combined with those from the other study participants. The results of the
study will come from the combined answers and it won’t be possible to identify you. In
addition, federal law requires us to keep all your answers confidential. Any information you give
us will only be used by authorized personnel for statistical purposes.
To help keep information about you confidential, we have obtained a Certificate of
Confidentiality from the Department of Health and Human Services (DHHS). This adds special
protection for the research information about you and the participant because it protects the
research team from being forced, even under a court order or subpoena, to release information
that could identify you or the participant. However, there are some exceptions to this privacy
rule. If you tell me about the abuse of a child or that you plan to hurt yourself or others, we may
need to notify a mental health professional or other authorities.

WHOM TO CONTACT ABOUT THIS STUDY
During the study, if you have questions, concerns or complaints about the study, please contact
the Investigator at the contact information on the first page of this consent.
An institutional review board (IRB) is an independent committee established to help protect the
rights of research participants. If you have any questions about your rights as a research
participant, and/or concerns or complaints regarding this research study, contact:
• By mail:
Study Subject Adviser
Advarra IRB
6940 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
• or call toll free: 877-992-4724

Attachment G. Informed Consent Forms

25

•

or by email:

[email protected]

Please reference the following number when contacting the Study Subject Adviser:
Pro00042170.
You are not giving up any of your legal rights by agreeing to be in this study.

Do you agree to participate in this study?
YES
NO

Interview Audio/Video Consent to be administered at the beginning of the Interview
I am [IF PHONE FILL: recording this phone interview; IF IN PERSON OR VIDEO: video
recording this interview] so my supervisor can make sure I am following the correct procedures.
The recording will be kept private and will be deleted after my work has been reviewed. If you
don’t want me to record the interview I will stop the recording. You can still do the interview
even if you do not want it to be recorded.
May we record this interview?
1=YES
2=NO

Attachment G. Informed Consent Forms

26

Attachment H
Household Respondent Materials
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
21)
22)
23)
24)
25)
26)
27)
28)
29)
30)
31)

Roster Mailing 1 Lead Letter
Roster Mailing 2 Pressure Seal Self-Mailer
Roster Mailing 3 Postcard 1
Roster Mailing 4 Reminder Letter
Roster Mailing 5 Paper Reminder Letter
Roster Mailing 6 Postcard 2
Roster Mailing 7 Final Pressure Seal Self-Mailer
Screener Mailing 1 Lead Letter
Screener Mailing 2 Pressure Seal Self-Mailer
Screener Mailing 3 Reminder Letter
Screener Mailing 4 Follow-up Reminder Letter
Screener Mailing 5 Final Postcard
Screener Mailing 6 Final Pressure Seal Self-Mailer
Screener Reminder Emails
Screener Notification Card
Clinical Interview Scheduling Script
Clinical Interview Appointment Emails & Letters
Clinical Interview Follow-Up Letter
Clinical Interview Recontact Letter (Screener CI Reluctance)
Letters (Unable to Contact, Controlled Access, Call Me, Reluctance)
Automated Emails: New, Rescheduled, Canceled, Missed Appointments
Texts
Unable to Contact Text
Website Content
COVID Risk Form Vaccinated Protocol A
COVID Risk Form Unvaccinated Protocol B
Incentive/Thank You E-mail (Roster, Screener, CI)
Incentive Receipt In-person
Brochure Text
FAQs
Field and Clinical Interviewer Authorization Letter

Roster Mailing 1 Lead Letter

Attachment H Household Respondent Materials

1

Roster Mailing 2 Pressure Seal Self-Mailer

Attachment H Household Respondent Materials

2

Attachment H Household Respondent Materials

3

Roster Mailing 3 Postcard 1

Attachment H Household Respondent Materials

4

Roster Mailing 4 Reminder Letter

Attachment H Household Respondent Materials

5

Roster Mailing 5 Paper Reminder Letter

Attachment H Household Respondent Materials

6

Roster Mailing 6 Postcard 2

Attachment H Household Respondent Materials

7

Roster Mailing 7 Final Pressure Seal Self-Mailer

Attachment H Household Respondent Materials

8

Attachment H Household Respondent Materials

9

Screener Mailing 1 Lead Letter

Attachment H Household Respondent Materials

10

Screener Mailing 2 Pressure Seal Self-Mailer

Attachment H Household Respondent Materials

11

Attachment H Household Respondent Materials

12

Screener Mailing 3 Reminder Letter

Attachment H Household Respondent Materials

13

Screener Mailing 4 Follow-up Reminder Letter

Attachment H Household Respondent Materials

14

Screener Mailing 5 Final Postcard

Attachment H Household Respondent Materials

15

Screener Mailing 6 Final Pressure Seal Self-Mailer

Attachment H Household Respondent Materials

16

Attachment H Household Respondent Materials

17

Screener Reminder Emails
NSMH Screening Survey Email Reminders

1.

1st Email Reminder (Day 4)
E-mail Subject: Reminder: Participate in the National Study of Mental Health!
Dear [RESPONDENT NAME],
You have been chosen for a groundbreaking study, helping researchers understand mental health
and health services in the United States! You will receive $20 when you complete the 15-minute
screening survey by web or telephone.
To complete the survey via a website on a personal computer, smartphone, laptop, or tablet:
•

Use this link: 
OR

•

Call us toll-free at 877-267-2910

More information is available on the study website: https://nsmh.rti.org. If you have questions,
you can call our study assistance line toll-free at 833-947-2575 or email us at [email protected].
Your participation is critical to the success of the National Study of Mental Health!
Thank you,

Heather Ringeisen, PhD
Principal Investigator, NSMH
RTI International

Attachment H Household Respondent Materials

18

2.

2nd Email Reminder (Day 12)
E-mail Subject: Reminder: Participate in the 15-minute NSMH Survey for $20!
Dear [RESPONDENT NAME],
You can help researchers better understand mental health and health services in the United States.
Please complete the 15-minute National Study of Mental Health screening survey by web or
telephone and you will receive $20.
To complete the screening survey via a website on a personal computer, smartphone, laptop, or
tablet:
•

Use this link: 
OR

•

Call us toll-free at 877-267-2910

Once you complete the screening survey you may be selected to complete the main interview and
receive an additional $30.
More information is available on the study website: https://nsmh.rti.org. If you have questions,
you can call our study assistance line toll-free at 833-947-2575 or email us at [email protected].
Your participation is critical to the success of the National Study of Mental Health!
Thank you,

Heather Ringeisen, PhD
Principal Investigator, NSMH
RTI International

Attachment H Household Respondent Materials

19

3.

3rd Email Reminder (Day 21)
E-mail Subject: It is not too late to participate in the National Study of Mental Health!
Dear [RESPONDENT NAME],
We are reaching out to you again because your participation is so important. You can help
researchers better understand mental health and health services in the United States. In
appreciation for the time it takes to complete the National Study of Mental Health (NSMH) screening
survey you will receive $20.
To complete the NSMH screening survey via a website on a personal computer, smartphone, laptop,
or tablet:
•

Use this link: 
OR

•

Call us toll-free at 877-267-2910

More information is available on the study website: https://nsmh.rti.org. If you have questions,
you can call our study assistance line toll-free at 833-947-2575 or email us at [email protected].
Thank you in advance for your participation!

Heather Ringeisen, PhD
Principal Investigator, NSMH
RTI International

Attachment H Household Respondent Materials

20

4.

Final Email Reminder (Day 54)
E-mail Subject: Time Is Running Out - Participate in the National Study of Mental Health by web or
telephone now!
Dear [RESPONDENT NAME],
Your participation is critical to the success of our study!
We are nearing the end of the National Study of Mental Health (NSMH). Your data will
help researchers understand mental health and health services in the United States. Please complete
the survey today!
If you cannot complete the survey by web or telephone, one of our professional interviewers will
contact you at your home to complete it in person.
To complete the survey via a website on a personal computer, smartphone, laptop, or tablet:
•

Use this link: 
OR

•

Call us toll-free at 877-267-2910

For more information on the study, please visit the study website: https://nsmh.rti.org. If you have
questions or need help completing the survey, please call our study assistance line toll-free at 833-9472575 or email us at [email protected].
Thank you in advance for your participation!

Heather Ringeisen, PhD
Principal Investigator, NSMH
RTI International

Attachment H Household Respondent Materials

21

Screener Notification Card

Attachment H Household Respondent Materials

22

Clinical Interview Scheduling Script
Clinical Interview – First Contact/Scheduling Script
VERIFY NUMBER AND LOCATE RESPONDENT
Hi, my name is _______________ and I’m calling on behalf of RTI International, a nonprofit research
Institute. Is this [PHONE NUMBER]?
YES: PROCEED BELOW.
NO: I apologize. I need to double check my records. Thank you for your time. END CALL.
NO ANSWER: GO TO VOICEMAIL SECTION
I’m trying to reach [FIRST NAME] about a study we are conducting. May I speak to [FIRST NAME]?
IF R NOT HOME OR UNAVAILABLE
When would be a good time to call again? ENTER CODE 1204 AND DETAILS IN ROC.
Thank you for your time. END CALL.
IF R AVAILABLE
(Hi, my name is _______________.)
You recently completed a screening survey for the National Study of Mental Health. Before I continue,
can you confirm that you are not driving right now?
NOT DRIVING: PROCEED BELOW.
DRIVING: When would be a good time to call again? ENTER CODE 1204 AND DETAILS IN
ROC. Thank you for your time. END CALL.]
Do you recall completing the screening survey?

YES: PROCEED TO SCHEDULING INTERVIEW SECTION BELOW.
NO: VERIFY FIRST NAME OF PERSON YOU ARE SPEAKING TO.
IF NOT SPEAKING TO CORRECT RESPONDENT, ASK TO SPEAK TO RESPONDENT.
IF NAME IS CORRECT AND RESPONDENT DOESN’T RECALL INITIAL INTERVIEW,
REMIND OF DATE OF INITIAL INTERVIEW.
IF CORRECT RESPONDENT STILL NOT FOUND: I apologize. I need to double check my
records. Thank you for your time. END CALL. ENTER CODE 1579 AND INVESTIGATE.

Attachment H Household Respondent Materials

23

Scheduling the Interview

IF SCREENING MODE = WEB, PHONE, OR IN PERSON: Thank you for agreeing to be interviewed for
the National Study of Mental Health. I would like to schedule a video interview for a date and time that
works best for you.
IF SCREENING MODE = MAIL OR JAIL: Thank you for completing the screening survey for the National Study
of Mental Health. You are eligible to participate in the full interview for which you will receive a $30
incentive. I would like to schedule a video interview for a date and time that works best for you.
R CANNOT DO A VIDEO INTERVIEW
DISCUSS OBSTACLES TO VIDEO INTERVIEW AND ATTEMPT TO PROBLEM SOLVE.
IF VIDEO INTERVIEW IS NOT POSSIBLE AND IN PERSON INTERVIEWS ARE NOT PERMITTED:
Unfortunately, at this time in person interviews are not permitted. As soon as in person
interviews are allowed I will contact you to schedule your interview.
IF VIDEO INTERVIEW IS NOT POSSIBLE AND IN PERSON INTERVIEWS ARE PERMITTED: Since
you are not able to do a video interview I’d like to schedule an in person interview. Your health
and safety are of critical importance, which is why I am required to follow the Centers for
Disease Control and Prevention (CDC) and World Health Organization (WHO) guidelines when
conducting in person interviews. SHARE SAFETY PRECAUTIONS THAT WILL BE TAKEN FOR IN
PERSON INTERVIEW.
R CAN DO VIDEO INTERVIEW & PROVIDED BEST DAYS & TIMES:
You indicated [BEST DAYS AND TIMES R PROVIDED] would work best.
Would [FILL DAY, DATE, AND TIME IN THE NEXT WEEK THAT FALLS IN R’S PARAMETERS] work for
you?

YES: Wonderful, thank you.
NO: What date and time would work best for you?
RECORD DATE & TIME:
R CAN DO VIDEO INTERVIEW & DID NOT PROVIDE BEST DAYS & TIMES:
What date and time would work best for you?]
RECORD DATE & TIME:

Attachment H Household Respondent Materials

24

IF VIDEO INTERVIEW:
I will send a confirmation e-mail with a private zoom link for the video interview scheduled for [FILL DAY,
DATE, TIME]. Let me confirm I have the correct e-mail address.
CONFIRM/COLLECT CORRECT EMAIL
Thank you! I look forward to our interview. You should receive an e-mail from me in the next hour.
ENTER APPOINTMENT INFO IN ROC
IF IN PERSON INTERVIEW:
Let me confirm I have the right address. My records indicate you live at [FILL FULL ADDRESS]. Is that
correct?
YES:
Great. I will see you there on [FILL DAY, DATE, TIME]. If something comes up and you need
to reschedule please contact 833-947-2575. I also want to let you know that the beginning
of our interview will be video recorded to ensure that I am following the proper
procedures, including reviewing information about the study, your rights as a
participant, confidentiality, and asking for your permission to video record the
interview. If you don’t want me to record the interview, I will stop the recording. You can still
do the interview even if you do not want it to be recorded.
Thank you again for participating in the study. I look forward to our interview on DAY,
DATE, TIME.
ENTER APPOINTMENT INFO IN ROC
NO:
Did you live at [FILL FULL ADDRESS] on [DATE ROSTER WAS COMPLETED]?
YES: What is your current address?
RECORD ADDRESS.
Great. I will see you there on [FILL DAY, DATE, TIME]. If something comes up and
you need to reschedule please contact 833-947-2575. I also want to let you know
that the beginning of our interview will be video recorded to ensure that I am
following the proper procedures, including reviewing information about the
study, your rights as a participant, confidentiality, and asking for your
permission to video record the interview. If you don’t want me to record the
interview, I will stop the recording. You can still do the interview even if you do not
want it to be recorded. Thank you again for participating in the study. I look forward
to our interview on DAY, DATE, TIME.
ENTER APPOINTMENT INFO IN ROC

Attachment H Household Respondent Materials

25

NO: INTERVIEWER: FIND OUT IF THEY HAVE EVER LIVED AT THE SAMPLED ADDRESS,
AND IF THEY HAVE WHEN THEY LIVED THERE.

I need to talk with my supervisor before I can schedule the appointment. I will be
back in touch. Thank you.

RECORD IF THEY HAVE EVER LIVED AT THE SAMPLED ADDRESS (AND IF THEY HAVE
WHEN THEY LIVED THERE) IN THE ROC AND FOLLOW-UP WITH YOUR CS.

Voicemail Script

Hello, I’m trying to reach [RESPONDENT NAME] about a study being conducted by RTI International, a nonprofit
research institute. This study is sponsored by the Substance Abuse and Mental Health Services Administration.
Please have [RESPONDENT NAME] call 833-947-2575 as soon as possible and refer to caseid [FILL]. That’s 833947-2575, ID number [FILL]. Thank you.

Missed Appointment Voicemail

Hello. I’m [YOUR NAME] and I’m calling on behalf of RTI International, a nonprofit research institute, regarding a
national study that is sponsored by the Substance Abuse and Mental Health Services Administration. When we
spoke previously about this study, you asked that we contact you at [TIME & DATE]. Please call 833-947-2575 to
reschedule your appointment for a date and time that works best for you. Thank you for taking time for
this important study!

Attachment H Household Respondent Materials

26

Clinical Interview Appointment Emails & Letters
NSMH CI Emails/Letters
NOTE: CIs will schedule the Zoom meeting via Outlook invitation. They will use the text below and
remove the ‘extra’ zoom information that is included in the invitation.
1.

Clinical Interview Initial Contact Email (When R completed screening online, by telephone, or in
person, and indicated e-mail contact preference in screener)
E-mail - Title: Scheduling Your National Study of Mental Health (NSMH) Interview
Dear [RESPONDENT NAME],
Thank you for agreeing to be interviewed for the National Study of Mental Health! I would like to
schedule a video interview at a date and time that works best for you. You indicated [FILL BEST
DAYS AND TIMES R PROVIDED] would work best. Please let me know if [FILL DAY, DATE, AND
TIME IN THE NEXT WEEK THAT FALLS IN R’S PARAMETERS] will work for you. If not, please suggest
another date and time and I will do my best to accommodate your schedule. Once we have the
date and time I will send a confirmation e-mail with a private zoom link for the video call.
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.
Thank you!
[CI NAME]

2.

Clinical Interview Initial Contact Email – Mail or Jail Screening (When R completed screening by mail
or jail and indicated e-mail contact preference in screener)
E-mail - Title: National Study of Mental Health (NSMH) Interview
Dear [RESPONDENT NAME],
Thank you for completing the screening survey for the National Study of Mental Health! You are
eligible to participate in the main interview for which you will receive a $30 electronic prepaid
Visa© or $30 check. I would like to schedule a video interview at a date and time that works best
for you. You indicated [FILL BEST DAYS AND TIMES R PROVIDED] would work best. Please let me
know if [FILL DAY, DATE, AND TIME IN THE NEXT WEEK THAT FALLS IN R’S PARAMETERS] will work
for you. If not, please suggest another date and time and I will do my best to accommodate your
schedule. Once we have the date and time I will send a confirmation e-mail with a private zoom
link for the video call.
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.
Thank you!
[CI NAME]

Attachment H Household Respondent Materials

27

3.

Follow-Up to Initial Contact E-mail (If no response; when R completed screening online, by telephone,
or in person, and indicated e-mail contact preference in screener)
E-mail - Title: Scheduling Your National Study of Mental Health (NSMH) Interview
Dear [RESPONDENT NAME],
Thank you again for agreeing to be interviewed for the National Study of Mental Health! Your
participation is critical to the success of the study, which is why I’m reaching out to you again to
schedule your interview. I would like to schedule a video interview at a date and time that works
best for you. You indicated [FILL BEST DAYS AND TIMES R PROVIDED] would work best. Please let
me know if [FILL DAY, DATE, AND TIME IN THE NEXT WEEK THAT FALLS IN R’S PARAMETERS] will
work for you. If not, please suggest another date and time and I will do my best to accommodate
your schedule. Once we have the date and time I will send a confirmation e-mail with a private
zoom link for the video call.
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.
Thank you!
[CI NAME]

4.

Follow-Up to Initial Contact E-mail– Mail or Jail Screening (When R completed screening by mail or
jail and indicated e-mail contact preference in screener)
E-mail - Title: Scheduling Your National Study of Mental Health (NSMH) Interview
Dear [RESPONDENT NAME],
Thank you again for completing the screening survey for the National Study of Mental Health!
You are eligible to participate in the main interview for which you will receive a $30 electronic
prepaid Visa© or $30 check. Your participation is critical to the success of the study, which is why
I’m reaching out to you again to schedule your interview.
I would like to schedule a video interview at a date and time that works best for you. You
indicated [FILL BEST DAYS AND TIMES R PROVIDED] would work best. Please let me know if [FILL
DAY, DATE, AND TIME IN THE NEXT WEEK THAT FALLS IN R’S PARAMETERS] will work for you. If
not, please suggest another date and time and I will do my best to accommodate your schedule.
Once we have the date and time I will send a confirmation e-mail with a private zoom link for the
video call.
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.
Thank you!
[CI NAME]

Attachment H Household Respondent Materials

28

5.

When R indicates Unable to do Video (Email/Letter)
5a. IF RESPONDENT INDICATES THEY ARE UNABLE TO DO VIDEO INTERVIEW AND IN PERSON
INTERVIEWS ARE NOT PERMITTED
E-mail - Title: Scheduling Your National Study of Mental Health (NSMH) Interview
Dear [RESPONDENT NAME],
Unfortunately, at this time in person interviews are not permitted. As soon as in person
interviews are allowed I will contact you to schedule your interview.
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.
Thank you!
[CI NAME]
5b. IF RESPONDENT INDICATES THEY ARE UNABLE TO DO VIDEO INTERVIEW AND IN PERSON
INTERVIEWS ARE PERMITTED
E-mail - Title: Scheduling Your National Study of Mental Health (NSMH) Interview
Dear [RESPONDENT NAME],
Since you are not able to do a video interview, I’d like to schedule an in-person interview.
Your health and safety are of critical importance, which is why I am required to follow the
Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO)
guidelines when conducting in person interviews.
SHARE SAFETY PRECAUTIONS THAT WILL BE TAKEN FOR IN PERSON INTERVIEW.
You indicated [FILL BEST DAYS AND TIMES R PROVIDED] would work best. Please let me
know if [FILL DAY, DATE, AND TIME IN THE NEXT WEEK THAT FALLS IN R’S PARAMETERS]
will work for you. If not, please suggest another date and time and I will do my best to
accommodate your schedule. Once we have the date and time, I will send a confirmation
e-mail.
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.

Thank you!
[CI NAME]

Attachment H Household Respondent Materials

29

6.

Clinical Interview Appointment Email for Video Conference
E-mail - Meeting Title: NSMH Interview Appointment – [DAY OF WEEK, FILL DATE @ FILL TIME] via
Zoom

Dear [RESPONDENT NAME],
I appreciate you taking time for this important study and look forward to our appointment to
complete the interview. Your appointment is scheduled for [DAY OF WEEK], [DATE], at [TIME].
The beginning of our interview will be video recorded to ensure that I am following the
proper procedures, including reviewing information about the study, your rights as a
participant, confidentiality, and asking for your permission to video record the interview. If
you don’t want me to record the interview, I will stop the recording. You can still do the interview
even if you do not want it to be recorded.
To access the video conference please click on this link:
[ZOOM LINK]
Select “Allow” if you are asked this question: “Do you want to allow this website to open a
program on your computer?”

Once you are in Zoom you will choose the audio conference option that works best for you:
a. “Call Me”: Enter your phone number and click “Call Me” and Zoom will call you.
b. “Computer Audio”: Click “Join with Computer Audio”
a. “Phone Call”: Dial this toll-free number: [FILL] and enter the Meeting ID: [FILL] and
Password: [FILL]
I have also attached two documents we will reference during the interview.
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.

Thank you!
[CI NAME]

Attachment H Household Respondent Materials

30

7.

Clinical Interview Appointment Letter for Video Conference
Dear [RESPONDENT NAME],
I appreciate you taking time for this important study and look forward to our appointment to
complete the interview. Your appointment is scheduled for [DAY OF WEEK], [DATE], at [TIME].
The beginning of our interview will be video recorded to ensure that I am following the
proper procedures, including reviewing information about the study, your rights as a
participant, confidentiality, and asking for your permission to video record the interview. If
you don’t want me to record the interview, I will stop the recording. You can still do the interview
even if you do not want it to be recorded.
To access the video conference please follow these steps at our appointment time:
1.
2.
3.
4.
5.

Go to www.zoom.us
Click on “JOIN A MEETING”
Enter the Meeting ID: [FILL] and click “Open Zoom”, if prompted
Enter the Meeting Password: [FILL], if prompted.
Choose the audio conference option that works best for you:
a. “Phone Call”: Dial this toll-free number [FILL] and enter the Meeting ID: [FILL] and
Password: [FILL]
b. “Computer Audio”: Click “Join with Computer Audio”
c. “Call Me”: Enter your phone number and click “Call Me” and Zoom will call you.

I have also included two documents we will reference during the interview.
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.

Thank you!
[CI NAME]

8.

Clinical Interview Appointment Email/Letter for In Person Appointment
E-mail - Meeting Title: NSMH Interview Appointment – [FILL DATE @ FILL TIME]
Dear [RESPONDENT NAME],
I appreciate you taking time for this important study and look forward to our appointment to
complete the interview. Your appointment is scheduled for [DAY OF WEEK], [DATE], at [TIME]
at [ADDRESS].
Your health and safety are of critical importance, which is why I am required to follow the Centers
for Disease Control and Prevention (CDC) and World Health Organization (WHO) guidelines when
conducting in person interviews.
SHARE SAFETY PRECAUTIONS THAT WILL BE TAKEN FOR IN PERSON INTERVIEW.
The beginning of our interview will be video recorded to ensure that I am following the
proper procedures, including reviewing information about the study, your rights as a
Attachment H Household Respondent Materials

31

participant, confidentiality, and asking for your permission to video record the interview. If
you don’t want me to record the interview, I will stop the recording. You can still do the interview
even if you do not want it to be recorded.
I have also [attached/included] two documents we will reference during the interview.
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.

Thank you!
[CI NAME]

9.

Clinical Interview Appointment Email/Letter for Phone Appointment
E-mail - Meeting Title: NSMH Interview Appointment – [FILL DATE @ FILL TIME]
Dear [RESPONDENT NAME],
I appreciate you taking time for this important study and look forward to our appointment to
complete the interview. Your appointment is scheduled for [DAY OF WEEK], [DATE], at [TIME].
[IF CONTACTING R DIRECTLY: I will contact you at [R’s PHONE] at that time. FILL ZOOM
SPECIFIC INSTRUCTIONS; IF PROVIDING R DIAL IN: At our appointment time please [FILL
SPECIFIC ZOOM INSTRUCTIONS].
The beginning of our interview will be recorded to ensure that I am following the proper
procedures, including reviewing information about the study, your rights as a participant,
confidentiality, and asking for your permission to record the interview. If you don’t want me to
record the interview, I will stop the recording. You can still do the interview even if you do not want it
to be recorded.
I have also [attached/included] two documents we will reference during the interview.
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.

Thank you!
[CI NAME]
10. Missed Appointment Clinical Interview Email/Letter
E-mail - Subject: NSMH – Rescheduling Your Interview
Dear [RESPONDENT NAME],
I’m sorry we were unable to meet for our scheduled appointment. Please call 833-947-2575 and
reference your caseid ([FILL CASEID]) to reschedule your appointment for a date and time that
works best for you. Thank you for taking time for this important study!
Regards,
[CI NAME]
Attachment H Household Respondent Materials

32

11. Clinical Interview Appointment Letter to Encourage R for whom we have no e-mail or phone to call in
to schedule appointment.
Dear [RESPONDENT NAME],
Thank you for completing the National Study of Mental Health screening survey and agreeing to
be interviewed. Please contact us toll-free at 833-947-2575 or email us at [email protected] to
schedule your appointment. Please reference your caseid (FILL CASEID) when you call.

If you have any questions, please do not hesitate to call 833-947-2575.
Thank you!
[CI NAME]

12. Clinical Interview Appointment Letter to Notify Rs that a CI will be making an in person contact (for
Rs that do not have phone or email AND for in person contact phase (last month of DC for the case))
Dear [RESPONDENT NAME],
Thank you for completing the National Study of Mental Health screening survey and agreeing to
be interviewed. You indicated [FILL DAYS/TIMES R INDICATED ARE BEST FOR CONTACT] are/is the
best time to contact you, so I will stop by your home on [FILL DATE & TIME].
If you have any questions, please do not hesitate to call 833-947-2575. Please reference your
caseid (FILL CASEID) when you call.
Thank you!
[CI NAME]

Attachment H Household Respondent Materials

33

Clinical Interview Follow-Up Letter

Attachment H Household Respondent Materials

34

Clinical Interview Recontact Letter (Screener CI Reluctance)

Attachment H Household Respondent Materials

35

NSMH Roster, Screener, Clinical Interview Unable to Contact, Too Busy, Reluctance Letters & Flyers
Roster No Contact Letter

[DATE]
Resident
[STREET ADDRESS]
[CITY], [STATE] [ZIP]
Dear Resident:
Recently, a professional interviewer from RTI International attempted to contact your household about
participating in the National Study of Mental Health*. Your participation in this study is important—this is why
we continue to try and reach you.
Some people are cautious about speaking to a stranger at the door, and that is understandable. Please know that
we are not soliciting or selling anything—we have just a few general questions to ask that will take about five
minutes, and the adult that answers the questions will receive $5 in cash if completed with a field interviewer in
person or a $10 electronic prepaid Visa© or $10 check if completed via web or telephone.
It is not necessary for you to let the interviewer into your home—you can answer the questions right at your door.
Or, you can answer the questions online or via telephone. To complete the 5-minute household membership
listing via telephone please call us toll-free at 877-267-2910 between [FILL], Eastern Time. To complete the
household membership listing via a website on a personal computer, laptop, or tablet:
1.
2.

In your web browser type the study website address: https://nsmh.rti.org
On the login screen, type your password exactly as shown below:
Password: 

After these initial questions, someone in your household may or may not be randomly selected to answer a few
more questions to find out if they are eligible to participate in the main interview. These questions will take about
15 minutes to complete. We will give the person answering these additional questions $20. Then, if anyone is
selected for and completes the main interview, that person will receive $30 as a token of appreciation.
A limited number of households were randomly selected to represent the population of the U.S. Your household
cannot be replaced. If you choose not to participate, your experiences and views—as well as the thousands of
people you represent—will not have a chance to be heard.
Thank you for your time. I hope you’ll choose to participate in this extremely important and beneficial study.
Sincerely,
[FS NAME], Field Supervisor
P.S. Please, if you have any questions or would like to set up an appointment, telephone me toll-free at [TOLL
FREE NUMBER].
*The National Study of Mental Health is conducted by RTI International for the Substance Abuse and Mental
Health Services Administration, an agency in the U.S. Department of Health and Human Services.
http://www.samhsa.gov]

Attachment H Household Respondent Materials

36

Screener No Contact Letter

[DATE]
[NAME]
[STREET ADDRESS]
[CITY], [STATE] [ZIP]
Dear [FILL NAME]:
Recently, a professional interviewer from RTI International came to your home to speak with you about
answering a few questions for the National Study of Mental Health*. You were not available to answer the
questions at that time and have been away or unavailable each time the interviewer has returned since then. Your
participation is important—this is why we continue to try and reach you.
Your answers to these questions, which will take about 15 minutes to complete, will tell us whether you are
selected to participate in the main interview for the study.
We appreciate that your time is precious. As a token of our appreciation, you will receive $20 for answering
these questions. If you are selected for and complete the main interview which will occur on a different day,
you will receive an additional $30.
You can complete the screening survey online, via telephone, or an interviewer can come to your home at a time
that is convenient for you. To complete the 15-minute survey via telephone please call us toll-free at 877-2672910 between [FILL], Eastern Time. To complete the screening survey via a website on a personal computer,
laptop, or tablet:
1. In your web browser type the study website address: https://nsmh.rti.org
2. On the login screen, type your password exactly as shown below:
Password: 
If you would like to set up an appointment for an interviewer to come to your home, please telephone me toll-free
at [TOLL FREE NUMBER].
A limited number of people were randomly selected to represent the population of the U.S. You cannot be
replaced. If you choose not to participate, your experiences and views—as well as the thousands of people you
represent—will not be heard.
Thank you for your time. I hope you’ll choose to participate in this extremely important and beneficial study.
Sincerely,
[FS NAME], Field Supervisor
P.S. Please, if you have any questions or would like to set up an appointment, telephone me toll-free at [TOLL
FREE NUMBER].
* The National Study of Mental Health is conducted by RTI International for the Substance Abuse and Mental
Health Services Administration, an agency in the U.S. Department of Health and Human Services.
[http://www.samhsa.gov]

Attachment H Household Respondent Materials

37

Clinical Interview No Contact Letter

[DATE]
[NAME]
[STREET ADDRESS]
[CITY], [STATE] [ZIP]
Dear [FILL NAME]:
Recently, a professional interviewer from RTI International tried to contact you about your participation in the National
Study of Mental Health*. You were not available at that time and have been away or unavailable each time the interviewer
has tried to reach you. Your participation in this study is important—this is why we continue to try and reach you.
A limited number of people were randomly selected to represent the population of the U.S. You cannot be replaced. If you
choose not to participate, your experiences and views—as well as the thousands of people you represent—will not be heard.
Your answers are combined with the answers of thousands of other people and reported only as overall numbers. Also, the
option to refuse to answer any question is always available.
The results of this study will help state and national policymakers learn about mental health—including information on
access to and use of treatment, as well as alcohol, tobacco, and drug use—so that informed decisions about policies and
programs can be made. By participating in this study, you will be contributing to furthering our understanding of important
health-related issues.
Your participation is critical to the success of this study, and we are happy to make a special effort to work around your
schedule so that you can be included. Please feel free to call me to set up an appointment—the interview can be conducted
[FILL: via video; via video or telephone; via video, telephone, or at any private location of your choice].
We appreciate that your time is precious. [IF SCREENER MODE = MAIL OR JAIL FILL: As a token of our appreciation, you
will receive $30 at the end of the interview; IF SCREENER MODE = ELSE FILL: As a token of our appreciation for agreeing
to participate in the main interview you received $30]].
Thank you for your time. I hope you’ll choose to participate in this extremely important and beneficial study.
Sincerely,
[CS NAME], Field Supervisor
P.S. Please, if you have any questions or would like to set up an appointment, call me toll-free at [TOLL FREE NUMBER].

*

The National Study of Mental Health is conducted by RTI International for the Substance Abuse and Mental Health
Services Administration, an agency in the U.S. Department of Health and Human Services. [http://www.samhsa.gov]

Attachment H Household Respondent Materials

38

ROSTER UNABLE TO CONTACT COMPLEX/GATED COMMUNITY

[DATE]
Resident [COMPLEX/COMMUNITY NAME]
[ADDRESS]
[CITY], [STATE] [ZIP]
Dear Resident:
Recently we sent a letter requesting your help with the National Study of Mental Health conducted by RTI International
for the Substance Abuse and Mental Health Services Administration (SAMHSA).
A limited number of household addresses—including yours—were randomly chosen to take part in this important study.
No other household or person can take your place. Information gathered from this study will be helpful for researchers
and local, state and federal health agencies in developing various mental health-related policies and programs.
Typically, a professional interviewer from RTI International visits each selected residence in person. We respect the
policies of [COMPLEX/COMMUNITY NAME] and appreciate your desire for privacy, so we are contacting you by mail
instead. Your participation in this study is very important or we would not continue to try to reach you.
Since we cannot contact you in person, please complete the household membership listing via telephone or online. To
complete the 5-minute household membership listing via telephone please call us toll-free at 877-267-2910 between
[FILL], Eastern Time. You will receive $10 for answering these questions via telephone or online. To complete
the survey via a website on a personal computer, laptop, or tablet:
1. In your web browser type the study website address: https://nsmh.rti.org
2. On the login screen, type your password exactly as shown below:
Password: 
Or, please call our supervisor for your area, [FIRST & LAST NAMES] to set an appointment for an interviewer to visit
your household. If you answer these questions with a field interviewer in person you will receive $5 in cash.

[FIRST & LAST NAME]
[PHONE NUMBER] (toll free)
We only need a few minutes of your time to see if someone in your household will be chosen to answer a few additional
questions to find out if they are eligible for an interview. Every person who answers the additional questions will receive
$20, and if someone is chosen and completes the main interview, he or she will receive $30 as a token of
appreciation. Any information you provide is kept completely confidential and will be used only for statistical purposes.
For more details about the study, please visit https://nsmh.rti.org.Your call to [MR./MS. LAST NAME] is extremely
important to the success of this study, and I thank you in advance for your cooperation.
Sincerely,
National Field Director

Attachment H Household Respondent Materials

39

SCREENER UNABLE TO CONTACT COMPLEX/GATED COMMUNITY

[DATE]
[NAME OF COMPLEX/COLLEGE/UNIVERSITY]
[ADDRESS]
[CITY], [STATE] [ZIP]
Dear [FILL NAME]:
Recently, an interviewer from RTI International came to your [HOME /RESIDENCE HALL] to ask you a few
questions to find out if you are selected to participate in the National Study of Mental Health*. Your
participation is important—which is why we continue to try to reach you.
We want to provide you with additional information about the study:
• A limited number of individuals—including you—were randomly chosen to take part. No other person
can take your place in this study.
• Your answers to these questions, which will take about 15 minutes to complete, will tell us whether
you are selected to participate in the main interview for the study.
• As a token of our appreciation, you will receive $20 for answering these brief questions.
• If you are selected for and complete the longer interview, which will take place on a different day, you
will receive $30.
• Any information you provide is kept completely confidential and will be used only for statistical
purposes.
• For more details about the study, please visit https://nsmh.rti.org.
We are happy to work around your schedule so that you can be included. To complete the 15-minute screening
survey via telephone please call us toll-free at 877-267-2910 between [FILL], Eastern Time. To complete the
screening survey via a website on a personal computer, laptop, or tablet:
1. In your web browser type the study website address: https://nsmh.rti.org
2. On the login screen, type your password exactly as shown below:
Password: 
Or, please contact our supervisor for your area, [FIRST & LAST NAME], to set up an appointment.
[FIRST & LAST NAME]
[PHONE NUMBER] (toll free)
If [MR./MS. LAST NAME] is not available when you call, please leave your phone number, address and the
time you wish to be interviewed. [HE/SHE] will call you to confirm your appointment.
* The National Study of Mental Health is conducted by RTI International or the Substance Abuse and Mental Health
Services Administration, an agency in the U.S. Department of Health and Human Services. [http://www.samhsa.gov]
Attachment H Household Respondent Materials

40

ROSTER/SCREENER/CI TOO BUSY LETTER

[DATE]
[IF SCREENER OR CI FILL: [NAME]]
[STREET ADDRESS]
[CITY], [STATE] [ZIPCODE]
Dear [IF ROSTER FILL: Resident; ELSE FILL [NAME]]:
Recently, a professional interviewer from RTI International contacted you about participating in
[IF ROSTER FILL: a household membership listing; IF SCREENER FILL: a screening survey;
IF CLINICAL INTERVIEW FILL: an interview] for the National Study of Mental Health*. At
the time, you expressed some reluctance about spending the time necessary to participate.
A limited number of [IF ROSTER FILL: households; ELSE FILL: people] were randomly selected
to represent the population of the U.S. [IF ROSTER FILL: Your household; ELSE FILL: You]
cannot be replaced. If [IF ROSTER FILL: your household chooses; ELSE FILL: you choose] not
to participate, your experiences and views—as well as the thousands of people you represent—
will not be heard.
As you know, this nation is made up of all kinds of people, and so we are interviewing all kinds
of people—including busy people like you. If we only interviewed people who have a lot of free
time, then active people like yourself would not be fairly represented. Your participation is
critical to the success of this study, and we are happy to make a special effort to work around
your schedule so that you can be included.
We appreciate that your time is precious. [IF ROSTER FILL: As a token of our appreciation,
you will receive $5 in cash if completed with a field interviewer in person or $10 if
completed via web or telephone. It is not necessary for you to let the interviewer into your
home—you can answer the questions right at your door. Or, you can answer the questions online
or via telephone. To complete the 5-minute household membership listing via telephone please
call us toll-free at 877-267-2910 between [FILL], Eastern Time. To complete the household
membership listing via a website on a personal computer, laptop, or tablet:
1. In your web browser type the study website address: https://nsmh.rti.org
2. On the login screen, type your password exactly as shown below:
Password: ]
[IF SCREENER FILL: As a token of our appreciation, you will receive $20. It is not
necessary for you to let the interviewer into your home—you can answer the questions right at
your door. Or, you can answer the questions online or via telephone. To complete the 15-minute
screening survey via telephone please call us toll-free at 877-267-2910 between [FILL], Eastern
Time. To complete the screening survey via a website on a personal computer, laptop, or tablet:

Attachment H Household Respondent Materials

41

1. In your web browser type the study website address: https://nsmh.rti.org
2. On the login screen, type your password exactly as shown below:
Password: ]
[IF CLINICAL INTERVIEW AND SCREENER MODE = MAIL OR JAIL FILL: As a token
of our appreciation, you will receive $30 at the end of the interview. Please let me know a
date and time that works best for you and I will do my best to accommodate your schedule.] [IF
CLINICAL INTERVIEW AND SCREENER MODE = WEB OR IN PERSON OR PHONE
FILL: As a token of our appreciation for agreeing to participate in the main interview you
received $30] I would like to schedule your interview at a date and time that works best for
you. You indicated [FILL BEST DAYS AND TIMES R PROVIDED] would work best.
Please let me know if [FILL DAY, DATE, AND TIME IN THE NEXT WEEK THAT
FALLS IN R’S PARAMETERS] will work for you. If not, please suggest another date and
time and I will do my best to accommodate your schedule.].
We combine your answers with the answers of thousands of other people and report them only as
overall numbers. [IF NOT SCREENER OR (IF SCREENER AND SCREENER NE TO CATMH) FILL: Also, the option to refuse to answer any question is always available.]
The National Study of Mental Health is a major source of national data concerning mental
health, substance use, and emotional issues. Information from this study will be used by
government agencies, policy makers, and researchers to understand trends in mental health and
substance use treatment. Results may be used to help design and support prevention, treatment,
and education programs. By participating in this study, you will contribute to furthering our
understanding of important health-related issues.
Thank you for your time. I hope you’ll reconsider and choose to participate in this extremely
beneficial study.
Sincerely,
[FS NAME], Field Supervisor
P.S. Please, if you have any questions or would like to set up an appointment, contact me toll-free at
[TOLL FREE NUMBER].
*The National Study of Mental Health is conducted by RTI International for the Substance Abuse and Mental Health Services
Administration, an agency in the U.S. Department of Health and Human Services. [] [http://www.samhsa.gov]

Attachment H Household Respondent Materials

42

ROSTER/SCREENER/CI RELUCTANCE CONFIDENTIALITY LETTER

[DATE]
[IF SCREENER OR CI FILL [NAME]]
[STREET ADDRESS]
[CITY], [STATE] [ZIPCODE]
Dear [IF ROSTER FILL: Resident; ELSE FILL [NAME]],
Recently, a professional interviewer from RTI International contacted you and asked you to
participate in the National Study of Mental Health*. At the time, you expressed some concerns
about participating in the study.
We understand that your privacy is important—RTI International does not provide
individual answers to anyone. Your answers are combined with the answers of thousands
of other people and reported only as overall numbers. Also, we never ask for your full
name.
[IF NOT SCREENER OR (IF SCREENER AND SCREENER NE TO CAT-MH) FILL: In
addition, the option to refuse to answer any question is always available.]
A limited number of [IF ROSTER FILL: households; ELSE FILL: people] were randomly
selected to represent the population of the U.S. [IF ROSTER FILL: Your household; ELSE
FILL: You] cannot be replaced. If [IF ROSTER FILL: your household chooses; ELSE FILL:
you choose] not to participate, your experiences and views—as well as the thousands of
people you represent—will not be heard.
We also appreciate that your time is precious. [IF CLINICAL INTERVIEW AND SCREENER
MODE = MAIL OR JAIL FILL: As a token of our appreciation, you will receive $30 after
completing the interview. Please let me know a date and time that works best for you and I will
do my best to accommodate your schedule.]
[IF CLINICAL INTERVIEW AND SCREENER MODE = WEB OR IN PERSON OR PHONE
FILL: As a token of our appreciation for agreeing to participate in the interview you
received $30. I would like to schedule [IF R INDICATED ABILITY TO DO VIDEO
CALL FILL: a video interview; ELSE FILL: an in person interview] at a date and time that
works best for you. You indicated [FILL BEST DAYS AND TIMES R PROVIDED]
would work best. Please let me know if [FILL DAY, DATE, AND TIME IN THE NEXT
WEEK THAT FALLS IN R’S PARAMETERS] will work for you. If not, please suggest
another date and time and I will do my best to accommodate your schedule.]
[IF ROSTER FILL: As a token of our appreciation, you will receive $5 in cash if completed
with a field interviewer in person or $10 if completed via web or telephone. It is not
necessary for you to let the interviewer into your home—you can answer the questions right at
your door. Or, you can answer the questions online or via telephone. To complete the 5-minute

Attachment H Household Respondent Materials

43

household membership listing via telephone please call us toll-free at 877-267-2910 between
[FILL], Eastern Time. To complete the household membership listing via a website on a personal
computer, laptop, or tablet:
1. In your web browser type the study website address: https://nsmh.rti.org
2. On the login screen, type your password exactly as shown below:
Password: 
[IF SCREENER FILL: As a token of our appreciation, you will receive $20. It is not
necessary for you to let the interviewer into your home—you can answer the questions
right at your door. Or, you can answer the questions online or via telephone. To complete
the 15-minute screening survey via telephone please call us toll-free at 877-267-2910
between [FILL], Eastern Time. To complete the screening survey via a website on a
personal computer, laptop, or tablet:
1. In your web browser type the study website address: https://nsmh.rti.org
2. On the login screen, type your password exactly as shown below:
Password: 
The National Study of Mental Health is a major source of national data concerning mental
health, substance use, and emotional issues. Information from this study will be used by
government agencies, policy makers, and researchers to understand trends in mental health
and substance use treatment. Results may be used to help design and support prevention,
treatment, and education programs. By participating in this study, you will be contributing
to furthering our understanding of important health issues.
Thank you for your time. I hope you’ll reconsider and choose to participate in this
extremely important and beneficial study.
Sincerely,
[FS NAME], Field Supervisor
P.S. Please, if you have any questions, contact me toll-free at [TOLL FREE NUMBER].
*The National Study of Mental Health is conducted by RTI International for the Substance Abuse and Mental Health
Services Administration, an agency in the U.S. Department of Health and Human Services. [] [http://www.samhsa.gov]

Attachment H Household Respondent Materials

44

Automated Emails: New, Rescheduled, Canceled, Missed Appointments
New Appointment:
Subject Line: Your Upcoming Appointment for the NSMH (T2183422)
Message Body: Thank you for scheduling your appointment for the National Study of Mental Health. Your
appointment has been scheduled for August 12, 2021 at 7AM-9AM Eastern. Your interviewer’s name is CHRISTINE.
Please be on the lookout for an email from CHRISTINE with the specific instructions for joining the interview call.
In the meantime, if you have any questions about your upcoming interview, please contact us at 833-947-2575
between 9am and 5pm Eastern on weekdays. You may be asked to provide your interview identification number
which is T2183422 .
If it is necessary for you to reschedule your appointment, you can do that at this link:
https://nsmh.rti.org/ScheduleAppointment.aspx?passcode=TEST&Language=English&TimeZone=Eastern&Lang=1
Thank you for your willingness to participate in this important study.
Sincerely,
Heather Ringeisen, PhD
Principal Investigator, NSMH
RTI International

Rescheduling Appointment:
Subject Line: 'Rescheduling your Appointment for the NSMH (T0029912)
Message Body: Based on your recent request to reschedule your appointment for the National Study of Mental
Health, your appointment is now set for September 04, 2021 at 7AM-9AM Pacific. Your interviewer’s name is
CHRISTINA. Please be on the lookout for an email from CHRISTINA with the specific instructions for joining the
interview call.
In the meantime, if you have any questions about your upcoming interview, please contact us at 833-947-2575
between 9am and 5pm Eastern on weekdays. You may be asked to provide your interview identification number
which is T0029912.
If it is necessary for you to reschedule your appointment, you can do that at this link:
https://nsmh.rti.org/ScheduleAppointment.aspx?passcode=TEST&Language=English&TimeZone=Pacific&Lang=1
Thank you for your willingness to participate in this important study.
Sincerely,
Heather Ringeisen, PhD
Principal Investigator, NSMH
RTI International

Attachment H Household Respondent Materials

45

Canceled Appointment:
Subject Line: Canceling Your Appointment for the NSMH (TT753012)
Message Body: We received your recent request to cancel your appointment to be interviewed for the National
Study of Mental Health.
We have canceled your appointment and updated our records to indicate you no longer wish to participate.
If you have any further questions about the National Study of Mental Health, please contact us at 833-947-2575
between 9am and 5pm Eastern on weekdays.
You may be asked to provide your interview identification number which is T0029912 .
You can reschedule your appointment at this link:
https://nsmh.rti.org/ScheduleAppointment.aspx?passcode=TEST&Language=English&TimeZone=Pacific&Lang=1
Thank you for your willingness to participate in this important study.
Sincerely,
Heather Ringeisen, PhD
Principal Investigator, NSMH
RTI International

Missed Appointment Email:
Subject Line: Missed Interview Appointment for NSMH
Message Body: Hello [INSERT R NAME],
This message was sent to notify you of a missed main interview appointment scheduled with Clinical Interviewer
[INSERT CI NAME].
You have two options to reschedule another time to complete the main interview:
•
•

Select a new date/time at this link [HYPERLINK TO SCHEDULER]; or
Contact [INSERT CI NAME] to identify a new date/time.

If you have any questions, please call the NSMH project line: 833-947-2575.
Thanks for your time,
NSMH Management Team

Attachment H Household Respondent Materials

46

Texts
NSMH Texts

Screener Text Invitations (Only Applicable to the RR if selected for screening):
•

Text Invitations #1 - 2:
Please complete the National Study of Mental Health survey and receive $20. Text STOP
to opt out. [unique survey link here]

•

Final Text Invitation:
Last chance to complete the National Study of Mental Health survey before a field
interviewer contacts you at home. Complete now and you will receive $20. Text STOP to
opt out. [unique survey link here]

Clinical Interview Appointment Text
I appreciate you taking time for this important study and look forward to our appointment
to complete the interview. Your appointment is scheduled for [DAY OF WEEK], [DATE],
at [TIME]. Thank you!
Missed Appointment Clinical Interview Appointment Text
I’m sorry we were unable to meet for our scheduled appointment. Please let me know a
date and time that works best for you and I’ll reschedule it. Thank you for taking time for
this important study!
Or
I was unable to reach you for our interview appointment. Please let me know a date and time
that works best for you and I’ll reschedule it. Thank you for taking time for this important
study!

Attachment H Household Respondent Materials

47

Unable to Contact Text
NSMH Text Message

To Clinical Interview Respondents We’ve Been Unable to Contact/Schedule

Thank you for agreeing to participate in the National Study of Mental Health! We haven’t been
able to reach you to schedule your interview. Please contact us at 833-947-2575 to schedule
your interview at a date and time that works best for you.

Attachment H Household Respondent Materials

48

Website Content
NSMH Website Content
A. Public Information
1. Landing Page

The National Study of Mental Health (NSMH) is a research effort that will provide critical
information on mental health and health behaviors in the United States.
The NSMH will help begin to answer questions on these important topics by interviewing
people who live at home as well as those who are currently hospitalized, incarcerated, or
residing in homeless shelters. Participants across the United States will be invited to
participate in this important national study. This initiative represents one of the largest studies
on mental health in the United States. We’re very pleased to invite you to participate in this
exciting research opportunity!
There will be links at the top of the landing page to separate pages for items 2 – 6
2. About

You may have received a letter inviting you to complete a short household membership listing.
Once that is complete, up to two people in your household may be invited to complete a short
screening survey and an interview.
You can complete the household membership listing and screening survey online, by phone, by
mail, or if needed, a trained interviewer can come to your home. You can complete the main
interview by video, by phone, or if needed, a trained interviewer can come to your home to
conduct the interview.
You will be asked questions about mental health, health behaviors including tobacco, alcohol,
and drug use, and access to medical care and treatment. More details on the household
membership listing, short screening survey, and main interview will be provided to you.
Please be assured that all your data will be kept confidential.

If you ever feel that you need to talk to someone about mental health issues, you can call
the National Lifeline Network. Counselors are available to talk at any time of the day or night
and they can give you information about services in your area.
1-800-273-TALK or 1-800-273-8255
1-888-628-9454 (Spanish)
http://suicidepreventionlifeline.org/

Attachment H Household Respondent Materials

49

If you ever feel that you need to talk to someone about drug use issues, you can call the
Substance Abuse and Mental Health Services Administration’s Treatment Referral Helpline.
This is a 24-hour service that will help you locate treatment options near you.
1-800-662-HELP or 1-800-662-4357
1-800-487-4889 (TDD)

3. Confidentiality

Confidentiality is critical to this research effort and RTI places great importance on maintaining
the highest standards of confidentiality and integrity of participants’ data.
Participants cannot be identified through any information they provide. Participants’ names
and addresses will never be connected to their answers. All answers will be combined with
responses from other participants; the results of the study will come from the combined
answers and it won’t be possible to identify any individual. Information provided by a
participant will only be used by authorized personnel for statistical purposes.
Federal law requires us to keep all answers confidential. The right of privacy is guaranteed by
the federal Privacy Act of 1974. This Act prohibits the release of personal information gathered
by or for a federal agency without the written consent of the respondent. Fines and penalties
apply to individuals or organizations that violate this law.
The National Study of Mental Health project has also obtained a Certificate of Confidentiality
from the Department of Health and Human Services (DHHS). This adds special protection for
the research information about participants because it protects the research team from being
forced, even under a court order or subpoena, to release information that could identify
anyone.
4. RTI & Collaborators

The National Study of Mental Health is led by RTI International in collaboration with Columbia
University/New York State Psychiatric Institute (CU/NYSPI), the University of Washington, Duke
Health, Harvard University, the Treatment Advocacy Center, and the University of Chicago. The
study is funded by a grant to RTI from the Substance Abuse and Mental Health Services
Administration (SAMHSA) within the Department of Health and Human Services (DHHS).
Founded in 1958, RTI is an independent, nonprofit research organization dedicated to improving the
human condition. Our vision is to address the world’s most critical problems with science-based
solutions in pursuit of a better future.

Attachment H Household Respondent Materials

50

Our experts hold degrees in more than 250 scientific, technical, and professional disciplines
across the social and laboratory sciences, engineering, and international development fields.
Our staff of nearly 6,000 works in more than 75 countries—tackling hundreds of projects each
year to address complex social and scientific challenges on behalf of governments, businesses,
foundations, universities, and other clients and partners.
Principal Investigators
Dr. Heather Ringeisen (Photo)
Dr. Mark Edlund (Photo)
For more information about RTI please visit www.rti.org
This study is led by RTI International in collaboration with:
• Columbia University (CU) / New York State Psychiatric Institute (NYSPI)
o Dr. Lisa Dixon, Co-Investigator
o Dr. Michael First, Co-Investigator
o Dr. Mark Olfson, Co-Investigator
o Dr. Thomas Smith, Co-Investigator
o Dr. T. Scott Stroup, Co-Investigator
• University of Washington
o Dr. Lydia Chwastiak, Co-Investigator
o Dr. Maria Monroe-DeVita, Co-Investigator
• Duke University
o Dr. Jeffrey Swanson, Co-Investigator
o Dr. Marvin Swartz, Senior Advisor
o Dr. Allison Robertson, Research Scientist
• Harvard University
o Dr. Ronald Kessler, Co-Investigator
• University of Chicago
o Dr. Robert Gibbons, Co-Investigator
5. Selected Participants

Thank you for visiting the National Study of Mental Health (NSMH) Website. Your participation
in this national study is very important and we appreciate your interest.
For the study, household addresses are randomly selected through scientific methods. Once
your household has been selected, no other household can take your place. For this reason,
please know your participation matters and is critical for furthering our understanding of
mental health and substance use in the United States.
If your address has been selected, you should have received a letter inviting you to complete a
short household membership listing. This will only take a few minutes, and the household

Attachment H Household Respondent Materials

51

member who completes this online, by telephone, or by mail will receive a $10 check or $10
electronic prepaid Visa©. Or a trained interviewer can come to your home and you will receive
$10 in cash for your participation.
Once the household membership listing is complete, up to two people in your household may
be invited to complete a short screening survey. This 15-minute survey can be completed
online, by phone, by mail, or if needed, a trained interviewer can come to your home. To thank
you for your participation you will receive $20 (a $20 check or $20 electronic prepaid Visa© if
completed online, by telephone, or by mail; $20 in cash if completed in person).
Those that complete the screening survey may be selected for the main interview, which can be
completed by video, by phone, or if needed, a trained interviewer can come to your home to
conduct the interview. You will be asked questions about mental health, health behaviors
including tobacco, alcohol and drug use, and access to medical care and treatment. This
interview will take about 80 minutes, and to thank you for your participation you will receive
$30 (a $30 check or $30 electronic prepaid Visa© if completed by video or telephone; $30 in
cash if completed in person).
Please review the NSMH brochure and/or use your study password to access additional
information here.
Ready to complete the NSMH Household Membership Listing or NSMH Screening Survey
online or by telephone?
You can do it in three different ways:

•
•
•

Enter your password here: (the box goes here)
Scan your QR Code from the letter we sent you, or
Call us toll-free at 877-267-2910.

Ready to schedule the NSMH interview?
• Call us toll-free at 833-947-2575
To speak with a project representative, please call 833-947-2575 (a toll-free number).
We sincerely appreciate your help in this important effort and look forward to talking with you
soon.
If you ever feel that you need to talk to someone about mental health issues, you can call
the National Lifeline Network. Counselors are available to talk at any time of the day or night
and they can give you information about services in your area.
1-800-273-TALK or 1-800-273-8255
1-888-628-9454 (Spanish)

Attachment H Household Respondent Materials

52

http://suicidepreventionlifeline.org/
If you ever feel that you need to talk to someone about drug use issues, you can call the
Substance Abuse and Mental Health Services Administration’s Treatment Referral Helpline.
This is a 24-hour service that will help you locate treatment options near you.
1-800-662-HELP or 1-800-662-4357
1-800-487-4889 (TDD)
6. Contact Us

If you have questions or concerns about the study, please contact the project via phone, email,
or mail:
•

Toll-free project number: 833-947-2575

•

E-mail: [email protected]

•

Mail:
o NSMH Project
RTI International
3040 E Cornwallis Rd, PO Box 12194
Research Triangle Park, NC 27709

B. Information Accessible to Respondents that Log-In
1. Frequently Asked Questions
file://RTPNFIL02/mdps/Data_Collection_Household/Website/13481_Info_Access_Respo
n_that_NSMH_WEB_09_21_20_PDFs.pdf

2. Advarra - Institutional Review Board Information
An institutional review board (IRB) is an independent committee established to help protect the
rights of research subjects. If you have any questions about your rights as a research subject,
and/or concerns or complaints regarding this research study, contact:
• By mail:
Study Subject Adviser
Advarra IRB
6940 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
• or call toll free: 877-992-4724
• or by email:
[email protected]

Attachment H Household Respondent Materials

53

Please reference the following number when contacting the Study Subject Adviser:
Pro00042170.
IRB Protocol Number: Pro00042170
IRB Approval Date: [FILL]
3. Main Interview Showcards
Showcard #1:
file://Rtpnfil02/mdps/Data_Collection_Household/Showcards/Showcard%201%20–
%20Medications.pdf
Showcard #2:
file://Rtpnfil02/mdps/Data_Collection_Household/Showcards/Showcard%202%20–
%20Income%20Type.pdf
4. Consent Forms
• Screening Survey Informed Consent Form https://blaise5esn.rti.org/mdps_screening/MDPS_Fullconsent.pdf).

•

Interview Informed Consent Form file://RTPNFIL02/mdps/Management/IRB/Advarra/ICFs%20(Approvals%20and%20Subm
issions)/Approved/August_2020/Site/Ringeisen%20Household%20ICF%20Pro00042170
%20Aug1320.pdf

Attachment H Household Respondent Materials

54

COVID Risk Form Vaccinated Protocol A
Important Information about COVID-19 and Your Participation in NSMH
This document contains important information about COVID-19 and how participating in research may impact
you. COVID-19 is the disease caused by a newly identified type of coronavirus. Study participation will include
visiting with a NSMH interviewer. If the interviewer who conducts the household membership listing and/or
screening survey(s) tests positive for COVID-19 in the future, the state or local health department or their
agents may reach out to this household for the purpose of contact tracing. Please be assured that if this occurs,
the interviewer will only share with the health department or their agents the address of this household and
the time and dates of the interviewer’s visits. None of the answers you provide during the household
membership listing or screening survey will be shared. It is also possible that the contact tracers may use the
address shared by the interviewer to find other means to contact this household such as by phone or email.
How is COVID-19 spread? People can catch COVID-19 from other people who have the virus. The disease
spreads mainly from person to person through small droplets from the nose or mouth, which are spread when
a person with COVID-19 coughs, sneezes, or speaks.
What are the symptoms of COVID-19? Symptoms of COVID-19 may include:
•
•
•
•
•

Fever or chills
Cough
Shortness of breath
Fatigue
Muscle or body aches

•
•
•

Headache
New loss of taste or
smell
Sore throat

•
•
•

Congestion or runny
nose
Nausea or vomiting
Diarrhea

Symptoms typically appear 2-14 days after exposure to the virus. It is possible that individuals with the COVID19 virus will not display any of these symptoms. You can find more information at
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.
What are some ways to reduce the risk of getting or spreading COVID-19?
•
•
•
•
•
•

Regularly wash your hands for at least 20 seconds with soap and water or alcohol-based hand sanitizer.
Maintain at least 6 feet between yourself and others.
Avoid going to crowded places where you are more likely to come into close contact with someone who
has COVID-19 and it is more difficult to maintain physical distance.
Wear a mask that covers your mouth and nose when you go out in public or have in-person
contact with someone from outside of your household.
Avoid touching your eyes, nose and mouth. Your hands can transfer the virus to your eyes, nose or
mouth. From there, the virus can enter your body.
If you are not wearing a mask and need to cough or sneeze, cover your mouth and nose with a bent
elbow or tissue.

Attachment H Household Respondent Materials

55

What happens if someone gets COVID-19? People with COVID-19 may have a wide range of symptoms–
ranging from mild symptoms to severe illness. Older adults and people who already have serious medical
conditions like heart or lung disease or diabetes seem to be at higher risk for developing complications or dying
from COVID-19. Vaccines and new treatment options will help decrease the severity of a COVID-19 infection,
although they may not be readily available in your community or to all individuals. We want to provide you this
information because your choice about whether to participate in this study or to invite an interviewer into your
home might be informed by whether there is someone in your household who is older or has a medical
condition that increases the risk of becoming severely ill as a result of COVID-19.
How do I know a NSMH interviewer does not have COVID-19? Unfortunately, there is no guarantee that an
interviewer does not have COVID-19. This is because individuals can have the virus but only have mild
symptoms or even no symptoms of COVID-19 at all. However, interviewers have promised to take their
temperature every day and are not allowed to work if they have a fever. Interviewers have also promised that
they will not conduct in-person data collection if they or any members of their household show symptoms of or
have been diagnosed with COVID-19.
What steps are interviewers required to take to keep me and others safe? While out in the field, an
interviewer is required to use hand sanitizer frequently. The interviewer must wear a disposable mask to help
reduce the likelihood that he or she could give you COVID-19. The interviewer will practice social distancing,
which means he or she will sit or stand at least 6 feet from you and other persons during the household
membership listing and screening survey and will remain outside if possible. The interviewer will not have
physical contact with you or other members of your household.
Does the interview need to be conducted inside my home? No, it does not need to be conducted inside your
home. You and the interviewer can talk outside—on a porch or steps, in your yard, or in some nearby public
outdoor space that allows sufficient privacy. If you want to participate at another location, you and the
interviewer will have to maintain social distance from each other as well as other people. We must keep our
data confidential so we need a location where no one will be able to hear or see your answers.
You can complete the household membership listing and the screening survey online or by phone if you prefer.
You may have already received your login and password. If you no longer have it, please contact our study
assistance line toll-free at 833-947-2575 to obtain your password and then visit the NSMH website
(https://nsmh.rti.org). To complete by phone, call 877-267-2910; this is a toll-free number. If you are selected
for the main interview it will be done by video or phone.
How will I complete the interview? I will ask you questions to complete the household membership listing. If
you are selected for the screening survey you will use a tablet. The tablet will be sanitized prior to your use and
we can provide you with gloves if that would make you more comfortable. Paper forms are single-use and
have not been touched by other participants. If you are selected for the main interview an interviewer will ask
you questions by video or phone.

If you have additional questions about your participation in NSMH, please call 1-833-947-2575.

Attachment H Household Respondent Materials

56

COVID Risk Form Unvaccinated Protocol B
Important Information about COVID-19 and Your Participation in NSMH
This document contains important information about COVID-19 and how participating in research may impact
you. COVID-19 is the disease caused by a newly identified type of coronavirus. Study participation will include
visiting with a NSMH interviewer. If the interviewer who conducts the household membership listing and/or
screening survey(s) tests positive for COVID-19 in the future, the state or local health department or their
agents may reach out to this household for the purpose of contact tracing. Please be assured that if this occurs,
the interviewer will only share with the health department or their agents the address of this household and
the time and dates of the interviewer’s visits. None of the answers you provide during the household
membership listing or screening survey will be shared. It is also possible that the contact tracers may use the
address shared by the interviewer to find other means to contact this household such as by phone or email.
How is COVID-19 spread? People can catch COVID-19 from other people who have the virus. The disease
spreads mainly from person to person through small droplets from the nose or mouth, which are spread when
a person with COVID-19 coughs, sneezes, or speaks.
What are the symptoms of COVID-19? Symptoms of COVID-19 may include:
•
•
•
•
•

Fever or chills
Cough
Shortness of breath
Fatigue
Muscle or body aches

•
•
•

Headache
New loss of taste or
smell
Sore throat

•
•
•

Congestion or runny
nose
Nausea or vomiting
Diarrhea

Symptoms typically appear 2-14 days after exposure to the virus. It is possible that individuals with the COVID19 virus will not display any of these symptoms. You can find more information at
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.
What are some ways to reduce the risk of getting or spreading COVID-19?
•
•
•
•
•
•

Regularly wash your hands for at least 20 seconds with soap and water or alcohol-based hand sanitizer.
Maintain at least 6 feet between yourself and others.
Avoid going to crowded places where you are more likely to come into close contact with someone who
has COVID-19 and it is more difficult to maintain physical distance.
Wear a mask that covers your mouth and nose when you go out in public or have in-person
contact with someone from outside of your household.
Avoid touching your eyes, nose and mouth. Your hands can transfer the virus to your eyes, nose or
mouth. From there, the virus can enter your body.
If you are not wearing a mask and need to cough or sneeze, cover your mouth and nose with a bent
elbow or tissue.

Attachment H Household Respondent Materials

57

What happens if someone gets COVID-19? People with COVID-19 may have a wide range of symptoms–
ranging from mild symptoms to severe illness. Older adults and people who already have serious medical
conditions like heart or lung disease or diabetes seem to be at higher risk for developing complications or dying
from COVID-19. Vaccines and new treatment options will help decrease the severity of a COVID-19 infection,
although they may not be readily available in your community or to all individuals. We want to provide you this
information because your choice about whether to participate in this study or to invite an interviewer into your
home might be informed by whether there is someone in your household who is older or has a medical
condition that increases the risk of becoming severely ill as a result of COVID-19.
How do I know a NSMH interviewer does not have COVID-19? Unfortunately, there is no guarantee that an
interviewer does not have COVID-19. This is because individuals can have the virus but only have mild
symptoms or even no symptoms of COVID-19 at all. However, interviewers have promised to take their
temperature every day and are not allowed to work if they have a fever. Interviewers have also promised that
they will not conduct in-person data collection if they or any members of their household show symptoms of or
have been diagnosed with COVID-19.
What steps are interviewers required to take to keep me and others safe? While out in the field, an
interviewer is required to use hand sanitizer frequently. The interviewer must wear an N95 mask and may wear
a face shield as well to help reduce the likelihood that he or she could give you COVID-19. The interviewer will
practice social distancing, which means he or she will sit or stand at least 6 feet from you and other persons
during the household membership listing and screening survey and will remain outside if possible. The
interviewer will not have physical contact with you or other members of your household.
Does the interview need to be conducted inside my home? No, it does not need to be conducted inside your
home. You and the interviewer can talk outside—on a porch or steps, in your yard, or in some nearby public
outdoor space that allows sufficient privacy. If you want to participate at another location, you and the
interviewer will have to maintain social distance from each other as well as other people. We must keep our
data confidential so we need a location where no one will be able to hear or see your answers.
You can complete the household membership listing and the screening survey online or by phone if you prefer.
You may have already received your login and password. If you no longer have it, please contact our study
assistance line toll-free at 833-947-2575 to obtain your password and then visit the NSMH website
(https://nsmh.rti.org). To complete by phone, call 877-267-2910; this is a toll-free number. If you are selected
for the main interview it will be done by video or phone.
How will I complete the interview? I will ask you questions to complete the household membership listing. If
you are selected for the screening survey you will use a tablet. The tablet will be sanitized prior to your use and
we can provide you with gloves if that would make you more comfortable. Paper forms are single-use and
have not been touched by other participants. If you are selected for the main interview an interviewer will ask
you questions by video or phone.

If you have additional questions about your participation in NSMH, please call 1-833-947-2575.

Attachment H Household Respondent Materials

58

Incentive/Thank You E-mail (Roster, Screener, CI)

NSMH Incentive E-mail
From: [PROJECT EMAIL]
Date: [FILL]
To: [RESPONDENT NAME]
Subject: How to redeem your study incentive
Hello, [RESPONDENT NAME],
Thank you for your help with this important research! This [FILL AMOUNT ($10/$20/$30/$50/$60)]
electronic prepaid Visa© is to thank you for your participation.
Here is the link to your $[FILL] electronic prepaid Visa©.
[INSERT LINK]

Thank You,
National Study of Mental Health (NSMH) staff
For more information please email: [email protected].
If you have questions, you can call our study assistance line toll-free at 833-947-2575.
If you ever feel that you need to talk to someone about mental health issues, you can call the National Lifeline
Network. Counselors are available to talk at any time of the day or night and they can give you information
about services in your area.
1-800-273-TALK or 1-800-273-8255
1-888-628-9454 (Spanish)
http://suicidepreventionlifeline.org/
If you ever feel that you need to talk to someone about drug use issues, you can call the Substance Abuse and
Mental Health Services Administration’s Treatment Referral Helpline. This is a 24-hour service that will help you
locate treatment options near you.
1-800-662-HELP or 1-800-662-4357
1-800-487-4889 (TDD)

Attachment H Household Respondent Materials

59

Incentive Receipt In-person
Substance Abuse and Mental Health Services Administration
and
RTI International
thank you for participating in the National Study of Mental Health.

In appreciation of your participation in this important study, you are eligible to receive:

□ $10 Cash Incentive for Completing the Household Membership Listing
□ $20 Cash Incentive for Completing the Screening Survey
□ $30 Cash Pre-Incentive for Agreeing to Complete the Main Interview / Incentive for
Completing the Main Interview
Since maintaining the confidentiality of your information is important to us, your name will
not be entered on this form. However, the interviewer must sign and date this form to
certify you received (or declined) the cash incentive.
Case ID:

Interviewer:

Date:

□ Accepted Cash Incentive
□ Declined Cash Incentive
If you have questions about the study you can call our study assistance line toll-free at 833-947-2575.

If you ever feel that you need to talk to someone about mental health issues, you can call
the National Lifeline Network. Counselors are available to talk at any time of the day or
night and they can give you information about services in your area.
1-800-273-TALK or 1-800-273-8255
1-888-628-9454 (Spanish)
http://suicidepreventionlifeline.org/
If you ever feel that you need to talk to someone about drug use issues, you can call the
Substance Abuse and Mental Health Services Administration’s Treatment Referral
Helpline. This is a 24-hour service that will help you locate treatment options near you.
1-800-662-HELP or 1-800-662-4357
1-800-487-4889 (TDD)
http://findtreatment.samhsa.gov

Attachment H Household Respondent Materials

60

Brochure Text
Front panel
What is the National Study of Mental Health?
The National Study of Mental Health (NSMH) is a large-scale research effort to improve understanding of
mental health and health behaviors in the United States.
Back panel
Ready to participate? Go to https://nsmh.rti.org and enter your password or call 877-267-2910
For more information on RTI International contact:

Our Collaborators

Inside Panel
If you have questions about the National Study of Mental Health, please call 833-947-2575, e-mail:
[email protected], or visit our website at https://nsmh.rti.org
The NSMH asks questions about mental health and other health-related topics. This year 6,000 adults
from across the United States will be interviewed for this study. Information from the NSMH will be
used to determine national estimates of mental health and substance use disorders among U.S. adults
ages 18 to 65. The study will also provide information on the number of adults who receive treatment.

This study is led by RTI International in collaboration with Columbia University/New York State
Psychiatric Institute (CU/NYSPI), University of Washington, Duke Health, Harvard University, the
Treatment Advocacy Center, and the University of Chicago. The study is funded by a grant to RTI from
the Substance Abuse and Mental Health Services Administration (SAMHSA) within the Department of
Health and Human Services (DHHS).

Inside Panel - #1
Questions
Why Should I Participate? You are important! Your address was chosen to represent thousands of
households across the nation, and no other household can take your place. By participating in the
NSMH, you are contributing to a national effort to better understand mental health and health
behaviors. This research has the potential to inform federal, state, and local efforts to address the
unmet needs of individuals and families in terms of mental health and substance use. The adult who
completes the initial questions will receive $10. If an adult is selected for and completes the screening
survey they will receive $20. If an adult is selected for and completes the main interview they will
receive $30. What If I Do Not Have Any Mental Health Conditions? The responses of people who do not

Attachment H Household Respondent Materials

61

experience mental health conditions are just as important as the responses of people who do. Although
some questions ask about mental health conditions, other questions ask about important health-related
topics relevant for all people. How Was I Chosen? Household addresses, not specific people, were
randomly selected through scientific methods. Once a household has been selected, it cannot be
replaced for any reason. This ensures that the NSMH accurately represents the many different types of
adults in the United States.

Middle panel
How Does My Household Participate? To begin we need an adult 18 years old or older, who is
knowledgeable about your household, to complete a 5-minute household membership listing via our
study website, telephone, or mail. If the 5-minute household membership listing is not completed
online, by telephone, or by mail one of our professional interviewers will contact you to schedule a time
to complete the listing in person. After the 5-minute household membership listing has been completed
up to two adults could be chosen to complete a 15-minute screening survey to find out if they are
eligible for the main interview. This survey can be completed via our study website, telephone, mail, or
in person. Up to two adults could be chosen for the main interview. The main interview will be
conducted via video, in person, or by telephone. What Will Happen During the Interview? An
interviewer will conduct the interview with each selected person using a computer. The interviewer will
read the questions aloud and enter the participant’s responses into the computer. The interview takes
about 80 minutes to complete. People who complete the main interview will receive $30 as a token of
our appreciation.

Last inside panel
What is RTI International? RTI is an independent, nonprofit research organization dedicated to
improving the human condition. Our vision is to address the world’s most critical problems with sciencebased solutions in pursuit of a better future. What is the Substance Abuse and Mental Health Services
Administration? The Substance Abuse and Mental Health Services Administration (SAMHSA) is the
agency within the U.S. Department of Health and Human Services that leads public health efforts to
advance the behavioral health of the nation. Congress established SAMHSA in 1992 to make substance
use and mental disorder information, services, and research more accessible. SAMHSA’s mission is to
reduce the impact of substance abuse and mental illness on America’s communities. What is the U.S.
Department of Health and Human Services? DHHS is the nation’s principal agency for protecting the
health of all Americans and providing essential human services. The mission of DHHS is to enhance and
protect the health and well-being of all Americans.

All information collected for this study will be kept confidential and used only for statistical purposes. To
help keep information about you confidential, we have obtained a Certificate of Confidentiality (CoC)
from the DHHS. This CoC adds special protection for the research information about you. The privacy of
the information we collect about you will be very carefully protected.

Attachment H Household Respondent Materials

62

FAQs
Questions

What’s the study about?

Who is sponsoring this study?

Possible Response
The study asks questions about mental health, substance use,
and other health-related topics. This important study provides
up-to-date information on a variety of mental health
conditions in the United States and explores connections
between mental health issues and services.
This study is sponsored by the Substance Abuse and Mental
Health Services Administration (SAMHSA) within the U.S.
Department of Health and Human Services.
RTI International is a nonprofit research
organization dedicated to conducting research that improves
the human condition.

What is RTI International?

Located in North Carolina, RTI performs various types of
laboratory and social research for government and industrial
clients.
Your address was randomly chosen to represent thousands of
households across the nation.

Why me? Why this house?

How did you get my phone
number?

Will my answers be kept
private?

Once an address is chosen, no other address can be
substituted for any reason. This practice ensures that the
data represent the many different types of people in the
United States.
IF YOU ARE PLACING OUTBOUND CALLS TO RESPONDENTS TO
COMPLETE THE HOUSEHOLD MEMBERSHIP LISTING:
RTI did a cross-reference search in publicly available sources
to identify phone numbers associated with the selected
address. RTI is calling to ensure that the members of the
household have a chance to participate in the study.
IF YOU ARE PLACING OUTBOUND CALLS TO SELECTED
SCREENING RESPONDENTS:
The person who completed the household membership listing
provided your name and contact information.
Absolutely. No answers will be connected with any
individual and your name will never be identified with your
answers. Our interest is only in the set of all responses.

Attachment H Household Respondent Materials

63

Questions

Possible Response
Federal law protects the confidentiality of all personal
information you provide. Any violation of the law is a felony
punishable by fines and imprisonment.
Our initial questions will only take a few minutes. Once these
are completed we will know if any adult in your household has
been selected to be screened.

How long will this take?

The screening survey takes about 15 minutes. Once it is
completed we will know if the adult who completes the
screener survey has been selected to be interviewed.
The time for the interview varies, but it generally takes about
80 minutes. Of course, each person may take a little more or
less time depending on that individual.

How long will the screening
survey take?
How long will the interview
take?

I don’t think I have any mental
health issues. How can I help?

How will the study findings be
used?

The screening survey takes about 15 minutes. Once it is
completed, we will know if the adult who completes the
screening survey has been selected to be interviewed.
The time for the interview varies, but it generally takes about
80 minutes. Of course, each person may take a little more or
less time depending on that individual.
In order for our sample to represent all people living in this
country, we need people who do not experience health
issues to participate as well as those who do.
While some questions ask about mental health issues, other
questions ask about important health-related topics relevant
for all people.
Study findings may help inform and guide federal, state, and
local resource allocation decisions, programs, procedures, and
practices. The study will also allow SAMHSA to better
understand the unmet needs of individuals and families living
with mental illness.

The adult who completes the initial questions will receive a
$10 electronic prepaid Visa© or $10 check if completed online
What do I get for participating? or via telephone, or $5 cash if completed in person.
If an adult is selected for and completes the screening survey,
they will receive a $20 electronic prepaid Visa© or $20 check

Attachment H Household Respondent Materials

64

Questions

Possible Response
if completed online or via telephone, or $20 cash if completed
in person.
If an adult is selected for and completes the main interview,
they will receive a $30 electronic prepaid Visa© or $30 check
if completed via video or telephone, or $30 cash if completed
in person.
You will be contributing to important research that will inform
and guide federal, state, and local policymakers. The results of
this study will help state and national policymakers learn
about mental health issues—including information on access
to and use of treatment, as well as alcohol, tobacco, and drug
use. This information may be useful in making informed
decisions about policies and programs. By participating in this
study, you will contribute to furthering our understanding
about health-related issues.
By participating in the NSMH, you are contributing to a
national effort to better understand mental illness. This
research has the potential to inform federal, state, and local
efforts to address the unmet needs of individuals and families
experiencing mental illness and serious mental illness.
The study will provide information on the prevalence of
mental illness and serious mental illness that can be used to
help improve policy, program, and service implementation at
the federal, state, and local levels.
The NSMH is the first study to assess prevalence of serious
mental illness, including psychosis, in both household and
non-household settings. This will lead to a more accurate
estimate of prevalence and advance our understanding of the
barriers to treatment access and service use for this
vulnerable population.

Who will my data be shared
with?

Personally identifiable information, such as names and
addresses, will not be shared with anyone outside of the research
team. Federal law requires us to keep all answers confidential. The
right of privacy is guaranteed by the federal Privacy Act of 1974.
This Act prohibits the release of personal information gathered by
or for a federal agency without the written consent of the

Attachment H Household Respondent Materials

65

Questions

Possible Response
respondent. Fines and penalties apply to individuals or
organizations that violate this law.

Information you provide that is not personally identifiable will
be combined with responses from other participants; the
results of the study will come from the combined answers of
all participants, and it won’t be possible to identify any
individuals. Study data will be shared with SAMHSA but that
dataset will never include information that allows anyone to
identify you personally, such as your name or address. In
addition, a public use data file that does not include
personally identifiable information will be created and
available to researchers who apply for access and receive
approval.
Click on the link to your electronic prepaid Visa© that was sent via
email.
You may also redeem your code by visiting
https://www.prepaiddigitalsolutions.com and entering your Digital
How do I redeem the electronic Token which was included in the same email as the gift card link.

gift card?

Please redeem your electronic prepaid Visa© on or before the date
indicated in the email. After you have redeemed your card, you will
have 12 months to spend the funds on your card before they
expire. Please note this can only be used for an online purchase
that is equal to or less than the value of the Visa©.

Attachment H Household Respondent Materials

66

Field and Clinical Interviewer Authorization Letter

October 2020 - December 2021

To Whom It May Concern:
This letter certifies that «Fname» «Lname» is a representative for the National Study of Mental
Health, sponsored by the Substance Abuse and Mental Health Services Administration
(SAMHSA). This study is a grant to RTI International, a nationally recognized nonprofit research
organization with headquarters in Research Triangle Park, North Carolina, by SAMHSA.
(SAMHSA Grant Number: 6H79FG000030-01M002).
If you need additional assurance that «Fname» «Lname» is a legitimate RTI representative
assigned to this government sponsored study, please contact Kathleen Considine, Director of
Field Operations, at 1-800-334-8571 Ext. 26612, between 9:00 AM and 5:00 PM ET, Monday
through Friday.
Thank you for your cooperation.
Sincerely,

Kathleen Considine
Director of Field Operations

Attachment H Household Respondent Materials

67

Attachment I
Nonhousehold Facility Materials
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)

Recruitment Commencement Letter State DOCs
Recruitment Commencement Letter Combined
National Organizations Letter of Support Combined
SAMHSA NSMH Letter of Support
NSMH 1-page study description
Recruitment Commencement Letter Follow-up Email
Letter to Facility POC
NSMH FAQs Facility Staff
Summary of Clinical Interview Questionnaire Nonhousehold
SAMHSA NSMH Thank You Letter

Recruitment Commencement Letter State DOCs

Attachment I. Nonhousehold Facility Materials

1

Recruitment Commencement Letter Combined

Attachment I. Nonhousehold Facility Materials

2

Attachment I. Nonhousehold Facility Materials

3

National Organizations Letter of Support Combined
Organization logos
(DATE)

(AGENCY NAME)
(ADDRESS), (CITY, STATE, ZIP)

Dear (AGENCY CHIEF EXECUTIVE):

The Substance Abuse and Mental Health Services Association (SAMHSA) has awarded RTI International a cooperative
agreement to conduct the Mental and Substance Use Disorder Prevalence Study (MDPS). The study will examine the
prevalence of serious mental and substance use disorders and include clinical interviews with a national sample of adults living
in households and a national sample of adults in prisons. In addition, clinical interviews will be done with adults in state
psychiatric hospitals, jails, and those staying in homeless shelters located in New York City, rural North Carolina, and
suburban Seattle, Washington. Outreach to agencies with jurisdiction over the non-household facilities will begin in [FILL
DATE] and clinical interviewing will begin in [FILL DATE]. Data collection will last approximately 10 months.
Recognizing the importance of this work, the nation’s [HOSPITALS: ‘mental health care community as represented
by [INSERT HOSPITAL SUPPORT ORGANIZATIONS] provide their full support of these efforts.’ JAILS:
‘sheriffs as represented by [INSERT JAIL SUPPORT ORGANIZATIONS] provide their full support of these
efforts.’ SHELTERS: ‘advocates for the homeless and mental health care community as represented by [INSERT
SUPPORT ORGANIZATIONS] provide their full support of these efforts.’ PRISONS: ‘correctional and mental
health care communities as represented by [INSERT PRISON SUPPORT ORGANIZATION].’] These
organizations recognize the importance of this national data collection and encourage agency professionals to participate.

Your participation will help ensure that the MDPS is a success and that the results can be used by [HOSPITALS: ‘mental
health and drug abuse agency administrators’ JAILS, SHELTERS, PRISONS: ‘correctional agency administrators and
mental health care professionals’] with confidence. We know that your staff have many responsibilities and limited time, but
we hope that you will provide the requested information and contribute to this effort. No other data collection provides such a
complete examination of serious mental health and substance use disorders throughout the country.

We thank you in advance for your participation in this important study.

Sincerely,

Attachment I. Nonhousehold Facility Materials

4

SAMHSA NSMH Letter of Support

Attachment I. Nonhousehold Facility Materials

5

NSMH 1-page study description

Attachment I. Nonhousehold Facility Materials

6

Recruitment Commencement Letter Follow-up Email
Dear  <Last Name>:
I am writing to follow up on a letter from [INSERT SITE PRINCIPAL INVESTIGATOR NAME] and Heather Ringeisen
regarding the Mental and Substance Use Disorder Prevalence Study (MDPS), also known as the National Study of
Mental Health (NSMH). The MDPS has been funded by the Substance Abuse and Mental Health Services Administration
and will be conducted by RTI International in collaboration with Columbia University, Duke Health, and the University of
Washington. RTI International, a not-for-profit research organization, is conducting the MDPS in your state beginning
[FILL TIME FRAME].
I am trying to contact your office to obtain permission to conduct the study in <## facilities under your
jurisdiction:> [INSERT FACILITY NAME(S)]. This study will provide important and timely information about
the prevalence of mental and substance use disorders in the United States. This information is critical for
furthering research and treatment efforts in behavioral health.
More information about this study can be found in the printed materials enclosed in the package you previously received.
Please feel free to contact me via reply email or [INSERT PHONE NUMBER] to:
• Ask any questions you may have about the study procedures or schedule; or
• Provide the contact information of someone from your staff who can assist in coordinating the MDPS in the
above [FILL facility/facilities].
Thank you in advance for your assistance.
Sincerely,
[SIGNATURE]

Attachment I. Nonhousehold Facility Materials

7

Letter to Facility POC

Attachment I. Nonhousehold Facility Materials

8

Attachment I. Nonhousehold Facility Materials

9

NSMH FAQs Facility Staff

[Federal and State Prison Facility FAQs; State Psychiatric Hospital Facility FAQs;
Homeless Shelter Facility FAQs; Jail Facility FAQs]
What is the National Study of Mental Health?
The National Study of Mental Health will generate up-to-date information on mental illness [HOSPITAL, SHELTER: , alcohol
and drug use,] and other related health issues in the United States. The information can be used to help ensure that
treatments and programs are available to all those who need them.
What do the interviews involve?
A member of the research team will first describe the study to the <inmate/patient/resident> and ask if they want to
participate in an interview that will last approximately [PRISON, HOSPITAL, SHELTER: 90 minutes.; The interview will
include questions on mental health conditions and treatment, tobacco use, (HOSPITAL, SHELTER: alcohol and drug use,)
participation in public assistance programs and health care coverage, and socio-demographic characteristics (e.g.,
race/ethnicity, income, housing).; JAIL: 15 minutes. The interview will include questions about the inmate’s general health,
emotional and mental health, and any difficulties that they may be experiencing or have experienced before.]
Why should this <prison/hospital/shelter/jail> participate?
[PRISON: Approximately 50 state and federal prisons were selected for this study using scientific sampling techniques; no
other prison can take the place of this facility.; HOSPITAL, SHELTER, JAIL: <Four hospitals/ Eighteen homeless shelters/ Six
jails> were selected based on their proximity to our three collaborating organizations: Columbia University/New York State
Psychiatric Institute, Duke Health, and University of Washington. This <hospital/shelter/jail> was one of those selected.]
The information <inmates/patients/ residents> from this facility provide during the interview will help inform mental
health treatment and service needs throughout the United States.
How will <inmates/patients/residents> be selected to participate?
[PRISON, HOSPITAL, JAIL: The research team will randomly sample approximately [PRISON: 20 inmates; HOSPITAL: 100
patients; JAIL: 50 inmates] from a roster/list of <inmates/patients> at the facility one week prior to the start of data
collection. The process used to select <inmates/patients> works like a lottery or drawing names out of a hat.
<Prison/Hospital/Jail> staff will be notified which <inmates/patients> are selected before the data collection effort begins.
[SHELTER: We will select approximately 45 residents from this shelter. The research team will work with the facility to
determine the best method to select residents. For example, residents might be selected from a list of residents or beds
or, if a list is not available, as they arrive at the shelter throughout the day of data collection. Regardless of the method
used, the process used to randomly select residents will work like a lottery or drawing names out of a hat.]
Why should <an inmate/a patient/a resident> participate?
Each individual selected to participate in this study can provide information that will help people who may need healthrelated treatment and services. No one can take the place of a selected <inmate/patient/ resident>.

Attachment I. Nonhousehold Facility Materials

10

When and where will the interviews be conducted?
The research team will contact the facility to discuss data collection logistics, including: (1) whether data collection should
be done virtually (i.e., by web or phone) or in person and (2) the types of areas within the facility that would be suitable
for conducting interviews. Designated interview areas need to be private—so that the interviewer and
<inmate/patient/resident> cannot be overheard—and still within facility staff’s line of sight to meet facility security
requirements. [SHELTER: Depending on space availability, these interviews may be conducted at the shelter or at a nearby
off-site location, such as a public library or social service agency office.] Data collection will take place sometime between
December 2020 and December 2021; study staff will work with a facility point-of-contact to determine the specific dates.
[SHELTER: Interviews will take place on days of the week and times of day that best fit the pattern of resident stays at the
shelter.]
[PRISON, HOSPITAL, SHELTER, (NOT JAILS): Who will conduct the interviews? What credentials, training, and clearances
do they have?
All NSMH clinical interviewers either (1) have a master’s or doctoral degree in clinical or counseling psychology, social
work, or a similar field, (2) are currently enrolled in a doctoral program in one of those fields, or (3) have a medical degree
with a specialty in psychiatry. In addition, each interviewer has experience performing clinical assessments with highly
impaired populations and has been certified to work on NSMH after completing a 40-hour training and conducting practice
interviews with patients. Finally, each must pass various background checks, including Federal, state, county, and
multijurisdictional criminal conviction searches going back at least 7 years and sex offender registry searches. Each
interviewer will also pass any additional state or facility-specific checks that may be required prior to interviewing in the
facility.]
[HOSPITAL: Will patient administrative health records be needed?
With the patient’s consent, the research team will request administrative health records and work with hospital staff to
determine the most suitable process for obtaining the records. All information will be kept confidential and no information
from the records will be connected with the patient’s name.
To comply with HIPAA requirements, the research staff will administer a two-step consent process with the patient. The
first step will include information about the purpose of the study and the patient’s participation and involvement in the
interview. The second step will include asking for the patient’s consent to allow the study team to obtain administrative
health records and include the following points: (1) the purpose for requesting administrative health records, (2) the right
to refuse, and (3) how the data will be treated. When consent is provided, the researcher will ask the patient to sign a
record release form. A patient may participate in the interview but refuse to release their records.]
What are <prison/hospital/shelter/jail> staff asked to do?
Prior to data collection: [PRISON, HOSPITAL, JAIL: Facilities will be asked for a current roster/list of (PRISON: adjudicated
inmates in the prison.; HOSPITALS: patients in the hospital.; JAIL: inmates in the jail.) The research team will use the
roster/list to randomly select <inmates/patients> for participation in the study.] [HOSPITAL: This roster/list will not
contain patient names. It will instead list study identification numbers that correspond to patient hospital identification
numbers maintained by the facility.] To ensure the interviews are conducted smoothly and with as little disruption as
possible to normal <prison/hospital/shelter/jail> operations, a facility point-of-contact will be asked to provide the study
team with logistical information about the facility (e.g., [SHELTERS: number of beds,] schedules, hours available for
interviewing) before the data collection effort begins.
During data collection: On the days when the study interviews take place, facility staff will escort or direct
<inmates/patients/residents> to and from the designated interview areas and provide security and supervision
throughout the data collection. [HOSPITALS: In addition, a patient’s medical provider, counselor, or case manager will be
notified by the study researcher in the unlikely event of significant patient distress.
Attachment I. Nonhousehold Facility Materials

11

After data collection: Based on protocols approved by the hospital, administrative health records for consenting patients
will be provided via secured electronic or paper means, or during onsite review by a member of the research team. The
process will be implemented twice. The first request will be sent to the hospital 2 months after the data collection and
cover those patients who have been discharged during that period. The second request will be sent no later than
December 2021 and cover all other patients who consented to the records release (regardless of discharge status).]

Attachment I. Nonhousehold Facility Materials

12

Mental and Substance Use Disorder Prevalence Study
Summary of the Clinical Interview Questionnaire
This is a summary of the Mental and Substance Use Disorder Prevalence Study and the types of questions which are
asked during the interview. As you review this document, note that not all participants will be asked every question as the
interview varies based on each person’s experiences. Furthermore, participants can always refuse to answer any question
during the interview.
Section 1: Interview Overview
Demographics and Study Overview
This section consists of questions about the participant such as his or her age, sex, and gender identity, relationship status,
education, and employment.
Sample Questions:

What is your date of birth?

What is your highest completed level of education?
Section 2: Disorders
Current and Past Psychological Difficulties
In this section, the interviewer asks about any mental health problems the participant might have had.
 Schizophrenia
 Schizoaffective disorder
 Major depressive disorder
 Generalized anxiety disorder
 Bipolar I
 Post-traumatic stress disorder
 Obsessive compulsive disorder
 Anorexia nervosa
 Alcohol, benzodiazepine, opioid, stimulant, and cannabis use disorder
Sample Question:

In the year since (ONE YEAR AGO), has there been a period of time when you were feeling depressed or down
most of the day, nearly every day?
Hospitalization History
In this section, the interviewer asks about hospitalization for psychological, drug, or alcohol problems.
Sample Question:

Have you ever been hospitalized for psychological problems or a drug or alcohol problem?
Suicidal Ideation and Behavior, Other Problems in Past Year
In this section, the interviewer asks suicidal thoughts and behaviors, and the experiences associated with the thoughts and
behaviors.
Sample Question:

Have you ever thought about taking your own life or just going to sleep and not waking up, or thinking that you
would be better off dead? (Tell me about that.)

Have you had any problems in the past year other than what we’ve talked about so far?
Section 3
Cigarette and E-Cigarette Use
This section consists of questions about the participants’ use, and frequency of use, of cigarettes and e-cigarettes, inpatient
hospitalization, and housing assistance.
Attachment I. Nonhousehold Facility Materials

13

Sample Questions:

Have you ever smoked part or all of a cigarette?

Did you smoke part or all of a cigarette during the past 12 months?
Treatment
This section asks questions about the participants’ experiences with inpatient and outpatient counseling, medication, and
mental health, emotional, and behavioral treatment, in addition to inpatient and outpatient hospitalization for drugs and
alcohol, medication usage, and health insurance coverage.
Sample Questions:

Have you ever received professional counseling, medication or other treatment to help with your mental health,
emotions, or behavior?

During the past 12 months, have you received inpatient or residential treatment, that is have you stayed overnight
or longer to receive professional counseling, medication, or other treatment for your mental health, emotions, or
behavior at any of these places?

During the past 12 months, did you take any medication that was prescribed by a doctor or health care
professional to help with your mental health, emotions, behavior, energy, concentration, or ability to cope with
stress?

Are you currently covered by any kind of health insurance, that is, any policy or program that provides or pays for
medical care?
Section 4
Socio-Demographics and Background
This section includes questions about marital status, ethnicity, race, education, student status, military status, employment
status, and household income, and other similar topics.
Sample Questions:

Are you now married, widowed, divorced, separated, or have you never married?

Are you currently attending a college, university, or trade school either full-time or part-time?

Not counting minor traffic violations, have you been arrested or booked for breaking the law during the past 12
months?

Did you work at a job or business at any time last week?
Section 5
Living Situations
This section includes questions about the participants’ living location outside of his or her current facility (i.e., prison, jail,
homeless shelter, psychiatric hospital) and length of stay within the facility.
Sample Question:

During the past 12 months, before your current incarceration, in which state did you live in for most of the time?
Final Section
Conclusion
This section includes questions about the participants’ comfort with the interview, contact information for possible
follow-up, and general feedback, among other topics.
Sample Questions:

What is an e-mail address you are likely to have should we need to contact you again?

Did you have any feedback you would like to share regarding this interview?

Attachment I. Nonhousehold Facility Materials

14

SAMHSA NSMH Thank You Letter

[DATE]
[NAME], [TITLE]
[FACILITY/AGENCY NAME]
[ADDRESS]
[CITY], [STATE] [ZIP]
Dear [TITLE.] [NAME]:
On behalf of the Substance Abuse and Mental Health Services Administration (SAMHSA), I would like to
express our gratitude for your assistance in implementing the Mental and Substance Use Disorders
Prevalence Study/National Study of Mental Health in your facility/ies. The study is dependent on the
cooperation of agency and facility leadership and staff, and we appreciate the time, resources, and guidance
provided to us as we worked with you on this important, challenging study.
Specifically, we appreciate all that AGENCY AND FACILITY NAMES did to accommodate the team of
interviewers, from our early conversations about logistics to providing the interviewers with everything they
needed during the data collection effort, as well as to support your staff and residents/inmates/patients
throughout the data collection process.
If you would like to share your feedback on the logistics process or speak to us about how data collection
went in your facility/ies, please contact Tim Smith, the Mental and Substance Use Disorders Prevalence
Study/National Study of Mental Health Non-household Team Lead at RTI International, at nsmh@rti.org.
Otherwise, I would be happy to discuss other aspects of the study with you.
Sincerely,

Thomas Clarke PhD, MPH
Director, National Mental Health and Substance Use Policy Lab
Substance Abuse and Mental Health Services Administration
5600 Fishers Lane
Rockville, MD 20856

Attachment I. Nonhousehold Facility Materials

15

Attachment J
Nonhousehold Respondent Materials
1)
2)
3)
4)
5)
6)
7)

NSMH FAQs Respondents
Contact Cards
Shelter Flyer
Shelter Flyer No Incentive
Jail Flyer
Jail Contact Card
COVID Risk Form Nonhousehold

NSMH FAQs Respondents

[Federal and State Prison Inmate FAQs; State Psychiatric Hospital Patient FAQs;
Homeless Shelter Resident FAQs; Jail Inmate FAQs]
1. What is the National Study of Mental Health?
The National Study of Mental Health will gather up-to-date information on mental health [SHELTER, HOSPITAL: ,
alcohol and drug use,] and other related health issues in the United States. The information can be used to help make
sure that treatments and programs are available to all those who need them.
2. What am I being asked to do?
[PRISON, HOSPITAL, SHELTER: You’re invited to take part in an interview about your general health, emotional and
mental health, and any difficulties that you might have experienced. You will also be asked about your background,
for example, your race, income and participation in public assistance programs, housing, and healthcare coverage and
treatment you have received in the past.]
[JAIL: You’re invited to take part in a short interview that asks questions about your mental and emotional health.
You may also be asked to participate in a second interview after you get out of jail that will ask questions about your
general health, emotional and mental health, and difficulties that you may have experienced. This second interview
will also ask about your background, for example, your race and ethnicity, income and participation in public assistance
programs, housing, and healthcare coverage and treatment you have received in the past.]
3. Why should I participate?
Because you matter! The information that you can share might help you or those who may need health related
treatment and services. No one else can take your place.
[JAIL: You might be asked to take part in a second interview after you get out of jail. If you are chosen and
participate in that part of the study, you will receive a $30 electronic gift card or $30 in cash at the end of the
interview.]
4. How did I get selected for the study?
You and others at this <facility/hospital/shelter> were randomly chosen from a list of <inmates,/patients,/residents
or as you arrived,> just like a lottery or drawing names from a hat.
5. Where will the interview take place and how long will it take?
[PRISON, HOSPITAL: The interview will take place at this <facility/hospital>; SHELTER: Depending on available space,
the interview will either take place at this shelter or at a nearby location like a public library or social service agency
office,] [PRISON, HOSPITAL, SHELTER: where you and the interviewer can talk without being overheard. The interview
usually takes about 90 minutes to complete. Your interview may take more or less time depending on your answers.]
[JAIL: You will be asked to take part in one or two interviews. The first one will take place at this facility where you
and the interviewer can talk without being overheard. This interview usually takes about 15 minutes.
Attachment J. Nonhousehold Respondents Materials

1

If you are chosen for a second interview, a member of the research team will contact you after you get out of jail. That
interview will be done by phone or take place where you’re living at that time or some other place nearby. That
interview usually takes about 90 minutes to complete, but your interview may take more or less time depending on
your answers.]
6. [PRISONS, SHELTERS, JAILS (NOT HOSPITALS): What if I don’t have any mental health issues?
The information we collect from you is still very important. We hope to learn how many people have a mental
health condition or related health issue, and how many do not. So, we need hear from all kinds of people.
While some questions ask about mental health, other questions ask about different kinds of health issues and other
topics. You do not need to know anything about mental health conditions to answer the questions.]
6. [HOSPITALS ONLY: Will anyone see my health records?
If you give your permission, the hospital will release some of your health records to our research team. Your name
will not be included with the information gathered from your records. Information from your records will be added to
the answers you give during the interview.
You can take part in the interview even if you don’t give permission for us to receive your health records.]
7. Who will see my answers [HOSPITALS: to the interview questions]?
You cannot be identified through any information you give us. Your name will never be connected to your answers.
Your answers will be combined with those from the other study participants. We are legally required to keep all your
answers confidential.
8. Do I have to participate? What if I do not wish to answer a question? [HOSPITALS: What if I do not want my health
records reviewed?]
No, it is completely voluntary. If you decide to participate, you can refuse to answer any question that you do not
want to answer. Your decision to participate or not will have no effect on your treatment at this [PRISON, JAIL:
<prison/jail> or affect your legal status or any decisions regarding your release.; HOSPITALS: hospital. You can take
part in the interview even if you don’t give permission for us to receive your health records.; SHELTERS: shelter or
your receipt of any federal, state, or local assistance.]
9. How was this <prison/hospital/shelter/jail> chosen?
[PRISON: We randomly selected around 50 state and federal prisons across the country. This prison was one of those
selected.; HOSPITAL, SHELTERS, JAILS: We chose <four hospitals/18 shelters/six jails> that are close to our three
collaborating organizations: Columbia University/New York State Psychiatric Institute, Duke Health, and University of
Washington.; HOSPITAL: This hospital is one of the four.; SHELTER: This shelter is one those 18.; JAIL: This jail was one
of the six selected.]
10. Who is collecting the information?
RTI International, a nonprofit research organization, is collecting the information. RTI is not connected to this
<prison/hospital/shelter/jail> in any way.

Attachment J. Nonhousehold Respondents Materials

2

Contact Cards
For Additional Information about the National Study of Mental Health
Questions About the Project

Questions About Your Rights as
A Research Participant

NSMH Principal Investigator
Dr. Heather Ringeisen
RTI International
3040 Cornwallis Road
Research Triangle Park, NC 27709

Institutional Review Board
Advarra
6940 Columbia Gateway Drive
Suite 110
Columbia, MD 21046

For Additional Information about the National Study of Mental Health
Questions About the Project

Questions About Your Rights as
A Research Participant

NSMH Principal Investigator
Dr. Heather Ringeisen
RTI International
3040 Cornwallis Road
Research Triangle Park, NC 27709

Institutional Review Board
Advarra
6940 Columbia Gateway Drive
Suite 110
Columbia, MD 21046

For Additional Information about the National Study of Mental Health
Questions About the Project

Questions About Your Rights as
A Research Participant

NSMH Principal Investigator
Dr. Heather Ringeisen
RTI International
3040 Cornwallis Road
Research Triangle Park, NC 27709

Institutional Review Board
Advarra
6940 Columbia Gateway Drive
Suite 110
Columbia, MD 21046

Attachment J. Nonhousehold Respondents Materials

3

Shelter Flyer

Attachment J. Nonhousehold Respondents Materials

4

Shelter Flyer No Incentive

Attachment J. Nonhousehold Respondents Materials

5

Jail Flyer

Attachment J. Nonhousehold Respondents Materials

6

Jail Contact Card

Thank you for taking part in the NSMH.
To schedule your next interview, after
your release, please contact the research
team at NSMH@rti.org or 833-947-2575.

Thank you for taking part in the NSMH.
To schedule your next interview, after
your release, please contact the research
team at NSMH@rti.org or 833-947-2575.

Thank you for taking part in the NSMH.
To schedule your next interview, after
your release, please contact the research
team at NSMH@rti.org or 833-947-2575.

Thank you for taking part in the NSMH.
To schedule your next interview, after
your release, please contact the research
team at NSMH@rti.org or 833-947-2575.

Thank you for taking part in the NSMH.
To schedule your next interview, after
your release, please contact the research
team at NSMH@rti.org or 833-947-2575.

Thank you for taking part in the NSMH.
To schedule your next interview, after
your release, please contact the research
team at NSMH@rti.org or 833-947-2575.

Thank you for taking part in the NSMH.
To schedule your next interview, after
your release, please contact the research
team at NSMH@rti.org or 833-947-2575.

Thank you for taking part in the NSMH.
To schedule your next interview, after
your release, please contact the research
team at NSMH@rti.org or 833-947-2575.

Attachment J. Nonhousehold Respondents Materials

7

COVID Risk Form Nonhousehold

Attachment J. Nonhousehold Respondents Materials

8

Attachment J. Nonhousehold Respondents Materials

9

</pre><Table class="table"><tr><Td>File Type</td><td>application/pdf</td></tr><tr><Td>Author</td><td>wreed</td></tr><tr><Td>File Modified</td><td>2021-10-15</td></tr><tr><Td>File Created</td><td>2021-10-15</td></tr></table></div></div></div><hr>
© 2024 OMB.report | <a href="/privacy_policy.php" rel="nofollow">Privacy Policy</a> 

<hr >
</div>
</body>
<script defer async src="/js/instant.page.3.0.0.js" type="module" data-cfasync="false"></script>
</html><script data-cfasync="false" src="/cdn-cgi/scripts/5c5dd728/cloudflare-static/email-decode.min.js"></script>