[Psychiatr]

Сообщение от Anthioh

Владимир Николаевич, обе ссылки пароль требуют!

Прошу прощения, я думал, что в Medscape CME все зарегистрированы и пользуются

March 19, 2007 — Anxiety disorders are prevalent and often untreated in the primary care setting, and 2 screening tests are useful in detecting anxiety disorders, according to the results of a criterion-standard study reported in the March 6 issue of the Annals of Internal Medicine.

"Anxiety often manifests as a physical symptom like pain, fatigue, or inability to sleep, so it is not surprising that one out of five patients who come to a doctor's office with a physical complaint have anxiety," lead author Kurt Kroenke, MD, from the Regenstrief Institute for Health Care and Indiana University in Indianapolis, Indiana, said in a news release. "The seven-question GAD-7 [Generalized Anxiety Disorder-7] and remarkably even the two-question 'ultra brief' version gives the physician a tool to quantify the patient's symptoms — sort of a lab test for anxiety."

Between November 2004 and June 2005 at 15 US primary care clinics, 965 randomly sampled patients from consecutive clinic patients who completed a self-report questionnaire and agreed to a follow-up telephone interview were evaluated with a 7-item anxiety measure (GAD-7 scale). This was followed by a telephone-administered, structured psychiatric interview by a mental health professional blinded to the GAD-7 results. Other outcomes were functional status on the Medical Outcomes Study Short Form-20, depressive and somatic symptoms, and self-reported disability days and clinician visits.

At least 1 anxiety disorder was present in 19.5% of the 965 patients (95% confidence interval [CI], 17.0% - 22.1%). Specific diagnoses were posttraumatic stress disorder in 8.6% (95% CI, 6.9% - 10.6%), GAD in 7.6% (95% CI, 5.9% - 9.4%), panic disorder in 6.8% (95% CI, 5.3% - 8.6%), and social anxiety disorder in 6.2% (95% CI, 4.7% - 7.9%).

Each disorder was associated with substantial impairment that increased significantly (P < .001) with increasing number of anxiety disorders. However, 41% of patients with an anxiety disorder reported no current treatment.

Receiver-operating characteristic curve analysis revealed that the GAD-7 scale as well as its 2 core items (GAD-2) were good screening tools for all 4 anxiety disorders (area under the curve, 0.80 - 0.91).

"Anxiety disorders are prevalent, disabling, and often untreated in primary care," the authors write. "A 2-item screening test may enhance detection."

Study limitations include patient population enrolled from a nonrandom sample of selected primary care practices, possible overestimate of the prevalence of anxiety disorders because frequent clinic attendees could be overrepresented, the 965 patients analyzed had slightly higher anxiety scores than patients who were not undergoing a mental health professional interview, outcomes such as disability days and clinician visits were assessed exclusively by patient self-report, and lack of information on comorbid medical illnesses or on the number and types of medications used.

"Considering the frequency with which depression and anxiety co-occur, a search for one condition should always be accompanied by an assessment of the other," the authors conclude. "The validation of brief (GAD-7 and PHQ-9 [Patient Health Questionnaire-9]) and ultra-brief (GAD-2 and PHQ-2 [Patient Health Questionnaire-2]) measures considerably enhances the efficiency of screening for and monitoring anxiety and depression. These tools provide an opportunity to improve the mental health of primary care populations by identifying patients who may benefit from pharmacologic or psychotherapeutic treatment."

Pfizer, Inc., supported this study. Some of the authors have disclosed various financial relationships with Eli Lilly, Inc., Pfizer, Inc., GlaxoSmith-Kline, and/or Wyeth.

Ann Intern Med. 2007;146:317-325.
Clinical Context

Anxiety and depression are the 2 most frequent mental health problems seen in the general medical setting. Despite increasing recognition of anxiety, it still lags far behind depression in research and in clinical and public health efforts in screening, diagnosis, and treatment. Anxiety affects more than 30 million Americans during their lifetime and is associated with estimated direct and indirect healthcare costs of $42 billion dollars annually in the United States.

In the busy, complex primary care setting, simplifying initial recognition of mental disorders may lead to higher rates of treatment and better outcomes. This large, primary-care–based, criterion-standard study (PHQ anxiety study) evaluated the prevalence of 4 specific anxiety disorders; compared them in terms of functional impairment, healthcare use, and comorbid depressive and somatic symptom burden; and determined the efficacy of a brief anxiety measure in screening for each disorder.
Study Highlights
This study took place between November 2004 and June 2005 at 15 US primary care clinics (13 family practice and 2 internal medicine sites) located in 12 states.
The GAD-7 scale was developed and validated in 2149 patients. Scores on the GAD-7 range from 0 to 21; scores of 5, 10, and 15 represent mild, moderate, and severe anxiety symptoms, respectively. The first 2 items of the GAD-7 represent core anxiety symptoms, with scores ranging from 0 to 6.
Of 2982 persons invited to participate, 2740 (92%) completed the 4-page questionnaire and had no or minimal missing data. Of these, 1654 agreed to a telephone interview, of whom 965 were randomly selected to undergo this structured psychiatric telephone interview by a mental health professional blinded to the GAD-7 results. This interview established independent diagnoses based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Other outcomes were functional status on the Medical Outcomes Study Short Form-20, which measures functional status in 6 domains; the 10-item anxiety subscale from the Hopkins Symptom Checklist; the PHQ-8 depression scale; a 3-item version of the Social Phobia Inventory (Mini-SPIN); the 5-item PHQ panic module; and the PHQ-15 somatic symptom scale; depressive and somatic symptoms, self-reported disability days, and physician visits; and single-item global assessments of anxiety, depression, and pain on a scale of 0 to 10.
Mean age of the 965 patients was 47.1 ± 15.5 (range, 18 - 87) years; 69% were women, 81% were non-Hispanic white, 7% were black, and 9% were Hispanic; 65% were married; 21% were divorced, separated, or widowed; and 14% were never married; 5% had not completed high school, 29% had a high school degree or equivalent, 39% had some college education or an associate's degree, and 27% were college graduates.
At least 1 anxiety disorder was present in 188 (19.5%) of the 965 patients (95% CI, 17.0% - 22.1%). Of these 188 patients, 124 had 1 disorder, 42 had 2 disorders, 14 had 3 disorders, and 8 had 4 disorders. Specific diagnoses were posttraumatic stress disorder in 8.6% (95% CI, 6.9% - 10.6%), GAD in 7.6% (95% CI, 5.9% - 9.4%), panic disorder in 6.8% (95% CI, 5.3% - 8.6%), and social anxiety disorder in 6.2% (95% CI, 4.7% - 7.9%).
Each disorder was associated with substantial impairment that increased significantly (P < .001) with increasing number of anxiety disorders; 32% to 43% of patients with anxiety disorders vs only 4% of patients with no anxiety disorders stated that their anxiety made it "very or extremely difficult" to do their work, to take care of things at home, or to get along with other people. Each anxiety disorder also had moderate levels of depressive (mean PHQ-8 score, 12.0 - 12.5) and somatic (mean PHQ-15 score, 12.0 - 14.0) symptom burdens, also suggesting comorbidity with nonanxiety psychiatric disorders. However, 41% of patients with an anxiety disorder reported no current treatment.
Receiver-operating characteristic curve analysis revealed that the GAD-7 scale and GAD-2 were good screening tools for all 4 anxiety disorders (area under the curve, 0.80 - 0.91). At a GAD-7 cutoff point of 8 or higher, sensitivity and specificity was about 0.75 or greater for all disorders, and the positive likelihood ratio exceeded 3.0. The likelihood ratio is similar to that of most measures used to screen for depression in primary care. On the GAD-2, a cutoff point of 3 or more may be preferable than a cutoff point of 2 given the low specificity and high false-positive rate for the latter.
Pearls for Practice
Anxiety disorders are prevalent, disabling, and often untreated in primary care. At least 1 anxiety disorder was present in 188 (19.5%) of the 965 patients in this study, but 41% of patients with an anxiety disorder reported no current treatment.
The GAD-7 scale as well as the GAD-2 were good screening tools for all 4 anxiety disorders. GAD-2 is easily and quickly administered and may improve detection of anxiety disorders in the primary care setting.

GAD-7 scale (первые 2 вопроса это субшкала GAD-2):
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