Screening
As GAD is not uncommon, and the internalizing disorders (all anxiety, obsessive, and depressive disorders) are fairly common, there is a question as to whether one should screen for anxiety and depression. Screening is recommended in some parts of the world within specific demographic groups (see below).
A positive screening result suggests a probable diagnosis of an anxiety disorder, and requires further clinical evaluation, such as questioning on symptom persistence, associated distress, and functional impairment, to establish whether patients meet criteria for a formal diagnosis of GAD.[1] Validated screening instruments may be used as part of the diagnostic process, and may also be used for tracking symptom change over time with treatment.
Screening recommendations in different age groups
The US Preventive Services Task Force (USPSTF) recommends screening for anxiety disorders in all adults between the ages of 19 to 64, including pregnant and postpartum people. They conclude that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety disorders in older adults ages 65 and over.[62]
The USPSTF recommends screening for anxiety in all children and adolescents ages 8-18 years in primary care. They conclude that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety in children 7 years or younger.[63]
The Women’s Preventive Services Initiative (WPSI) in the US recommends primary care screening for anxiety disorders in all women and girls ages 13 years and older.[64]
In contrast, UK guidance from the National Institute for Health and Care Excellence (NICE) does not offer specific guidance on screening for anxiety in the nonpregnant population.[65]
Screening for anxiety in pregnancy
The prevalence of GAD is under-recognized throughout pregnancy and the postpartum period.
US guidance from The American College of Obstetricians and Gynecologists (ACOG) recommends that everyone receiving well-woman, prepregnancy, prenatal and postpartum care be screened for anxiety at multiple timepoints using the same standardized, validated screening instrument. An example mentioned by ACOG is the Generalized Anxiety Disorder-7 (GAD-7) score.[54]
UK guidelines from NICE recommend that clinicians consider using Generalized Anxiety Disorder-2 (GAD-2) to screen for anxiety symptoms. If a woman scores 3 or more on the GAD-2 scale, the GAD-7 can be used for further assessment.[53]
Other screening tools which may be used in pregnancy include the Edinburgh Postnatal Depression Scale three-item anxiety subscale (EPDS-3A), the Hospital Anxiety and Depression Scale anxiety subset (HADS-A), the State-Trait Anxiety Inventory (STAI), the Pregnancy-Related Anxiety Questionnaire-Revised 2 (PRAQ-R2), the Brief Measure of Worry Severity (BMWS), the Cambridge Worry Scale (CWS), and the Wijma Delivery Expectancy Questionnaire (W-DEQ).[66] Further research into the screening performance of anxiety scales during pregnancy and the postpartum period is needed.
Screening instruments: general considerations
Simple generalized instruments have been suggested for this.[64]
A reasonable approach is to use shorter instruments, such as the GAD-7 score.[67]
The following clinical instruments should be considered if the clinician has concerns about whether a person has GAD, or the severity of their GAD.
2-item Generalized Anxiety Disorder (GAD-2) score and 7-item Generalized Anxiety Disorder (GAD-7) score
For clinical use, shorter, more robust measures that are freely available are recommended.
GAD-7 is a validated diagnostic tool designed originally for use in primary care. Generalized Anxiety Disorder 7-item scale Opens in new window The first two questions of the GAD-7 make up the GAD-2, which can be used as a very short diagnostic tool. Generalized Anxiety Disorder 2-item Opens in new window Both are useful as screening methods, and as a way to track severity of anxiety symptoms over time.[68]
Hamilton anxiety rating scale (HAM-A)
A clinician-administered assessment of psychic and somatic anxiety symptoms, which are rated in severity from mild to severe. Hamilton Anxiety Rating Scale Opens in new window Used to assess the severity of anxiety after a clinical interview to confirm the diagnosis of GAD. It is often administered at 2-week intervals.
This scale predates the concept of GAD by two decades, and although it has been used consistently since the 1960s as an outcome measure for anxiety disorders in general, it is a more global measure.
Clinical global impression (CGI) scale
A standardized assessment tool in which a clinician assesses the rate of severity of the patient's illness on a 7-point scale over time.[69] Clinical Global Impression (CGI) scale Opens in new window The CGI scale can be used to rate the severity of anxiety at each clinical encounter.
Screening tools for use in children and adolescents
The screen for child anxiety-related emotional disorders (SCARED) is commonly used to evaluate anxiety symptoms in children and adolescents. The SCARED instrument is a 41-item inventory rated on a 3-point, Likert-type scale. Child and parent versions are also available. It has been shown to perform consistently well in community and clinical settings in various countries.[70] Screen for Child Anxiety Related Disorders (SCARED) Opens in new window
The Revised Child Anxiety and Depression Scale (R-CADS) also performs well for cross-cultural use and has subscales for parent- and child-reported symptoms.[71]
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