Anxiety Screening

Anxiety Screening

Description

This skill helps administer and interpret validated anxiety screening instruments. The GAD-2 serves as a brief initial screener, while the GAD-7 provides comprehensive assessment of generalized anxiety severity.

Clinical Context: These tools help quantify anxiety symptoms, track treatment response, and support clinical decision-making. The GAD-7 also screens reasonably well for panic disorder, social anxiety, and PTSD. These are support tools that supplement, not replace, comprehensive clinical evaluation.

Quick Reference

Assessment Comparison

For detailed comparison: See references/screening-comparison.md

GAD-7 Severity Levels

For detailed severity interpretations: See references/severity-levels.md

For treatment recommendations: See references/clinical-decision-trees.md

Interactive Administration (Optional)

Use this mode when the clinician says "start" or "administer" the GAD-2/GAD-7.

1. Confirm readiness and explain the past 2 weeks time frame plus the 0-3 response scale. 2. Ask one item at a time (verbatim from the asset file) and wait for a response before continuing. 3. Accept numeric or verbal responses; if unclear or out of range, ask for clarification. 4. Record each response and keep a running total. 5. If responses indicate severe anxiety or there is any safety concern, pause and assess safety (see Safety Considerations). 6. After the final item, calculate the total score, interpret severity, and provide next-step guidance. 7. Offer a brief documentation summary if requested.

Assessment Tools

GAD-7 (Generalized Anxiety Disorder-7)

Complete assessment with items, scoring, and documentation: → assets/gad-7.md

Key Facts:

• 7 items, 0-3 scale each, total score 0-21
• Cutoff ≥10: 89% sensitivity/82% specificity for GAD
• 5-point change: Indicates treatment response
• Validated for screening GAD, panic, social anxiety, PTSD
• Does NOT: Include safety item (screen for suicidal ideation with PHQ-9 if needed)

GAD-2 (Generalized Anxiety Disorder-2)

Complete assessment with items, scoring, and documentation: → assets/gad-2.md

Key Facts:

• 2 items (first 2 from GAD-7), 0-3 scale each, total score 0-6
• Cutoff ≥3: Positive screen → administer full GAD-7
• Use for: Rapid screening, universal screening in time-limited settings
• Does NOT: Assess severity or screen for suicidal ideation

When to use GAD-2 vs GAD-7: See references/screening-comparison.md

Clinical Workflow

1. Choose Assessment

digraph assessment_selection {
    rankdir=LR;
    node [shape=box, style=rounded];

    start [label="Patient\nPresentation", shape=ellipse];
    time_check [label="Time-limited\nencounter?", shape=diamond];
    purpose_check [label="Treatment\nmonitoring?", shape=diamond];
    gad2 [label="Start with\nGAD-2", style="filled", fillcolor=lightblue];
    gad2_score [label="GAD-2\nscore ≥3?", shape=diamond];
    gad7 [label="Administer\nGAD-7", style="filled", fillcolor=lightgreen];
    monitor [label="Negative\nscreen", style="filled", fillcolor=gray90];

    start -> time_check;
    time_check -> gad2 [label="yes\n(primary care,\nER)"];
    time_check -> purpose_check [label="no"];
    purpose_check -> gad7 [label="yes"];
    purpose_check -> gad7 [label="no\n(suspected\nanxiety)"];
    gad2 -> gad2_score;
    gad2_score -> gad7 [label="yes"];
    gad2_score -> monitor [label="no"];
}

2. Administer Assessment

GAD-2: assets/gad-2.md - 2 items, <1 minute GAD-7: assets/gad-7.md - 7 items, 2-3 minutes

3. Score and Interpret

Scoring:

• Sum all item responses
• GAD-2: 0-6 range
• GAD-7: 0-21 range

Interpretation:

• See quick reference table above
• Detailed interpretations: references/severity-levels.md

4. Clinical Decision-Making

Follow clinical decision trees: references/clinical-decision-trees.md

General pathways:

• GAD-7 0-4: Monitor, psychoeducation
• GAD-7 5-9: Relaxation techniques, stress management, watchful waiting
• GAD-7 10-14: Active treatment (CBT or medication)
• GAD-7 15-21: Combination therapy, specialty referral

5. Document

Use documentation templates in:

• assets/gad-2.md
• assets/gad-7.md

Documentation standards: ../../docs/references/documentation-standards.md

Treatment Monitoring

Use GAD-7 to track progress:

• Baseline: Administer at treatment start
• Follow-up: Every 2-4 weeks during active treatment
• Response indicators:
• <5-point decrease: Minimal response (consider treatment change)
• 5-9 point decrease: Partial response (continue, monitor)
• ≥5-point decrease AND score <10: Good response
• Score <5: Remission (treatment goal)

Do NOT use GAD-2 for treatment monitoring - insufficient detail

Safety Considerations

GAD-7 Does NOT Screen for Suicidal Ideation

Important: Unlike PHQ-9, GAD-7 has no safety item

When to assess suicidal ideation:

• Severe anxiety (GAD-7 ≥15)
• Co-occurring depression
• Any clinical concern

How to assess:

• Administer PHQ-9 (includes Item 9 for suicidal ideation)
• Direct clinical questioning
• See ../depression-screening/references/item-9-safety-protocol.md

Always assess:

• Panic attacks and their impact
• Avoidance behaviors affecting functioning
• Substance use (especially self-medication)
• Co-occurring depression (administer PHQ-9)

Crisis Resources:

• 988 Suicide & Crisis Lifeline (call or text)
• Crisis Text Line: Text HOME to 741741
• Emergency: 911

Universal crisis protocols: ../../docs/references/crisis-protocols.md

Special Considerations

Differential Diagnosis

When GAD-7 is Elevated

digraph differential_diagnosis {
    rankdir=TB;
    node [shape=box, style=rounded];

    high_gad7 [label="GAD-7 ≥10", shape=ellipse, style="filled", fillcolor=yellow];
    assess_type [label="Assess Anxiety\nPresentation", style="filled", fillcolor=lightblue];

    chronic_worry [label="Chronic worry\nabout multiple\nthings?", shape=diamond];
    panic_attacks [label="Recurrent panic\nattacks?", shape=diamond];
    social_fears [label="Fear of social\nsituations?", shape=diamond];
    trauma_hx [label="Trauma\nhistory?", shape=diamond];

    gad [label="Likely GAD\n(Generalized\nAnxiety)", style="filled", fillcolor=lightgreen];
    panic [label="Likely\nPanic Disorder", style="filled", fillcolor=lightgreen];
    social [label="Likely Social\nAnxiety", style="filled", fillcolor=lightgreen];
    ptsd [label="Screen for\nPTSD", style="filled", fillcolor=orange];
    other [label="Consider:\n• Health anxiety\n• OCD\n• Medical causes", style="filled", fillcolor=lightyellow];

    further [label="Further\nClinical Assessment\nRequired", style="filled", fillcolor=lightblue];

    high_gad7 -> assess_type;
    assess_type -> chronic_worry;
    chronic_worry -> gad [label="yes"];
    chronic_worry -> panic_attacks [label="no"];
    panic_attacks -> panic [label="yes"];
    panic_attacks -> social_fears [label="no"];
    social_fears -> social [label="yes"];
    social_fears -> trauma_hx [label="no"];
    trauma_hx -> ptsd [label="yes"];
    trauma_hx -> other [label="no"];

    gad -> further;
    panic -> further;
    social -> further;
    ptsd -> further;
    other -> further;
}

Note: GAD-7 screens for anxiety severity but does not differentiate specific disorders. Further clinical assessment required for diagnosis.

• Medical causes: Rule out hyperthyroidism, cardiac arrhythmias, respiratory conditions, caffeine/substances, medication side effects
• Co-occurring depression: Very common (60% overlap)—administer both GAD-7 and PHQ-9, integrated treatment
• Substance use: May be self-medication; substances worsen anxiety; withdrawal causes anxiety
• Cultural factors: Expression varies across cultures; use validated versions
• Age: Validated for teens (12+) and older adults; different tools for children <12

Referral Guidelines

When to Refer to Specialty Mental Health

Immediate/Urgent:

• GAD-7 ≥15 at initial presentation
• Severe functional impairment
• Inadequate response to initial treatment
• Patient request for specialty care

Routine:

• GAD-7 10-14 if patient prefers specialist
• Complex presentation (trauma, substance use)
• Need for specialized anxiety treatment (exposure therapy, etc.)

Complete referral guidance: ../../docs/references/referral-guidelines.md

Limitations

Screening tools, not diagnostic instruments. Do not replace clinical assessment; do not differentiate specific anxiety disorders. Clinical judgment supersedes scores. Potential issues: false positives (medical conditions, substances), false negatives (minimization), cultural/linguistic factors.

Usage Examples

Example requests: "Administer GAD-7", "Screen for anxiety", "Score GAD-7", "Treatment for score 17", "Screen anxiety and depression together?"

References

Primary Literature:

• Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097.
• Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317-325.

Clinical Guidelines:

• Bandelow B, et al. Treatment of anxiety disorders. Dialogues Clin Neurosci. 2017;19(2):93-107.
• Katzman MA, et al. Canadian clinical practice guidelines for the management of anxiety. BMC Psychiatry. 2014;14 Suppl 1:S1.

No copyright restrictions - GAD-2 and GAD-7 are freely available for clinical and research use

Generalized Anxiety Disorder-2 (GAD-2)

Overview

• Items: 2
• Time: < 1 minute
• Purpose: Brief anxiety screening (first 2 items of GAD-7)
• Population: Adults (18+), useful for time-limited settings

Items

Over the last 2 weeks, how often have you been bothered by the following problems?

Response Scale: 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day

1. Feeling nervous, anxious, or on edge 2. Not being able to stop or control worrying

Scoring

Algorithm: 1. Sum responses to both items 2. Total score range: 0-6

Interpretation:

• 0-2: Negative screen
• ≥3: Positive screen - administer full GAD-7 for comprehensive assessment

For detailed guidance on when to use GAD-2 vs GAD-7, see references/screening-comparison.md

Clinical Significance:

• High sensitivity for detecting anxiety disorders
• Positive screen (≥3) warrants full GAD-7
• Used for initial screening in busy clinical settings

Documentation Template

Assessment: GAD-2 (Generalized Anxiety Disorder-2) Date: [Date administered] Patient: [Name/ID]

Item Responses: 1. Feeling nervous, anxious, on edge: [0-3] 2. Not able to stop/control worrying: [0-3]

Total Score: [0-6] Result: [Negative screen (0-2) / Positive screen (≥3)]

Recommendations:

• If score ≥3: Administer full GAD-7 for comprehensive assessment
• If score 0-2: Monitor, reassess as indicated

Follow-up: [Recommended timing for rescreening]

Generalized Anxiety Disorder-7 (GAD-7)

Overview

• Items: 7
• Time: 2-3 minutes
• Purpose: Assess anxiety severity and screen for generalized anxiety disorder
• Population: Adults (18+), validated in primary care and mental health settings

Items

Over the last 2 weeks, how often have you been bothered by the following problems?

Response Scale: 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day

1. Feeling nervous, anxious, or on edge 2. Not being able to stop or control worrying 3. Worrying too much about different things 4. Trouble relaxing 5. Being so restless that it's hard to sit still 6. Becoming easily annoyed or irritable 7. Feeling afraid as if something awful might happen

Scoring

Algorithm: 1. Sum responses to all 7 items 2. Total score range: 0-21 3. Higher scores indicate greater anxiety severity

Interpretation:

• 0-4: Minimal anxiety
• 5-9: Mild anxiety
• 10-14: Moderate anxiety
• 15-21: Severe anxiety

For detailed clinical interpretation and treatment recommendations, see references/severity-levels.md and references/clinical-decision-trees.md

Clinical Significance:

• Cutoff ≥10: 89% sensitivity and 82% specificity for generalized anxiety disorder
• 5-point change: Indicates treatment response
• Validated for screening GAD and tracking treatment outcomes

Documentation Template

Assessment: GAD-7 (Generalized Anxiety Disorder-7) Date: [Date administered] Patient: [Name/ID]

Item Responses: 1. Feeling nervous, anxious, on edge: [0-3] 2. Not able to stop/control worrying: [0-3] 3. Worrying too much: [0-3] 4. Trouble relaxing: [0-3] 5. Restlessness: [0-3] 6. Easily annoyed/irritable: [0-3] 7. Feeling afraid: [0-3]

Total Score: [0-21] Severity: [Minimal/Mild/Moderate/Severe]

Clinical Interpretation: [Brief interpretation based on score and item pattern]

Functional Impact: [How anxiety affects daily functioning]

Recommendations: [Treatment recommendations based on severity - see references/clinical-decision-trees.md]

Follow-up: [Recommended timing for reassessment]

Clinical Decision Trees for Anxiety

Treatment recommendations and clinical pathways based on GAD-7 severity levels.

Overview

This guide provides evidence-based treatment recommendations based on GAD-7 scores and clinical presentation. Always use clinical judgment and individualize treatment.

Primary Decision Tree

GAD-7 Administered
    ↓
What is total score?
    ↓
0-4 (Minimal) → Monitor, psychoeducation, reassess
5-9 (Mild) → Relaxation/stress management, reassess 2-4 weeks
10-14 (Moderate) → Active treatment (therapy or medication), monitor every 2-4 weeks
15-21 (Severe) → Active treatment (combination often recommended), close monitoring, specialty referral

Minimal Anxiety (GAD-7: 0-4)

Clinical Assessment

• No significant anxiety symptoms
• Normal functioning
• No treatment indicated for anxiety

Recommended Actions

Monitoring:

• Reassess during routine care
• Annual GAD-7 screening

Psychoeducation:

• Discuss anxiety symptoms to watch for
• Stress management basics
• Healthy lifestyle (sleep, exercise, limit caffeine)

When to Reassess Sooner:

• Patient reports subjective distress despite low score
• Life stressors develop
• Symptoms emerge between routine visits

Follow-up:

• Next routine appointment or annually
• Patient instructed to contact if symptoms develop

Mild Anxiety (GAD-7: 5-9)

Clinical Assessment

• Mild symptoms with minimal functional impairment
• May be subsyndromal anxiety
• Consider watchful waiting before active treatment

Recommended Actions

First-Line: Self-Management and Behavioral Strategies

1. Relaxation Training:

• Deep breathing exercises
• Progressive muscle relaxation
• Mindfulness meditation
• Guided imagery

2. Stress Management:

• Identify stressors
• Problem-solving strategies
• Time management
• Work-life balance

3. Lifestyle Modifications:

• Regular exercise (30+ min, 3-5x/week)
• Sleep hygiene
• Reduce caffeine and alcohol
• Social support activation

4. Psychoeducation:

• Nature of anxiety
• Anxiety triggers
• Self-care strategies
• When to seek help

Monitoring:

• Reassess GAD-7 in 2-4 weeks
• Watch for worsening or improvement

Decision Point at 2-4 Weeks:

GAD-7 improved to 0-4?
    ↓ YES → Continue current approach, monitor
    ↓ NO
    ↓
GAD-7 stable (5-9)?
    ↓ Continue self-management 4-8 more weeks, or
    ↓ Consider initiating active treatment if:
      - Patient preference
      - Functional impairment
      - Symptoms distressing
    ↓
GAD-7 worsened (≥10)?
    ↓ YES → Move to Moderate Anxiety pathway

When to Consider Active Treatment Earlier:

• Patient preference for therapy or medication
• Significant functional impairment despite "mild" score
• Previous history of anxiety disorder (higher risk of progression)
• Persistent for >2 months without improvement

Treatment Options if Active Treatment Indicated:

• Psychotherapy (CBT for anxiety)
• OR medication (SSRI/SNRI)
• Consider patient preference

Follow-up:

• GAD-7 every 2-4 weeks during watchful waiting
• Every 2-4 weeks if treatment initiated

Moderate Anxiety (GAD-7: 10-14)

Clinical Assessment

• Meets threshold for anxiety disorder (89% sensitivity, 82% specificity at cutoff ≥10)
• Noticeable functional impairment
• Active treatment recommended

Recommended Actions

First-Line Treatment Options:

Choose based on patient preference, availability, previous response:

1. Psychotherapy alone:

• Cognitive-Behavioral Therapy (CBT) - first-line for anxiety
• Weekly sessions initially
• 8-12 week trial

2. Medication alone:

• SSRI or SNRI first-line
• Start low, titrate as needed
• 4-8 week trial at therapeutic dose

3. Combination therapy:

• Both medication and psychotherapy
• May offer advantages for some patients
• Consider if:
• Previous partial response to monotherapy
• Patient preference
• Severe functional impairment

Monitoring:

• GAD-7 every 2-4 weeks
• Assess side effects if on medication
• Treatment response expected by 4-8 weeks

Decision Point at 4-8 Weeks:

GAD-7 decreased by ≥5 points?
    ↓ YES (Treatment Response)
    ↓ → Continue current treatment
    ↓ → Monitor for continued improvement
    ↓ → Target: GAD-7 < 5 (remission) or <10 (response)
    ↓
GAD-7 decreased by < 5 points OR worsened?
    ↓ (Inadequate Response)
    ↓ → Reassess diagnosis (rule out panic disorder, social anxiety, PTSD)
    ↓ → Check treatment adherence
    ↓ → Consider:
        - Increase treatment intensity (more frequent therapy, higher med dose)
        - Switch treatment (different therapy approach or medication)
        - Add treatment (combination if on monotherapy)
        - Refer for specialty evaluation

Additional Assessments:

• Rule out panic disorder (recurrent panic attacks)
• Rule out social anxiety disorder (fear of social situations)
• Assess for co-occurring depression (PHQ-9)
• Substance use assessment

Referral Indications:

• Inadequate response to initial treatment
• Patient request for specialty care
• Complicating factors (trauma, substance use)
• Need for specialized anxiety treatment

Follow-up:

• Every 2-4 weeks during active treatment
• Monthly once stable
• Continue GAD-7 monitoring

Severe Anxiety (GAD-7: 15-21)

Clinical Assessment

• Severe symptom burden
• Marked functional impairment
• High distress
• Active treatment strongly recommended

Recommended Actions

First-Line: Combination Therapy Often Recommended

1. Medication:

• SSRI or SNRI
• Consider psychiatry referral for medication management
• May need higher doses or augmentation

2. Psychotherapy:

• CBT for anxiety (evidence-based)
• Weekly sessions
• Focus on exposure, cognitive restructuring, relaxation

Monitoring:

• Close monitoring required
• GAD-7 every 1-2 weeks initially
• May need more frequent contact (phone check-ins between sessions)

Safety:

• Assess for co-occurring depression and suicidal ideation (administer PHQ-9)
• Assess functional impairment (work, relationships, self-care)
• Consider impact on quality of life

Decision Point at 4-8 Weeks:

GAD-7 decreased to <10?
    ↓ YES → Good response, continue current treatment
    ↓
GAD-7 decreased by 5-9 points but still ≥10?
    ↓ Partial response
    ↓ → Continue current treatment, monitor closely
    ↓ → Consider augmentation or intensification
    ↓
GAD-7 < 5-point decrease OR worsened?
    ↓ Inadequate response
    ↓ → Specialty mental health referral if not already engaged
    ↓ → Consider higher level of care (IOP) if severe impairment
    ↓ → Reassess diagnosis (may be panic disorder, PTSD, OCD, etc.)
    ↓ → Rule out medical causes (hyperthyroidism, cardiac, etc.)

Referral Strongly Recommended:

• Specialty mental health evaluation
• Psychiatry for medication management
• Consider at initial presentation for severe anxiety

Higher Level of Care Considerations:

Consider IOP (Intensive Outpatient Program) if:

• Inadequate response to standard outpatient treatment
• Severe functional impairment
• Co-occurring severe depression
• Need for intensive structure and support

Differential Diagnosis:

• Generalized Anxiety Disorder
• Panic Disorder (check for panic attacks)
• Social Anxiety Disorder
• PTSD (check trauma history)
• OCD (check for obsessions/compulsions)
• Medical anxiety (thyroid, cardiac, etc.)

Follow-up:

• Weekly or biweekly during acute phase
• Every 2-4 weeks once improving
• Frequent GAD-7 monitoring

Special Considerations

Panic Attacks

If patient reports panic attacks:

• GAD-7 screens for anxiety generally, not panic specifically
• Panic attacks may occur with GAD or as separate panic disorder
• Assess frequency, triggers, avoidance
• May need panic-focused treatment (exposure, interoceptive exposure)

Social Anxiety

If anxiety primarily in social situations:

• May be social anxiety disorder rather than GAD
• GAD-7 will be elevated but doesn't distinguish
• Social anxiety requires exposure-based treatment
• Medication (SSRIs) also effective

Health Anxiety

If worry focused on health/illness:

• May be health anxiety (formerly hypochondriasis)
• GAD-7 will be elevated
• Specific CBT for health anxiety needed
• Reassurance-seeking may maintain anxiety

Obsessive-Compulsive Features

If repetitive thoughts and behaviors:

• May be OCD rather than or in addition to GAD
• GAD-7 will be elevated but doesn't assess compulsions
• OCD requires specific treatment (ERP - Exposure and Response Prevention)
• Different medication approach (higher SSRI doses)

Medical Causes of Anxiety

Rule out medical conditions:

• Hyperthyroidism
• Cardiac arrhythmias
• Pheochromocytoma (rare)
• Medication side effects (steroids, stimulants)
• Substance use (caffeine, stimulants)
• Substance withdrawal (alcohol, benzodiazepines)

Approach:

• Basic medical workup if indicated (TSH, ECG, etc.)
• Treat medical conditions
• Still treat anxiety even if medical component present

Co-occurring Depression

Very common:

• 60% of those with anxiety also have depression
• Administer both GAD-7 and PHQ-9
• Integrated treatment
• SSRIs/SNRIs treat both conditions

Treatment approach:

• Address both conditions
• CBT can target both anxiety and depression
• Medication typically addresses both
• Monitor both with GAD-7 and PHQ-9

Substance Use

Anxiety and substance use:

• Substance use may be self-medication for anxiety
• Substances can cause or worsen anxiety
• Withdrawal can cause severe anxiety

Approach:

• Assess substance use
• May need substance use treatment first or concurrently
• Anxiety may improve with sobriety
• Reassess after stabilization

Treatment Monitoring

Regular GAD-7 Monitoring

Frequency:

• Every 2-4 weeks during active treatment (more frequent for severe)
• Monthly once stable
• Any time clinical concern

Use scores to guide treatment:

• Track improvement
• Identify plateaus
• Recognize worsening

Treatment Response Definitions

Minimal response: < 5-point decrease

• Consider treatment change

Partial response: 5-9 point decrease but score still ≥10

• Continue treatment, monitor
• May need augmentation or more time

Good response: ≥5-point decrease AND score <10

• Significant improvement
• Continue treatment

Remission: GAD-7 < 5

• Goal of treatment
• Plan for maintenance and relapse prevention

Medication Considerations

First-Line Medications

SSRIs:

• Sertraline (Zoloft)
• Escitalopram (Lexapro)
• Paroxetine (Paxil)

SNRIs:

• Venlafaxine XR (Effexor XR)
• Duloxetine (Cymbalta)

Typical approach:

• Start low, titrate gradually
• 4-8 weeks at therapeutic dose before assessing response
• Continue 6-12 months after remission
• Taper slowly when discontinuing

Benzodiazepines

Generally NOT first-line:

• Risk of dependence
• Cognitive side effects
• Withdrawal issues

May be used short-term:

• Severe acute anxiety while waiting for SSRI to work
• Limited duration (2-4 weeks typically)
• Prefer PRN use over standing dose
• Taper when discontinuing

Other Medications

Buspirone:

• Alternative for GAD
• No dependence risk
• Takes several weeks to work
• Less effective than SSRIs for many patients

Hydroxyzine:

• Antihistamine with anti-anxiety effects
• PRN use for acute anxiety
• No dependence risk
• Sedating

Psychotherapy Approaches

Cognitive-Behavioral Therapy (CBT)

Gold standard for anxiety:

• Identify and challenge anxious thoughts
• Behavioral experiments
• Exposure to feared situations
• Relaxation training

Typical course:

• 12-16 sessions
• Weekly initially
• Homework between sessions

Exposure Therapy

For specific fears/phobias:

• Gradual exposure to feared situations
• Habituation to anxiety
• Very effective for panic, social anxiety, specific phobias

Acceptance and Commitment Therapy (ACT)

Alternative to CBT:

• Accept anxiety rather than fight it
• Mindfulness-based
• Values-based action
• Effective for GAD

Mindfulness-Based Stress Reduction (MBSR)

Mindfulness approach:

• 8-week structured program
• Meditation practice
• Effective for anxiety and stress

Relapse Prevention

After Remission

Continue treatment:

• Medication: 6-12 months minimum after remission
• Therapy: Maintenance phase, less frequent sessions

Monitor:

• GAD-7 every 3-6 months
• Watch for early warning signs

Relapse prevention planning:

• Identify triggers
• Early warning signs
• Action plan if symptoms return
• Continue coping skills practice

Referral Guidelines

When to Refer

Refer to specialty mental health when:

• GAD-7 ≥15 at initial presentation
• Inadequate response to initial treatment
• Complex presentation (multiple anxiety disorders, trauma, substance use)
• Patient request

Refer to psychiatry when:

• Medication management needed beyond primary care scope
• Treatment-resistant anxiety
• Multiple failed medication trials
• Unclear diagnosis
• Co-occurring severe conditions

Refer to higher level of care when:

• Severe anxiety (GAD-7 ≥15) with marked impairment
• Failed outpatient treatment
• Co-occurring severe depression with suicidal ideation
• Need for intensive structure

See ../../docs/references/referral-guidelines.md for complete referral guidance.

Summary Tables

Treatment by Severity

Treatment Response Timeline

References

Bandelow B, et al. Treatment of anxiety disorders. Dialogues Clin Neurosci. 2017;19(2):93-107.

Katzman MA, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1:S1.

Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097.

Related Documents

• severity-levels.md - Detailed severity interpretations
• screening-comparison.md - When to use GAD-2 vs GAD-7
• ../../docs/references/referral-guidelines.md - Referral guidance

Anxiety Screening Comparison

Guide for choosing between GAD-2 and GAD-7 screening tools.

Quick Decision Guide

Need for anxiety screening identified
    ↓
Time-limited setting (primary care, ER, brief encounter)?
    ↓ YES → Start with GAD-2
    ↓ NO → Use GAD-7 for comprehensive assessment
    ↓
GAD-2 score ≥3?
    ↓ YES → Administer full GAD-7
    ↓ NO → Negative screen, monitor and reassess as needed

When to Use GAD-2

Ideal Settings:

• Primary care routine screening
• Emergency department visits
• Urgent care
• Annual wellness visits
• Large-scale screening programs
• Time-limited encounters

Advantages:

• Very brief (< 1 minute)
• High sensitivity for anxiety disorders
• Easy to administer
• Minimal patient burden
• Good for initial screening in busy settings

Limitations:

• Only a screener, not diagnostic
• Positive screen requires full GAD-7
• Does not assess severity
• Less useful for monitoring treatment response

Interpretation:

• Score 0-2: Negative screen (anxiety disorder unlikely)
• Score ≥3: Positive screen (administer GAD-7)

When to Use GAD-7

Ideal Settings:

• Mental health specialty settings
• Diagnostic assessments
• Treatment monitoring
• When time permits comprehensive screening
• Follow-up after positive GAD-2

Advantages:

• Comprehensive anxiety assessment
• Severity rating (minimal, mild, moderate, severe)
• Validated for multiple anxiety disorders (not just GAD)
• Can track change over time
• Good psychometric properties

Limitations:

• Takes 2-3 minutes (longer than GAD-2)
• May be too long for very brief encounters
• Screens for anxiety generally, not specific disorder

Interpretation:

• Score 0-4: Minimal anxiety
• Score 5-9: Mild anxiety
• Score 10-14: Moderate anxiety
• Score 15-21: Severe anxiety

Two-Stage Screening Approach

Stage 1: GAD-2 (Universal Screening)

Administer GAD-2 to all patients during routine visits.

If score 0-2:

• Negative screen
• No further anxiety screening needed at this time
• Reassess at next visit or if symptoms emerge

If score ≥3:

• Positive screen
• Proceed to Stage 2

Stage 2: GAD-7 (Comprehensive Assessment)

Administer full GAD-7 when GAD-2 is positive.

Benefits of two-stage approach:

• Efficient use of time (most patients complete only GAD-2)
• High sensitivity maintained
• Reduces screening burden
• Focuses detailed assessment on those who need it

When to Skip GAD-2 and Go Straight to GAD-7

Use GAD-7 directly when:

• Patient presents specifically for anxiety evaluation
• Anxiety already suspected based on presentation
• Monitoring established anxiety diagnosis
• Time is not a significant constraint
• Comprehensive assessment needed for treatment planning
• Need baseline severity for treatment monitoring

Example scenarios for direct GAD-7:

• "I can't stop worrying" (chief complaint)
• Follow-up for known anxiety disorder
• Mental health intake assessment
• Medication management visit
• Therapy session with anxiety focus

Monitoring Treatment Response

Use GAD-7 for Treatment Monitoring

Initial Assessment:

• Administer GAD-7 to establish baseline severity

Follow-up:

• Readminister GAD-7 at regular intervals (every 2-4 weeks typically)
• Track score changes over time
• 5-point decrease = meaningful treatment response
• Goal: Score <10 (below moderate threshold) or <5 (minimal)

Do NOT use GAD-2 for treatment monitoring:

• GAD-2 does not assess severity
• Cannot track meaningful change
• Insufficient detail for treatment decisions

Frequency of Screening

General Population (No Anxiety History)

GAD-2:

• Annual screening during wellness visits
• Or per organizational protocol

GAD-7:

• Only if GAD-2 positive
• Or if symptoms emerge between screenings

Patients with Anxiety History

During Active Treatment:

• GAD-7 every 2-4 weeks
• Monitor treatment response
• Adjust treatment based on scores

After Remission:

• GAD-7 every 3-6 months for first year
• Then annually or per clinical judgment
• Watch for relapse

High-Risk Populations

More frequent screening for:

• Chronic medical illness
• History of anxiety or depression
• Recent major life stressor
• Chronic pain conditions
• Substance use disorders

Frequency:

• GAD-2 at every visit, or
• GAD-7 every 1-3 months

Special Populations

Primary Care Settings

Recommendation:

• Universal GAD-2 screening at annual visits
• GAD-7 for positive GAD-2 screens
• GAD-7 for anyone presenting with anxiety symptoms

Emergency Department

Recommendation:

• GAD-2 for rapid screening if anxiety suspected
• GAD-7 if time permits and GAD-2 positive
• Focus on ruling out panic attacks, acute stress

Mental Health Settings

Recommendation:

• GAD-7 at intake for all patients
• Repeat GAD-7 every 2-4 weeks during active treatment
• GAD-2 generally not needed (sufficient time for full assessment)

Medical Specialty Clinics

Recommendation:

• Consider GAD-2 or GAD-7 in cardiology, pulmonology, GI clinics
• Anxiety common in chronic medical conditions
• Screen to identify comorbid anxiety needing treatment

Postpartum

Recommendation:

• Screen for postpartum anxiety (distinct from postpartum depression)
• GAD-7 appropriate
• Screen at postpartum visits (2 weeks, 6 weeks, 3 months)

Adolescents

Recommendation:

• GAD-7 validated in adolescents (ages 12+)
• Annual screening recommended
• Screen more often if risk factors present

Older Adults

Recommendation:

• GAD-7 validated in older adults
• May need to account for medical comorbidity
• Anxiety often under-recognized in this population

Comparison with Other Anxiety Measures

GAD-7 vs. Beck Anxiety Inventory (BAI)

GAD-7 advantages:

• Shorter (7 vs 21 items)
• Freely available (BAI requires purchase)
• Better for somatic symptoms related to medical illness

BAI advantages:

• More detailed assessment
• Well-established in research

Recommendation: GAD-7 for routine clinical use

GAD-7 vs. Hamilton Anxiety Rating Scale (HAM-A)

GAD-7 advantages:

• Self-report (faster)
• Freely available
• Validated in primary care

HAM-A advantages:

• Clinician-rated (may be more objective)
• Longer history in research

Recommendation: GAD-7 for routine screening, HAM-A for specialized research

GAD-7 vs. Disorder-Specific Measures

For specific anxiety disorders, consider:

• Panic: Panic Disorder Severity Scale (PDSS)
• Social Anxiety: Social Phobia Inventory (SPIN)
• OCD: Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
• PTSD: PCL-5 (see trauma-screening skill)

GAD-7 is good general screener but specific measures needed for detailed assessment

Combined Depression and Anxiety Screening

GAD-7 + PHQ-9 = Common Approach

Why combine:

• Anxiety and depression frequently co-occur
• Efficient to screen both
• Informs treatment approach

Workflow: 1. Administer GAD-2 + PHQ-2 for rapid screening 2. If either positive, administer full GAD-7 + PHQ-9 3. Use combined scores to guide treatment

Interpretation:

• High GAD-7 only: Primarily anxiety
• High PHQ-9 only: Primarily depression
• Both high: Co-occurring (very common)
• Both low: Minimal symptoms

Documentation

GAD-2 Documentation

GAD-2 administered [date]: Score [0-6]
- Item 1 (nervous/anxious): [0-3]
- Item 2 (can't control worry): [0-3]
Result: [Negative screen / Positive screen]
Plan: [If positive, will administer GAD-7]

GAD-7 Documentation

See assets/gad-7.md for complete documentation template.

Common Questions

Q: Can I use just the first 2 items of the GAD-7 as a GAD-2? A: Yes, the GAD-2 consists of the first two items of the GAD-7.

Q: If I'm already giving the GAD-7, do I need to score the GAD-2 separately? A: No, not necessary. The full GAD-7 includes all the information from the GAD-2 and more.

Q: Can I diagnose an anxiety disorder based on GAD scores alone? A: No. GAD-2 and GAD-7 are screening tools. Diagnosis requires clinical interview and judgment.

Q: What if GAD-2 is negative but I still suspect anxiety? A: Trust your clinical judgment. Administer GAD-7 if clinical concern remains despite negative GAD-2.

Q: Does a high GAD-7 mean the patient has Generalized Anxiety Disorder? A: Not necessarily. GAD-7 screens for anxiety generally. High scores can indicate GAD, panic disorder, social anxiety, PTSD, or other anxiety conditions. Further assessment needed for specific diagnosis.

Psychometric Properties

GAD-7 Validation Data

Diagnostic Accuracy:

• Optimal cutoff: Score of 8 (balances sensitivity and specificity)
• Sensitivity: 92% for generalized anxiety disorder (at cutoff of 8)
• Specificity: 76% for generalized anxiety disorder (at cutoff of 8)
• Cutoff of 10 commonly used in practice (higher specificity, adequate sensitivity)

Cross-Disorder Screening:

• Screens reasonably well for multiple anxiety disorders:
• Panic disorder
• Social anxiety disorder
• PTSD (though disorder-specific tools preferred)
• Not limited to generalized anxiety disorder despite the name

Reliability:

• Internal consistency: Excellent across multiple studies
• Test-retest reliability well-established

Treatment Monitoring:

• Meaningful change: 5-point decrease indicates treatment response
• Sensitive to symptom changes during treatment
• Goal: Reduction to <10 (below moderate threshold) or <5 (minimal symptoms)

Development:

• Created by same research team as PHQ-9 (Spitzer, Kroenke, Williams)
• Parallel design facilitates combined depression-anxiety screening

GAD-2 Validation Data

Diagnostic Accuracy:

• Optimized for sensitivity to minimize missed cases
• Positive screen (≥3) requires full GAD-7 for specificity

Efficiency:

• Reduces screening burden when combined with GAD-7
• Two-stage approach maintains high sensitivity with better efficiency

Summary Table

References

Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317-325.

Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097.

Anxiety Severity Levels

This reference provides detailed interpretation of anxiety severity across GAD-7 and GAD-2 screening tools.

GAD-7 Severity Levels

Minimal Anxiety (0-4)

Clinical Meaning: No or minimal anxiety symptoms. Within normal range.

Typical Presentation:

• Rare or absent anxiety symptoms
• Minimal functional impairment
• No treatment typically indicated

Recommended Actions:

• Monitor during routine care
• Provide psychoeducation about anxiety
• Reassess if symptoms change

Mild Anxiety (5-9)

Clinical Meaning: Mild anxiety symptoms with minimal functional impairment.

Typical Presentation:

• Some anxiety symptoms present
• Mild impact on daily functioning
• Patient often continues normal activities with effort
• May have periods of worry but generally manageable

Recommended Actions:

• Watchful waiting with close follow-up
• Relaxation techniques and stress management
• Psychoeducation about anxiety and coping strategies
• Consider brief counseling or support
• Reassess in 2-4 weeks

Moderate Anxiety (10-14)

Clinical Meaning: Moderate anxiety symptoms with noticeable functional impairment. Meets threshold for generalized anxiety disorder (89% sensitivity, 82% specificity at cutoff of 10).

Typical Presentation:

• Clear anxiety symptoms
• Functional impairment in work, social, or personal domains
• Difficulty controlling worry
• Physical symptoms (tension, restlessness)
• Patient struggles with daily activities

Recommended Actions:

• Active treatment plan required
• Consider psychotherapy (CBT, exposure therapy) and/or medication
• Regular monitoring (every 2-4 weeks)
• Assess impact on functioning and quality of life
• Rule out other anxiety disorders (panic, social anxiety, specific phobias)

Severe Anxiety (15-21)

Clinical Meaning: Severe anxiety with marked functional impairment. High symptom burden.

Typical Presentation:

• Severe, pervasive anxiety symptoms
• Significant impairment in multiple life domains
• Constant worry difficult to control
• Marked physical symptoms
• May have panic attacks or avoidance behaviors
• Sleep disturbance common

Recommended Actions:

• Active treatment strongly recommended
• Combination therapy (medication + psychotherapy) often indicated
• Close monitoring (weekly or biweekly)
• Specialty mental health referral
• Assess for co-occurring conditions (depression, substance use)
• Consider higher level of care (IOP) if:
• Severe functional impairment
• Co-occurring severe depression
• Inadequate outpatient response

GAD-2 Interpretation

Negative Screen (0-2)

Meaning: Low probability of anxiety disorder.

Actions:

• Routine monitoring during regular care
• Reassess if clinical presentation changes
• No GAD-7 needed unless clinical concern

Positive Screen (≥3)

Meaning: Elevated anxiety symptoms warrant further assessment.

Actions:

• Administer full GAD-7
• Do not diagnose based on GAD-2 alone
• GAD-2 is a screener, not diagnostic tool

Treatment Response Monitoring

Minimal Response (< 5-point decrease)

• Reassess treatment plan
• Consider treatment intensification or change
• Rule out barriers to treatment adherence
• Assess for co-occurring conditions

Partial Response (5-9 point decrease but score still ≥10)

• Continue current treatment
• Monitor progress closely
• Consider augmentation if plateaued
• May need longer trial of current treatment

Good Response (≥5-point decrease AND score <10)

• Significant improvement
• Continue current treatment
• Plan for maintenance and relapse prevention
• Gradually reduce monitoring frequency

Differential Diagnosis Considerations

GAD-7 Screens for Anxiety, Not Specific Disorder

High GAD-7 may indicate:

• Generalized Anxiety Disorder (most common)
• Panic Disorder
• Social Anxiety Disorder
• Specific Phobias
• PTSD (anxiety component)
• Depression with anxious features
• Medical conditions causing anxiety

Further assessment needed to determine:

• Specific anxiety disorder diagnosis
• Triggers and patterns
• Co-occurring conditions
• Treatment approach

Special Considerations

Physical Health Conditions

Medical conditions that may elevate GAD-7:

• Hyperthyroidism
• Cardiac arrhythmias
• Respiratory conditions (asthma, COPD)
• Chronic pain
• Caffeine or substance use

Approach:

• Rule out medical causes
• Treat medical conditions concurrently
• Still treat anxiety even if medical component present

Cultural Factors

• Expression of anxiety varies across cultures
• Somatic symptoms may be more prominent in some populations
• Use culturally validated versions when available
• Consider cultural context of worry themes

Age Considerations

• Adolescents: GAD-7 validated in teens
• Older adults: GAD-7 validated, account for medical comorbidity
• Children <12: Different screening tools recommended (SCARED, etc.)

Co-occurring Depression

• Anxiety and depression commonly co-occur
• Consider administering both GAD-7 and PHQ-9
• Integrated treatment often needed
• Treat both conditions concurrently

Substance Use

• Substance use/withdrawal can mimic anxiety
• Caffeine, stimulants increase anxiety symptoms
• Assess substance use in context
• May need substance use treatment

Item-Level Analysis

Items 1-3: Core Worry Symptoms

High scores on items 1, 2, 3 indicate core generalized anxiety features (nervousness, uncontrollable worry, excessive worry)

Items 4-5: Somatic/Motor Tension

High scores on items 4, 5 indicate physical manifestations (trouble relaxing, restlessness)

Items 6-7: Cognitive/Emotional Features

High scores on items 6, 7 may suggest:

• Item 6 (irritability): Common in anxiety, also seen in depression
• Item 7 (fear): May indicate panic features or specific fears

When GAD-7 Alone Is Insufficient

Additional assessment needed when:

• Severe anxiety (GAD-7 ≥15)
• Specific phobias suspected
• Panic attacks present
• Social anxiety prominent
• PTSD suspected
• Suicidal ideation (screen with PHQ-9 Item 9)
• Substance use concerns

References

Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097.