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The Generalized Anxiety Disorder Severity Scale (GADSS) is a validated measure of Generalized Anxiety Disorder symptom severity. Given the high prevalence of Generalized Anxiety Disorder (GAD) in the elderly and the need for a validated scale to assess GAD severity in this age group, we examined the psychometric properties of the GADSS in the elderly.
Design, Setting, Participants
We examined a sample of 134 elderly subjects (age 60 and above) who met diagnostic criteria for current GAD, 33 healthy elderly comparison subjects (age 60 and above) and 186 younger subjects (age 18 to 60) diagnosed with GAD.
The GADSS had a high internal consistency in the elderly subjects (raw Cronbach’s alpha =0.76). Pearson correlations showed a significant positive correlation between GADSS, Hamilton Rating Scale for Anxiety and Penn State Worry Questionnaire. Pearson correlations showed an inverse significant correlation between GADSS and the Medical Outcome Study SF-36. There was no correlation between GADSS and Mini Mental State Examination or Cumulative Illness Rating Scale for Geriatrics.
The results showed a good convergent, concurrent and discriminant validity of the GADSS when used for elderly with GAD. We conclude that GADSS is a valid measure of GAD symptom severity in older adults.
PMCID: PMC2803316  PMID: 18827227
Generalized Anxiety Disorder; Elderly; Severity Scale
2.  Pain Adversely Affects Outcomes to a Collaborative Care Intervention for Anxiety in Primary Care 
Primary care patients with Panic Disorder (PD) and Generalized Anxiety Disorder (GAD) experience poorer than expected clinical outcomes, despite the availability of efficacious pharmacologic and non-pharmacologic treatments. A barrier to recovery from PD/GAD may be the co-occurrence of pain.
To evaluate whether pain intensity interfered with treatment response for PD and/or GAD in primary care patients who had received collaborative care for anxiety disorders.
A secondary data analysis of a randomized, controlled effectiveness trial comparing a telephone-delivered collaborative care intervention for primary care patients with severe PD and/or GAD to their doctor’s “usual” care.
Patients had to have a diagnosis of PD and/or GAD and a severe level of anxiety symptoms. The 124 patients randomized at baseline to the collaborative care intervention were analyzed. Participants were divided into two pain intensity groups based on their response to the SF-36 Bodily Pain scale (none or mild pain vs. at least moderate pain).
Pain was assessed using the Bodily Pain scale of the SF-36. Anxiety symptoms were measured with the Hamilton Anxiety Rating Scale (HRS-A), Panic Disorder Severity Scale (PDSS) and Generalized Anxiety Disorder Severity Scale (GADSS). Measures were collected over 12 months.
At baseline, patients with at least moderate pain were significantly more likely to endorse more anxiety symptoms on the HRS-A than patients with no pain or mild pain (P < .001). Among patients with severe anxiety symptoms, 65 % (80/124) endorsed experiencing at least moderate pain in the previous month. A significantly lesser number of patients achieved a 50 % improvement at 12 months on the HRS-A and GADSS if they had at least moderate pain as compared to patients with little or no pain (P = 0.01 and P = 0.04, respectively).
Coexisting pain was common in a sample of primary care patients with severe PD/GAD, and appeared to negatively affect response to anxiety treatment.
PMCID: PMC3539032  PMID: 22878857
panic disorder; generalized anxiety disorder; pain; collaborative care; clinical trial
3.  Information Processing Bias and Pharmacotherapy Outcome in Older Adults with Generalized Anxiety Disorder 
Journal of anxiety disorders  2012;27(6):592-597.
Information processing bias was evaluated in a sample of 25 older adults with generalized anxiety disorder (GAD) over the course of 12 weeks of escitalopram pharmacotherapy. Using the CANTAB Affective Go/No Go test, treatment response (as measured by the Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, and Generalized Anxiety Disorder Severity Scale) was predicted from a bias score (i.e., difference score between response latencies for negative and positive words) using mixed-models regression. A more positive bias score across time predicted better response to treatment. Faster responses to positive words relative to negative words were associated with greater symptomatic improvement over time as reflected by scores on the GADSS. There was a trend towards significance for PSWQ scores and no significant effects related to HAMA outcomes. These preliminary findings offer further insights into the role of biased cognitive processing of emotional material in the manifestation of late-life anxiety symptoms.
PMCID: PMC3605197  PMID: 23245629
Generalized Anxiety Disorder; Aging; Attention; Information Processing Bias; Escitalopram
4.  The Pittsburgh Sleep Quality Index in Older Primary Care Patients with Generalized Anxiety Disorder: Pyschometrics and Outcomes Following Cognitive Behavioral Therapy 
Psychiatry research  2012;199(1):24-30.
The Pittsburgh Sleep Quality Index (PSQI) is a widely used, comprehensive self-report measure of sleep quality and impairment, which has demonstrated good psychometric properties within various populations, including older adults. However, the psychometric properties of the PSQI and its component scores have not been evaluated for older adults with generalized anxiety disorder (GAD). Additionally, changes in PSQI global or component scores have not been reported following cognitive-behavioral treatment (CBT) of late-life GAD. This study examined (1) the psychometric properties of the PSQI within a sample of 216 elderly primary care patients age 60 or older with GAD who were referred for treatment of worry and/or anxiety; as well as (2) response to CBT, relative to usual care, for 134 patients with principal or coprincipal GAD. The PSQI demonstrated good internal consistency reliability and adequate evidence of construct validity. Those receiving CBT experienced greater reductions in PSQI global scores at post-treatment, relative to those receiving usual care. Further, PSQI global and domain scores pertaining to sleep quality and difficulties falling asleep (i.e., sleep latency and sleep disturbances) demonstrated response to treatment over a 12-month follow-up period. Overall, results highlight the usefulness of the PSQI global and component scores for use in older adults with GAD.
PMCID: PMC3401329  PMID: 22503380
Pittsburgh Sleep Quality Index; psychometrics; generalized anxiety disorder; elderly; cognitive behavioral therapy
5.  Treating late-life GAD in primary care: An effectiveness pilot study 
To increase sustainability of Cognitive Behavior Therapy (CBT) in primary care for late-life anxiety, we incorporated non-expert counselors, options for telephone meetings, and integration with primary care clinicians.
This open trial examines the feasibility, satisfaction and clinical outcomes of CBT delivered by experienced and non-experienced counselors for older adults with generalized anxiety disorder (GAD). Clinical outcomes assessed worry (Penn State Worry Questionnaire), GAD (Generalized Anxiety Disorder Severity Scale), and anxiety (Beck Anxiety Inventory and Structured Interview Guide for Hamilton Anxiety Scale).
Following 3 months of treatment, Cohen’s d effect sizes for worry and anxiety ranged from .48 to .78. Patients treated by experienced and non-experienced counselors had similar reductions in worry and anxiety, although treatment outcomes were more improved on the Beck Anxiety Inventory for experienced therapists.
Preliminary results suggest adapted CBT can effectively reduce worry. The piloted modifications can provide acceptable and feasible evidence-based care.
PMCID: PMC3644354  PMID: 23588228
cognitive behavioral therapy; generalized anxiety disorder; primary care; older adults; mental health
6.  Symptomatic Severity of Prime-MD Diagnosed Episodes of Panic and Generalized Anxiety Disorder in Primary Care 
Panic disorder (PD) and generalized anxiety disorder (GAD) are often unrecognized by primary care physicians (PCPs). The Primary Care Evaluation of Mental Disorders (PRIME-MD) has been used as a case-finding instrument for depression. Yet, little is known on its usefulness as a case-finding tool for anxiety disorders within the context of a clinical trial.
To examine the: (1) completion rate of the PRIME-MD by patients approached to enroll in a treatment study for PD and GAD; (2) distribution of anxiety diagnoses generated; (3) severity of PD and GAD episodes thus identified; and (4) level of PCPs' agreement with these diagnoses.
Cross-sectional interview.
Individuals aged 18 to 64 who presented for care at 4 primary care practices.
The PRIME-MD, Structured Interview Guide for the Hamilton Anxiety Rating Scale (SIGH-A), and the Panic Disorder Severity Scale (PDSS).
Of the 6,700 patients who completed the PRIME-MD Patient Questionnaire (PQ), 2,926 (44%) screened positive for an anxiety disorder, and 1,216 (42%) met preliminary study eligibility and consented to the PRIME-MD Anxiety Module. Of these, 619 (51%) had either GAD (308), PD (94), or both (217) disorders. Later, 329 completed a telephone interview. Of these, 59% with GAD and 68% with PD reported moderate or greater levels of anxiety symptoms on the SIGH-A and PDSS, respectively, and PCPs agreed with the PRIME-MD diagnosis for 98% of these patients.
The PRIME-MD can efficiently screen patients for PD and GAD. Although patients thus identified endorse a wide range of anxiety symptoms, PCPs often agree with the diagnosis.
PMCID: PMC1490149  PMID: 16050857
anxiety; panic; generalized anxiety disorder; primary care; electronic medical record system
7.  A Web-Based Screening Instrument for Depression and Anxiety Disorders in Primary Care 
Major depressive disorder (MDD) and anxiety disorders are common and result in considerable suffering and economic loss. People suffering from major depressive disorder and/or anxiety disorders are commonly encountered in the primary care setting. Unfortunately, most people with these disorders remain either untreated or inadequately treated; current data suggest that general practitioners fail to diagnose up to half of cases of major depressive disorder or anxiety. There is a need for screening tools that will help physicians and other professionals in primary care recognize and adequately treat major depressive disorder and anxiety disorders. While the currently-available self-report screening instruments have been demonstrated to be reliable and valid, there remain considerable barriers to their widespread use in primary care.
The purpose of the present study is to report preliminary validation data for a freely-available, brief, Web-based, self-report screener for major depressive disorder and anxiety disorders.
The Web-Based Depression and Anxiety Test (WB-DAT) was administered to 193 subjects who presented for assessment and/or treatment in ongoing research projects being conducted at the Mood and Anxiety Program and Clinical Research Department at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada. Subjects completed the Web-based screening instrument and were subsequently interviewed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Axis I Disorders (SCID-I/P). The diagnostic data from the screening instrument were then compared with the data from the individual's SCID-I/P interview. Diagnostic concordance between SCID-I/P diagnoses and the Web-Based Depression and Anxiety Test were assessed using Cohen's kappa, sensitivity, specificity, positive predictive value, negative predictive value, and efficiency.
Agreement ranged from acceptable to good (0.57-0.70) for major depressive disorder, panic disorder with and without agoraphobia (PD+/-AG), social phobia/social anxiety disorder, obsessive compulsive disorder (OCD), generalized anxiety disorder (GAD), and post traumatic stress disorder (PTSD). With the exception of generalized anxiety disorder, the sensitivity (0.71-0.95) and specificity (0.87-0.97) for the major diagnostic categories assessed by the Web-Based Depression and Anxiety Test were good. The sensitivity for generalized anxiety disorder was somewhat lower (0.63) but acceptable. Positive predictive values were good (0.60-0.75) for major depressive disorder, obsessive compulsive disorder, generalized anxiety disorder, and post traumatic stress disorder, and acceptable for panic disorder with and without agoraphobia and for social phobia/social anxiety disorder.
These preliminary data suggest that the Web-Based Depression and Anxiety Test is reliable for identifying patients with and without major depressive disorder and the anxiety disorders of panic disorder with and without agoraphobia, social phobia/social anxiety disorder, obsessive compulsive disorder, and post traumatic stress disorder. Further research is required in a larger sample in primary care.
PMCID: PMC1550568  PMID: 14517114
depression; anxiety disorders; assessment of health care needs; screening; web-based services; treatment; primary care; diagnosis; mental health
8.  The 7-Item Generalized Anxiety Disorder Scale as a Tool for Measuring Generalized Anxiety in Multiple Sclerosis 
Background: Generalized anxiety disorder (GAD) is common in multiple sclerosis (MS) but understudied. Reliable and valid measures are needed to advance clinical care and expand research in this area. The objectives of this study were to examine the psychometric properties of the 7-item Generalized Anxiety Disorder Scale (GAD-7) in individuals with MS and to analyze correlates of GAD.
Methods: Participants (N = 513) completed the anxiety module of the Patient Health Questionnaire (GAD-7). To evaluate psychometric properties of the GAD-7, the sample was randomly split to conduct exploratory and confirmatory factor analyses.
Results: Based on the exploratory factor analysis, a one-factor structure was specified for the confirmatory factor analysis, which showed excellent global fit to the data (χ212 = 15.17, P = .23, comparative fit index = 0.99, root mean square error of approximation = 0.03, standardized root mean square residual = 0.03). The Cronbach alpha (0.75) indicated acceptable internal consistency for the scale. Furthermore, the GAD-7 was highly correlated with the Hospital Anxiety and Depression Scale–Anxiety (r = 0.70). Age and duration of MS were both negatively associated with GAD. Higher GAD-7 scores were observed in women and individuals with secondary progressive MS. Individuals with higher GAD-7 scores also endorsed more depressive symptoms.
Conclusions: These findings support the reliability and internal validity of the GAD-7 for use in MS. Correlational analyses revealed important relationships with demographics, disease course, and depressive symptoms, which suggest the need for further anxiety research.
PMCID: PMC4399767  PMID: 25892974
9.  Assessment of Anxiety in Older Home Care Recipients 
The Gerontologist  2009;49(2):141-153.
Purpose: This study determined the psychometric properties of a variety of anxiety measures administered to older adults receiving home care services. Design and Methods: Data were collected from 66 adults aged 65 years and older who were receiving home care services. Participants completed self-report and clinician-rated measures of anxiety and diagnostic interviews for generalized anxiety disorder (GAD). Results: Most measures demonstrated acceptable psychometric properties. All of the measures showed excellent interrater reliability to support verbal administration, which is the typical mode of assessment in home care. The ease of use for each measure (e.g., time of administration) was also evaluated. The Geriatric Anxiety Inventory (GAI) demonstrated the strongest and the Beck Anxiety Inventory the weakest psychometric properties. The GAI and the GAD screening questions from The Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) demonstrated the greatest utility in screening for anxiety disorders (either GAD or anxiety disorder not otherwise specified). Implications: These data support the use of anxiety measures within a geriatric home care setting. The strengths and weaknesses of each measure are discussed to facilitate selection of the optimal measure depending upon assessment goals and available resources.
PMCID: PMC2667674  PMID: 19363010
Anxiety; Home care; Assessment
10.  Cognitive Behavior Therapy for Generalized Anxiety Disorder Among Older Adults in Primary Care: A Randomized Clinical Trial 
Jama  2009;301(14):1460-1467.
Cognitive behavior therapy (CBT) is effective for late-life generalized anxiety disorder (GAD), but, only pilot studies have been conducted in primary care, where older adults most often seek treatment. .
To examine effects of CBT relative to enhanced usual care (EUC) in older adults with GAD in primary care.
Design, Setting, and Participants
A randomized clinical trial with 134 older adults (mean age, 66.9 years) recruited from March 2004 to August 2006 in two primary care settings. Treatment was provided for 3 months; assessments were conducted at baseline, post-treatment (3 months), and over a 12-month follow-up (6, 9, 12, and 15 months).
CBT (n = 70) was conducted in the primary care clinics. Treatment included education and awareness, relaxation training, cognitive therapy, exposure, problem-solving skills training, and behavioral sleep management. Patients assigned to EUC (n = 64) received biweekly calls to ensure patient safety and provide minimal support.
Main Outcome Measures
Primary outcomes included worry severity (Penn State Worry Questionnaire) and GAD severity (GAD Severity Scale).. Secondary outcomes included anxiety (Hamilton Anxiety Rating Scale, Beck Anxiety Inventory), coexistent depressive symptoms (Beck Depression Inventory II), and physical/mental health quality of life (SF-12).
CBT significantly improved worry severity [45.6; 95% CI 44.4 to 47.8; vs. 54.4; 95% CI 51.4 to 57.3; p < .0001), depressive symptoms (10.2; 95% CI 8.5 to 11.9; vs. 12.8; 95% CI 10.5 to 15.1; p = .02), and general mental health (49.6; 95% CI 47.4 to 51.8; vs. 45.3; 95% CI 42.6 to 47.9; p=.008) compared with EUC. . According to intent-to-treat analyses, response rates defined according to worry severity were higher following CBT than EUC at 3 months (40.0% [28/70] vs. 21.9% [14/64], p = .02).
Compared to EUC, CBT resulted in greater improvement in worry severity, depressive symptoms, and general mental health for older patients with GAD in primary care.
PMCID: PMC3328789  PMID: 19351943
11.  A Multitrait–Multimethod Analysis of the Construct Validity of Child Anxiety Disorders in a Clinical Sample 
The present study examines the construct validity of separation anxiety disorder (SAD), social phobia (SoP), panic disorder (PD), and generalized anxiety disorder (GAD) in a clinical sample of children. Participants were 174 children, 6 to 17 years old (94 boys) who had undergone a diagnostic evaluation at a university hospital based clinic. Parent and child ratings of symptom severity were assessed using the Multidimensional Anxiety Scale for Children (MASC). Diagnostician ratings were obtained from the Anxiety Disorders Interview Schedule for Children and Parents (ADIS: C/P). Discriminant and convergent validity were assessed using confirmatory factor analytic techniques to test a multitrait–multimethod model. Confirmatory factor analyses supported the current classification of these child anxiety disorders. The disorders demonstrated statistical independence from each other (discriminant validity of traits), the model fit better when the anxiety syndromes were specified than when no specific syndromes were specified (convergent validity), and the methods of assessment yielded distinguishable, unique types of information about child anxiety (discriminant validity of methods). Using a multi-informant approach, these findings support the distinctions between childhood anxiety disorders as delineated in the current classification system, suggesting that disagreement between informants in psychometric studies of child anxiety measures is not due to poor construct validity of these anxiety syndromes.
PMCID: PMC2917549  PMID: 20443053
Anxiety; Parent–child agreement; Construct validity
12.  A Psychometric Analysis of the Revised Child Anxiety and Depression Scale—Parent Version in a Clinical Sample 
The Revised Child Anxiety and Depression Scale—Parent Version (RCADS-P) is a 47-item parent-report questionnaire of youth anxiety and depression, with scales corresponding to the DSM-IV categories of Separation Anxiety Disorder, Social Phobia, Generalized Anxiety Disorder (GAD), Panic Disorder, Obsessive-Compulsive Disorder, and Major Depressive Disorder (MDD). The RCADS-P is currently the only parent-report questionnaire that concurrently assesses youth symptomatology of individual anxiety disorders as well as depression in accordance with DSM-IV nosology. The present study examined the psychometric properties of the RCADS-P in a large (N = 490), clinic-referred sample of youths. The RCADS-P demonstrated favorable psychometric properties, including high internal consistency, convergent/divergent validity, as well as strong discriminant validity—evidencing an ability to discriminate between anxiety and depressive disorders, as well as between the targeted anxiety disorders. Support for the DSM-related six-factor RCADS-P structure was also evidenced. This structure demonstrated superior fit to a recently suggested alternative to the DSM-IV classification of anxiety and affective disorders—namely, the MDD/GAD “distress” factor.
PMCID: PMC2820222  PMID: 19830545
Parent-report; Assessment; Anxiety; Depression; Diagnostic and statistical manual; Psychometrics
13.  The assessment of generalized anxiety disorder: psychometric validation of the Spanish version of the self-administered GAD-2 scale in daily medical practice 
To psychometrically validate the Spanish version of the self-administered 2-item GAD-2 scale for screening probable patients with generalised anxiety disorder (GAD).
The GAD-2 was self-administered by patients diagnosed with GAD according to DSM-IV criteria and by age- and sex-matched controls who were recruited at random in mental health and primary care centres. Criteria validity was explored using ROC curve analysis, and sensitivity, specificity and positive and negative predictive values were determined for different cut-off values. Concurrent validity was also established using the HAM-A, HADS, and WHODAS II scales.
The study sample consisted of 212 subjects (106 patients with GAD) with a mean age of 50.38 years (SD = 16.76). No items of the scale were left blank. Floor and ceiling effects were negligible. No patients with GAD had to be assisted to complete the questionnaire. Reliability (internal consistency) was high; Cronbach’s α = 0.875. A cut-off point of 3 showed adequate sensitivity (91.5%) and specificity (85.8%), with a statistically significant area under the curve (AUC = 0.937, p < 0.001), to distinguish GAD patients from controls. Concurrent validity was also high and significant with HAM-A (0.806, p < 0.001), HADS (anxiety domain, 0.825, p < 0.001) and WHO-DAS II (0.642, p < 0.001) scales.
The Spanish version of the GAD-2 scale has been shown to have appropriate psychometric properties to rapidly detect probable cases of GAD in the Spanish cultural context under routine clinical practice conditions.
PMCID: PMC3462108  PMID: 22992432
GAD-2; Generalised anxiety disorder; Screening; Primary care; Psychometric validity
14.  Use of Complementary and Alternative Medicine in a Large Sample of Anxiety Patients 
Psychosomatics  2012;53(3):266-272.
To examine a large sample of patients with anxiety and the association between types of complementary and alternative treatments that were used, demographic variables, diagnostic categories, and treatment outcomes.
Cross-sectional and longitudinal survey during the Coordinated Anxiety Learning and Management (CALM) study that assessed this intervention against the Usual Care in a sample of patients with anxiety recruited from primary care. Interviewer-administered questionnaires via a centralized telephone survey by blinded assessment raters. The interviews were done at baseline, 6, 12, and 18 months of the study. A total of 1004 adults ages 18–75 who met DSM-IV criteria for Generalized Anxiety Disorder (GAD), Panic Disorder, Social Anxiety Disorder, or Post-Traumatic Stress Disorder. We assessed medication/herbal use, the use of any alternative therapies, and combined Complementary and Alternative Medicine (CAM) use.
We found an extensive (43%) use of a variety of CAM treatments that is consistent with previous study results in populations with anxiety. Only a few significant demographic or interventional characteristics of CAM users were found. Users most often had a diagnosis of GAD, were older, more educated, and had two or more chronic medical conditions. CAM users who had a 50% or more drop in anxiety scores over 18 months were less likely to report continued use of alternative therapies.
The study confirms the importance of awareness of CAM use in this population for possible interference with traditional first-line treatments of these disorders, but also for finding the best integrative use for patients who require multiple treatment modalities.
PMCID: PMC4014348  PMID: 22304968
15.  Psychometric Properties of the Depression Anxiety and Stress Scale-21 in Older Primary Care Patients 
Journal of affective disorders  2008;110(3):248-259.
The Depression Anxiety Stress Scale (DASS) was designed to efficiently measure the core symptoms of anxiety and depression and has demonstrated positive psychometric properties in adult samples of anxiety and depression patients and student samples. Despite these findings, the psychometric properties of the DASS remain untested in older adults, for whom the identification of efficient measures of these constructs is especially important.
To determine the psychometric properties of the DASS 21-item version in older adults, we analyzed data from 222 medical patients seeking treatment to manage worry. Consistent with younger samples, a three-factor structure best fit the data. Results also indicated good internal consistency, excellent convergent validity, and good discriminative validity, especially for the depression scale. Receiver operating curve analyses indicated that the DASS-21 predicted the diagnostic presence of generalized anxiety disorder and depression as well as other commonly used measures.
These data suggest that the DASS may be used with older adults in lieu of multiple scales designed to measure similar constructs, thereby reducing participant burden and facilitating assessment in settings with limited assessment resources.
PMCID: PMC2709995  PMID: 18304648
Depression Anxiety Stress Scale; Older Adults; GAD; Anxiety; Assessment
16.  Psychometric properties of the Geriatric Anxiety Inventory (GAI) and its short-form (GAI-SF) in a clinical and non-clinical sample of older adults 
International Psychogeriatrics / Ipa  2014;27(7):1089-1097.
The Geriatric Anxiety Inventory is a 20-item geriatric-specific measure of anxiety severity. While studies suggest good internal consistency and convergent validity, divergent validity from measures of depression are weak. Clinical cutoffs have been developed that vary across studies due to the small clinical samples used. A six-item short form (GAI-SF) has been developed, and while this scale is promising, the research assessing the psychometrics of this scale is limited.
This study examined the psychometric properties of GAI and GAI-SF in a large sample of 197 clinical geriatric participants with a comorbid anxiety and unipolar mood disorder, and a non-clinical control sample (N = 59).
The internal consistency and convergent validity with other measures of anxiety was adequate for GAI and GAI-SF. Divergent validity from depressive symptoms was good in the clinical sample but weak in the total and non-clinical samples. Divergent validity from cognitive functioning was good in all samples. The one-factor structure was replicated for both measures. Receiver Operating Characteristic analyses indicated that the GAI is more accurate at identifying clinical status than the GAI-SF, although the sensitivity and specificity for the recommended cutoffs was adequate for both measures.
Both GAI and GAI-SF show good psychometric properties for identifying geriatric anxiety. The GAI-SF may be a useful alternative screening measure for identifying anxiety in older adults.
PMCID: PMC4501012  PMID: 25111285
anxiety disorders; anxiety; questionnaires; geriatric; Geriatric Anxiety Inventory; older adult
17.  A Randomized Controlled Trial of Telephone-Delivered Cognitive-Behavioral Therapy for Late-life Anxiety Disorders 
Older adults face a number of barriers to receiving psychotherapy, such as a lack of transportation and access to providers. One way to overcome such barriers is to provide treatment by telephone. The purpose of this study was to examine the effects of cognitive behavioral therapy delivered by telephone (CBT-T) to older adults diagnosed with an anxiety disorder.
Randomized controlled trial.
Participants' homes.
Sixty participants ≥ 60 years of age with a diagnosis of Generalized Anxiety Disorder, Panic Disorder, or Anxiety Disorder Not Otherwise Specified.
CBT-T vs. information-only comparison.
Co-primary outcomes included worry (Penn State Worry Questionnaire) and general anxiety (State Trait Anxiety Inventory). Secondary outcomes included clinician-rated anxiety (Hamilton Anxiety Rating Scale), anxiety sensitivity (Anxiety Sensitivity Index), depressive symptoms (Beck Depression Inventory), quality of life (SF-36), and sleep (Insomnia Severity Index). Assessments were completed prior to randomization, immediately upon completion of treatment, and 6 months after completing treatment.
CBT-T was superior to information-only in reducing general anxiety (ES = 0.71), worry (ES = 0.61), anxiety sensitivity (ES = 0.85), and insomnia (ES = 0.82) at the post-treatment assessment; however, only the reductions in worry were maintained by the 6 month follow-up assessment (ES = 0.80).
These results suggest that CBT-T may be efficacious in reducing anxiety and worry in older adults, but additional sessions may be needed to maintain these effects.
PMCID: PMC3407971  PMID: 22828172
anxiety; cognitive-behavioral therapy; elderly; Generalized Anxiety Disorder; Panic Disorder; telephone-delivered psychotherapy
18.  Prevention of Generalized Anxiety Disorder Using a Web Intervention, iChill: Randomized Controlled Trial 
Generalized Anxiety Disorder (GAD) is a high prevalence, chronic disorder. Web-based interventions are acceptable, engaging, and can be delivered at scale. Few randomized controlled trials evaluate the effectiveness of prevention programs for anxiety, or the factors that improve effectiveness and engagement.
The intent of the study was to evaluate the effectiveness of a Web-based program in preventing GAD symptoms in young adults, and to determine the role of telephone and email reminders.
A 5-arm randomized controlled trial with 558 Internet users in the community, recruited via the Australian Electoral Roll, was conducted with 6- and 12-month follow-up. Five interventions were offered over a 10-week period. Group 1 (Active website) received a combined intervention of psycho-education, Internet-delivered Cognitive Behavioral Therapy (ICBT) for anxiety, physical activity promotion, and relaxation. Group 2 (Active website with telephone) received the identical Web program plus weekly telephone reminder calls. Group 3 (Active website with email) received the identical Web program plus weekly email reminders. Group 4 (Control) received a placebo website. Group 5 (Control with telephone) received the placebo website plus telephone calls. Main outcome measures were severity of anxiety symptoms as measured by the GAD 7-item scale (GAD-7) (at post-test, 6, and 12 months). Secondary measures were GAD caseness, measured by the Mini International Neuropsychiatric Interview (MINI) at 6 months, Centre for Epidemiologic Studies-Depression scale (CES-D), Anxiety Sensitivity Index (ASI), Penn State Worry Questionnaire (PSWQ), and Days out of Role.
GAD-7 symptoms reduced over post-test, 6-month, and 12-month follow-up. There were no significant differences between Group 4 (Control) and Groups 1 (Active website), 2 (Active website with telephone), 3 (Active website with email), or 5 (Control with telephone) at any follow-up. A total of 16 cases of GAD were identified at 6 months, comprising 6.7% (11/165) from the Active groups (1, 2, 3) and 4.5% (5/110) from the Control groups (4, 5), a difference that was not significant. CES-D, ASI, and PSWQ scores were significantly lower for the active website with email reminders at post-test, relative to the control website condition.
Indicated prevention of GAD was not effective in reducing anxiety levels, measured by GAD-7. There were significant secondary effects for anxiety sensitivity, worry, and depression. Challenges for indicated prevention trials are discussed.
Trial Registration
International Standard Randomized Controlled Trial Number (ISRCTN): 76298775; (Archived by WebCite at
PMCID: PMC4211086  PMID: 25270886
anxiety disorders; prevention; early intervention; Internet; online systems; cognitive behavioral therapy
19.  Age Differences in Treatment Response to a Collaborative Care Intervention for Anxiety Disorders 
Some data suggest that older adults with anxiety disorders do not respond as well to treatment as do younger adults.
We examined age differences in outcomes from the Coordinated Anxiety Learning and Management (CALM) Study, an effectiveness trial comparing usual care to a computer-assisted collaborative care intervention for primary care patients with panic disorder, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and/or social anxiety disorder (SAD). This study represents the first investigation to examine the efficacy of a collaborative care intervention in a sample that included both younger and older adults with anxiety disorders. We hypothesized that older adults would show a poorer response to the intervention than younger adults.
We examined findings for the overall sample, as well as within each diagnostic category.
The CALM intervention was more effective than usual care among younger adults overall and for those with GAD, panic disorder, and SAD. Among elderly patients, the intervention was effective overall and for those with SAD and PTSD but not for those with panic disorder or GAD. The effects of the intervention also appeared to erode by the 18-month follow-up, and there were no significant effects on remission among the older adults.
These results are consistent with the findings of other investigators suggesting that medications and psychotherapy for anxiety disorders may not be as effective for older individuals as they are for younger people.
PMCID: PMC3696879  PMID: 23580378
Aged; Elderly; Geriatric; Cognitive-behavioral; Pharmacotherapy; Computer; Treatment
20.  Anxiety in middle adulthood: effects of age and time on the 14-year course of panic disorder, social phobia and generalized anxiety disorder 
Psychological medicine  2008;39(4):615-624.
Much about the long-term course of anxiety disorders is unknown. The present study utilizes a naturalistic, longitudinal, short-interval follow-up design to elucidate the course of anxiety disorders over 14 years in a largely middle-aged adult sample recruited from out-patient psychiatry and primary care facilities.
The sample consisted of 453 participants with a diagnosis of panic disorder (PD), social phobia (SP) and/or generalized anxiety disorder (GAD). Anxiety symptom ratings were tracked using weekly psychiatric status ratings (PSRs). Controlling for demographic and clinical variables, the course of PD, GAD and SP were examined using longitudinal growth models, with the most severe PSR at each follow-up point as the main outcome variable.
PSRs significantly decreased in severity over time in each of the three disorders. In the interaction effects models, age×time had a significant effect on course for PD and GAD, but not for SP, in that older age was associated with lower PSRs over time.
The present findings suggest that the severity of anxiety disorders declines over time, although this decline is modest and depends on the specific disorder being assessed. Older individuals with PD and GAD have a better prognosis than their younger counterparts, as their course is characterized by a steeper decline in severity. The present findings provide important information about the course of anxiety disorders in mid-life.
PMCID: PMC3679349  PMID: 18667095
Anxiety disorders; longitudinal studies; panic disorder; phobic disorders; prospective studies
21.  Disorder specific impact of CALM treatment for anxiety disorders in primary care 
Archives of general psychiatry  2011;68(4):378-388.
Anxiety disorders commonly present in primary care where evidence-based mental health treatments often are unavailable or suboptimally delivered.
Compare evidence-based treatment for anxiety disorders to usual care in primary care, for principal and comorbid generalized anxiety disorder (GAD), panic disorder (PD), social anxiety disorder (SAD) and posttraumatic stress disorder (PTSD). We hypothesized superiority of CALM for principal anxiety disorders and comorbid disorders.
A randomized, controlled trial comparing CALM intervention with Usual Care, at baseline, 6-month, 12-month and 18-month follow-ups.
17 primary care clinics in the United States.
Referred primary care sample, 1004 patients, with principal DSM-IV diagnoses of GAD (n=549), PD (n=262), SAD (n=132), or PTSD (n=61), mean 43.7 years (SD=13.7), 70.9% female,. 80% completed 18-month follow-up.
CALM (computer-guided CBT and/or pharmacotherapy recommendations) and Usual Care.
Main Outcome Measures
Generalized Anxiety Disorder Severity Scale, Panic Disorder Severity-Self Report scale, Social Phobia Inventory, and PTSD Checklist-Civilian Version.
CALM was superior to Usual Care for principal GAD at 6-month (−1.61; 95% CI = −2.42 to −.79), 12-month (−2.34; 95% CI = −3.22 to −1.45) and 18-month (−2.37; 95% CI = −3.24 to −1.50), PD at 6-month (−2.00; 95% CI = −3.55 to −0.44) and 12-month (−2.71; 95% CI = −4.29 to −1.14), and SAD at 6-month (−7.05; 95% CI = −12.11 to −2.00) outcomes. CALM was superior to Usual Care for comorbid SAD at 6-month (−4.26; 95% CI = −7.96 to −0.56), 12-month (−8.12, 95% CI = −11.84 to −4.40) and 18- month (−6.23, 95% CI = −9.90 to −2.55) outcomes. Effect sizes favored CALM, but were not statistically significant for other comorbid disorders.
CALM (CBT and psychotropic recommendations) is more effective than Usual Care for principal anxiety disorders, and to a lesser extent, comorbid anxiety disorders that present in primary care.
PMCID: PMC3074172  PMID: 21464362
22.  Validation of a Brief Measure of Anxiety-Related Severity and Impairment: The Overall Anxiety Severity and Impairment Scale (OASIS) 
Journal of affective disorders  2008;112(1-3):92-101.
The Overall Anxiety Severity and Impairment Scale (OASIS) is a 5-item self-report measure that can be used to assess severity and impairment associated with any anxiety disorder or multiple anxiety disorders. A prior investigation with a nonclinical sample supported the reliability and validity of the OASIS; however, to date it has not been validated for use in clinical samples.
The present study assessed the psychometric properties of the OASIS in a large sample (N = 1,036) of primary care patients whose physicians referred them to an anxiety disorders treatment study. Latent structure, internal consistency, convergent/discriminant validity, and cut-score analyses were conducted.
Exploratory and confirmatory factor analyses supported a unidimensional structure. The five OASIS items displayed strong loadings on the single factor and had a high degree of internal consistency. OASIS scores demonstrated robust correlations with global and disorder-specific measures of anxiety, and weak correlations with measures of unrelated constructs. A cut-score of 8 correctly classified 87% of this sample as having an anxiety diagnosis or not.
Convergent validity measures consisted solely of other self-report measures of anxiety. Future studies should evaluate the convergence of OASIS scores with clinician-rated and behavioral measures of anxiety severity.
Overall, this investigation suggests that the OASIS is a valid instrument for measurement of anxiety severity and impairment in clinical samples. Its brevity and applicability to a wide range of anxiety disorders enhance its utility as a screening and assessment tool.
PMCID: PMC2629402  PMID: 18486238
anxiety; self-report; assessment; validity; factor analysis
23.  Escitalopram for Older Adults With Generalized Anxiety Disorder 
Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders in older adults; however, few data exist to guide clinicians in efficacious and safe treatment. Selective serotonin reuptake inhibitors (SSRIs) are efficacious for younger adults with GAD, but benefits and risks may be different in older adults.
To examine the efficacy, safety, and tolerability of the SSRI escitalopram in older adults with GAD.
Design, Setting, and Participants
A randomized controlled trial in primary care practices and related specialty clinics in Pittsburgh, Pennsylvania, of 177 participants aged 60 years or older with a principal diagnosis of GAD randomized to receive either escitalopram or placebo and conducted between January 2005 and January 2008.
Twelve weeks of 10 to 20 mg/d of escitalopram (n=85) or matching placebo (n=92).
Main Outcome Measures
Cumulative response defined by Clinical Global Impressions-Improvement score of much or very much improved; time to response; and anxiety and role functioning changes measured by the Clinical Global Impressions-Improvement scale, Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, Late-Life Function and Disability Instrument activity limitations subscale, and the role-emotional impairment and social function subscales of the Medical Outcome Survey 36-item Short Form.
In the primary analytic strategy in which participants (n=33) were censored at the time of dropout, mean cumulative response rate for escitalopram was 69% (95% confidence interval [CI], 58%-80%) vs 51% (95% CI, 40%-62%) for placebo (P=.03). A conservative intention-to-treat analysis showed no difference in mean cumulative response rate between escitalopram and placebo (57%; 95% CI, 46%-67%; vs 45%; 95% CI, 35%-55%; P=.11). Participants treated with escitalopram showed greater improvement than with placebo in anxiety symptoms and role functioning (Clinical Global Impressions-Improvement scale: effect size, 0.93; 95% CI, 0.50-1.36; P<.001; Penn State Worry Questionnaire: 0.30; 95% CI, 0.23-0.48; P=.01; activity limitations: 0.32; 95% CI, 0.01-0.63; P=.04; and the role-emotional impairment and social function: 0.96; 95% CI, 0.03-1.90; P=.04). Adverse effects of escitalopram (P<.05 vs placebo) were fatigue or somnolence (35 patients [41.1%]), sleep disturbance (12 [14.1%]), and urinary symptoms (8 [9.4%]).
Older adults with GAD randomized to escitalopram had a higher cumulative response rate for improvement vs placebo over 12 weeks; however, response rates were not significantly different using an intention-to-treat analysis. Further study is required to assess efficacy and safety over longer treatment durations.
Trial Registration Identifier: NCT00105586
PMCID: PMC2840403  PMID: 19155456
24.  The Psychometric Properties of the Generalized Anxiety Disorder-7 scale in Hispanic Americans with English or Spanish Language Preference 
The Generalized Anxiety Disorder-7 scale (GAD-7) is a self-report questionnaire that is widely used to screen for anxiety. The GAD-7 has been translated into numerous languages, including Spanish. Previous studies evaluating the structural validity of the English and Spanish versions indicate a uni-dimensional factor structure in both languages. However, the psychometric properties of the Spanish language version have yet to be evaluated in samples outside of Spain, and the measure has not been tested for use among Hispanic Americans. This study evaluated the reliability, structural validity, and convergent validity of the English and Spanish language versions of the GAD-7 for Hispanic Americans in the United States. A community sample of 436 Hispanic Americans with an English (n = 210) or Spanish (n = 226) language preference completed the GAD-7. Multiple-group confirmatory factor analysis (CFA) was used to examine the goodness of fit of the uni-dimensional factor structure of the GAD-7 across language-preference groups. Results from the multiple-group CFA indicated a similar unidimensional factor structure with equivalent response patterns and item intercepts, but different variances, across language-preference groups. Internal consistency was good for both English and Spanish language-preference groups. The GAD-7 also evidenced good convergent validity as demonstrated by significant correlations in expected directions with the Perceived Stress Scale, the Patient Health Questionnaire-9, and the Physical health domain of the World Health Organization Quality of Life-BREF assessment. The uni-dimensional GAD-7 is suitable for use among Hispanic Americans with an English or Spanish language preference.
PMCID: PMC4129392  PMID: 25045957
generalized anxiety disorder; Hispanic Americans; multiple-group confirmatory factor analysis; GAD-7
25.  A multicomponent yoga-based, breath intervention program as an adjunctive treatment in patients suffering from generalized anxiety disorder with or without comorbidities 
International Journal of Yoga  2012;5(1):57-65.
The aim of this study is to evaluate the efficacy and tolerability of Sudarshan Kriya Yoga (SKY) course in generalized anxiety disorder (GAD) outpatients, who after eight weeks of an appropriate dose of traditional therapy had not yet achieved remission.
The adult participants (18-65 years) were outpatients with a primary diagnosis of GAD with or without comorbidities on the Mini-International Neuropsychiatric Interview (MINI). Participants had a minimum of eight weeks standard treatment with an appropriate dose of a standard prescription anxiolytic, a clinician global impression-severity (CGI-S) score of 5-7, a Hamilton anxiety scale (HAM-A) total score ≥20 including a score of >2 on the anxious mood and tension items.
Materials and Methods:
Forty-one patients were enrolled in an open-label trial of the SKY course as an adjunct to standard treatment of GAD at the START Clinic for Mood and Anxiety Disorders, a tertiary care mood and anxiety disorder clinic in Toronto. The SKY course was administered over five days (22 h total). Subjects were encouraged to practice the yoga breathing techniques at home for 20 min per day after the course and were offered group practice sessions for 2 h once a week led by certified yoga instructors. The primary outcome measure was the mean change from pre-treatment on the HAM-A scale. Psychological measures were obtained at baseline and four weeks after completing the intervention.
Thirty-one patients completed the program (mean age 42.6 ± 13.3 years). Among completers, significant reductions occurred in the pre- and post-intervention mean HAM-A total score (t=4.59; P<0.01) and psychic subscale (t=5.00; P≤0.01). The response rate was 73% and the remission rate 41% as measured on the HAM-A.
The results of this small pilot trial suggest that the SKY course represents a potentially valuable adjunct to standard pharmacotherapy in patients with GAD or treatment-resistant GAD, and warrants further investigation. In particular, changes in worry and body symptoms showed significant improvements that may further our understanding of the mechanism of change in the tolerance of anxiety and worry.
PMCID: PMC3276935  PMID: 22346068
Anxiety; cognitive behavioral therapy; generalized anxiety disorder; mindfulness based stress reduction; post-traumatic stress disorder; yoga

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