Anxiety has far-reaching effects on cognition, general health, and adherence to treatment. Almost any healthcare provider can benefit from measuring patients’ symptoms of anxiety in order to better understand patient health and demonstrate the impacts of treatment. CBS Health now includes the General Anxiety Disorder (GAD-7) questionnaire to integrate into any assessment alongside cognitive tasks or other questionnaires.
What is the GAD-7?
The GAD-7 is a measure of general anxiety symptoms. It is commonly used in many healthcare and research contexts where anxiety can be involved in a diagnosis or as a key outcome measure. The GAD-7 was developed to overcome issues with traditional anxiety measures, such as taking too long and requiring in-person administration, by streamlining the process with a 7-item self-administered assessment that is quick and easy to complete.
Questions on the GAD-7 ask about how often patients have been bothered by symptoms over the last 2 weeks. Each item is scored from 0 to 3, and a total score is indicative of anxiety severity.
Research has shown the GAD-7 is small but mighty. It has strong psychometric properties, despite taking very little time. In a recent paper, Johnson et al. (2019) administered the GAD-7 to a variety of psychiatric patients, and found that it has excellent reliability and validity. When used with a cutoff score of 8 for the purposes of screening or diagnosis of anxiety disorders, it also has good sensitivity and specificity. Furthermore, scores were responsive to changes due to treatments, even in this study's diverse sample.
Note: The purpose of the GAD-7 is to assist the clinician in quantifying anxiety symptoms and monitoring the severity of these symptoms over time. Any conclusions drawn from the GAD-7 should be paired with clinical interviews and observations, other mental health examinations or assessments administered, and evaluations of the patient’s level of distress, functional impairment, and/or family history. Please refer to the GAD-7 instruction manual for additional details.
How is anxiety related to cognition?
As a streamlined but valid measure, the GAD-7 serves a similar purpose as CBS Health’s quick and easy tests of cognitive function. Furthermore, anxiety is closely related with cognition, making the GAD-7 a natural fit with brain health measures. In two large studies using CBS tasks, we found that cognition was clearly related with self-reported anxiety. This relationship was especially pronounced for the short-term memory tasks: Monkey Ladder, Paired Associates, Spatial Span, and Token Search, so these tasks may be of particular interest when you are administering the GAD-7 and a cognitive battery side by side (see Hampshire et al., 2012, and Wild et al., 2018).
Research is also finding key associations in clinical contexts. For example, Nicol et al al. (2019) found that brain tumour survivors report lower subjective cognitive function, and GAD-7 scores uniquely account for a significant percentage of that impairment, highlighting the complex interplay between direct brain trauma, subjective cognitive complaints, and anxiety. Another study (Getaneh, Ballard, & Brooker, 2020) found that both anxiety (GAD-7) and depression (PHQ-9) scores were associated with decline in an executive function task among older adults. Healthcare providers must consider multiple mental health metrics when explaining or treating disruptions to cognitive functioning.
Which healthcare providers should measure anxiety using the GAD-7?
Mental health providers will often measure anxiety as part of screening, an initial patient interview, and/or to monitor treatment progress. Practitioners who treat anxiety will find a direct use for the GAD-7, providing evidence that treatment is on the right track. Treatments such as cognitive behavioural therapy (CBT) have been shown to be effective in reducing generalized anxiety disorder symptoms (Cuijpers et al., 2014). Those who already administer a GAD-7 by paper and pencil will find it much more efficient to include a computerized GAD-7 within a CBS Health assessment.
Even healthcare practitioners who do not directly treat anxiety may find a use for the scale, because anxiety can play a role in a wide variety of mental and physical health disorders. General physical health and quality of life are associated with anxiety (El-Gabalawy et al., 2011; Strine et al., 2004), as are many specific conditions, such as diabetes (Smith et al., 2013). Anxiety can also get in the way of treatments, with severe anxiety leading to reduced adherence to treatment programs (e.g., for cancer; Arrieta et al., 2013). Of course, anxiety also has strong links to other mental health conditions, such as depression (Jacobson & Newman, 2017), and treatment regimes may depend on the severity of symptoms. Furthermore, lifestyle interventions may improve anxiety symptoms, even if anxiety is not the primary focus. For example, physical activity interventions generally decrease anxiety (Conn, 2011).
In sum, nearly any healthcare provider will benefit from measuring anxiety severity, whether as a baseline, to assist in diagnosis, to plan and adjust treatments, and/or as an outcome measure.
How can a computerized GAD-7 be administered in CBS Health?
By administering the GAD-7 to your patients, you can begin to apply the scientific research above to your individual patients. Is a patient's subjective "brain fog" a result of objective cognitive impairment, or is it due to distraction from anxiety? Is anxiety exacerbating the effects of other physical or mental health conditions? Could successfully treating anxiety slow cognitive decline in your older patients? After quick CBS Health assessments, you will have additional information to help answer these questions, guiding your treatment plans and providing quantifiable evidence of success.
It is easy to include the GAD-7 in a CBS Health assessment, either as part of a longer set of cognitive tasks and questionnaires, or on its own. The procedure is the same for all questionnaires: when creating a protocol, click the Questionnaires section, then check off the GAD-7. You can check off additional questionnaires or cognitive assessments to include them all in one integrated patient experience.
For detailed instructions on administering questionnaires within CBS Health, please see our previous blog post on administering the PHQ-9.
The CBS Health version of the GAD-7 has all the advantages of computerized assessments. For you, the assessment process is almost entirely automated: with a few clicks, you can start a single assessment, or send a series of assessments on a schedule by email. Results are scored automatically and instantly, then scores and trends over time are automatically added to the patient’s reports. From patients’ perspectives, completing the GAD-7 is easy—they simply follow the self-directed process, then a few minutes and a handful of clicks later, their healthcare provider immediately has valuable mental health information to help improve treatments and measure outcomes.
GAD-7 billing procedures in the United States
Please note: Cambridge Brain Sciences cannot determine your eligibility for reimbursement and does not assume responsibility over the outcome of any claims. The CPT code(s) noted below to report the services provided will depend on other procedures performed, associated CCI edits, and other factors. Please contact your local payer to determine whether you qualify for these codes, and if any additional coding and coverage guidelines exist, such as which providers can perform the service, limits on billable time, or if the use of a modifier is required or allowed.
Providers utilizing the GAD-7 may be eligible for reimbursement through CPT code 96127, described as the following by the Centre for Medicare and Medicaid Services (CMS): Brief emotional/behavioral assessment, with scoring and documentation, per standardized instrument.
As per the latest guidelines from the American Medical Association, this code is also telehealth-approved. Usage limits and reimbursement amounts vary by state, payer types, and potentially other factors, though the average reimbursement value can range anywhere from $4–$8. When administering the GAD-7 alongside other mental health screening instruments, such as the PHQ-9, you may be able to report one unit for each questionnaire completed. For further information, please contact your local payer.
Need more digital health questionnaires?
Finally, if there are any questionnaires you are using today as part of your practice that you would like to have available in computerized form within CBS Health—or if you have other feedback or comments for the CBS team—please do not hesitate to let us know by commenting on this blog post or contacting us directly via email. We always look forward to hearing from you.
Thanks, as always,
— The Cambridge Brain Sciences Team