Screening Tools for Generalized Anxiety Disorder (GAD)
The GAD-7 (Generalized Anxiety Disorder-7) is the primary screening tool you should use to assess for GAD, with a score of ≥10 indicating moderate anxiety that warrants further diagnostic evaluation and potential treatment. 1, 2
Primary Screening Instrument
The GAD-7 is a 7-item self-report questionnaire that assesses anxiety symptoms over the past 2 weeks, asking patients to rate how often they've been bothered by problems such as feeling nervous, anxious, or on edge; being unable to stop or control worrying; worrying too much about different things; trouble relaxing; being so restless that it's hard to sit still; becoming easily annoyed or irritable; and feeling afraid as if something awful might happen. 1
Score interpretation follows a clear severity stratification: 0-4 indicates minimal or no anxiety, 5-9 indicates mild anxiety, 10-14 indicates moderate anxiety, and 15-21 indicates severe anxiety. 1, 2, 3
The GAD-7 demonstrates excellent diagnostic accuracy with 89% sensitivity and 82% specificity for detecting GAD at the recommended cut-off of ≥10. 4
Ultra-Brief Alternative Screening
The GAD-2 (first two items of the GAD-7) can serve as an initial ultra-brief screening tool, asking only about feeling nervous/anxious/on edge and being unable to stop or control worrying. 5
A GAD-2 score of ≥3 indicates the need for completing the full GAD-7 assessment, making it useful for time-constrained settings. 5
The GAD-2 has similar diagnostic accuracy to the full GAD-7 (sensitivity 68%, specificity 86% for detecting GAD), though the full GAD-7 provides more detailed severity assessment. 6
Action Thresholds Based on Scores
For GAD-7 scores of 0-4 (minimal symptoms):
- No intervention required beyond routine monitoring. 1
For GAD-7 scores of 5-9 (mild anxiety):
- Offer low-intensity interventions including education about GAD, active monitoring, guided self-help based on cognitive behavioral therapy principles, or group psychosocial interventions. 1
- Reassess in 2-4 weeks to monitor symptom progression. 7
For GAD-7 scores of 10-14 (moderate anxiety):
- Refer to psychology and/or psychiatry for formal diagnostic evaluation and treatment, as this severity level warrants specialist involvement. 1, 7
- Consider initiating pharmacologic treatment with SSRIs or SNRIs if specialist access is delayed. 1, 2
For GAD-7 scores of 15-21 (severe anxiety):
- Immediate referral to psychology/psychiatry is mandatory, with consideration of combined psychotherapy and pharmacotherapy. 1, 2
- Screen immediately for safety concerns including suicidal ideation, self-harm thoughts, severe agitation, or psychotic symptoms requiring emergency evaluation. 7
Essential Comorbidity Screening
Always administer the PHQ-9 (Patient Health Questionnaire-9) alongside the GAD-7 to screen for major depressive disorder, as depression co-occurs in approximately 31% of patients with anxiety disorders. 2
Systematically assess for alcohol or substance use/abuse, as this frequently complicates anxiety disorders and requires concurrent treatment. 7
Screen for other anxiety disorders including panic disorder and social phobia, as these commonly co-occur with GAD and require different management approaches. 1, 5
Additional Validated Assessment Tools
While the GAD-7 is the primary screening tool, other instruments may be useful in specific contexts:
The GAD-Q-IV (Generalized Anxiety Disorder Questionnaire-IV) is a 9-item self-report scale that assesses DSM-IV criteria for GAD including uncontrollable worry, functional impairment, physical symptoms, and subjective distress. 1
The Penn State Worry Questionnaire (PSWQ) with 16 items or abbreviated PSWQ-A with 8 items specifically assesses worry severity, the primary symptom of GAD, and can be scored continuously or dichotomously. 1
The Hospital Anxiety and Depression Scale (HADS) with 14 items provides separate anxiety and depression subscales, with scores ≥8 on the anxiety subscale indicating probable anxiety disorder; this tool excludes physical symptom items that may be confounded by medical illness. 1, 2
Critical Safety Assessment
Item 9 of the PHQ-9 regarding self-harm thoughts must never be omitted, as any positive response warrants immediate risk assessment regardless of total score. 2
Patients identified as at risk of harm to self or others require immediate referral for emergency psychiatric evaluation, with facilitation of a safe environment and one-to-one observation. 1
Common Pitfalls to Avoid
Do not miss comorbid depression—always screen with PHQ-9 or direct questioning about depressed mood and anhedonia, as GAD and major depression frequently co-occur. 7, 2
Do not overlook substance use disorders, which require concurrent treatment and complicate anxiety management. 7
Do not fail to rule out medical causes of anxiety symptoms including thyroid disorders, uncontrolled pain, delirium from infection or electrolyte imbalance, and medication side effects (particularly interferon, corticosteroids, and beta-blockers). 1, 2
Do not base treatment decisions on symptom severity alone—assess functional impairment across work, home responsibilities, and relationships to guide treatment intensity. 7, 2