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org
doi:10.1093/fampra/cmi025 Family Practice Advance Access originally published online on 6 April 2005

A brief case-finding questionnaire for common

mental disorders: the CMDQ
Kaj Sparle Christensena,b, Per Finka, Tomas Tofta, Lisbeth Frostholma,
Eva Ørnbøla and Frede Olesenb

Christensen KS, Fink P, Toft T, Frostholm L, Ørnbøl E and Olesen F. A brief case-finding
questionnaire for common mental disorders: the CMDQ. Family Practice 2005; 22: 448–457.
Objectives. The aim of the study was to validate a new case-finding instrument for common

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mental disorders (CMDQ).
Methods. A cross-sectional, stratified, two-phase study was carried out in 28 general practices
in Aarhus County, Denmark. 1785 consecutive patients, 18–65 years old, consulting 38 GPs with
a new health problem participated. Patients were screened before consultation using a one-
page screening questionnaire including subscales for somatisation (SCL-SOM and Whiteley-7),
anxiety (SCL-ANX4), depression (SCL-DEP6) and alcohol abuse (CAGE). A stratified subsample
of 701 patients was interviewed using the Schedules for Clinical Assessment in Neuropsychiatry
(SCAN) interview. We tested the external validity of the scales using the SCAN interview as gold
standard. All data were analysed using appropriate weighted procedures to control for the two-
phase sampling design and non-response bias.
Results. Estimates of sensitivity and specificity for relevant ICD-10 diagnoses at theoretical
optimal cut-off points on subscales: Depressive disorder: 78/86 (SCL-DEP6); Alcohol abuse or
dependence: 78/97 (CAGE); Severe anxiety disorder: 77/85 (SCL-ANX4); Somatisation disorder:
83/56 (SCL-SOM); and 75/52 (Whiteley-7); any mental disorder: 72/72 (SCL-8). At the theoretical
optimal cut-off points the CMDQ demonstrated higher diagnostic accuracy than GPs on any
diagnosis evaluated.
Conclusion. The study results suggest that the CMDQ has excellent external validity for use as
a diagnostic aid in primary care settings.
Keywords. Alcohol abuse, anxiety, depression, primary health care, screening tests,
somatization, validity.

Introduction improve GPs’ recognition of mental disorders may

Somatoform disorders, anxiety disorders, depressions and
alcohol abuse disorders are common, costly, frequently
unrecognised and not optimally treated in general
practice.1–3 In their capacity as family physicians and
gatekeepers to the secondary health care system GPs
play a central role in the recognition and treatment of
mental disorders.
Patients often present with a mixture of physical and
psychological complaints that are difficult to categorise.4
However, once a formal diagnosis has been made, appro-
priate treatment becomes more likely.5 Attempts to
Received 13 May 2004; Accepted 30 December 2004.
aThe Research Unit for Functional Disorders, Aarhus
University Hospital and bThe Research Unit for General
Practice, University of Aarhus, Denmark. Correspondence to
Kaj Sparle Christensen, Barthsgade 5.1, DK-8200 Aarhus N,
Denmark; Email: kasc@alm.au.dk
therefore be essential to promote mental health inter-
ventions and to prevent the somatic fixation6 of mental
health problems.
Previous efforts to improve GPs’ recognition of mental
disorders have mainly included screening measures of
general distress7 and screens for single specific mental
disorders.8 However, general distress is not readily
translated into specific, treatable disorders, and available
screens for a single mental disorder may ignore the patients
suffering from another or more than one disorder.9 The
feasibility and validity of composite instruments that
screen for a wider range of mental disorders in everyday
practice are sparsely investigated.9–12 The aim of this
study was to introduce and validate a new screening
instrument for common mental disorders in general
practice. The instrument is called the CMDQ (Common
Mental Disorder Questionnaire). The CMDQ is a brief
and easy-to-use screening instrument designed for case-
finding in the busy general practice setting.

448
 A brief case-finding questionnaire for common mental disorders 449

Methods symptoms and signs commonly associated with

The screening instrument
The CMDQ has three components: a one-page
questionnaire, a handy scoring template, and a one-page
guide for registration of the sum scores (Figs 1–3).
The questionnaire consists of 36 questions covering
somatoform disorders, anxiety, depression and alcohol
abuse, and a final question about the patient’s overall
health. Each question is rated on a five-point Likert
scale of distress ranging from ‘not at all’ to ‘extremely’
(0 to 4), except for alcohol-questions that are rated as
simple no/yes (0/1) answers. The time period covered by

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FIGURE 1 The CMDQ. Item 1–12: SCL-SOM; item 13–19: Whiteley-7; item 20–23: SCL-ANX4; item 21–28: SCL-8; item 27–32:
SCL-DEP6; item 33–36: CAGE. Example demonstrated: 34-year-old women consulting for ‘headache’
450 Family Practice—an international journal

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FIGURE 2 Evaluation of a 34-year-old woman consulting for ‘headache’. Scores on screening questionnaire are dichotomised
between 0 (not at all) and 1 (a little) using a handy scoring template

the CMDQ is the past 4 weeks for Likert scales, and the
last year for alcohol-questions. Answers on single items
are easily dichotomised and added to a sum score with
corresponding positive predictive values (PPVs) on
separate subscales. The completion of the CMDQ by the
patient takes 2–5 minutes, the rating by the GP less than
one minute.
The CMDQ is constructed by combining six different
subscales: from the SCL-90-R, the symptom checklist
(SCL-SOM)13,14 the SCL-815,16 for emotional psychiatric
disorders and two closely related subscales, the SCL-ANX4
for anxiety (unpublished data) and the SCL-DEP6 for
depression (unpublished data). Illness worry and convic-
tion is assessed using the Whiteley-7 scale.17 The SCL-8,
 A brief case-finding questionnaire for common mental disorders 451

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FIGURE 3 The sum score chart. Evaluation of a 34-year-old woman consulting for ‘headache’

SCL-ANX4, SCL-DEP6, and Whiteley-7 are all developed
by reducing larger scales using modern item response
theory.18,19 Alcohol abuse and dependence is assessed
using a well-known screening instrument, CAGE.20,21
Study population
Aarhus County has a population of about 600 000
people living in rural and urban areas. The county is
served by 431 GPs working in 271 practices. All the GPs
were invited to participate in a randomised controlled
trial on recognition and treatment of functional illness
in primary care (the FIP study). Thirty-eight GPs
(8.8%) working in 28 practices accepted. Included in the
study were consecutive patients aged 18–65 years
presenting with a new health problem during a 3-week
period (study period 3 March to 1 May 2000). Excluded
were patients of non-Scandinavian descent, patients
unable to speak or read Danish, and patients who were
too ill or demented to read and fill in questionnaires.
Only patients enrolled in the National Health Care
Programme, which covers 98% of the Danish population,
were included. Among 2424 patients assessed for
452 Family Practice—an international journal
Assessed for eligibility (n=2424)
Excluded (n=227)
Refused to participate (n=274)
Other reasons (n=138)
Included (n=1785)
Selected for SCAN interview
Refused interview (n=193)
SCAN interviewed (n=701)
FIGURE 4 Patient trial flow
eligibility, 227 met the exclusion criteria, 274 patients
declined, and 138 could not participate for other reasons
(time pressure in clinic, patients not bringing their
reading glasses, etc.). Declining patients had a mean age
of 42.2 years compared with 38.8 years among included
patients (P  0.001, t-test), whereas we found no
statistically significant gender differences. No significant
differences were found in age or gender between
included patients and patients not participating for
other reasons. Each patient was included only once; thus
1785 patients (81.2%) joined the study (Fig. 4). All the
patients included completed the CMDQ in the waiting
room before the consultation.
Selection of patients for diagnostic psychiatric
interview
After the consultation, a stratified second phase sample
including every ninth eligible patient and all patients
with high SQ scores was selected for a semi-structured
standardised psychiatric interview, the Schedules for
Clinical Assessment in Neuropsychiatry (SCAN).22 Each
item was dichotomised between ‘a little’ and ‘moder-
ately’ and added to a sum score for each subscale. High-
scorers were defined by dichotomised sum scores on
SCL-SOM  3, Whiteley-7  1, SCL-8  1 or CAGE  1.
Among the 894 patients selected for the SCAN
interview, 701 (78.4%) accepted. Patients with low
scores, younger patients and men refused the interview
more often than other groups, but the differences were
small. Inter-rater agreement on psychiatric diagnosis was
high (κ = 0.86) (for details, see Toft et al.23).
The psychiatric research interview
ICD-10 diagnoses generated from the SCAN interview
were used as gold standard. Six psychiatrically trained
physicians, certified at the Copenhagen WHO-SCAN
Training Centre, conducted the interviews. The interviews
were conducted as soon as possible after the index
contact, either in the clinic, in the research department
or in the patient’s home. Interviewers were blinded to
screening results (for details see Toft et al.23).
Statistics and data analysis
Unanswered questions on the SQ were automatically
set to ‘not at all’ (i.e. zero). The relative missing
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response rates and 95% confidence intervals (CIs) were
calculated by comparing missing response rates for
patients having a SCAN-diagnosed mental disorder to
missing response rates for patients not having a mental
health diagnosis (according to SCAN or GP). Estima-
tion of sensitivity (SE), specificity (SP), positive and
negative predictive values (PPV and NPV) and their
95% CIs, was obtained by weighted logistic regression
analysis with the observed sampling fractions of second-
phase patients as sample-weights.24 Performance char-
acteristics for the Likert-scales (SCL-scales and
Whiteley-7) were assessed after dichotomisation of each
item response between 0 and 1, and 1 and 2. Further
analyses were made using continuous (non-dichotomised)
scores. We conducted receiver operating curve (ROC)
analyses to completely determine the diagnostic
performance of the scales across the range of cut-off
points and to allow evaluation of the diagnostic perfor-
mance of the different scales by examining their areas
under the curve (AUCs).25 95% CI for AUCs were
calculated using a jackknife estimated standard error.26
The theoretical optimal cut-off was assessed estimating
the maximum area under the QROC-curve.27 Diagno-
stic properties of subscales were compared to GPs
unaided diagnostic performance as previously assessed.28
Data were processed by means of STATA 8.0 and SPSS
10.0 for Windows.
Results
Missing responses on subscales
80.8% of the 1785 questionnaires were fully completed.
9.6% of questionnaires had 1 missing, 2.4% had 2 missing
and 7.2% had 3 or more missing responses. Patients with
mental disorders had more missing responses on
corresponding subscales than patients without any mental
disorder: The relative missing response-rates were: 1.8
(95% CI 1.4–2.4) for SCL-SOM; 2.8 (95% CI 1.9–4.1) for
Whiteley-7; 2.0 (95% CI 1.1–3.5) for SCL-8; 1.3 (95% CI
0.5–3.9) for SCL-ANX4; 3.8 (95% CI 2.0–7.7) for SCL-
DEP6 (especially question no. 29, bothered by thoughts
of ending your life); and 6.4 (95% CI 2.4–17.9) for CAGE
(especially questions no. 34, been annoyed by people
 A brief case-finding questionnaire for common mental disorders
criticising your drinking; and 35, felt bad or guilty about
your drinking).
Outcomes and estimation
The diagnostic properties of each subscale, using 0/1
dichotomisation of item responses, are presented in
Tables 1 and 2. We used AUC for evaluating the overall
psychometric performance of each subscale across the
whole range of scores. An AUC = 1 matches the optimal
test, whereas AUC = 0.5 equals the random test result.
Psychometric characteristics were excellent for specific
ICD-10 disorders on the following subscales. AUC for
CAGE: 0.94 (95% CI 0.90–0.98); AUC for SCL-DEP6:
0.88 (95% CI 0.84–0.91); and AUC for SCL-ANX4: 0.87
(95% CI 0.82–0.92). The SCL-8 performed well with
an AUC reaching 0.78 (95% CI 0.71–0.85) for any
emotional psychiatric disorder. For SCL-SOM and
Whiteley-7 performances were modest to good with
AUCs ranging from 0.67 (95% CI 0.59–0.74) to 0.78
(95% CI 0.71–0.85) with highest values for Somatisation
disorder.
For SCL-SOM and Whiteley-7 the optimal theoretical
cut-offs were 4/2 for males, and 5/3 for females.
Corresponding cut-offs were 4/5 for patients aged 40
and 2/4 for patients aged 40. Overall Whiteley-7
performed best among patients 40 years.
The theoretical optimal cut-offs for SCL-ANX4,
SCL-8, SCL-DEP6 and CAGE were unaffected by
gender and age. SCL-8 and SCL-DEP6 demonstrated
best performances among men 40 years.
Performance characteristics on all continuous
SCL-subscales were slightly better than on scales
dichotomised between 0 and 1, whereas Whiteley-7 was
unaffected by 0/1-dichotomisation of items.
Further details on performance characteristics,
including 95% CIs on SE, SP, PPV and NPV, can be
obtained from the electronic version of this article or by
application to the corresponding author.
In Table 3 we compared the diagnostic performances
of the CMDQ with the GPs’ unaided assessments. At
the theoretical optimal cut-offs the CMDQ demonstrated
higher diagnostic accuracy than the GPs on any diagnosis
evaluated.
Discussion
Despite the brevity of the screening questionnaire, results
from this study suggest that the CMDQ has excellent
external validity for use in primary care settings. An
additional novel finding is that missing responses on
separate items need careful evaluation. Especially for
SCL-DEP6, CAGE, Whiteley-7 and SCL-SOM one or
more missing item-responses may indicate a markedly
increased risk of having the disorder inquired about.
Furthermore, our findings suggest that using the CMDQ
may improve GPs’ diagnostic accuracy.
453
We used a state-of-the-art independent standardised
psychiatric research interview29 performed by trained
psychiatric physicians as external criteria or gold standard.
We included all types of psychiatric diagnoses in the
analysis, and relatively few patients refused to be inter-
viewed. The study is free from any obvious selection bias
due to sociodemographic factors as primary health care
in Denmark is free of charge for patients. We made a
conservative evaluation of psychometric performances as
missing answers to items were scored zero.
The Whiteley-7 and SCL-8 subscales are both validated
for use in general practice.17,30 Forthcoming results on the
closely related anxiety (SCL-ANX4) and depression (SCL-
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DEP6) subscales will demonstrate their high internal
validity (personal communication). The SCL-SOM serves
as a simple symptom checklist and has therefore not been
formally internally validated.14 Previous studies suggest the
CAGE to be a valid a screening tool for alcohol abuse and
dependence in primary care.20
All measurements should demonstrate external
(criterion) and internal (construct) validity, reliability,
repeatability, sensitivity and responsiveness to be clini-
cally useful.19 Few rating scales for mental disorders, if
any, have documented all these characteristics. When it
comes to making psychiatric diagnoses in general practice,
one has to accept that diagnoses are largely based on GPs’
clinical experience. Psychiatric rating scales should
therefore demonstrate high internal validity/homogeneity
(i.e. each item in a scale belongs to the same dimension
and can be added to a sum score) to convince GPs about
their clinical significance. Furthermore, scales should be
brief and easy to interpret to be useful in general
practice.11,31 Results from a concomitant qualitative study
(in Danish) actually indicated that the CMDQ may be
useful in general practice due to its ease of use, usefulness
in the reframing of physical symptoms, diagnostic
accuracy and documentation of patients’ mental health
status.32
A limitation of the study is that the CMDQ has not
been tested in other cultures. So far, only the SCL-8 has
demonstrated modest cultural transferability.16 Our
finding that psychometric characteristics were improved
for SCL-SOM and Whiteley-7 by lowering the point of
dichotomisation might show some cultural varia-
tion. However, a work by Kessler et al. demonstrated that
normalising attributions are predominant in general
practice and a major cause for non-recognition of anxiety
and depression.33 The tendency to minimize symptoms
and worries might apply to somatisation as well. Another
limitation to our findings is that subscales await internal
validation in the current study. Furthermore, we have not
tested the ability of the instrument to measure changes
over time and its sensitivity in monitoring intervention
effect (i.e. responsiveness).
To our knowledge this is the first brief and easy-to-use
screening instrument enumerating PPVs on a range of
common mental disorders that has been validated for use
 454
TABLE 1 Sensitivity and specificity of subscales at different cut-off scores in 1785 primary care patientsa. Bold values indicate the theoretical optimal cutt-points (maximum area under the QROC
curve, which is a graphic representation of true positive and false positive rates corrected for prevalence of the disorder)

Sensitivity/specificity, %

ICD-10 Any Depressive Modest and Anxiety Severe Alcohol Any somatoform Somatisation Severe somatoform Hypo-
diagnosisb mental disorder severe depressive disorder anxiety abuse or disorder disorder disorder chondriasis
disorder disorder disorder dependence

Subscale score SCL-8 SCL-DEP6 SCL-DEP6 SCL-ANX4 SCL-ANX4 CAGE SCL-SOM Whiteley-7 SCL-SOM Whiteley-7 SCL-SOM Whiteley-7 Whiteley-7

Family Practice—an international journal

1 91/37 96/54 97/50 79/42 –/40 97/87 100/9 89/36 –/7 87/22 –/8 87/30 90/28
2 79/58 86/74 92/69 66/67 91/63 78/97 94/21 74/56 –/17 79/41 100/20 75/50 78/46
3 72/72 78/86 87/81 39/87 77/85 29/99 87/35 64/66 98/30 75/52 92/32 69/61 74/56
4 60/80 60/91 68/87 20/85 51/93 13/100 77/47 47/78 96/42 52/65 84/44 48/73 52/69
5 53/87 46/95 50/92 65/63 32/84 83/56 39/76 71/58 34/82 48/80
6 45/92 21/99 24/97 49/74 21/90 65/69 28/84 54/71 24/89 34/87
7 30/95 38/83 8/98 59/79 13/95 46/81 10/97 19/96
8 17/98 26/89 49/87 32/88
9 17/95 32/92 22/93
10 9/97 19/97 13/97
11 5/99 11/98 7/99
12 2/100 4/100 2/100
Prevalence % 27.2 10.4 2.7 16.3 2.4 2.2 38.4 10.9 22.1 5.8

aWeighted data (number of patients SCAN interviewed = 701), item responses were dichotomised between 0 and 1.
bICD-10 diagnoses were generated from the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview: Any mental disorder: apart from abuse, simple phobia and somatoform
disorders; Depressive disorder: F32-F33; Modest and severe depressive disorder,: F32.1–2, F33.1–2; Any anxiety disorder: F40–49 excluding any somatoform disorder; Severe anxiety disorder:
F40.0–1, F441.0–1, F42; Alcohol abuse or dependence: F10.01–F10.6; Any somatoform disorder: F44, F45 and F48; Severe somatoform disorder: F44.4–7, F45.0–2, F45.4, F48.0; Somatisation
disorder: F45.0; Hypochondriasis: F45.2.

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 TABLE 2 Positive and negative predictive values of questionnaire subscales at different cut-off scores in 1785 primary care patientsa

A brief case-finding questionnaire for common mental disorders

Positive/negative predictive value, %

ICD-10 Any Depressive Modest and Anxiety Severe Alcohol Any somatoform Somatisation Severe Hypo-
diagnosis mental disorder severe depressive disorder anxiety abuse or disorder disorder somatoform chondriasis
disorder disorder disorder dependence disorder

Subscale score SCL-8 SCL-DEP6 SCL-DEP6 SCL-ANX4 SCL-ANX4 CAGE SCL-SOM Whiteley-7 SCL-SOM Whiteley-7 SCL-SOM Whiteley-7 Whiteley-7

1 35/91 19/99 5/100 21/91 4/– 14/100 41/99 47/84 12/– 13/95 24/– 26/89 7/98
2 41/88 27/98 7/100 28/91 6/100 34/99 43/85 51/77 13/– 16/95 26/100 30/88 8/97
3 50/88 39/97 11/100 38/88 11/99 45/98 45/81 54/74 15/99 18/95 28/93 34/88 9/97
4 52/84 43/95 12/99 44/86 16/99 57/98 48/77 57/70 17/99 18/92 30/91 33/83 9/96
5 59/83 54/94 15/99 52/74 56/67 19/98 20/91 33/88 35/81 13/96
6 68/82 67/92 19/98 54/70 57/65 20/94 22/91 34/84 39/81 14/96
7 71/78 58/68 68/63 26/94 30/90 41/84 48/79 25/95
8 80/76 59/66 32/93 43/82
9 67/65 36/92 48/81
10 67/63 41/91 57/80
11 77/63 44/90 62/79
12 91/62 58/89 67/78
Prevalence, % 27.2 10.4 2.7 16.3 2.4 2.2 38.4 10.9 22.1 5.8

a Weighted data (number of patients SCAN interviewed = 701), item responses were dichotomised between 0 and 1.

455
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456 Family Practice—an international journal

TABLE 3 Comparisons of sensitivity and specificity (%) of GPsa and systems in place to assure accurate diagnosis, effective
the CMDQb at the theoretical optimal cut-offs (maximum area under treatment, and follow-up. It is our hope, that the CMDQ
the QROC curve, which is a graphic representation of true positive
and false positive rates corrected for prevalence of the disorder) can improve the effectiveness of the diagnostic evalua-
tion by guiding clinicians towards symptom areas requir-
ing particular assessment. We suggest that the instrument
Depression Any Alcohol Any
anxiety abuse or somatoform should be used and validated as a case-finding instru-
disorder dependence disorder ment in general practice. A forthcoming paper will docu-
ment the monitoring capacity (sensitivity to change) of
Sensitivity (SE) the instrument. Future studies should assess the impact of
GP 46 20 25 37 using the CMDQ on patient health outcomes. Computer-
CMDQ 78 39 78 74
based versions of the instrument are about to be
Specificity (SP) developed. The CMDQ is freely available at http://www.
GP 95 94 87 82
CMDQ 86 84 97 56
auh.dk/cl_psych/uk/research.htm.

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Relative diagnostic
accuracy
SE(CMDQ)·SP (CMDQ) Acknowledgements
SE(GP)·SP(GP) 1.5 1.7 3.5 1.4
We thank the GPs, the secretaries and the patients who
a Unaided assessment, n = 885 (weighted data).
participated in this study.
b n = 1785 (weighted data).

in general practice. The first version of the instrument28 Declaration

used a higher dichotomisation of item responses. The
scale-performances were based on studies30 which used a
4-point scale. In our study we chose the original SCL-90-
R 5-point Likert scale13 and used a dichotomisation of
item-responses that, in fact, weakened the performances
of the rating scales. By lowering the point of dichotomi-
sation our results became fully comparable to previous
findings.17,30
No studies have shown whether the use of standardised
research interviews actually predicts clinical outcome.34
In other words: what is the optimal diagnostic accuracy of
mental disorders in primary care? Until such studies have
been conducted, the CMDQ may, however, serve as an
effective adjunct to the GPs’ unstructured diagnostic
interviews.
For research and routine screening, cut-off scores may
be selected to optimise the sensitivity or specificity of the
subscales. With constant sensitivity and specificity, the
PPV of a test is higher (and the NPV lower) in samples
with high versus low prevalence of disease. For clinical
use, one may benefit from using a selective case-finding
approach artificially increasing disease prevalence by
using a few opening key questions.35 Used as a diagnostic
aid, we believe that screening results are most effectively
presented to the physician as continuous measures of
psychopathology and not simply as dichotomised positive
or negative reports.31
Generally, there is limited evidence to support mental
health screening in primary care.10,11 The draft guidelines
on depression from the UK’s National Institute for
Clinical Excellence (NICE) recommend screening
among high risk groups only. The US Preventive Services
Task Force36 stated in 2002 that there is sufficient
evidence to encourage primary care clinicians to screen
their adult patients for depression, as long as they have
Funding: the Interdisciplinary Research Programme
of the Danish National Research Council: [Sundheds-
fremme og forebyggelsesforskning] (grant number
9801278) and the Regional Health Insurance, Aarhus
County (project number 0871) funded this study.
Ethical approval: the Scientific Ethics Committee in the
County of Aarhus approved this study.
Conflicts of interest: none.
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