34

Performance Characteristics of Self-report Instruments for Diagnosing 

Generalized Anxiety and Panic Disorders in Primary Care Evidence-based Synthesis Program

APPENDIX A. Search Strategy

Step Category Terms Resulta

1 Disorders (generalized AND anxiety AND disorder[tiab]) OR panic 

disorder[tiab] OR “generalized anxiety disorder” OR panic 

disorder[mesh] OR panic[title/abstract] 

12293

2 Measurement 

instruments

GAD or PD

Broad terms for 

instruments

“gad7”[tiab] OR “generalized anxiety disorder 7”[tiab] OR 

“gad-7”[tiab] OR “beck anxiety”[tiab] OR “geriatric anxiety 

inventory”[tiab] OR “short anxiety screening test”[tiab] OR 

“hospital anxiety and depression scale”[tiab] OR PHQ[tiab] OR 

“patient health questionnaire”[tiab] OR “zung anxiety scale”[tiab] 

OR “penn state worry questionnaire”[tiab] OR “multicenter 

collaborative panic disorder severity scale” 

OR

“Psychiatric Status Rating Scales”[Mesh] OR 

questionnaires[MeSH Terms] OR questionnaires[tiab] OR 

questionnaire[tiab] OR tools[tiab] OR tool[tiab] OR scale[tiab] OR 

scales[tiab] OR inventory[tiab] OR screening[tiab] 

3801

1,094,242

3 Instrument 

characteristics

medical history taking[mh] OR reproducibility of results[mh] OR 

observer variation[mh] OR sensitivity[tiab] OR specificity[tiab] 

OR “sensitivity and specificity”[mh] OR likelihood [tiab] OR 

accura*[tiab]

1,249,615

4 Combine results and 

apply limits

#1 AND #2 AND #3

English and Human and Adult

850

a

Numbers reflect the result of the PubMed search only.
35

Performance Characteristics of Self-report Instruments for Diagnosing 

Generalized Anxiety and Panic Disorders in Primary Care Evidence-based Synthesis Program

APPENDIX B. Study Selection Form

Inclusion criteria: 

• Sample population is adults age ≥18 years presenting with a somatic symptom or 

presenting to a medical clinic for a scheduled appointment. 

• Setting is primary care (general internal medicine, family medicine, geriatrics) or general 

medical (emergency department, women’s health clinic). 

• Intervention is a self-report instrument (index test) designed to screen for or facilitate 

diagnosis of GAD, PD, or anxiety disorders. The instrument must be feasible in a clinical 

setting without requiring special equipment and may be performed by a nonexpert. 

• Reference standard diagnosis of GAD or PD is made using acceptable criteria (e.g., 

DSM-III or later, ICD-9 or later) and administered by a trained clinician.

• Study reports a measure of reliability or sensitivity/specificity or the data to calculate at 

least one of these performance characteristics.

• Study design is prospective comparison of an anxiety questionnaire to a reference 

standard; reference standard must be applied to all subjects or to a randomly selected 

subsample that allows correction for verification bias.

• Study must be published in a peer-reviewed publication.

Exclusion criteria:

• Study is a non-English language publication. English language articles that address 

Spanish version of instruments will be included. 

• Study is conducted outside of North America, Western Europe, New Zealand or Australia.

• Study populations are patients with current mental illness (e.g., substance abuse disorder), 

and screening is for comorbid anxiety disorder.

• Anxiety measure and reference standard are performed by the same individual.
36

 Self-report Instruments for Diagnosing 

Disorders in Primary Care Evidence-based Synthesis Program

xcluded Studies

reviewed in their full-text version and excluded for the reason indicated. An alphabetical reference list follows the 

Population 

not of 

interest

Setting 

not PC, 

clinic, or 

ER

No selfreported 

index 

test at 

screening

Reference 

standard not 

acceptable

No instrument 

characteristics 

data

Design not 

prospective

Reference 

standard 

not applied 

correctly

Publication 

not English

Screening 

tool not 

English/ Spanish

X

X

X

X

XX

X

XXXXX

X

X

X

XX

X

XXXX

X

XX

X

X

X

X

X
37

 Self-report Instruments for Diagnosing 

Disorders in Primary Care Evidence-based Synthesis Program

Population 

not of 

interest

Setting 

not PC, 

clinic, or 

ER

No selfreported 

index 

test at 

screening

Reference 

standard not 

acceptable

No instrument 

characteristics 

data

Design not 

prospective

Reference 

standard 

not applied 

correctly

Publication 

not English

Screening 

tool not 

English/ Spanish

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

XX

X

X

X

X

X

X

X
38

Performance Characteristics of Self-report Instruments for Diagnosing 

Generalized Anxiety and Panic Disorders in Primary Care Evidence-based Synthesis Program

List of Excluded Studies

Andersson G, Carlbring P, Kaldo V, et al. 

Screening of psychiatric disorders via the Internet. 

A pilot study with tinnitus patients. Nord J 

Psychiatry. 2004;58(4):287-91.

Andjreu Y, Galdón MJ, Dura E, et al. 

Psychometric properties of the Brief Symptoms 

Inventory-18 (BSI-18) in a Spanish sample 

of outpatients with psychiatric disorders. 

Psicothema. 2008;20(4):844-850.

Andreescu C, Belnap BH, Rollman BL, et 

al. Generalized anxiety disorder severity 

scale validation in older adults. Am J Geriatr 

Psychiatry. 2008;16(10):813-8.

Apfeldorf WJ, Shear MK, Leon AC, et al. A brief 

screen for panic disorder. Journal of Anxiety 

Disorders. 1994;8(1):71-78.

Argyropoulos SV, Ploubidis GB, Wright 

TS, et al. Development and validation of the 

Generalized Anxiety Disorder Inventory (GADI). 

J Psychopharmacol. 2007;21(2):145-52.

Austin DW, Richards JC, Klein B. Modification 

of the Body Sensations Interpretation 

Questionnaire (BSIQ-M): validity and reliability. 

Journal of Anxiety Disorders. 2006;20(2):237-51.

Baughman OL. Rapid diagnosis and treatment 

of anxiety and depression in primary care: 

The somatizing patient. The Journal of Family 

Practice. 1994;39(4):373-378.

Beck JG, Stanley MA, Zebb BJ. Characteristics 

of generalized anxiety disorder in older 

adults: a descriptive study. Behav Res Ther. 

1996;34(3):225-34.

Behar E, Alcaine O, Zuellig AR, et al. Screening 

for generalized anxiety disorder using the Penn 

State Worry Questionnaire: a receiver operating 

characteristic analysis. J Behav Ther Exp 

Psychiatry. 2003;34(1):25-43.

Berrocal C, Ruiz Moreno M, Merchan P, et al. 

The Mood Spectrum Self-Report: validation 

and adaptation into Spanish. Depress Anxiety. 

2006;23(4):220-35.

Berrocal C, Ruiz Moreno MA, Gil Villa M, et 

al. Multidimensional assessment of the PanicAgoraphobic Spectrum: reliability and validity 

of the Spanish version of the PAS-SR. Journal of 

Anxiety Disorders. 2006;20(5):562-79.

Bieling PJ, Antony MM, Swinson RP. The StateTrait Anxiety Inventory, Trait version: structure 

and content re-examined. Behav Res Ther. 

1998;36(7-8):777-88.

Bobes J, Garcia-Calvo C, Prieto R, et al. 

Psychometric properties of the Spanish version 

of the screening scale for DSM-IV Generalized 

Anxiety Disorder of Carroll and Davidson. Actas 

Esp Psiquiatr. 2006;34(2):83-93.

Bucholz KK, Robins LN, Shayka JJ, et al. 

Performance of two forms of a computer 

psychiatric screening interview: Version I of the 

DISSI. J Psychiatr Res. 1991;25(3):117-129.

Bystritsky A, Waikar SV, Vapnik T. Fourdimensional Anxiety and Depression Scale: 

a preliminary psychometric report. Anxiety. 

1996;2(1):47-50.

Clum GA, Broyles S, Borden J, et al. Validity 

and reliability of the panic attack symptoms 

and cognitions questionnaires. Journal of 

Psychopathology and Behavioral Assessment. 

1990;12(3):233-245.

Connor KM, Kobak KA, Churchill LE, et al. 

Mini-SPIN: A brief screening assessment for 

generalized social anxiety disorder. Depress 

Anxiety. 2001;14(2):137-140.

Dammen T, Ekeberg O, Arnesen H, et al. The 

detection of panic disorder in chest pain patients. 

Gen Hosp Psychiatry. 1999;21(5):323-32.

Eack SM, Greeno CG, Lee B-J. Limitations of 

the Patient Health Questionnaire in Identifying 

Anxiety and Depression in Community Mental 

Health: Many Cases are Undetected. Research on 

Social Work Practice. 2006;16(6):625-631.
39

Performance Characteristics of Self-report Instruments for Diagnosing 

Generalized Anxiety and Panic Disorders in Primary Care Evidence-based Synthesis Program

Eack SM, Singer JB, Greeno CG. Screening 

for anxiety and depression in community 

mental health: the beck anxiety and depression 

inventories. Community Ment Health J. 

2008;44(6):465-74.

Epstein JF, Barker PR, Kroutil LA. Mode effects 

in self-reported mental health data. Public Opin 

Q. 2001;65(4):529-549.

Farvolden P, McBride C, Bagby RM, et al. A 

Web-based screening instrument for depression 

and anxiety disorders in primary care. J Med 

Internet Res. 2003;5(3):e23.

Fleet RP, Dupuis G, Marchand A, et al. Detecting 

panic disorder in emergency department chest 

pain patients: a validated model to improve 

recognition. Ann Behav Med. 1997;19(2):124-31.

Gladstone GL, Parker GB, Mitchell PB, et al. 

A Brief Measure of Worry Severity (BMWS): 

personality and clinical correlates of severe 

worriers. Journal of Anxiety Disorders. 

2005;19(8):877-92.

Gloster AT, Rhoades HM, Novy D, et al. 

Psychometric properties of the Depression 

Anxiety and Stress Scale-21 in older primary care 

patients. J Affect Disord. 2008;110(3):248-59.

Jackson JL, Passamonti M, Kroenke K. Outcome 

and impact of mental disorders in primary care at 

5 years. Psychosom Med. 2007;69(3):270-6.

Kobak KA, Taylor LH, Dottl SL, et al. 

Computerized screening for psychiatric disorders 

in an outpatient community mental health clinic. 

Psychiatr Serv. 1997;48(8):1048-57.

Kuijpers PM, Denollet J, Lousberg R, et al. 

Validity of the hospital anxiety and depression 

scale for use with patients with noncardiac chest 

pain. Psychosomatics. 2003;44(4):329-35.

Lowe B, Grafe K, Zipfel S, et al. Detecting 

panic disorder in medical and psychosomatic 

outpatients: comparative validation of the 

Hospital Anxiety and Depression Scale, the 

Patient Health Questionnaire, a screening 

question, and physicians’ diagnosis. J Psychosom 

Res. 2003;55(6):515-9.

Lykouras L, Adrachta D, Kalfakis N, et al. 

GHQ-28 as an aid to detect mental disorders in 

neurological inpatients. Acta Psychiatr Scand. 

1996;93(3):212-216.

McQuaid JR, Stein MB, McCahill M, et al. Use of 

brief psychiatric screening measures in a primary 

care sample. Depress Anxiety. 2000;12(1):21-9.

Means-Christensen AJ, Arnau RC, Tonidandel 

AM, et al. An efficient method of identifying 

major depression and panic disorder in primary 

care. J Behav Med. 2005;28(6):565-72.

Means-Christensen AJ, Sherbourne CD, RoyByrne PP, et al. Using five questions to screen 

for five common mental disorders in primary 

care: diagnostic accuracy of the Anxiety and 

Depression Detector. Gen Hosp Psychiatry. 

2006;28(2):108-18.

Meyer TJ, Miller ML, Metzger RL, et al. 

Development and validation of the Penn 

State Worry Questionnaire. Behav Res Ther. 

1990;28(6):487-95.

Mori DL, Lambert JF, Niles BL, et al. The 

BAI–PC as a Screen for Anxiety, Depression, 

and PTSD in Primary Care. Journal of Clinical 

Psychology in Medical Settings. 2003;10(3):187-

192.

Morlock RJ, Williams VS, Cappelleri JC, et 

al. Development and evaluation of the Daily 

Assessment of Symptoms - Anxiety (DAS-A) 

scale to evaluate onset of symptom relief in 

patients with generalized anxiety disorder. J 

Psychiatr Res. 2008;42(12):1024-36.

Mowry BJ, Burvill PW. Screening the elderly in 

the community for psychiatric disorder. Aust N Z 

J Psychiatry. 1990;24(2):203-206.

Mussell M, Kroenke K, Spitzer RL, et al. 

Gastrointestinal symptoms in primary care: 

prevalence and association with depression and 

anxiety. J Psychosom Res. 2008;64(6):605-12.

Newman MG, Holmes M, Zuellig AR, et al. The 

reliability and validity of the panic disorder selfreport: a new diagnostic screening measure of 

panic disorder. Psychol Assess. 2006;18(1):49-61.
40

Performance Characteristics of Self-report Instruments for Diagnosing 

Generalized Anxiety and Panic Disorders in Primary Care Evidence-based Synthesis Program

Novy DM, Stanley MA, Averill P, et al. 

Psychometric comparability of English- and 

Spanish-language measures of anxiety and 

related affective symptoms. Psychol Assess. 

2001;13(3):347-55.

Olssøn I, Mykletun A, Dahl AA. The hospital 

anxiety and depression rating scale: A crosssectional study of psychometrics and case finding 

abilities in general practice. BMC Psychiatry. 

2005;5.

Parker G, Roussos J, Hadzi-Pavlovic D, et 

al. The development of a refined measure of 

dysfunctional parenting and assessment of its 

relevance in patients with affective disorders. 

Psychol Med. 1997;27(5):1193-203.

Parkerson GR, Jr., Broadhead WE. Screening 

for anxiety and depression in primary care with 

the Duke Anxiety-Depression Scale. Fam Med. 

1997;29(3):177-81.

Robinson CM, Klenck SC, Norton PJ. 

Psychometric properties of the Generalized 

Anxiety Disorder Questionnaire for DSM-IV 

among four racial groups. Cognitive Behaviour 

Therapy. 2010;39(4):251-261.

Rollman BL, Belnap BH, Mazumdar S, et al. 

Symptomatic severity of PRIME-MD diagnosed 

episodes of panic and generalized anxiety 

disorder in primary care. J Gen Intern Med. 

2005;20(7):623-8.

Senior, A.C, Kunik, M.E, Rhoades, H.M, et al. 

Utility of telephone assessments in an older adult 

population. Psychol Aging. 2007:22(2): p. 392-7.

Sandin B, Chorot P, McNally RJ. Validation of 

the Spanish version of the Anxiety Sensitivity 

Index in a clinical sample. Behav Res Ther. 

1996;34(3):283-90.

Stein MB, Jang KL, Livesley WJ. Heritability of 

anxiety sensitivity: A twin study. The American 

Journal of Psychiatry. 1999;156(2):246-251.

Svanborg P, Asberg M. A new self-rating scale 

for depression and anxiety states based on the 

Comprehensive Psychopathological Rating Scale. 

Acta Psychiatr Scand. 1994;89(1):21-8.

Vujanovic AA, Arrindell WA, Bernstein A, 

et al. Sixteen-item Anxiety Sensitivity Index: 

confirmatory factor analytic evidence, internal 

consistency, and construct validity in a young 

adult sample from the Netherlands. Assessment. 

2007;14(2):129-43.

Webb SA, Diefenbach G, Wagener P, et 

al. Comparison of self-report measures for 

identifying late-life generalized anxiety in 

primary care. J Geriatr Psychiatry Neurol. 

2008;21(4):223-31.

Weissman MM, Broadhead WE, Olfson M, et al. 

A diagnostic aid for detecting (DSM-IV) mental 

disorders in primary care. Gen Hosp Psychiatry. 

1998;20(1):1-11.

Wetherell JL, Birchler GD, Ramsdell J, et al. 

Screening for generalized anxiety disorder in 

geriatric primary care patients. Int J Geriatr 

Psychiatry. 2007;22(2):115-23.

Yingling KW, Wulsin LR, Arnold LM, et al. 

Estimated prevalences of panic disorder and 

depression among consecutive patients seen in an 

emergency department with acute chest pain. J 

Gen Intern Med. 1993;8(5):231-5.
41

Performance Characteristics of Self-report Instruments for Diagnosing 

Generalized Anxiety and Panic Disorders in Primary Care Evidence-based Synthesis Program

APPENDIX D. Data Extraction Form

Data abstraction for anxiety screening in primary care        

                      

Reviewer initials    Endnote ref #:         

First Author:    Year Published:    Country:          

Primary study:  1) Yes    2)No.                  Linked study:  1) Yes     2) No   

I) Study setting          Comments:        

1)Outpatient primary care clinic 2) Specialty clinic (specify):             

3)ER    4)OB/GYN or women's health                  

                      

II) Patient presentation:  Did the patients present with a physical symptoms   

1)Chest pain 2)Unselected 3)Other Symptom:           4)NR‐99    

                      

III) Type of setting    NR ‐99     Comments:           

1) Academic 2) Community 3) Mixed                 

4) Other (specify):                         

                      

IV) VA clinics NR ‐99    1) Only VA 2) Mixed    3) No VA      

                      

V) Selection of population for screening    NR ‐99 Comments:           

1) Random 2)Consecutive 3)Convenience               

4) Other (specify)                         

                      

VI) Selection of population for criterion standard NR ‐99 Comments:           

1) Random 2)Consecutive 3)Convenience               

4) Other (specify)                         

                      

VII) Description of study population    NR ‐99 Comments:           

Potentially eligible: N=                      

Met eligibility criteria: N=                     

Screened: N=                       

Completed criterion standard:                          

                      
42

Performance Characteristics of Self-report Instruments for Diagnosing 

Generalized Anxiety and Panic Disorders in Primary Care Evidence-based Synthesis Program

VIII) Age    NR‐99    (Age is for results not for selection)    

Mean age (SD)             Comments:           

Age range:                            

                      

IX) Gender NR‐99                  

Male (n)=            Comments:             

Female (n)=                          

                      

X) Ethnicity NR‐99                  

1) Caucasian N=          2) Black N=              

3) Hispanic N =           4) Asian N=             

5) Other N=                         

Comments:                    

                      

XI) Education NR‐99                  

Mean years completed (±SD):          Comments:           

Other measures:                         

                      

XII) Name of the screening instrument (specify version and number when applicable: eg GAD‐7 OR GAD‐2)

                                 

                      

XIII) Methods of administration of screening test    NR‐99          

1) Self‐administered 2) Interviewer administered    3) Via telephone      

4) Computer assisted    5) Other (specify):            

                      

XIV) What was the criterion standard NR‐99            

1) DSM IV    2) DSM IIIR 3) DSM III    4) ICD 9/10     

5) Research diagnostic criteria (RDC) 6) Other (specify)            

                      

XV) Method used to determining standard NR‐99            

1) SCID 2)DIS 3)CIDI 4)DSM3/4 5)ADIS 6) Other (specify):        

                      

XVI) Medical comorbidity:   specific diseases or average measures 1) Yes    NR‐99    

List top 3 or measures:                        

                      
43

Performance Characteristics of Self-report Instruments for Diagnosing 

Generalized Anxiety and Panic Disorders in Primary Care Evidence-based Synthesis Program

XVII) Psychiatric comorbidity 1) Yes    NR‐99            

    Excluded   (1) <10%   (2) 10‐25% (3)   >25% (4)   NR (‐99)   

Depression                             

PTSD                                

Substance abuse                             

Social anxiety                             

GAD                                

PD                                

Other (                     )                             

Other (                     )                             

                      

XVIII) Other measures:      

Responsiveness:        NR‐99    

Test retest reliability:        NR‐99    

                      

RESULTS                     

Total sample/ Subgroup .  If subgroup, specify:      

Test used to detect   1)GAD 2)PD 3) Both Results for multiple cutoffs given: 1) Yes 2)No   

Cutoff picked a priori? 1)Yes 2) No    Same as traditional  cutoff: 1) Yes 2) No   

Gold standard ↓                   

pos neg     Other measures, eg sensitivity, PPV, LR: (give 95% CI or NR‐99 )

pos             Statistic:     Data     95% CI      

co= (        )                             

neg            

co= (        )                             

                           

Data validated? 1) Yes 2) No      Data adjusted for sampling:    1) Yes            2) No   

                      

Total sample/ Subgroup .  If subgroup, specify:    

2) Test used to detect   1)GAD 2)PD 3) Both Results for multiple cutoffs given: 1) Yes 2)No   

Cutoff picked a priori? 1)Yes 2) No    Same as traditional cutoff: 1) Yes 2) No   

Gold standard ↓                   

pos neg     Other Measures., eg sensitivity, PPV, LR: (give 95% CI or NR‐99 )

pos             Statistic:     Data     95% CI      

co= (        )                             

neg            

co= (        )                             

                           

                    

                      

Data validated? 1) Yes 2) No       Data adjusted for sampling:    1) Yes            2) No   

                      
44

Performance Characteristics of Self-report Instruments for Diagnosing 

Generalized Anxiety and Panic Disorders in Primary Care                        Evidence-based Synthesis Program

Total sample/ Subgroup .  If subgroup, specify:     

Test used to detect   1)GAD 2)PD 3) Both Results for multiple cutoffs given: 1) Yes 2)No   

Cutoff picked a priori? 1)Yes 2) No    Same as traditional cutoff: 1) Yes 2) No   

Gold standard ↓                   

pos neg     Other Measures., eg sensitivity, PPV, LR: (give 95% CI or NR‐99 )

pos             Statistic:     Data     95% CI      

co= (        )                             

neg                             

co= (        )                             

                           

Data validated?   1) Yes 2) No                         

                      

Total sample/ Subgroup .  If subgroup, specify:      

Test used to detect   1)GAD 2)PD 3) Both Results for multiple cutoffs given: 1) Yes 2)No

Cutoff picked a priori? 1)Yes 2) No    Same as traditional cutoff: 1) Yes 2) No   

Gold standard ↓                   

pos neg     Other Measures., eg sensitivity, PPV, LR: (give 95% CI or NR‐99 )

pos             Statistic:     Data     95% CI      

co= (        )                             

neg                             

co= (        )                             

                           

Data validated? 1) Yes 2) No                

                      

Inclusion and Exclusion Criteria:     

                      
45

Performance Characteristics of Self-report Instruments for Diagnosing 

Generalized Anxiety and Panic Disorders in Primary Care Evidence-based Synthesis Program

APPENDIX E. Criteria Used in Quality Assessment

QUADAS tool* with modified item 12.

Item Yes No Unclear

1. Was the spectrum of patients representative of the patients who will receive 

the test in practice?

( ) ( ) ( )

2. Were selection criteria clearly described? ( ) ( ) ( )

3. Is the reference standard likely to correctly classify the target condition? ( ) ( ) ( )

4. Is the time period between reference standard and index test short enough to 

be reasonably sure that the target condition did not change between the two 

tests? (Yes if one month or less)

( ) ( ) ( )

5. Did the whole sample or a random selection of the sample, receive 

verification using a reference standard of diagnosis?

( ) ( ) ( )

6. Did patients receive the same reference standard regardless of the index test 

result?

( ) ( ) ( )

7. Was the reference standard independent of the index test (i.e. the index test 

did not form part of the reference standard)?

( ) ( ) ( )

8. Was the execution of the index test described in sufficient detail to permit 

replication of the test?

( ) ( ) ( )

9. Was the execution of the reference standard described in sufficient detail to 

permit its replication?

( ) ( ) ( )

10. Were the index test results interpreted without knowledge of the results of the 

reference standard?

( ) ( ) ( )

11. Were the reference standard results interpreted without knowledge of the 

results of the index test?

( ) ( ) ( )

12. Was the cut off point for the test chosen a priori? ( ) ( ) ( )

13. Were uninterpretable/intermediate test results including missing data 

reported? 

( ) ( ) ( )

14. Were withdrawals from the study explained? ( ) ( ) ( )

Whiting PF, Weswood ME, Rutjes AW, Reitsma JB, Bossuyt PN, Kleijnen J. Evaluation of QUADAS, a 

tool for the quality assessment of diagnostic accuracy studies. BMC Med Res Methodol. 2006;6:9.
46

 Self-report Instruments for Diagnosing 

Disorders in Primary Care Evidence-based Synthesis Program

eer Review Comments/Author Responses

Response

s, scope, and methods for this review clearly described?

Thank you.

mportant and is clearly justified in the introduction. The scope 

d. I was a bit disappointed that the scope did not include 

iety in the context of depression, given the high comorbidity. The 

eptional job of writing methods that were easy for this reader to 

Thank you.Including studies that assess the performance of anxiety measures in patients with concurrent depression is an excellent idea. We did not encounter any such studies conducted in primary care settings. A future report could include a broader range of settings that might include this population.

y is clearly described and appropriate to the question asked. Thank you.

we identified no recent systematic reviews and 12 observational 

e studies that addressed one of the key questions. 

t clear to me; is it: 1) No systematic reviews; 2) 12 observational 

e studies?

We have changed this sentence to read “12 articles from 9 unique studies...” to clarify that there were nine studies, some of which had more than one resulting publication.Thank you.

s are clear-cut, and the review clarifies the potential and 

ations of prior research on screening tools for GAD and panic 

ly and of great importance. The authors correctly point out that 

sorder are quite common mental illnesses in the VA population, 

impairment in quality of life and physical and cognitive 

atments – SSRIs, other antidepressants, and CBT (all quite 

thin the VA health care system) – are effective for these common 

tected conditions. In my own opinion, the lack of detection of 

rders within the health care system is one of the “low-hanging 

mprove mental health treatment. 

Thank you.

ment below re: Page 8, Table 1 inclusion and exclusion criteria and 

KQ1.

Acknowledged

cation of bias in our synthesis of the evidence?

Acknowledged

idence of bias in the data synthesis. Thank you.
47

 Self-report Instruments for Diagnosing 

Disorders in Primary Care Evidence-based Synthesis Program

Response

osures indicate no overt bias. In selecting articles, they did 

sh-language measures and articles, possibly excluding high

ough it is true the excluded studies would likely have been 

he VHA population. As the authors point out, there is some 

ication bias, as there is no trials register for diagnostic studies; 

ble, the search strategy was thorough and comprehensive.

Unfortunately, our resource limitations do not permit bilingual staff or translation services. Since foreign language publications often deal with foreign language questionnaires and this report was written to serve a Veteran population in the United States, we do not think we have missed many pertinent articles. We acknowledge the language limitation in the discussion.AcknowledgedAcknowledgedThank you.Acknowledged

dies of interest to the VA that we have overlooked?

Acknowledged

separate search, particularly looking for anxiety assessment in 

ould find no studies that were not already included.

Thank you for checking our work! We are glad we did not miss key studies.

language articles (these studies were excluded). Unfortunately, our resource limitations do not permit 

bilingual staff or translation services. Since foreign language publications often deal with foreign language questionnaires and this report was written to serve a Veteran population in the United States, we do not think we have missed many pertinent articles. We acknowledge the language limitation in the discussion.Acknowledged

y documented in report appears thorough. Thank you.

workgroup on late-life anxiety disorders has recently published 

ficulties of detecting anxiety disorders in older adults. Within 

me potentially helpful recommendations for improving the 

creening and diagnostic measures for this difficult to assess 

 insight and memory problems). The citation is Mohlman et al, 

nal of Geriatric Psychiatry. If it is not yet available, you could 

m the 1st author, Jan Mohlman, Ph.D., jmohlman@rci.rutgers.

Thank you for this suggestion. We have cited this article in our discussion. 

Acknowledged
48

 Self-report Instruments for Diagnosing 

Disorders in Primary Care Evidence-based Synthesis Program

Response

nical performance measures, programs, quality improvement measures, patient care services, or conferences that will be 

rt? If so, please provide detail.

ted programs (e.g., primary care-mental health integration) are 

o these results. Casefinding, identification of comorbid anxiety 

king treatment progress (i.e., measurement-based care) are 

s for these programs.

We have revised the discussion to identify specific programs (e.g. PACT, primary care-mental health integration) that may want to the recommended instruments. As none of the instruments have been tested for response to change, we think it is too early to implement them for monitoring treatment response. 

did not find one measure superior to others, it is not clear that this 

n immediate change in these areas. The report does highlight the 

earch on outcomes of anxiety screening.

Based on feasibility and performance characteristics, we identified and recommended the most promising instruments. We have noted the need for further research on the effects of routine screening for anxiety disorders.AcknowledgedAcknowledged

ot appear to recommend any additions to VA services at this time. 

makes no practical recommendations so this question is hard to 

We have revised the report to make more explicit recommendations, including a summary table of recommendations. 

familiar with the VA programs to fully answer this, but it appears 

sion from this report is that there is insufficient evidence regarding 

g screening methods for these disorders in VA settings (especially 

e logical conclusion would be to recommend to the VA HSR&D 

ortunity be made to create and test screening methods.

Thank you for your comment. We are assured that the report will be widely disseminated within the VA system. We have also included a specific recommendation for VA R&D to consider supporting studies on anxiety measures and anxiety screening.Acknowledged

y recommendations on how this report can be revised to more directly address or assist implementation needs.

ate and explicit aims of the report are specifically framed and 

plished, addition or further discussion of three issues could be 

aces (namely, framing the questions up front, recommending 

ections, and suggesting implementation needs) to further enhance 

eport or inform future work. Specifically, these three issues are: 

nknown science and the advisability on a practical level of using 

wing treatment progress in addition to casefinding; 2) the role 

ration in future research; and 3) advice for implementation or 

st clinical or population contexts for using these instruments for 

tive casefinding in general medical settings.

1) This is a very good point and idea. Our review did not 

specifically address the advisability of measurementbased care but we cite two anxiety care management studies that used this approach with positive results. 

2) This is also a very good point, and we have amended 

the report to address it to a limited degree in the Recommendation for Future Research section as well as in the Summary of Recommendations.

3) We revised the discussion to comment on current 

recommended uses and the research on the performance of anxiety measures in specific populations.
49

 Self-report Instruments for Diagnosing 

Disorders in Primary Care Evidence-based Synthesis Program

Response

e, the report might include some comment about screening for 

pressives and comorbidity of these illnesses.

We discussed the potential for change in performance in individuals with depressive or medical illness. In addition, we commented on applicability to specific VA programs.

nt contribution of untreated mental illness to overall healthcare 

t, reasonably effective and feasible diagnostic screening tools for 

istration in the medical setting could have an impact on overall 

ealthcare expenditures. Use of screening tools for GAD and PD 

nics may be an important first step; an algorithm for “what to do ns positive” might be helpful in encouraging implementation of a 

.

We agree that such an algorithm would be highly useful if the policy implementation experts at the VA decide to start routine screening for anxiety disorders in primary care venues.

Patients referred to the integrated-care programs are also screened 

itions, including anxiety disorders. 

creening for comorbid conditions including anxiety disorders 

programs. If this were being done, it seems like we might have 

aw on or would have some information on what screening tools 

The original call for proposals to establish mental health–primary care programs specified routine screening for anxiety disorders. However, these data are not being collected routinely at a national level. We will promote our report to the MH-PC program.

is sound and the evidence appears clear. The conclusions are 

not appear to provide any practical recommendations (e.g., that 

res examined should be implemented, that VA should devote 

g and researching new screening instruments, etc.). Also, it is 

e overall VA policy will be to manage GAD and PD in primary 

itating a diagnostic instrument) or refer positive screens to 

more accurate diagnosis (which would necessitate only a brief 

he brief screenings VA uses now in primary care).

Thank you. We revised the report to offer more practical recommendations, including the need for research to inform the effects of screening in primary care. Making recommendations for VA policy—such as care for patients in primary care versus mental health settings—is beyond the scope of the report.
50

 Self-report Instruments for Diagnosing 

Disorders in Primary Care Evidence-based Synthesis Program

Response

mments. My apologies if some of these go beyond the stated 

ert review:

creening instrument will need to do more than simply detect 

ed to diagnose and track the severity of these disorders, as 

A system (other than psychologists) will not have the time, ability, 

o these.

 is that the VA health care system has a lot of older adults. A 

needed on whether the screening instruments would have 

 detect anxiety disorders in this age group. Older adults are 

lt to screen for and diagnose anxiety disorders, given memory 

 among others. 

 is that the report does not seem to be taking the changes in these 

M-V into account. For example, will the GAD-7 still be relevant 

ed into a disorder that more reflects the core concept of worry iated symptoms)? 

ne, there is increasingly a move to question the diagnostic 

e disorders and instead focus on (in the case of anxiety disorders) 

f pathological anxiety such as distress and avoidance. As a 

of this issue, wouldn’t the VA be better off with an instrument 

nly GAD but also “anxiety disorder NOS” in the context of 

reviewers want to consider the PROMIS anxiety item banks in 

my knowledge, these have not been used in exactly the way the 

mining, but they have been the most extensively psychometrically 

easuring anxiety symptoms. I’ve reviewed them in the past, and 

appear quite good – very effective at assessing both the presence 

hological anxiety

We agree that tracking responsiveness to change is an important attribute of a good screening instrument. However, the instruments included in the review have not been evaluated for sensitivity to change. Therefore, we included this as a recommendation for future research and have highlighted it again in the Summary of Recommendations section. The reviewer is correct in that the VA does have a lot of older adults in whom detection of anxiety disorders is challenging. We have amended the Recommendations for Future Research section of the report to highlight this point. We agree that changes in the diagnostic criteria can affect the performance of an instrument that has been validated using a different version of the DSM. This has been addressed Summary and Discussion section.The potential changes in the diagnosis of anxiety disorders resulting from the current discussions about diagnostic boundaries are pertinent. We have addressed the specificity of scales under development in the Recommendations for Future Research section.We have added a brief comment on the issue of developing and evaluating scales that detect general anxiety versus those that assess for specific disorders. There are tradeoffs for each decision.Thank you for this suggestion. We contacted one of the investigators regarding the PROMIS scales and also reviewed their Web site. We also conducted a literature search for the PROMIS anxiety scale. It appears that the scale has not yet been validated in a primary care sample and, therefore, could not be included in this report.
51

 Self-report Instruments for Diagnosing 

Disorders in Primary Care Evidence-based Synthesis Program

Response

sion sections: Include more of a discussion of implementation 

. You provide a brief discussion of parallels with the PHQ-9 

d expanding this discussion related to how the recommended 

uld be implemented within VA settings could be helpful for policy 

ers who will make use of the findings. 

mmendations for universal screening?

ls be included in CPRS and administered to certain populations at 

We have added our recommendations for current implementation, limited to case-finding and a recommendation for research to address systematic screening.USPTF does not have a current recommendation on routine anxiety screening, and we have specifically noted the lack of a recommendation. We did not conduct a systematic review of the effect of anxiety screening; however, this is an important question for future research. This is a good suggestion, and we have recommended that the most promising tools be added to the MH assistant.

with contact details of any additional individuals/stakeholders who should be made aware of this report.

Thank you, we will make sure Dr. Pomerantz is aware of our report. 

d this to Dr. Eric Lenze at Washington University, who is an 

n the elderly. His email is lenzee@wustl.edu

Thank you. The report will be disseminated broadly.

tive (medical / mental health) work, this is important information 

ed in healthcare policy and reform. 

Thank you.Acknowledged

nk of. Acknowledged

ted above would be a good start. Acknowledged

ed screening tools should be implemented. This could be done at 

hrough central office, or at the VISN or Chief of mental health 

) responsible for implementation should be made aware of this 

Acknowledged. We are assured that the report will be widely circulated inside the VA system.

ional suggestions or comments below. If applicable, please indicate the page and line numbers from the draft report.

Acknowledged

n report Thank you.

AcknowledgedAcknowledged
52

 Self-report Instruments for Diagnosing 

Disorders in Primary Care Evidence-based Synthesis Program

Response

ents from item 5 above, some consideration should be given 

hich this literature examination is taking place (i.e., VA setting 

 facility), and there should be some mention of possible ways that 

ents could be used (e.g., whether positive screens will be assessed 

 by PC personnel, whether they will be walked over to integrated 

r they will be referred to MH), as this would affect the type of 

uld be developed and researched.

We agree that the setting in which an instrument is administered is important. Though we would have liked to have included studies done in the VA, we did not identify any and have suggested this as a recommendation for future research. Subsequent treatment and referral of patients who screen positive is important; however, it was beyond the scope of this review. 

 and well thought out report. I enjoyed reading it. Thank you.

1: Provide citations for introductory paragraph.1: Often is stated twice in the last sentence. Change last “often” 3: should be “detailed review of” (not review on).

nclusion/exclusion criteria related to population is unclear given 

ytic framework described throughout the report. It is unclear 

symptoms” referred to in the KQ1 and analytic framework is the 

s is described in this table.

ge 2, paragraph 5) you refer to patients in primary care settings. 

ch populations and settings were included and excluded from this 

istent terminology throughout the report (e.g., Included studies were 

mary care settings with patients who (a) presented with somatic 

) did not have a preexisting mental health diagnosis, hereafter 

mary care patients with somatic symptoms”). In the introduction 

with a description of you population (primary care settings), yet 

rification related to the presence of somatic symptoms and lack of 

health diagnosis. This is confusing because earlier in the paragraph 

d for anxiety disorder screening tools and make reference to the 

e disorders are present in populations with other mental illnesses—

her or not these populations are included in the scope of this report.

n/exclusion criteria include non-primary care settings in the 

rhaps clarification that all these settings were included, however 

setting studies were found.

We have added citations. We have made this change.We have made this change.We have added text in the Methods section to clarify this further and have changed the wording in the table.This has been clarified in the Results section.Thank you.
53

 Self-report Instruments for Diagnosing 

Disorders in Primary Care Evidence-based Synthesis Program

Response

r, concise description of quality assessment, data synthesis, and 

evidence.

arch of a relevant systematic review should be changed to search 

atic reviews.

f excluded articles includes 17 listed as “population not of 

sted as “setting not PC/clinic/ER.” Not sure if this needs more 

 might be beneficial to describe these excluded studies in greater 

ove comments re: population and setting description. I think it 

ng to know more about these excluded studies and why they were 

the scope of this report (if there are many studies conducted in 

opulations who have a pre-existing MH diagnosis, for example, 

nteresting future SR in and of itself, even if beyond the scope of 

is an excellent and concise description of measure characteristics. 

so it all made sense to me, however many readers likely don’t 

kground to understand the analyses. Try including a summary 

ype of analysis with a more “plain English” description of the 

it means so that non-statsy folks can follow along, too.

t figure!

use either case finding or case-finding, not both.

ast/first paragraph on effective treatments for ADs seems a bit 

ust provide the citations or tie it in to the findings a little more.

, clear, and concise report. Very useful and well written. Will be 

plementing changes within the VA.

We have clarified these descriptions.We have corrected this text.We rechecked the 17 studies listed as “population not of interest.” Fifteen studies were of subjects already diagnosed with an anxiety disorder; one was of Native Americans on a reservation; and the last was on inpatients. We also checked those listed as having “setting not PC/MH clinic/ER.” Five were conducted at a university, five were recruited from MH clinics (and already diagnosed with an anxiety disorder), four were ads in the general community, two were specialty-based (neurology and geriatric), two were internet-based and one interviewed subjects in their homes.We have included a section describing sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio in plain English.Thank you.We have made case-finding consistent.We have clarified this text.Thank you.