ArticlePDF Available

A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7


Abstract and Figures

Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity. A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use. A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale. The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.
Content may be subject to copyright.
A Brief Measure for Assessing Generalized
Anxiety Disorder
The GAD-7
Robert L. Spitzer, MD; Kurt Kroenke, MD; Janet B. W. Williams, DSW; Bernd Lo¨we, MD, PhD
Background: Generalized anxiety disorder (GAD) is one
of the most common mental disorders; however, there
is no brief clinical measure for assessing GAD. The ob-
jective of this study was to develop a brief self-report scale
to identify probable cases of GAD and evaluate its reli-
ability and validity.
Methods: A criterion-standard study was performed in
15 primary care clinics in the United States from No-
vember 2004 through June 2005. Of a total of 2740 adult
patients completing a study questionnaire, 965 patients
had a telephone interview with a mental health profes-
sional within 1 week. For criterion and construct valid-
ity, GAD self-report scale diagnoses were compared with
independent diagnoses made by mental health profes-
sionals; functional status measures; disability days; and
health care use.
Results: A 7-item anxiety scale (GAD-7) had good re-
liability, as well as criterion, construct, factorial, and pro-
cedural validity. A cut point was identified that opti-
mized sensitivity (89%) and specificity (82%). Increasing
scores on the scale were strongly associated with mul-
tiple domains of functional impairment (all 6 Medical Out-
comes Study Short-Form General Health Survey scales
and disability days). Although GAD and depression symp-
toms frequently co-occurred, factor analysis confirmed
them as distinct dimensions. Moreover, GAD and de-
pression symptoms had differing but independent ef-
fects on functional impairment and disability. There was
good agreement between self-report and interviewer-
administered versions of the scale.
Conclusion: The GAD-7 is a valid and efficient tool for
screening for GAD and assessing its severity in clinical
practice and research.
Arch Intern Med. 2006;166:1092-1097
mon anxiety disorders
seen in general medical
practice and in the gen-
eral population is gener-
alized anxiety disorder (GAD). The disor-
der has an estimated current prevalence in
general medical practice of 2.8% to 8.5%
and in the general population of 1.6% to
Whereas depression in clinical set-
tings has generated substantial research,
there have been far fewer studies of anxi-
ety. In part, this may be because of the pau-
city of brief validated measures for anxiety
compared with the numerous measures for
such as the Primary Care
Evaluation of Mental Disorders 9-item Pa-
tient Health Questionnaire (PHQ).
situation is unfortunate, given the high
prevalence of anxiety disorders, as well as
their associated disability and the availabil-
ity of effective treatments, both pharmaco-
logical and nonpharmacological.
Measures of anxiety are seldom used in
clinical practice because of their length,
proprietary nature, lack of usefulness as
a diagnostic and severity measure,
requirement of clinician administration
rather than patient self-report.
The goal
of this study was to develop a brief scale
to identify probable cases of GAD and to
assess symptom severity. We conducted
a study in multiple primary care sites to
select the items for the final scale and to
evaluate its reliability and validity.
We first selected potential items for a brief GAD
scale. The initial item pool consisted of 9 items
that reflected all of the Diagnostic and Statisti-
cal Manual of Mental Disorders, Fourth Edition
(DSM-IV) symptom criteria for GAD and 4
items on the basis of review of existing anxi-
ety scales. A 13-item questionnaire was devel-
oped that asked patients how often, during the
last 2 weeks, they were bothered by each symp-
tom. Response options were “not at all,” “sev-
Author Affiliations: Biometrics
Research Department, New
York State Psychiatric Institute
and Department of Psychiatry,
Columbia University, New York
(Drs Spitzer and Williams);
Regenstrief Institute for Health
Care and Department of
Medicine, Indiana University,
Indianapolis (Dr Kroenke); and
Department of Psychosomatic
and General Internal Medicine,
University of Heidelberg,
Heidelberg, Germany
(Dr Lo¨we).
©2006 American Medical Association. All rights reserved.
on December 15, 2007 www.archinternmed.comDownloaded from
eral days,” “more than half the days,” and “nearly every day,”
scored as 0, 1, 2, and 3, respectively. In addition, an item to
assess duration of anxiety symptoms was included. Our goal
was to determine the number of items necessary to achieve good
reliability and procedural, construct, and diagnostic criterion
Patients were enrolled from November 2004 through June 2005
from a research network of 15 primary care sites located in 12
states (13 family practice, 2 internal medicine) administered
centrally by Clinvest, Inc (Springfield, Mo). The purpose of the
project’s first phase (n=2149) was to select the scale items and
cutoff scores to be used for making a GAD diagnosis. The pur-
pose of the second phase (n=591) was to determine the scale’s
test-retest reliability. In all, 2982 subjects were approached and
2739 (91.9%) completed the study questionnaire with no or
minimal missing data. To minimize sampling bias, we ap-
proached consecutive patients at each site in clinic sessions un-
til the target quota for that week was achieved.
In the first phase, 1654 subjects also agreed to a telephone
interview, and of these, a random sample of 965 were inter-
viewed within 1 week of their clinic visit by 1 of 2 mental
health professionals (MHPs)—a PhD clinical psychologist and
a senior psychiatric social worker. In the study’s second
phase, 591 subjects who had completed the research ques-
tionnaire were sent a 1-page questionnaire that consisted of
the 13 potential GAD scale items. Of these, 236 subjects
returned the completed 1-page questionnaire with no or mini-
mal missing data within a week of completing the research
questionnaire at the clinic. The mean GAD scale score of sub-
jects returning the questionnaire did not differ from that of
subjects who did not return the questionnaire. The study was
approved by the Sterling Institutional Review Board, Spring-
field, Mo.
Before seeing their physicians, patients completed a 4-page ques-
tionnaire that included the 13 items being tested for use in the
GAD scale, as well as questions about age, sex, education, eth-
nicity, and marital status; the Medical Outcomes Study Short-
Form General Health Survey (SF-20),
which measures func-
tional status in 6 dimensions; and either the 12-item anxiety
subscale from the Symptom Checklist-90
(first study phase
only) or the Beck Anxiety Inventory
(second study phase only).
Depression was assessed with the PHQ-8, which includes all
items from the PHQ-9 except for the item about suicidal ide-
ation; PHQ-8 and PHQ-9 scores are highly correlated and have
nearly identical operating characteristics.
Finally, patients com-
pleted items regarding physician visits and disability days dur-
ing the previous 3 months.
The 2 MHPs conducted structured psychiatric interviews by
telephone, blinded to the results of the self-report research ques-
tionnaire. The interview consisted of the GAD section of the
Structured Clinical Interview for DSM-IV,
modified with sev-
eral additional questions to assess in greater detail some of the
GAD diagnostic criteria of DSM-IV. The resulting DSM-IV GAD
diagnosis, with the DSM-IV 6-month duration criterion, was
used as the criterion standard for assessing the validity of the
new scale. The interview also included the 13 potential GAD
scale items to test agreement between self-report and clinician
administration (ie, procedural validity).
The best items for the GAD scale were selected by rank order-
ing the correlation of each item with the total 13-item scale score
in the sample of 1184 patients who did not undergo the MHP
interview. Item-total score correlations were reexamined in 2
independent subsamples of the study population: the 965 pa-
tients who underwent the MHP interview and the 591 pa-
tients in the second phase of the study. In addition, we con-
ducted receiver operating characteristic analyses with varying
numbers of items in these 965 patients by using an MHP di-
agnosis of GAD as the criterion standard. Divergent validity of
each item was assessed by calculating the difference between
the item correlations with the 13-item anxiety score and the
PHQ-8 depression score. Convergent validity was assessed by
examining correlations of the final version of the GAD scale
with the Beck Anxiety Inventory and the anxiety subscale of
the Symptom Checklist-90, even though neither scale is spe-
cific for GAD.
To assess construct validity, we used analysis of covari-
ance to examine associations between anxiety severity on the
final GAD scale and SF-20 functional status scales, self-
reported disability days, and physician visits, controlling for
demographic variables. For criterion validity, we investi-
gated sensitivity, specificity, predictive values, and likeli-
hood ratios for a range of cutoff scores of the final scale with
respect to the MHP diagnosis. To investigate whether anxi-
ety as measured by the GAD-7 and depression as measured
by the PHQ-8 reflect distinct dimensions, we assessed facto-
rial validity by using confirmatory factor analyses. Finally,
procedural validity and test-retest reliability were assessed
by means of intraclass correlation.
The mean (SD) age of the patients was 47.4 (15.5) years
(range, 18-95 years). Most (65%) were female; 80% were
white non-Hispanic, 8% were African American, and 9%
were Hispanic; 64% were married, 13% were divorced,
and 15% were never married; and 31% had a high school
degree or equivalent, whereas 62% had attended some
The GAD-7 (
Figure 1) consists of the 7 items with
the highest correlation with the total 13-item scale
score (r=0.75-0.85). Receiver operating characteristic
analysis with this set of items showed an area under
the curve (0.906) as good as scales with as much as
the full 13-item set. These 7 items also had the highest
rank correlations in the developmental sample
(n=1184) and the 2 replication samples (n=965 and
n=591). The 2 core criteria (A and B) of the DSM-IV
definition of GAD are captured by the first 3 items of
the scale.
Of note, 6 of the 7 items had the greatest
divergent validity (ie, the highest difference between
the item-total scale score correlation and item-PHQ-8
depression score correlation [ r=0.16-0.21]). Because
each of the 7 items is scored from 0 to 3, the GAD-7
scale score ranges from 0 to 21.
©2006 American Medical Association. All rights reserved.
on December 15, 2007 www.archinternmed.comDownloaded from
The internal consistency of the GAD-7 was excellent
(Cronbach =.92). Test-retest reliability was also good
(intraclass correlation=0.83). Comparison of scores de-
rived from the self-report scales with those derived from
the MHP-administered versions of the same scales yielded
similar results (intraclass correlation =0.83), indicating
good procedural validity.
Table 1 summarizes the operating characteristics of the
GAD-7 at various cut points. As expected, as the cut point
increases, sensitivity decreases and specificity increases in
a continuous fashion. At a cut point of 10 or greater, sen-
sitivity and specificity exceed 0.80, and sensitivity is nearly
maximized. Results were similar for men and women and
for those aged less and those aged more than the mean age
of 47 years. The proportion of primary care patients who
score at this level is high (23%). A cut point of 15 or greater
maximizes specificity and approximates a prevalence (9%)
more in line with current epidemiologic estimates of GAD
prevalence in primary care. However, sensitivity at this high
cut point is low (48%). Most patients (89%) with GAD had
GAD-7 scores of 10 or greater, whereas most patients (82%)
without GAD had scores less than 10.
The mean (SD) GAD-7 score was 14.4 (4.7) in the 73
patients with GAD diagnosed according to the MHP and
4.9 (4.8) in the 892 patients without GAD. The preva-
lence of GAD according to the MHP interview was 9%
in women and 4% in men. In the entire sample of 2739
patients, the mean GAD-7 score was 6.1 in women and
4.6 in men.
Although the GAD-7 scale inquires about symptoms
in the past 2 weeks, the criterion-standard MHP inter-
view required at least a 6-month duration of symptoms
consistent with DSM-IV diagnostic criteria for GAD. None-
theless, the operating characteristics of the scale were good
because most patients with high symptom scores had
chronic symptoms. Of the 433 patients with GAD-7 scores
of 10 or greater, 96% had symptoms for 1 month or more,
and 67% had symptoms for 6 months or more.
There was a strong association between increasing GAD-7
severity scores and worsening function on all 6 SF-20
scales (
Table 2). As GAD-7 scores went from mild to
moderate to severe, there was a substantial stepwise de-
cline in functioning in all 6 SF-20 domains. Most pair-
wise comparisons within each SF-20 scale between suc-
cessive GAD-7 severity levels were significant. The
relationship between GAD severity and functional im-
pairment was similar in men and women.
Figure 2 illustrates graphically the relationship be-
tween increasing GAD-7 scale scores and worsening func-
tional status. Decrements in SF-20 scores are shown in terms
of effect size (ie, the difference in mean SF-20 scores, ex-
pressed as the number of SDs, between each GAD-7 inter-
val subgroup and the reference group). The reference group
is the group with the lowest GAD-7 scores (ie, 0-4), and
the SD used is that of the entire sample. Effect sizes of 0.5
and 0.8 are typically considered moderate and large be-
tween-group differences, respectively.
When the GAD-7 was examined as a continuous vari-
able, its strength of association with the SF-20 scales was
concordant with the pattern seen in Figure 2. The GAD-7
correlated most strongly with mental health (0.75), fol-
lowed by social functioning (0.46), general health per-
ceptions (0.44), bodily pain (0.36), role functioning
(0.33), and physical functioning (0.30).
Table 3 shows the association between GAD-7 se-
verity levels and 3 other measures of construct validity:
self-reported disability days, clinic visits, and the gen-
eral amount of difficulty patients attribute to their symp-
toms. Greater levels of anxiety severity were associated
with a monotonic increase in disability days, health care
use, and symptom-related difficulty in activities and re-
lationships. When the GAD-7 was examined as a con-
tinuous variable, its correlation was 0.27 with disability
days, 0.22 with physician visits, and 0.63 with symptom-
related difficulty.
Convergent validity of the GAD-7 was good, as dem-
onstrated by its correlations with 2 anxiety scales: the Beck
Anxiety Inventory (r=0.72) and the anxiety subscale of
the Symptom Checklist-90 (r=0.74). Consistent with re-
sults of previous studies of anxiety and depression,
GAD-7 and Symptom Checklist-90 anxiety scales also
strongly correlated with our depression measure, the
PHQ-8 (r=0.75 and r=0.74, respectively). Nonetheless,
measuring anxiety and depression was complementary
rather than duplicative. We determined the prevalence
of high anxiety and high depression symptom severity
in our sample, defined as severe scores (15) on the
GAD-7 and PHQ-8 depression scales, respectively. In the
2114 patients who completed the GAD-7 and the PHQ-8,
there were 1877 (88.8%) patients with neither high anxi-
ety nor high depression, 99 (4.68%) with high anxiety
only, 68 (3.2%) with high depression only, and 70 (3.31%)
with high anxiety and high depression. Thus, more than
half (99/169) of patients with high anxiety scores did not
7. Feeling afraid as if something awful might happen 0 1 2 3
at all
than half
the days
Over the last 2 weeks, how often have you been
bothered by the following problems?
01 2 31. Feeling nervous, anxious or on edge
01 2 32. Not being able to stop or control worrying
01 2 33. Worrying too much about different things
01 2 34. Trouble relaxing
01 2 35. Being so restless that it is hard to sit still
01 2 36. Becoming easily annoyed or irritable
If you checked off any problems, 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?
Not difficult
at all
Figure 1. The generalized anxiety disorder 7-item (GAD-7) scale.
©2006 American Medical Association. All rights reserved.
on December 15, 2007 www.archinternmed.comDownloaded from
have high depression scores. Also, when patients had high
anxiety and high depression scores, there was an addi-
tive effect on the SF-20 mental health and social func-
tioning scales, as well as self-reported disability days and
health care use.
Principal component analysis of a set of 15 items that in-
cludes the 8 depression items of the PHQ-8 and the 7 anxi-
ety items of the GAD-7 indicated that the first 2 emer-
gent factors had an eigenvalue greater than 1. Sixty-
three percent of the total variance was explained by the
first 2 factors. The varimax-rotated component-matrix
clearly confirmed the original allocation of the items to
the PHQ scales, with all depression items having the high-
est factor loadings on 1 factor (0.58-0.75) and all anxi-
ety items having the highest factor loadings on the sec-
ond factor (0.69-0.81).
This study has several major findings. First, a 7-item anxi-
ety scale—the GAD-7—is a useful tool with strong cri-
terion validity for identifying probable cases of GAD. Sec-
ond, the scale is also an excellent severity measure as
demonstrated by the fact that increasing scores on the
GAD-7 are strongly associated with multiple domains of
functional impairment and disability days. Third, al-
though many patients had anxiety and depressive symp-
toms, factor analysis confirms GAD and depression as dis-
tinct dimensions.
This study reports the development and validation of
a measure for evaluating the presence and severity of GAD
in clinical practice, the GAD-7, one of the few GAD mea-
sures that is also specifically linked to the DSM-IV (Text
Revision) criteria.
A score of 10 or greater on the GAD-7
represents a reasonable cut point for identifying cases of
GAD. Cut points of 5, 10, and 15 might be interpreted
as representing mild, moderate, and severe levels of anxi-
ety on the GAD-7, similar to levels of depression on the
The GAD-7 may be particularly useful in as-
sessing symptom severity and monitoring change across
time, although its responsiveness to change remains to
be tested in treatment studies.
Construct validity was demonstrated by the fact that
increasing scores on the GAD-7 scale were strongly as-
sociated with multiple domains of functional impair-
Table 1. Operating Characteristics of GAD-7 at Different Cutoffs*
GAD-7 Scale Score† Sensitivity, % Specificity, % PPV, % NPV, % LR Prevalence, %
8 92 76 24 99 3.8 29
9 90 79 26 99 4.3 26
10 89 82 29 99 5.1 23
11 82 85 31 98 5.5 20
12 73 89 35 98 6.5 16
13 66 91 38 97 7.7 13
14 56 92 37 96 7.2 12
15 48 95 42 96 8.7 9
Abbreviations: GAD-7, generalized anxiety disorder 7-item scale; LR, likelihood ratio for a positive test; NPV, negative predictive value; PPV, positive predictive
*In 965 patients who underwent structured psychiatric interview by a mental health professional to determine the presence of generalized anxiety disorder by
using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria.
†The actual score is greater than or equal to the score shown.
Table 2. Relationship Between GAD-7 Severity Score and SF-20 Health-Related Quality of Life Scales*
Level of Anxiety Severity
GAD-7 Scale Score
Mean (95% Confidence Interval) SF-20 Scale Score
Mental Social Role General Pain Physical
0-4 (n = 1182) 82 (81-83) 91 (89-92) 84 (82-86) 68 (67-69) 71 (70-72) 84 (82-85)
5-9 (n = 511) 65 (64-66) 79 (77-81) 69 (66-73) 52 (50-54) 56 (54-58) 74 (72-76)
10-14 (n = 264) 54 (52-55) 69 (66-71) 59 (54-63) 43† (40-45) 51† (48-54) 66† (63-69)
5-21 (n = 171) 41 (39-43) 55 (52-59) 46 (40-52) 39† (36-43) 47† (43-50) 61† (58-65)
Abbreviations: GAD-7, generalized anxiety disorder 7-item scale; SF-20, Medical Outcomes Study Short-Form General Health Survey.
*SF-20 scores are adjusted for age, sex, race, education, and study site. Point estimates for the mean and 95% confidence intervals (±1.96 standard error of
the mean) are displayed. Number of patients adds to 2128 because of missing data. Missing data for any subscale of SF-20 was less than 5%.
†Pairwise comparisons within each scale that are not significant from one another. However, most pairwise comparisons of mean SF-20 scores with each
GAD-7 scale level within each scale are significant at P.05 by using a Bonferroni correction for multiple comparisons.
©2006 American Medical Association. All rights reserved.
on December 15, 2007 www.archinternmed.comDownloaded from
ment. Furthermore, there was a strong association with
self-reported disability days and a modest association with
increased health care use.
To facilitate assessment of change in severity of anxi-
ety symptoms, the GAD-7 asks about recent symptoms
(ie, in the past 2 weeks). However, most patients with
high scores had chronic symptoms, which is why the op-
erating characteristics proved good with use of our cri-
terion-standard MHP interviews based on the conven-
tional GAD duration criterion of 6 months. However, the
National Comorbidity Survey showed that patients with
episodes of 1 to 5 months do not differ greatly from those
with episodes of 6 months or more in onset, persis-
tence, impairment, comorbidity, parental GAD, or so-
ciodemographic correlates.
Kessler et al
conclude that
there is little basis for excluding these people from a di-
agnosis. Notably, 96% of patients with GAD-7scores of
10 or greater in our primary care sample had symptoms
of a month or more, whereas 67% had symptoms of 6
months or longer. It may be that in treatment trials in
which response to therapy is evaluated, assessing GAD
symptom change during a shorter time (eg, the past week)
may be desirable.
The high comorbidity of anxiety and depressive dis-
orders and the high correlation between depressive
and anxiety measures is well known.
Not surpris-
ingly, our depression measure, the PHQ-8, strongly
correlated with the GAD-7 and the Symptom
Checklist-90 anxiety scales. Nonetheless, factor analy-
sis confirmed the value of assessing anxiety and
depression as 2 separate dimensions. In addition, a
number of patients with high anxiety symptoms
according to the GAD-7 did not have high depression
symptom severity, and patients with increasing sever-
ity of anxiety symptoms had corresponding greater
impairment in multiple domains of functional status.
Together, these findings indicate that using only a
depression measure to identify depressed patients who
may benefit from treatment will miss a clinically
important part of the patient population with dis-
abling anxiety who also would benefit from treatment.
Several limitations of our study should be noted. First,
the GAD-7 scale focuses on only 1 anxiety disorder, al-
though there are many patients with other anxiety dis-
orders, such as social phobia and posttraumatic stress dis-
order, who need clinical attention. However, GAD is one
of the most common mental disorders seen in outpa-
tient practice. Second, the GAD-7 provides only prob-
able diagnoses that should be confirmed by further evalu-
ation. Third, because our study was cross-sectional,
prospective observational and treatment studies are
needed to determine the responsiveness of the GAD-7
in assessing change across time. Because there is already
evidence for the responsiveness of the PHQ-9 and PHQ-2
depression scales,
future research also likely will dem-
onstrate that the GAD-7 scale is useful in assessing changes
in the severity of anxiety over time.
This study has a number of strengths, including its
large sample size, diverse clinical settings, and its gen-
eralizability to primary care, where most patients with
anxiety and depression are treated.
Also, the GAD-7 is
efficient in that it is brief and can be completed entirely
by the patient. This latter feature is particularly impor-
tant, given the time constraints and competing de-
mands for busy clinicians.
Although the GAD-7 was de-
veloped and validated in primary care, we expect that,
like the PHQ-9 depression measure, the GAD-7 will have
considerable utility in busy mental health settings and
clinical research, which is especially important given the
high prevalence and substantial disability associated with
Social General Role Pain Physical
SF-20 Scale
Effect Size
Figure 2. Relationship between anxiety severity as measured with the
generalized anxiety disorder 7-item (GAD-7) scale and decline in functional
status as measured with the 6 subscales of the Medical Outcomes Study
Short-Form General Health Survey (SF-20). The decrement in SF-20 scores
is shown as the difference between each GAD-7 scale severity group and the
reference group (ie, those with GAD-7 scale scores of 0 to 4). Effect size is
the difference in group means divided by the SD.
Table 3. Relationship Between GAD-7 Anxiety Severity
Score and Disability Days, Symptom-Related Difficulty,
and Clinic Visits*
Level of Anxiety
Severity GAD-7
Scale Score
Mean No. of
Disability Days
(95% CI)†
Mean No. of
(95% CI)†
of Symptom-
0-4 (n = 1182) 3.9 (3.0-4.7) 1.2 (1.1-1.3) 15.0
5-9 (n = 511) 7.5 (6.2-8.7) 1.7 (1.5-1.9) 5.5
10-14 (n = 264) 10.7 (8.9-12.4) 2.2 (1.9-2.5) 13.7
15-21 (n = 171) 16.8 (14.6-19.1) 2.4 (2.0-2.8) 47.4
Abbreviations: GAD-7, generalized anxiety disorder 7-item scale;
CI, confidence interval.
*All pairwise comparisons between each GAD-7 scale severity level are
significant at P.05 by using a Bonferroni correction for multiple
comparisons, with the exception of mean physician visits at moderate vs
severe GAD-7 score severity levels.
†Disability days refers to number of days in the past 3 months that the
patients’ symptoms interfered with their usual activities. Physician visits also
refers to the past 3 months. Both are self-reported, and means are adjusted
for age, sex, race, education, study site, and number of physical disorders.
Number of patients adds to 2128 because of missing data. Missing data
were less than 5%.
‡Response to single question: “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?” The 4 response categories are “not difficult at all,” “somewhat
difficult,” “very difficult,” and “extremely difficult.” Symptom-related
difficulty in this table refers to patients reporting “very” or “extremely”
©2006 American Medical Association. All rights reserved.
on December 15, 2007 www.archinternmed.comDownloaded from
Accepted for Publication: January 2, 2006.
Correspondence: Robert L. Spitzer, MD, Department of
Psychiatry, New York State Psychiatric Institute, Unit 60,
1051 Riverside Dr, New York, NY 10032 (RLS8
Funding/Support: The development of the GAD-7 scale
was underwritten by an unrestricted educational grant
from Pfizer Inc (New York, NY). Dr Spitzer had full ac-
cess to the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data analy-
Acknowledgment: Mark Davies, MS, assisted in the sta-
tistical analysis. Jeffrey G. Johnson, PhD, assisted in data
collection and commented on early drafts. Diane Engel,
MSW, also assisted in data collection.
1. Olfson M, Fireman B, Weissman MM, Leon AC, Sheehan DV, Kathol RG. Mental
disorders and disability among patients in a primary care group practice. Am J
Psychiatry. 1997;154:1734-1740.
2. Roy-Byrne PP, Wagner A. Primary care perspectives on generalized anxiety disorder.
J Clin Psychiatry. 2004;65(suppl 13):20-26.
3. Leon AC, Olfson M, Broadhead WE, et al. Prevalence of mental disorders in pri-
mary care: implications for screening. Arch Fam Med. 1995;4:857-861.
4. Wittchen HU, Zhao S, Kessler RC, Eaton WW. DSM-III-R generalized anxiety dis-
order in the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:355-
5. Kessler RC, Brandenburg N, Lane M, et al. Rethinking the duration requirement
for generalized anxiety disorder: evidence from the National Comorbidity Sur-
vey Replication. Psychol Med. 2005;35:1073-1082.
6. Kessler RC, Keller MB, Wittchen HU. The epidemiology of generalized anxiety
disorder. Psychiatr Clin North Am. 2001;24:19-39.
7. Williams JW, Pignone M, Ramirez G, Perez SC. Identifying depression in pri-
mary care: a literature synthesis of case-finding instruments. Gen Hosp Psychiatry.
8. Lo¨we B, Spitzer RL, Gra¨fe K, et al. Comparative validity of three screening ques-
tionnaires for DSM-IV depressive disorders and physicians’ diagnoses. J Affect
Disord. 2004;78:131-140.
9. Spitzer RL, Kroenke K, Williams JB; Patient Health Questionnaire Primary Care
Study Group. Validation and utility of a self-report version of PRIME-MD: the PHQ
primary care study. JAMA. 1999;282:1737-1744.
10. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression
severity measure. J Gen Intern Med. 2001;16:606-613.
11. Lo¨weB,Gra¨fe K, Zipfel S, Witte S, Loerch B, Herzog W. Diagnosing ICD-10 de-
pressive episodes: superior criterion validity of the Patient Health Questionnaire.
Psychother Psychosom. 2004;73:386-390.
12. Fricchione G. Clinical practice: generalized anxiety disorder. N Engl J Med. 2004;
13. Westen D, Morrison K. A multidimensional meta-analysis of treatments for de-
pression, panic, and generalized anxiety disorder: an empirical examination of
the status of empirically supported therapies. J Consult Clin Psychol. 2001;
14. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxi-
ety: psychometric properties. J Consult Clin Psychol. 1988;56:893-897.
15. Zimmerman M, Mattia JI. A self-report scale to help make psychiatric diag-
noses: the Psychiatric Diagnostic Screening Questionnaire. Arch Gen Psychiatry.
16. Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins Symp-
tom Checklist (HSCL): a measure of primary symptom dimensions. Mod Probl
Pharmacopsychiatry. 1974;7:79-110.
17. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety
and Depression Scale: an updated literature review. J Psychosom Res. 2002;
18. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;
19. Antony MM, Orsillo SM, Roemer L, eds. Practitioner’s Guide to Empirically Based
Measures of Anxiety. New York, NY: Kluwer Academic/Plenum Publishers; 2001.
20. Stewart AL, Hays RD, Ware JE Jr. The MOS short-form general health survey:
reliability and validity in a patient population. Med Care. 1988;26:724-735.
21. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36),
I: conceptual framework and item selection. Med Care. 1992;30:473-483.
22. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity
measure. Psychiatr Ann. 2002;9:1-7.
23. First MB, Spitzer RL, Williams JBW, Gibbon M. Structured Clinical Interview for
DSM-IV (SCID). Washington, DC: American Psychiatric Association; 1995.
24. Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing
depression in primary care with the PHQ-9: can it be carried out over the telephone?
J Gen Intern Med. 2005;20:738-742.
25. Deyo RA, Diehr P, Patrick DL. Reproducibility and responsiveness of health sta-
tus measures: statistics and strategies for evaluation. Control Clin Trials. 1991;
26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders DSM-IV-TR (Text Revision). 4th ed. Washington, DC: American Psy-
chiatric Association; 2000.
27. Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health
status. Med Care. 1989;27:S178-S189.
28. Carter RM, Wittchen HU, Pfister H, Kessler RC. One-year prevalence of sub-
threshold and threshold DSM-IV generalized anxiety disorder in a nationally rep-
resentative sample. Depress Anxiety. 2001;13:78-88.
29. Clark DA, Steer RA, Beck AT. Common and specific dimensions of self-reported
anxiety and depression: implications for the cognitive and tripartite models.
J Abnorm Psychol. 1994;103:645-654.
30. Lo¨weB,Unu¨tzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression
treatment outcomes with the Patient Health Questionnaire-9. Med Care. 2004;
31. Lo¨we B, Kroenke K, Gra¨fe K. Detecting and monitoring depression with a 2-item
questionnaire (PHQ-2). J Psychosom Res. 2005;58:163-171.
32. Klinkman MS. Competing demands in psychosocial care: a model for the iden-
tification and treatment of depressive disorders in primary care. Gen Hosp
Psychiatry. 1997;19:98-111.
©2006 American Medical Association. All rights reserved.
on December 15, 2007 www.archinternmed.comDownloaded from
... In research on occupational exposures and their psychological and medical effects on workers, anxiety measurements with general symptom scales [e.g., BAI: (15); GHQ-28: (16); STAI: (17)], it is common practice (e.g., (18)). But, the development of brief and inexpensive measures is handy in response to the requirement to assess anxiety symptoms in primary health care, particularly in the workplace, and a unidimensional measure may be a promising choice (19). The GAD-7 is strongly advised for primary health care (20) because is one of the most extensively used instruments in the world, as well as one of the most validated (21). ...
... To measure anxiety, we used the GAD-7 (19), which was translated and validated into Spanish by García-Campayo et al. (27). The GAD-7 is a seven-item self-report questionnaire that measures general anxiety symptomatology and asked patients how often, during the last 2 weeks, they were bothered by each symptom. ...
... In addition, an item to assess duration of anxiety symptoms was included. When originally developing the GAD-7, Spitzer et al. (19) selected 9-items that reflected the symptom criteria of general anxiety disorder of the DSM-IV, but finally they selected the best correlated 7-items. Based on an assumed unidimensionality, the GAD-7 is interpreted as the sum of the responses to all items. ...
Full-text available
Objective To evaluate the psychometric properties of the GAD-7 by obtaining evidence of internal structure (dimensionality, precision and differential functioning of items) and association with external variables. Methods A total of 2,219 protocols from three different studies conducted with Puerto Rican employees that administered the GAD-7 were selected for the current study. Item response theory modeling was used to assess internal structure, and linear association with external variables. Results The items were adapted to a graduated response model, with high similarity in the discrimination and location parameters, as well as in the precision at the level of the items and in the total score. No violation of local independence and differential item functioning was detected. The association with convergent (work-related rumination) and divergent (work engagement, sex, and age) variables were theoretically consistent. Conclusion The GAD-7 is a psychometrically robust tool for detecting individual variability in symptoms of anxiety in workers.
... We also measured self-reported symptoms of depression using the Patient Health Questionnaire (PHQ-9), a 9-item questionnaire that asks individuals about the frequency with which certain problems have been bothersome (eg, "feeling down, depressed, or hopeless") in the past 2 weeks (14). The resultant score of the PHQ-9 ranges from 0 to 27, and we assigned the following levels of depression severity: none/minimal [0-4]; mild [5][6][7][8][9]; moderate [10][11][12][13][14]; moderately severe [15][16][17][18][19]; and severe [20][21][22][23][24][25][26][27] (15). For purposes of our study, we further created a binary variable with scores of 10 or more indicating having symptoms of depression, which has been shown to have a sensitivity of 88% and a specificity of 88% for major depression (15). ...
... For purposes of our study, we further created a binary variable with scores of 10 or more indicating having symptoms of depression, which has been shown to have a sensitivity of 88% and a specificity of 88% for major depression (15). We also used the Generalized Anxiety Disorder 7-item (GAD-7) Scale to assess for self-reported generalized anxiety disorder (16). The GAD-7 is a 7-item questionnaire evaluating how often individuals were bothered by feelings of anxiety, worry, and nervousness over the previous 2 weeks (16). ...
... We also used the Generalized Anxiety Disorder 7-item (GAD-7) Scale to assess for self-reported generalized anxiety disorder (16). The GAD-7 is a 7-item questionnaire evaluating how often individuals were bothered by feelings of anxiety, worry, and nervousness over the previous 2 weeks (16). The GAD-7 score ranges from 0 to 21, and we assigned the following levels of anxiety severity: none/minimal [0-4]; mild [5][6][7][8][9]; moderate [10][11][12][13][14]; and severe [15][16][17][18][19][20][21] (16). ...
Full-text available
Objective: The study objective was to assess mental and social health outcomes for individuals with rheumatic disease during the COVID-19 pandemic and evaluate the relationship of loneliness and social isolation with depression and anxiety. Methods: We administered an international cross-sectional online survey to individuals with rheumatic disease(s) (≥18 years) between April 2020 and September 2020, with a follow-up survey from December 2020 to February 2021. We used questionnaires to evaluate loneliness (3-item UCLA Loneliness Scale [UCLA-3]), social isolation (Lubben Social Network Scale [LSNS-6]), depression (Patient Health Questionnaire [PHQ-9]), and anxiety (Generalized Anxiety Disorder 7-item [GAD-7] Scale). We used multivariable linear regression models to evaluate the cross-sectional associations of loneliness and social isolation with depression and anxiety at baseline. Results: Seven hundred eighteen individuals (91.4% women, mean age: 45.4 ± 14.2 years) participated in the baseline survey, and 344 completed the follow-up survey. Overall, 51.1% of participants experienced loneliness (UCLA-3 score ≥6) and 30.3% experienced social isolation (LSNS-6 score <12) at baseline. Depression (PHQ-9 score ≥10) and anxiety (GAD-7 score ≥10) were experienced by 42.8% and 34.0% of participants at baseline, respectively. Multivariable models showed that experiencing both loneliness and social isolation, in comparison to experiencing neither, was significantly associated with an average 7.27 higher depression score (ß = 7.27; 95% confidence interval [CI]: 6.08-8.47) and 5.14 higher anxiety score (ß = 5.14; 95% CI: 4.00-6.28). Conclusion: Aside from showing substantial experience of loneliness and social isolation during the COVID-19 pandemic, our survey showed significant associations with depression and anxiety. Patient supports to address social health have potential implications for also supporting mental health.
... The common attributes of depressive thoughts include the inability to feel joy, loss of meaning, and desire to escape or die (Terluin et al., 2006). The features of generalized anxiety are excessive worry and restlessness (Spitzer et al., 2006). Some ERI studies have examined life satisfaction (e.g., Kanwal and Isha, 2022), but so far, ERI studies that examine positive mental health have been scarce. ...
... The scale captures core traits of major depression such as self-harming thoughts and a sense of worthlessness. Anxiety was measured using the seven-item Generalized Anxiety Disorder (Spitzer et al., 2006). The measure captures typical anxiety symptomology such as nervousness, anxiousness, and trouble relaxing. ...
Full-text available
We aimed to identify different, both balanced and imbalanced, effort–reward profiles and their relations to several indicators of employee well-being (work engagement, job satisfaction, job boredom, and burnout), mental health (positive functioning, life satisfaction, anxiety, and depression symptoms), and job attitudes (organizational identification and turnover intention). We examined data drawn randomly from Finnish population ( n = 1,357) of young adults (23–34 years of age) collected in the summer of 2021 with quantitative methods. Latent profile analysis revealed three emerging groups in the data characterized by different combinations of efforts and rewards: underbenefitting (16%, high effort/low reward), overbenefitting (34%, low effort/high reward), and balanced employees (50%, same levels of efforts and rewards). Underbenefitting employees reported poorest employee well-being and mental health, and more negative job attitudes. In general, balanced employees fared slightly better than overbenefitting employees. Balanced employees experienced higher work engagement, life satisfaction, and less depression symptoms. The findings highlight the importance of balancing work efforts with sufficient rewards so that neither outweighs the other. This study suggests that the current effort–reward model would benefit from conceptualizing the previously ignored perspective of overbenefitting state and from considering professional development as one of the essential rewards at work.
Full-text available
Access to psychological interventions for people under Crisis Resolution and Home Treatment Teams (CRHTTs) is limited. The Crisis Toolbox (CTB) is a skills-based intervention designed to increase access using flexible methods of delivery. This study aimed to evaluate the clinical effects of the CTB. A retrospective service evaluation of 399 participants who accessed the CTB between November 2020 and February 2021 was employed. Sessional measures comprising the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Scale (GAD-7) were recorded across three time points. Overall, there were significantly decreasing trends in PHQ-9 (β = − 1.6, p < 0.001) and GAD-7 scores (β = − 1.5, p < 0.001) in participants who accessed the CTB. The magnitude and direction of specific trends differed according to age, diagnosis, and neurodiversity. The CTB could help reduce depression and anxiety in people experiencing crisis. Randomised controlled trials are now required to test its acceptability, feasibility, and effectiveness.
Full-text available
The project is a crossborder partnership with 7 partners from the UK (HEC, Devon Mind, SCC, KCC, IHV, KMPT, Bournemouth University), 1 partner from the Netherlands (Maasstad Hospital), 1 partner from France (EPSM Lille Métropole) and 4 partners from Flanders (Belgium) (AP Hogeschool Antwerp, Odisee Hogeschool, vzw GiO, KdG Hogeschool). Besides the project partners, there are also 24 observing, remotely involved partners: 5 in Flanders, 7 in France, 5 in the Netherlands, 5 in the UK, 1 in Greece and 1 in the USA. The project started in February 2019 and ran until December 2022. PATH wanted to contribute to the prevention of mild and moderate forms of PMI and the ability to effectively screen and successfully support women, families and caregivers with regard to PMI. For this purpose, a holistic approach was envisioned, elaborated in two work packages, consisting of six different outputs. These outputs consisted of various trainings and interventions developed within PATH. The report evaluates the various work packages.
Hypervigilance is often theoretically invoked as a psychological mechanism linking stigma to internalizing psychopathology among sexual minorities. Empirically, however, hypervigilance is rarely explicitly assessed but is instead commonly conflated with putatively related constructs, including sexual-orientation-related rejection sensitivity and rumination, hindering conceptual and mechanistic understandings of this process. We therefore embedded a hypervigilance measure in a longitudinal, population-based study of 811 Swedish sexual-minority young adults (ages 17–34). Hypervigilance—but neither sexual-orientation-related rejection sensitivity nor rumination, with which it was only weakly correlated (rs = .23–.24)—uniquely mediated prospective associations between perceived discrimination and internalizing symptoms 2 years later, explaining up to 40% of these effects. Sexual-orientation-related rejection sensitivity and rumination prospectively predicted hypervigilance on these paths. Findings suggest that hypervigilance represents a distinct construct and transdiagnostic mechanism through which stigma-related experiences and processes undermine sexual-minority mental health. We discuss implications for enhancing psychological interventions for sexual minorities by addressing hypervigilance.
Full-text available
Physical activity (PA) is a known approach for managing anxiety symptoms in older adults. This systematic review and meta-analysis address the benefits of PA and its dimensions (frequency, session time, type, and intervention period) on anxiety symptoms in older adults aged 65 years and above. Searches covered eight databases reporting eight randomized controlled trials (RCTs) and five non-RCTs. Meta-analysis of RCTs (standardized mean difference = -0.41; 95% confidence interval [-0.58, -0.24]; p < .00001) and Fisher's method of combining p values for non-RCTs supported the effectiveness of PA for managing anxiety symptoms in older adults. Subgroup analysis revealed significant effects for all PA types, session times, frequency, and intervention periods compared with control groups, albeit with different magnitudes of effect. In conclusion, although some dimensions of PA contribute to its effectiveness for anxiety, PA intensity and mode required to maximize PA effects remain unclear.
Full-text available
Our objective was to examine associations between maternal symptoms of stress, depression, and anxiety in late pregnancy and child temperament in the context of the COVID-19 pandemic, and whether maternal postpartum sleep quality mediates associations.
Full-text available
The literature reviewed here is consistent in showing that GAD is a common mental disorder that typically has an early age of onset, a chronic course, and a high degree of comorbidity with other anxiety and mood disorders. Comorbid GAD is often temporally primary, especially in relation to mood disorders, and is associated with an increased risk for the subsequent onset and severity of secondary disorders. The weight of evidence reviewed here argues against the view expressed by early commentators that GAD is better conceptualized as a prodrome, residual, or severity marker of other disorders than as an independent disorder. Focused studies of comorbidity between GAD and major depression, in which comorbidity is high, lead to the same conclusion. The crucial evidence for this conclusion includes the following: 1. Contrary to the findings of clinical studies, GAD in the community does not have a higher comorbidity than do most other anxiety or mood disorders. 2. The symptoms of GAD form an empiric cluster distinct from the symptoms of major depression in studies of symptom profiles. 3. Family studies show distinct aggregation of GAD and major depression. 4. Twin studies show that the environmental determinants of GAD are different from the environmental determinants of major depression. 5. The sociodemographic predictors of GAD in epidemiologic studies are different from the predictors of major depression. 6. The clinical course of GAD is less consistently related to comorbidity than is the course of other anxiety and mood disorders. 7. The impairments associated with GAD are equivalent to, or greater than, those associated with other severely impairing chronic physical and mental disorders. These findings show that the status of GAD as an independent disorder is at least as strongly supported by available evidence as is that of other anxiety or mood disorders. This article also shows that uncertainty remains regarding even the basic epidemiologic characteristics of the GAD syndrome. Lingering concerns about the independence of GAD have conspired to exacerbate this problem by promoting repeated changes in the diagnostic criteria for GAD from the DSM-III to DSM-III-R and to DSM-IV. These successive changes have made it difficult to amass consistent long-term data on the natural history of GAD. Available evidence on the empiric validity of current diagnostic thresholds for GAD raises questions about the requirements, such as whether a 6-month minimum duration and four or more additional psychophysiologic symptoms are optimal for identifying all of the people in the general population who suffer from a clinically significant GAD syndrome. An additional source of potential bias in this regard is that the DSM system requires that anxiety be excessive or unrealistic for a diagnosis of GAD. Interestingly, there is no comparable DSM requirement that dysphoria must be excessive or unrealistic to qualify as major depression. These diagnostic uncertainties make it difficult to gain a clear understanding of the true breadth and depth of the GAD syndrome in the general population. Additional research is needed, ideally from unbiased epidemiologic samples, to resolve these basic uncertainties. The strong comorbidity between GAD and major depression, the fact that most people with this type of comorbidity report that the onset of GAD occurred before the onset of depression, and the fact that temporally primary GAD significantly predicts the subsequent onset of depression and other secondary disorders raise the question of whether early intervention and treatment of primary GAD would effectively prevent the subsequent first onset of secondary anxiety and depression. Unfortunately, little is known about this possibility because, as mentioned earlier, few people with pure GAD seek treatment. Why this is true is unknown. Given the early onset of GAD and its strong effects in predicting the subsequent onset, severity, and persistence of other disorders, efforts are needed to collect epidemiologic data on the reasons for the low rate of help seeking among people with pure GAD and to develop outreach strategies that may correct this situation.
Full-text available
Context The Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed as a screening instrument but its administration time has limited its clinical usefulness.Objective To determine if the self-administered PRIME-MD Patient Health Questionnaire (PHQ) has validity and utility for diagnosing mental disorders in primary care comparable to the original clinician-administered PRIME-MD.Design Criterion standard study undertaken between May 1997 and November 1998.Setting Eight primary care clinics in the United States.Participants Of a total of 3000 adult patients (selected by site-specific methods to avoid sampling bias) assessed by 62 primary care physicians (21 general internal medicine, 41 family practice), 585 patients had an interview with a mental health professional within 48 hours of completing the PHQ.Main Outcome Measures Patient Health Questionnaire diagnoses compared with independent diagnoses made by mental health professionals; functional status measures; disability days; health care use; and treatment/referral decisions.Results A total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585 had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of independent mental health professionals (for the diagnosis of any 1 or more PHQ disorder, κ = 0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the PHQ was far less than to administer the original PRIME-MD (<3 minutes for 85% vs 16% of the cases). Although 80% of the physicians reported that routine use of the PHQ would be useful, new management actions were initiated or planned for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously recognized.Conclusion Our study suggests that the PHQ has diagnostic validity comparable to the original clinician-administered PRIME-MD, and is more efficient to use. Figures in this Article Mental disorders in primary care are common, disabling, costly, and treatable.1- 5 However, they are frequently unrecognized and therefore not treated.2- 6 Although there have been many screening instruments developed,7- 8 PRIME-MD (Primary Care Evaluation of Mental Disorders)5 was the first instrument designed for use in primary care that actually diagnoses specific disorders using diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition9(DSM-III-R) and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition10(DSM-IV). PRIME-MD is a 2-stage system in which the patient first completes a 26-item self-administered questionnaire that screens for 5 of the most common groups of disorders in primary care: depressive, anxiety, alcohol, somatoform, and eating disorders. In the original study,5 the average amount of time spent by the physician to administer the clinician evaluation guide to patients who scored positively on the patient questionnaire was 8.4 minutes. However, this is still a considerable amount of time in the primary care setting, where most visits are 15 minutes or less.11 Therefore, although PRIME-MD has been widely used in clinical research,12- 28 its use in clinical settings has apparently been limited. This article describes the development, validation, and utility of a fully self-administered version of the original PRIME-MD, called the PRIME-MD Patient Health Questionnaire (henceforth referred to as the PHQ). DESCRIPTION OF PRIME-MD PHQ ABSTRACT | DESCRIPTION OF PRIME-MD PHQ | STUDY PURPOSE | METHODS | RESULTS | COMMENT | REFERENCES The 2 components of the original PRIME-MD, the patient questionnaire and the clinician evaluation guide, were combined into a single, 3-page questionnaire that can be entirely self-administered by the patient (it can also be read to the patient, if necessary). The clinician scans the completed questionnaire, verifies positive responses, and applies diagnostic algorithms that are abbreviated at the bottom of each page. In this study, the data from the questionnaire were entered into a computer program that applied the diagnostic algorithms (written in SPSS 8.0 for Windows [SPSS Inc, Chicago, Ill]). The computer program does not include the diagnosis of somatoform disorder, because this diagnosis requires a clinical judgment regarding the adequacy of a biological explanation for physical symptoms that the patient has noted. A fourth page has been added to the PHQ that includes questions about menstruation, pregnancy and childbirth, and recent psychosocial stressors. This report covers only data from the diagnostic portion (first 3 pages) of the PHQ. Users of the PHQ have the choice of using the entire 4-page instrument, just the 3-page diagnostic portion, a 2-page version (Brief PHQ) that covers mood and panic disorders and the nondiagnostic information described above, or only the first page of the 2-page version (covering only mood and panic disorders) (Figure 1). Figure 1. First Page of Primary Care Evaluation of Mental Disorders Brief Patient Health QuestionnaireGrahic Jump Location+View Large | Save Figure | Download Slide (.ppt) | View in Article ContextCopyright held by Pfizer Inc, but may be photocopied ad libitum. For office coding, see the end of the article. The original PRIME-MD assessed 18 current mental disorders. By grouping several specific mood, anxiety, and somatoform categories into larger rubrics, the PHQ greatly simplifies the differential diagnosis by assessing only 8 disorders. Like the original PRIME-MD, these disorders are divided into threshold disorders (corresponding to specific DSM-IV diagnoses, such as major depressive disorder, panic disorder, other anxiety disorder, and bulimia nervosa) and subthreshold disorders (in which the criteria for disorders encompass fewer symptoms than are required for any specific DSM-IV diagnoses: other depressive disorder, probable alcohol abuse or dependence, and somatoform and binge eating disorders). One important modification was made in the response categories for depressive and somatoform symptoms that, in the original PRIME-MD, were dichotomous (yes/no). In the PHQ, response categories are expanded. Patients indicate for each of the 9 depressive symptoms whether, during the previous 2 weeks, the symptom has bothered them "not at all," "several days," "more than half the days," or "nearly every day." This change allows the PHQ to be not only a diagnostic instrument but also to yield a measure of depression severity that can be of aid in initial treatment decisions as well as in monitoring outcomes over time. Patients indicate for each of the 13 physical symptoms whether, during the previous month, they have been "not bothered," "bothered a little," or "bothered a lot" by the symptom. Because physical symptoms are so common in primary care, the original PRIME-MD dichotomous-response categories often led patients to endorse physical symptoms that were not clinically significant. An item was added to the end of the diagnostic portion of the PHQ asking the patient if he or she had checked off any problems on the questionnaire: "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?" As with the original PRIME-MD, before making a final diagnosis, the clinician is expected to rule out physical causes of depression, anxiety and physical symptoms, and, in the case of depression, normal bereavement and history of a manic episode. STUDY PURPOSE ABSTRACT | DESCRIPTION OF PRIME-MD PHQ | STUDY PURPOSE | METHODS | RESULTS | COMMENT | REFERENCES Our major purpose was to test the validity and utility of the PHQ in a multisite sample of family practice and general internal medicine patients by answering the following questions: Are diagnoses made by the PHQ as accurate as diagnoses made by the original PRIME-MD, using independent diagnoses made by mental health professionals (MHPs) as the criterion standard?Are the frequencies of mental disorders found by the PHQ comparable to those obtained in other primary care studies?Is the construct validity of the PHQ comparable to the original PRIME-MD in terms of functional impairment and health care use?Is the PHQ as effective as the original PRIME-MD in increasing the recognition of mental disorders in primary care patients?How valuable do primary care physicians find the diagnostic information in the PHQ?How comfortable are patients in answering the questions on the PHQ, and how often do they believe that their answers will be helpful to their physicians in understanding and treating their problems?
Full-text available
A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
Conference Paper
Recently, there has been increased interest in the impact and treatment of anxiety disorders. However, one type of anxiety disorder, generalized anxiety disorder (GAD), has received less attention than other disorders, such as panic disorder, despite the prevalence and amenability of this disorder to treatment in the primary care setting. Rates of GAD have been found to be between 2.8% and 8.5%, with a median prevalence of 5.8%-at least twice the rate reported in the National Comorbidity Survey. Up to one third of patients presenting to primary care clinics with somatic complaints had a mood or anxiety disorder. Generalized anxiety disorder is linked to the overuse of medical services: emergency department visits, hospitalizations, diagnostic and laboratory tests, pharmacy costs, and so on. Recognition of anxiety and depression in primary care is poor, with only 23% of pure anxiety cases being recognized compared with 56% of depression cases. The various stakeholders (patients, family members, employers, and insurers) in a patient's outcome often complicate treatment of anxiety. Barriers to effective treatment include time constraints, acute disease orientation of most care systems, lack of planned follow-up and monitoring, and relative unavailability of specialist access. The collaborative care approach is designed to overcome these barriers. With this approach, the patient is provided with additional educational materials, physicians are supported by physician extenders (nurses, social workers, or expert consultants) who provide case-based feedback, follow-up, extra visits, and telephone calls to patients. Providing efficacious treatment to primary care for GAD will require improving knowledge of providers and increasing patient engagement.
• A test-retest reliability study of the Structured Clinical Interview for DSM-III-R was conducted on 592 subjects in four patient and two nonpatient sites in this country as well as one patient site in Germany. For most of the major categories, ks for current and lifetime diagnoses in the patient samples were above.60, with an overall weighted k of.61 for current and.68 for lifetime diagnoses. For the nonpatients, however, agreement was considerably lower, with a mean k of.37 for current and.51 for lifetime diagnoses. These values for the patient and nonpatient samples are roughly comparable to those obtained with other structured diagnostic instruments. Sources of diagnostic disagreement, such as inadequate training of interviewers, information variance, and low base rates for many disorders, are discussed.
Objective: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity. Measurements: The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. Results: As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples. Conclusion: In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
The nine-item Patient Health Questionnaire depression scale is a dual-purpose instrument that can establish provisional depressive disorder diagnoses as well as grade depression severity.
A considerable body of knowledge now exists in the area of depressive disorders in primary care. Primary care clinicians appear to identify less than half of patients with major depressive disorder and adequately treat only a portion of those they identify. However, recent research suggests that identification and treatment of depressive disorders in primary care is a far more complex process than previously assumed. The presence of significant differences in patient expectations, the process of care, and the clinical epidemiology of depression between psychiatric and primary care settings makes it difficult to interpret existing studies of primary care clinician performance. This paper describes an alternative conceptual model for the identification and management of depression in primary care which incorporates the concept of “competing demands” derived from the preventive services literature. The central premise of this model is that primary care encounters present competing demands for the attention of the clinician and that there is not enough time to address each demand. The identification and treatment of depression represents an active choice from multiple clinician and patient priorities such as treatment of acute illness, provision of preventive services, and response to patient requests. Choice is influenced by three sets of interrelated “domains,” representing the clinician, the patient, and the practice ecosystem. Each domain is indirectly influenced by the general policy environment. Detection and treatment of depression in this model occurs over time as clinicians work through these competing demands. Although the competing demands model contains many unproven elements, it is likely to have a great deal of “face validity” for practicing primary care clinicians, and its validity can be empirically tested. Using the model as a framework to guide inquiry into the identification and management of depression and other mood disorders in primary care may lead to the discovery of more creative and effective solutions to the problem of underdiagnosis and undertreatment.