The GAD-7 has the best evidence and utility in the primary care setting for generalized anxiety disorder (strength of recommendation [SOR]: A), while the proprietary Quick PsychoDiagnostics Panel (QPD) has the best operating characteristics for panic disorder (SOR: B)

Hallgren, John D.

Morton, Jacquelyn R.

University of Missouri: MOspace

	 vol	56,	No	7	/	july	2007	 579www.jfponline.comCliniCal INquIrIes From the Family Physicians Inquiries Networkfast trackThe GAD-7 is  an effective screening tool  for anxiety  and is in  the public domain; for a printable copy, click on this article at www.jfponline.com  What’s the best way to screen for anxiety and panic disorders?John D. Hallgren, MDUniformed Services University of the Health Sciences, RAF Menwith Hill, UKJacquelyn R. Morton, MlSAmgen Inc, Thousand Oaks, Calif The	GAD-7	has	the	best	evidence	and	utility	in	the	primary	care	setting	for	generalized	anxiety	disorder	(strength	of	recommendation	[sor]:	A),	while	the	proprietary	quick	PsychoDiagnostics	Panel	(qPD)	has	the	best	operating	characteristics	for	panic	disorder		(sor:	B).These time-saverscan narrow the optionsThe	family	physician’s	office	is	awash	with	psychosocial	problems—sometimes	intertwined	with	physical	illness,	sometimes	just	noted	as	a	smoldering	comorbidity.	Clearly,	when	you	strongly	suspect	a	patient’s	chief	complaint	is	due	to	anxiety	or	panic,	a	focused	interview	that	adheres	to	Diagnostic and Statistical Manual of Mental Disorders,	4th	ed	(DSM-IV)	is	the	gold	standard	for	making	the	diagnosis.	However,	validated	questionnaires	are	helpful	time	savers	in	a	busy	practice	and	they	assure	a	certain	baseline	level	of	thoroughness.	They	are	also	helpful	in	narrowing	the	diagnostic	options	when	the	presenting	complaint	is	vague	and	multiple	diagnoses	are	being	entertained.Jon O. neher, MDvalley	Family	Medicine,	renton,	WashClinical commentaryEvidence-based answerz Evidence summaryAll diagnoses of generalized anxiety dis-order and panic disorder are clinical; they require the clinician’s judgment of objective findings. This Clinical Inquiry assesses the accuracy of case finding for these disorders, using screening tools, against the reference standard of a struc-tured interview established by the crite-ria of the DSM-IV. The TablE compares the tools dis-cussed here. Sensitivity, specificity, and likelihood ratios are calculated according to the authors’ designated cut points for the tools’ scores.None of the authors recommend us-ing these tools alone to make a diagnosis; clinicians must combine these instruments with an office interview to establish their diagnosis.GaD-7 tool is brief  and in the public domainFor diagnosing generalized anxiety disor-der, the GAD-7 has the best evidence for its utility. It was studied in a large, primary care–based sample size, is brief, and is in the public domain. It has a positive likelihood ratio of 4.9 (ie, the odds that a person has generalized anxiety disorder are 4.9 times higher if the GAD-7 is positive).1 The Anxiety Screening Question-naire (ASQ-15) also has good likelihood ratios, but the sample population was Copyright® Dowden Health Media  For per onal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.fast track580 vol	56,	No	7	/	july	2007		ThE JournAl of fAmily PrACTiCECliniCal INquIrIes table How the anxiety and panic disorder screening tools stack upDisEAsE Tool sn (%) sp (%) lr+ lr– sAmPlE sizEGeneralized anxiety GAD-71	 89	 82	 4.9	 0.13	 965	disorder	 Asq-152	 93	 96	 23.3	 0.07	 250	 qPD3	 79	 90	 7.9	 0.23	 203Panic disorder	 qPD3	 71	 97	 23.7	 0.30	 203		 MHI-54	 100	 65	 2.9	 0	 246		 PDsr5	 89	 100	 ∞	 0.11	 139sn,	sensitivity;	sp,	specificity;	lr+,	positive	likelihood	ratio;	lr–,	negative	likelihood	ratio.small, selected, and over half of the sub-jects were from a psychiatric practice.2 The QPD has similar likelihood ratios to the GAD-7, but it requires purchase of proprietary software, and the supporting evidence is based on a small, selected, and compensated study group.3 likelihood ratios are good  for QPD and panic disorderPanic disorder research yielded 3 screen-ing tools: QPD, the Mental Health Index 5 (MHI-5), and the Panic Disorder Self-Report (PDSR).• The QPD reports an excellent posi-tive likelihood ratio and good negative likelihood ratio for panic disorder. As mentioned above, these results are limited by the quality of its sample size and the expense.3 • The MHI-5 screens for panic disor-der with a single item taken from a larger questionnaire for panic disorder and de-pression. It has 100% sensitivity but a poor positive likelihood ratio. The sample size was very small—only 9 persons with panic disorder were tested.4 • The PDSR shows 100% specificity at the recommended cut-off point and a good negative likelihood ratio. Its weak-nesses are a small study size, the homoge-neity of the study population, who were self-selected, as well as the lengthiness of the questionnaire.5 Recommendations from othersA clinical practice guideline from the Na-tional Institute for Health and Clinical Excellence (UK) recommends a screening tool and structured interview or clinician consultation to establish a DSM-IV di-agnosis for anxiety disorders. It reviews several ratings scales without grading utility or accuracy.6 The American Psychiatric Associa-tion has one guideline specifically ad-dressing panic disorder, with a short paragraph describing the use of the DSM-IV via a structured interview to es-tablish the diagnosis.7  nreferences	 1.	 	spitzer	rl,	Kroenke	K,	Williams	jB,	lowe	B.	A	brief	measure	for	assessing	generalized	anxiety	disorder:	the	GAD-7.	Arch Intern Med	2006;	166:1092–1097.		 2.	 	Wittchen	Hu,	Boyer	P.	screening	for	anxiety:	sensi-tivity	and	specificity	of	the	Anxiety	screening	ques-tionnaire	(Asq-15).	Br J Psychiatry	1998;	173(suppl	34):10–17.		 3.	 	shedler	j,	Beck	A,	Bensen	s.	Practical	Mental	Health	Assessment	 in	Primary	Care:	 validity	 and	utility	 of	the	 quick	 PsychoDiagnostics	 Panel.	 J Fam Pract 2000;	49:614–621.	 4.	 	Means-Christensen	Aj,	Arnau	rC,	Tonidandel	AM,	Bramson	 r,	Meagher	MW.	 An	 efficient	method	 of	identifying	major	 depression	 and	 panic	 disorder	 in	primary	care.	J Behav Med 2005;	28:565–72.		 5.	 	Newman	MG,	Holmes	M,	Zuellig	Ar,	Kachin	Ke,	Be-har	e.	The	reliability	and	validity	of	the	panic	disorder	self-report:	a	new	diagnostic	screening	measure	of	panic	disorder.	Psychol Assess	2006;	18:49–61.	 6.	 	Clinical	Guidelines	 for	 the	Management	of	Anxiety:	Management	of	Anxiety	(panic	disorder,	with	or	with-out	agoraphobia	and	generalised	anxiety	disorder).	london,	 england:	National	 Institute	 for	Health	 and	Clinical	 excellence;	 Dec	 2006.	 Available	 at:	 www.nice.org.uk/guidance/CG22.	Accessed	on	june	14,	2007.	 7.	 	Practice	Guideline	for	the	Treatment	of	Patients	with	Panic	Disorder.	Arlington,	virginia:	American	Psychi-atric	 Association,	 May	 1998	 (updated	 April	 2006).	Available	at:	www.psych.org/psych_pract/treatg/pg/prac_guide.cfm.	Accessed	on	june	14,	2007.The QPD panel  has the best  characteristics  for diagnosing panic disorder 

What's the best way to screen for anxiety and panic disorders?

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