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Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection

Kurt Kroenke, MD; Robert L. Spitzer, MD; Janet B.W. Williams, DSW; Patrick O. Monahan, PhD; and Bernd Löwe, MD, PhD
[+] Article and Author Information

From Regenstrief Institute for Health Care and Indiana University, Indianapolis, Indiana; New York State Psychiatric Institute and Columbia University, New York, New York; and University of Heidelberg, Heidelberg, Germany.


Acknowledgments: The authors thank Monika Mussell, PhD, and Dieter Schellberg, PhD, University of Heidelberg, Heidelberg, Germany, for their invaluable assistance in some data analyses.

Grant Support: Pfizer Inc.

Potential Financial Conflicts of Interest: Consultancies: K. Kroenke (Eli Lilly Inc., Pfizer Inc.), J.B.W. Williams (Eli Lilly Inc., GlaxoSmithKline); Honoraria: K. Kroenke (Eli Lilly Inc., Wyeth); Grants received: K. Kroenke (Eli Lilly Inc., Pfizer Inc., Wyeth), R.L. Spitzer (Pfizer Inc.), J.B.W. Williams (Pfizer Inc.), B. Löwe (Pfizer Inc.).

Requests for Single Reprints: Kurt Kroenke, MD, Regenstrief Institute, 1050 Wishard Boulevard, Indianapolis, IN 46202; e-mail, kkroenke@regenstrief.org.

Current Author Addresses: Dr. Kroenke: Regenstrief Institute for Health Care, 1050 Wishard Boulevard, Indianapolis, IN 46202.

Drs. Spitzer and Williams: New York State Psychiatric Institute, Unit 60, 1051 Riverside Drive, New York, NY 10533.

Dr. Monahan: Division of Biostatistics, Department of Medicine, Indiana University, 1050 Wishard Boulevard, RG4 101, Indianapolis, IN 46202.

Dr. Löwe: Klinik für Psychosomatische und Allgemeine Klinische Medizin, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.

Author Contributions: Conception and design: K. Kroenke, R.L. Spitzer, J.B.W. Williams, B. Löwe.

Analysis and interpretation of the data: K. Kroenke, R.L. Spitzer, J.B.W. Williams, P.O. Monahan, B. Löwe.

Drafting of the article: K. Kroenke.

Critical revision of the article for important intellectual content: K. Kroenke, R.L. Spitzer, P.O. Monahan, B. Löwe.

Final approval of the article: K. Kroenke, R.L. Spitzer, J.B.W. Williams, P.O. Manahan, B. Löwe.

Statistical expertise: K. Kroenke, R.L. Spitzer, P.O. Monahan.

Obtaining of funding: K. Kroenke, R.L. Spitzer, B. Löwe.

Collection and assembly of data: J.B.W. Williams.


Ann Intern Med. 2007;146(5):317-325. doi:10.7326/0003-4819-146-5-200703060-00004
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Our study contributes several new insights to what is already known about anxiety disorders in primary care. First, 4 of the most common anxiety disorders are more alike with each other than different in terms of functional impairment, disability, and comorbidity as well as with depressive and somatic symptoms. Second, one third of patients with an anxiety disorder had 1 or more additional anxiety disorders, and the number of disorders was strongly associated with impairment and health care use. Third, an ultra-brief 2-item measure is a useful screening tool for all 4 anxiety disorders.

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Appendix Figure.
The Generalized Anxiety Disorder (GAD)-7 scale.

The first 2 items constitute the GAD-2 subscale. GAD-7 © 2006 Pfizer Inc. All rights reserved. Used with permission.

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Figure.
Association between the number of anxiety disorders and decline in functional status as determined by analysis of covariance models adjusted for sex, age, race, education, and study site.

The decrement in the Medical Outcomes Study Short Form-20 (SF-20) scores is shown as the difference between each group (i.e., those with 1 anxiety disorder [n = 124], 2 anxiety disorders [n = 42], or 3 to 4 anxiety disorders [n = 22]) and the reference group (i.e., those with no anxiety disorder [n = 777]). Effect size is the difference in group means divided by the SD for the entire sample. For each SF-20 scale, the overall F test is significant (P < 0.001) for declining function with an increasing number of anxiety disorders. In pairwise comparisons using the Bonferroni correction, all groups with anxiety disorders differed markedly (P < 0.001) from patients with no anxiety disorders for each SF-20 scale except pain (P < 0.039). Likewise, patients with 3 to 4 anxiety disorders differed (P < 0.050) from those with 1 anxiety disorder for all scales. When models were rerun using the rank transformation of SF-20 scales, results remained highly significant (P < 0.001) for 5 of the scales and significant (P < 0.025) for the sixth scale (bodily pain) when comparing persons with 1, 2, or 3 to 4 anxiety disorders with those with no anxiety disorder and results remained significant (P < 0.014) for all scales except mental health and bodily pain when comparing the group with 3 to 4 anxiety disorders with the group with 1 anxiety disorder.

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Comments

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No Title
Posted on March 17, 2007
Alan L. Fine
Group Health Permanente
Conflict of Interest: None Declared

As a busy primary care internist, I was happy to read about a validated brief screening method for anxiety disorders. I would have been happier still if your article had actually included the GAD-7 or GAD-2 in the text; the utility of the article would most definitely have been enhanced.

Conflict of Interest:

None declared

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Summary for Patients

Anxiety Disorders in Primary Care Patients

The summary below is from the full report titled “Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection.” It is in the 6 March 2007 issue of Annals of Internal Medicine (volume 146, pages 317-325). The authors are K. Kroenke, R.L. Spitzer, J.B.W. Williams, P.O. Monahan, and B. Löwe.

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