The assessment should determine: which anxiety disorders are present; what other conditions (e.g., depression, substance abuse and pain) accompany it, which treatments have been tried in the past, and what the patient expects of treatment. While performing a comprehensive diagnostic interview is not practical, asking a single question for each of the four common anxiety disorders, is simple, quick and sensitive(18
). Asking two simple questions about mood and anhedonia for depression (a positive answer to either suggests major depression) may be as effective as using longer instruments(19
). The 3-item AUDIT-C is highly sensitive for problem alcohol use(21
), with cutoff scores of 6 for men and 4 for women indicating problem use, and a single 0-10 analogue item asking about pain has been previously validated(22
). This brief screening battery (Appendix 1
) will suggest how many of the four anxiety disorders are present, and if major depression, problem alcohol use, or chronic pain are also issues. Patients screening positive for panic attacks might have them cued by social situations (social anxiety) or traumatic memories (PTSD) so a follow up question about whether they occur when the individual is alone and were unexpected can be useful in clarifying whether panic disorder is present.
All anxious patients, whether or not they also have depression, should be assessed for current thoughts of active self harm, passive thoughts of being “better off dead”, and a history of suicide attempts(23
). Ask patients with suicidal thoughts whether they have a plan, access to means (i.e., firearms, stockpiled medications), or “reasons for living” that would stop them from acting (24
). Caution them that substance abuse increases risk for suicide. Patients unable to both contract for safety and agree to a specific safety plan should be referred to mental health professionals for evaluation.
A patient who has failed to respond to several antidepressants and has a mixture of anxiety and depressive symptoms could be suffering from unrecognized bipolar illness(25
). Such patients may also complain of overstimulation with antidepressants and may report brief positive responses to these agents that rapidly wane. This is a difficult diagnosis to make since it often requires multiple observations over a period of time to confirm retrospective reports of mood fluctuations. Patients endorsing less than 7 of 13 yes/no items on The Mood Disorder Questionnaire(26
) are highly unlikely to have bipolar illness but scores greater than 7 detect less than half the cases(27
). Hence, consultation with a psychiatrist is usually the most prudent option.
Anxiety severity can be measured with the GAD-7 scale, modeled after the now familiar PHQ-9 scale for depression(28
). A score above 10 suggests sufficient anxiety severity to consider treatment. Though this scale contains six GAD items and one panic disorder specific item, patients with other anxiety disorders also score high on this (see scale at http://www.healthandage.com/public/health-center/7/article/3308/gm=20!gid2=3129
). For measurement of functional impairment due to anxiety, the five-item Overall Anxiety Severity and Impairment Scale(30
) is ideal. It measures, in addition to the frequency and intensity of anxiety, the degree of avoidance, and interference with work, and social function, and has a cut-off score of 8 for clinically significant anxiety (see Appendix 2
). Once done at baseline, these scales should be used to monitor treatment outcome on subsequent visits, since multiple studies show that outcome improves with ongoing monitoring of treatment(32
Ask patients whether they’ve had medication or psychotherapy treatment in the past for their anxiety and how helpful it has been. Since there are no standardized scales to determine this, ask whether a treatment has helped a little, moderately, or a lot (i.e. returned them to their prior state). These questions correspond to frequently used measures in medication trials of “partial response” (25% improvement), “response” (50% improvement) and remission (75-100% improvement)(34
). It is also important to know if treatment was stopped because of side-effects, and the nature of these. This is critical for anticipating problems with adherence. Finally, ask two simple questions about how much on a scale of 0-10 (none-definitely) the patient thinks treatment might work (“outcome expectancy”) and how confident they are they can help the treatment along (self-efficacy expectancy). Both these measures are powerful determinants of whether patients remain in treatment and whether they improve (35
). If any problems with treatment adherence arise, these measures can be used productively in a follow-up counseling session with the physician or non-MD team members, employing the motivational interviewing approach outlined below.