Identifying the Internalizing Disorder Clusters Among Recently Hospitalized Cardiovascular Disease Patients: A Receiver Operating Characteristics Study

Generalized Anxiety Disorder 7-item (GAD-7) and 2-item (GAD-2) scales for detecting anxiety disorders in adults

BACKGROUND

Anxiety disorders often remain undetected and can cause substantial burden. Amongst the many anxiety screening tools, the 7-item Generalized Anxiety Disorder (GAD-7) scale and its short version, the 2-item Generalized Anxiety Disorder (GAD-2) scale, are the most frequently used instruments.

OBJECTIVES

Primary: to determine the diagnostic accuracy of GAD-7 and GAD-2 to detect generalised anxiety disorder (GAD) and any anxiety disorder (AAD) in adults. Secondary: to investigate whether their diagnostic accuracy varies by setting, anxiety disorder prevalence, reference standard, and risk of bias; to compare the diagnostic accuracy of GAD-7 and GAD-2; to investigate how diagnostic performance changes with the test threshold.

SEARCH METHODS

We searched MEDLINE, Embase, PubMed-not-MEDLINE subset, and PsycINFO from 1990 to 18 January 2024. We checked reference lists of included studies and review articles.

SELECTION CRITERIA

We included cross-sectional studies conducted in adults, containing diagnostic accuracy information on GAD-7 and/or GAD-2 questionnaires for the target conditions generalised anxiety disorder and/or any anxiety disorder, and allowing the generation of 2x2 tables. The target conditions must have been diagnosed using a structured or semi-structured clinical interview. We excluded case-control studies and studies in which the time elapsed between the index tests and reference standards exceeded four weeks. We excluded studies involving people (1) seeking help in mental health settings or (2) recruited specifically due to mental health symptoms in other settings.

DATA COLLECTION AND ANALYSIS

At least two review authors independently decided on study eligibility, extracted data, and assessed the risk of bias and applicability of included studies. For each questionnaire and each target condition, we present sensitivity and specificity with 95% confidence intervals (95% CI) in forest plots. We used the bivariate model to obtain summary estimates based on cut-offs closest to the recommended values (i.e. within a core range). In secondary analyses, we used the bivariate model and the multiple thresholds model to obtain summary estimates for all available cut-off points. Using the multiple thresholds model, we also calculated the area under the receiver operating characteristic curve to obtain a general indicator of the diagnostic accuracy of GAD-7 and GAD-2.

MAIN RESULTS

We included 48 studies with 19,228 participants from 27 different countries, evaluating the GAD-7 and the GAD-2 in 24 different languages. Seven studies were performed in non-clinical settings, nine in clinical settings recruiting participants across conditions, and 32 in clinical settings with participants having specific conditions. Even after categorisation into three settings, the study populations were substantially different. The most frequently studied populations were people: with epilepsy (nine studies); with cancer (five studies); with cardiovascular disease (five studies); and in primary care regardless of their condition (five studies). We considered the risk of bias low in eight studies, and we had low concerns about the applicability of findings in three studies. Thirty-five studies contributed to the primary analyses of GAD-7 for detecting generalised anxiety disorder (median prevalence 12%); 22 studies to analyses of GAD-7 for any anxiety disorder (median prevalence 19%); 24 studies to analyses of GAD-2 for generalised anxiety disorder (median prevalence 9%); and 19 studies to analyses of GAD-2 for any anxiety disorder (median prevalence 19%). At the recommended cut-off of 10 or higher (or the closest available cut-off), the GAD-7 questionnaire yielded a summary sensitivity of 0.64 (95% CI 0.56 to 0.72) and a summary specificity of 0.91 (95% CI 0.87 to 0.93) in detecting generalised anxiety disorder. For detecting any anxiety disorder, summary sensitivity was 0.48 (95% CI 0.40 to 0.57) and summary specificity 0.91 (95% CI 0.89 to 0.93). At the recommended cut-off of 3 or higher (or the closest available cut-off), the GAD-2 yielded a summary sensitivity of 0.68 (95% CI 0.59 to 0.75) and a summary specificity of 0.86 (95% CI 0.82 to 0.89) for detecting generalised anxiety disorder. For detecting any anxiety disorder, the summary sensitivity was 0.53 (95% CI 0.44 to 0.62) and the summary specificity was 0.89 (95% CI 0.86 to 0.91). The 95% prediction region of GAD-7 for detecting generalised anxiety disorder was larger (indicating pronounced statistical heterogeneity) than for the three other analyses. Specificity varied by setting in the analysis of GAD-7 and GAD-2 for detecting any anxiety disorder, and by reference standard in the analysis of GAD-2 for detecting generalised anxiety disorder. Sensitivity varied with prevalence in the analysis of GAD-7 for generalised anxiety disorder. Other investigations of potential sources of heterogeneity did not show statistically significant associations with test accuracy. In all analyses, sensitivity tended to be higher and specificity lower in participants with specific conditions compared to the other two settings. Overall, the heterogeneity in the subgroup analyses remained high. The area under the receiver operating characteristic curve in the multiple thresholds model was 0.86 (95% CI 0.84 to 0.88) for the GAD-7 scale in detecting generalised anxiety disorder, and 0.80 (95% CI 0.78 to 0.82) in detecting any anxiety disorders. For the GAD-2 scale, the value was 0.82 (95% CI 0.81 to 0.86) for detecting generalised anxiety disorder, and 0.77 (95% CI 0.76 to 0.82) for detecting any anxiety disorders. Comparative bivariate analyses revealed no statistically significant differences between the diagnostic test accuracy of GAD-7 and GAD-2.

AUTHORS' CONCLUSIONS

The GAD-7 and the GAD-2 scales have been tested in numerous languages and different populations. Overall, the GAD-7 and the GAD-2 seem to have acceptable or good diagnostic accuracy for both generalised anxiety disorder and any anxiety disorder. The GAD-2 scale seems to have similar diagnostic accuracy as the GAD-7 scale. However, due to the diversity of the included studies and the heterogeneity of our findings, our summary estimates of sensitivity and specificity should be interpreted as rough averages. The performance of GAD-7 and GAD-2 may deviate substantially from these values in specific situations.

Transdiagnostic Cognitive-Behavioral Therapy for Depression and Anxiety Disorders in Cardiovascular Disease Patients: Results From the CHAMPS Pilot-Feasibility Trial

OBJECTIVE

The aim of the Cardiovascular Health in Anxiety and Mood Problems Study (CHAMPS) is to pilot the Unified Protocol (UP) for the transdiagnostic treatment of depression and anxiety disorders in patients recently hospitalized for cardiovascular diseases (CVDs) and evaluate the feasibility.

METHODS

The present study is a controlled, block randomized pragmatic pilot-feasibility trial incorporating qualitative interview data, comparing UP (n = 9) with enhanced usual care (EUC, n = 10). Eligible trial participants had a recent CVD-cause admission and were above the severity threshold for depression or anxiety denoted by Patient Health Questionnaire (PHQ-9) total scores ≥10 and/or Generalized Anxiety Disorder (GAD-7) total scores ≥7 respectively on two occasions, and met criteria for one or more depression or anxiety disorders determined by structured clinical interview. Study outcomes were analyzed as intention-to-treat using linear mixed models and qualitative interview data were analyzed with content analysis.

RESULTS

Quantitative and qualitative measured indicated acceptability of the transdiagnostic CBT intervention for CVD patients with depression or anxiety disorders. Satisfaction with UP was comparable to antidepressant therapy and higher than general physician counseling. However, there were difficulties recruiting participants with current disorders and distress on two occasions. The UP was associated with a reduction in total number of disorders determined by blinded raters. Linear mixed models indicated that a significantly greater reduction in anxiety symptoms was evident in the UP group by comparison to the EUC group (GAD-7, p between groups = 0.011; Overall Anxiety Severity and Impairment Scale, p between groups = 0.013). Results favored the UP group by comparison to EUC for change over 6 months on measures of physical quality of life and harmful alcohol use. There was no difference between the two groups on changes in depression symptoms (PHQ-9), stress, metacognitive worry beliefs, physical activity, or adherence.

DISCUSSION

In conclusion, this feasibility trial indicates acceptability of transdiagnostic CBT intervention for CVD patients with depression or anxiety disorders that is tempered by difficulties with recruitment. Larger trials are required to clarify the efficacy of transdiagnostic depression and anxiety disorder CBT in populations with CVDs and depressive or anxiety disorders.

CLINICAL TRIAL REGISTRATION

https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12615000555550, identifier: ACTRN12615000555550.