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Useful screening tools for generalized anxiety and panic disorder

Clinical Question:
Are there any useful screening tools for the diagnosis of generalized anxiety or panic disorder in adults in the primary care setting?

Bottom Line:
The Generalized Anxiety Disorder 7-Item Scale (GAD-7) has the highest accuracy for the diagnosis of generalized anxiety disorder (GAD), and the Patient Health Questionnaire has the highest accuracy for the diagnosis of panic disorder. (LOE = 2a-)

Herr NR, Williams JW, Benjamin S, McDuffie J. Does this patient have generalized anxiety or panic disorder? The rational clinical examination systematic review. JAMA 2014;312(1):78-84.  [PMID:25058220]

Study Design:
Systematic review



These investigators searched multiple databases including MEDLINE, PsychINFO, the Cochrane Library, and bibliographies of systematic reviews for studies from general medical settings that evaluated self-report instruments for the diagnosis of GAD and panic disorder. Eligible studies included English-language reports of patients aged at least 18 years with validated GAD or panic disorder based on criteria from acceptable diagnostic gold standards (including the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases). Two reviewers independently assessed individual studies for inclusion criteria and methodologic quality using a standard study evaluation tool. Disagreements were resolved by consensus discussion with a third reviewer. A total of 12 publications representing 10 unique studies met inclusion criteria (N = 2785 for GAD; N = 2637 for panic disorder). Overall the studies had a low risk of significant bias. The prevalence of GAD was 10.1% (5.7% - 17%) and the prevalence of panic disorder was 8.8% (6.6% - 12%). For the diagnosis of GAD, the GAD-7 — using a cutoff point of greater than or equal to 10 — had a sensitivity of 89% and a specificity of 83%, and the highest positive likelihood ratio (LR+; 5.1 [4.3 - 6.0]). The GAD-7 also produced the lowest negative likelihood ratio (LR-; 0.13 [0.07-0.26]) for a score of less than 10. For the diagnosis of panic disorder, the Patient Health Questionnaire, using a positive response to all 5 questions, had a sensitivity of 81% and a specificity of 99%, the best LR+ (78 [29 – 210]), and the best LR- (0.20 [0.11 - 0.37]). The Beck Anxiety Inventory–Primary Care can identify patients with either GAD or panic disorder with an LR+ of 4.6 (2.3 - 8.9) and an LR- of 0.19 (0.05 - 0.68). The Primary Care Evaluation of Mental Disorders has the fewest number of questions (3) and easy literacy and, when using no positive responses, has the lowest LR- (0.12 [0.05 - 0.29]).


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