Screening for Anxiety Disorders Using GAD-7 Scoring Clinical Guide

This content is intended as a Quick Reference for screening for anxiety disorders (i.e. social anxiety) using GAD-7 and will cover an overview of the General Anxiety Disorder-7 scale & how it measures the severity of anxiety. 

Overview of GAD-7 Scoring

What is the GAD-7?

General Anxiety Disorder-7® and GAD-7® are registered trademarks of Pfizer, Inc (Spitzer et al., 2006). Pfizer is neither affiliated with nor endorses this course.

The Generalized Anxiety Disorder-7 (GAD-7) is a brief screening instrument designed to identify the presence of seven common symptoms of generalized anxiety disorder (GAD). It also has a moderate degree of sensitivity for detecting:

• Panic disorder
• Social anxiety disorder
• Posttraumatic stress disorder

The GAD-7 is more effective as a screening for GAD. A positive result on the GAD-7 suggests “probable” cases of GAD that should be further assessed. It is not meant to replace a clinical interview by a licensed mental health provider.

Why Do We Need GAD Scoring?

GAD has the lowest diagnostic reliability among the anxiety disorders (Johnson et al., 2019). It is often missed by clinicians despite it being one of the most common psychiatric disorders in the general population. These findings highlight the need for reliable and effective screening measures that can help clinicians recognize GAD in their clients.

Usefulness of the Tool

Although developed and initially validated with a primary care patient sample, the GAD-7 has since been studied and validated for use with many clinical populations, including:

• Acute psychiatry settings
• Pregnant and perinatal women
• People with epilepsy
• People suffering from migraines
• People with multiple sclerosis
• People diagnosed with substance use disorders

Many translations of the GAD-7 have been developed and are accessible on the PHQ Screener website. A link to the website can be found in the Resources section of this course.

Research examining the reliability and validity of the GAD-7 shows that it has good (Johnson et al., 2019; Toussaint et al., 2020):

• Internal consistency
• Test-retest reliability
• Construct validity
• Convergent validity
• Sensitivity to minimal clinical change over time

A review of the research recommended that the GAD-7 is also effective in identifying anxiety disorders after traumatic brain injury (Sapra et al., 2020; Zachar-Tirado & Donders, 2021).

Administering and GAD-7 Scoring

Administering the GAD-7

The instrument takes 5 to 10 minutes to administer and is designed to be self-administered, with the client completing the items themselves. Non-clinicians can also administer it. This is a plus for busy clinicians. The person rates how much they have been bothered by the symptom over the past 2-week period, using the following scale:

GAD Score Interpretation & Meaning

1. Not at all
2. Several days
3. More than half of the days
4. Nearly every day

Although the instrument uses a timeframe of 2 weeks, validity studies show that most people who score high on the GAD-7 have chronic symptoms (Johnson et al., 2019).

To administer the GAD-7, you have several convenient options available:

• Download and print a copy. You can get the instrument at no cost in the person’s chosen language and have them circle their responses directly onto the form. One benefit of this approach is that you can keep a copy of the completed screener for the person’s clinical record. A link to the PDF is in the Resource section of this course.
• Access the screener. The screener is available on the PHQ website, www.phqscreeners.com. Again, you can select the language preferred by the person. Scores cannot be entered directly into the website using this method, but you can easily calculate their score and record it in the person’s record.
• Download one of the free apps. Your client can search “GAD-7” on Google Play or the App Store on a smartphone or other device. The client can enter scores directly into the app, which calculates their total score. Some of these apps also allow clients to email a copy of the report, for example, to the prescribing provider, other members of the care team, or to themselves so that you can file it in their record. Some of the apps track the scores over time, which may be useful for treatment planning purposes.

Scoring the GAD-7

To score the GAD-7, simply add the values for each column, and then add each of those subtotals to arrive at a total score. The instrument yields a total score range of 0 to 21. Scores correspond to the following severity levels:

• 5 = Mild symptoms
• 10 = Moderate symptoms, considered a “yellow flag” suggesting a possibly significant issue with anxiety
• 15 = Severe symptoms, considered a “red flag” indicating that treatment for anxiety is warranted

Only trained clinicians should interpret a person’s score. A score of 10 is typically recommended as the cutoff for further evaluation of symptoms. Scores higher than 10 are often associated with greater levels of functional impairment. Recent research suggests even lower cutoff scores ranging from 7 to 10 may accurately identify those with GAD (Byrd-Bredbenner et al., 2021; Plummer et al., 2016).

A Guide to Assessment and Treatment

If the person rates any items as problematic (i.e., a rating other than 0), one additional question is asked: “How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?” This question is not used to compute the final score, but it does offer qualitative information about:

• The degree of a person’s impairment
• Treatment decisions

GAD-7 and Culture

When evaluating diverse populations, the impact of culture on the structure of the GAD-7 and how participants respond must be considered. Recent research studies have shown that the various adaptations of the GAD-7 for different cultures and languages are reliable and valid. Studies included adolescents and adults in countries such as (Adjorlolo, 2019; Ahn et al., 2019; Dhira et al., 2021; Budikayanti et al., 2019; Gong et al., 2021):

• Bangladesh
• Korea
• China
• Indonesia
• Ghana

Course Contributor

The content for this course was revised by Amanda L. Gayle, Ph.D.

Amanda Gayle received her Ph.D. in Counseling Psychology from the University of Tennessee. She completed a pre-doctoral internship at the University of Georgia in the Counseling and Testing Center. She also completed a post-doctoral fellowship at Duke University Medical Center in the Occupational Health Department working in both the internal and external employee assistance programs. She is licensed in North Carolina where she was in private practice for 15 years serving primarily adults in individual and couples counseling with many presenting issues. Her focus was on cognitive behavioral therapy to treat anxiety, mood disorders, grief, relationship difficulties, stress management, self-esteem, and parenting. She joined Relias as a subject matter expert writer for behavioral health in 2021.

Acknowledgment: Monique Kahn, Psy.D. was the previous author of this educational activity but did not participate in the revision of the current version of this course.

Resources

Translations of GAD-7 can be found here: https://www.phqscreeners.com/

PDF version of GAD-7 https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf

References

• Adjorlolo, S. (2019). Generalised anxiety disorder in adolescents in Ghana: Examination of the psychometric properties of the Generalised Anxiety Disorder-7 scale. African Journal of Psychological Assessment, 1(1).
• Ahn, J. K., Kim, Y., & Choi, K. H. (2019). The psychometric properties and clinical utility of the Korean version of GAD-7 and GAD-2. Frontiers in psychiatry, 10, 127.
• Budikayanti, A., Larasari, A., Malik, K., Syeban, Z., Indrawati, L. A., & Octaviana, F. (2019). Screening of generalized anxiety disorder in patients with epilepsy: Using a valid and reliable Indonesian version of generalized anxiety disorder-7 (GAD-7). Neurology research international, 2019.
• Byrd-Bredbenner, C., Eck, K., & Quick, V. (2021). GAD-7, GAD-2, and GAD-mini: Psychometric properties and norms of university students in the United States. General hospital psychiatry, 69, 61-66.
• Dhira, T. A., Rahman, M. A., Sarker, A. R., & Mehareen, J. (2021). Validity and reliability of the Generalized Anxiety Disorder-7 (GAD-7) among university students of Bangladesh. PloSone, 16(12), e0261590.
• Gong, Y., Zhou, H., Zhang, Y., Zhu, X., Wang, X., Shen, B., ... & Ding, Y. (2021). Validation of the 7-item Generalized Anxiety Disorder scale (GAD-7) as a screening tool for anxiety among pregnant Chinese women. Journal of affective disorders, 282, 98-103.
• Johnson, S. U., Ulvenes, P. G., Øktedalen, T., & Hoffart, A. (2019). Psychometric properties of the general anxiety disorder 7-item (GAD-7) scale in a heterogeneous psychiatric sample. Frontiers in psychology, 10, 1713.
• Plummer, F., Manea, L., Trepel, D., & McMillan, D. (2016). Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic meta-analysis. General Hospital Psychiatry, 39: 24-31.
• Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). Using generalized anxiety disorder-2 (GAD-2) and GAD-7 in a primary care setting. Cureus, 12(5).
• Spitzer, R.L., Kroenke, K., Williams, J.B.W., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder - The GAD-7. Archives of Internal Medicine.166:1092-1097.
• Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395- 401.
• Zachar-Tirado, C. N., & Donders, J. (2021). Clinical utility of the GAD-7 in identifying anxiety disorders after traumatic brain injury. Brain injury, 35(6), 655-660.