TL;DR: Summary

✅ Available on Bravely Connect

The GAD-7 is a self-report measure used to assess symptoms of generalised anxiety disorder. It consists of 7 questions that ask the client to report how often over the last two weeks they have been bothered by certain symptoms. The measure is scored out of a maximum of 21, with scores of 8 and above being recognized as the optimal cut-off for clinically relevant levels of anxiety. Research suggests that the GAD-7 is able to screen for generalised anxiety disorder and other anxiety disorders to a relatively good level of accuracy, however it’s not considered accurate for low-level anxiety. It has good reliability and criterion, construct, factorial, and procedural validity. The GAD-7 was developed based on the Patient Health Questionnaire (PHQ-9) and there are over 50 translations of the measure available.

Highlights

📏 Lengths: 7 questions (2-5 minutes)

📋 Administration: Self-Report

🎯 Uses: For monitoring symptoms of generalized anxiety, but can also be used for panic, social anxiety, and PTSD.

⚠️ Important Caveats: Not accurate for low-level anxiety

✅ Available in Bravely Connect? Yes

🌏 Culturally Applicable? No (Western-Centric)

💬 Translations? 50+

The GAD-7 Question type and length

The client is presented with 7 questions, and for each question the client is asked to report how often over the last two weeks they have been bothered by the problem.

All questions are statements with the same 4 subjective answers:

• Not at all

• Several Days

• More than half the days

• Nearly every day

For the full list of questions check out the measures on Bravely Connect, or follow the following link to the original unautomated version: GAD-7

What does the GAD-7 measure

The GAD-7 measures severity of anxiety symptoms. Research suggests that it’s able to screen for generalised anxiety disorder, but also a variety of other anxiety disorders to a relatively good level of accuracy.

GAD-7 Factor structure

In academic research, factor analyses have been conducted to identify what the underlying constructs are that the GAD-7 is measuring. Across two studies, traditional factor analyses have found a one-factor structure with all questions mapping onto anxiety. However, one of these studies found, via an exploratory graph analysis, a two-factor structure of cognitive-emotional and somatic anxiety. The most relevant symptoms within these factor structures were ‘worrying too much’ and ‘difficulty relaxing’.

The history and theory behind GAD-7

The GAD-7 was developed by Spritzer et al. as a brief measure for assessing generalised anxiety disorder. It was modelled based on the Patient Health Questionnaire (PHQ-9), which measures depression, and was developed because there was no brief clinical measure for assessing generalised anxiety disorder at the time.

They validated their measure in 15 primary care clinics in the United States based on a sample of 2740 adult patients. Criterion and construct validity were established by comparing the diagnoses made via their GAD self-report scale (GAD-7) with those made by independent mental health professionals, functional status measures, disability days, and health care use.

They found the measure to have good reliability, and criterion, construct, factorial, and procedural validity. In factor analyses, they found that generalised anxiety disorder and depression symptoms often co-occurred, but they were found to be distinct dimensions. They also found that the self-report nature of the questionnaire was in strong agreement with interview-administered versions of the scale.

Research has since suggested that the first 4 questions in the GAD-7 align well with anxious disorders, but this is less the case for the final 3 questions. On the back of this, an even shorter version of the GAD-7 was developed called the GAD-2, consisting of just 2 questions.

There are currently over 50 translations of the GAD-7 (find them here)

GAD-7 Scoring Interpretation

The following scores are given for each answer on the GAD-7:

• Not at all = 0

• Several Days = 1

• More than half the days = 2

• Nearly every day = 3

This means that the GAD-7 is scored out of a maximum of 21, with scores of 8 and above being recognised as the optimal cut-off to optimise sensitivity without compromising specificity for clinically relevant levels of anxiety. With this cut-off, there’s a sensitivity of 92% and a specificity of 76%.  Alternatively, a cut-off of 10 or greater has found a sensitivity of 89% with a specificity of 82% for generalised anxiety disorder. This cut-off can also be moderately useful when screening for other anxiety disorders.

For example, a cut-off of 10 has the following sensitivity-specificities:

• Panic Disorder: Sensitivity = 74%, specificity = 81%

• Social Anxiety Disorder: Sensitivity = 72%, specificity = 80%

• PTSD: Sensitivity = 66%, specificity = 81%

It’s important to note that further diagnostic assessment and clinical judgement is required to determine the presence of an anxiety disorder, along with the type of anxiety disorder. However, if you are wanting to track change over time, a meaningful change is 5 or more points on the GAD-7. If an individual has shown scores of less than 5 twice in a row, at least 2 weeks apart, then maintenance treatment may then be most appropriate.

The qualitative labels and their cut-offs provided for the GAD-7, though, are:

• Minimal Anxiety = 0-4

• Mild Anxiety = 5-9

• Moderate Anxiety = 10-14

• Severe Anxiety = 15+

Who developed the measures, licensing and how to obtain the GAD-7

The GAD-7 was developed by Dr Robert Spitzer, Dr Janet Willians, Dr Kurt Kroenke and Dr Bernd Löwe. The measure is freely available in the public domain, and no permission is required to reproduce, translate, display or distribute the measure.

The GAD-7 is available on Bravely Connect as part of our automated measures.

Limitations, biases and when you should/shouldn’t use the GAD-7

It is important to highlight that the GAD-7 was validated based on data gathered from 15 primary care clinics in the United States, meaning it’s a Western-centric measure. Although the GAD-7 has been used across a multitude of cultural groups, evidence suggests that the GAD-7 might not be a great fit for many cultures. The prevalence of GAD varies across ethnic/cultural groups, and researchers have argued that this could be due to cross-cultural measurement error rather than actual differences in the rates of GAD across cultures i.e. the GAD-7 has lower sensitivity in some cultures. This theory is supported by a study that found Black/African American people with high generalised anxiety disorder symptoms scores lower on the GAD-7 than participants with comparable symptoms. This suggests that until more culturally sensitive GAD screening tools are developed, the GAD-7 should be used with caution when applied outside of a Western context.

The GAD-7 is a measure that can be consistently used to establish the presence of anxiety disorders symptoms experienced in the last 2 weeks. Therefore, the GAD-7 should not be used to determine historical symptoms, as it’s a snapshot in time, and should instead be used consistently to determine clinically significant change. This means the GAD-7 is useful as a way of determining whether treatment is having a positive impact, and treatment planning.

The GAD-7 is also considered highly effective in identifying moderate to severe anxiety disorders, but is less reliable in identifying individuals with mild symptoms. Therefore, scores below close to the threshold for anxiety symptoms should still be considered in the context of clinical professional evaluations.

As always, if you’ve found a measure you would like adding to Bravely Connect as an automated measure, just drop us a measure request here.