Generalized Anxiety Disorder 2-item (GAD-2)

Introduction

The GAD-2 (Generalized Anxiety Disorder 2-item) is a two-question survey that screens for anxiety. Kurt Kroenke, MD, Robert L. Spitzer, MD, Janet B.W. Williams, DSW, and colleagues introduced it in 2007, built from the first two items of the GAD-7. It asks about the two core symptoms of generalized anxiety disorder: feeling nervous and being unable to control worry. It takes less than a minute, so it’s widely used in primary care, often alongside the PHQ-2.

What it asks: Over the last 2 weeks, how often have you been bothered by the following problems? 1. Feeling nervous, anxious or on edge 2. Not being able to stop or control worrying. Each item uses the same four answers: Not at all (0), Several days (1), More than half the days (2), or Nearly every day (3).

How it’s scored: The two item scores are added together for a total from 0 to 6. A score of 3 is the preferred cutoff for identifying possible cases where further diagnostic evaluation for generalized anxiety disorder is warranted. At that cutoff, the GAD-2 has a sensitivity of 86% and a specificity of 83% for generalized anxiety disorder. A lower cutoff of 2 catches more cases but produces more false positives: sensitivity rises to 86% for any anxiety disorder, but specificity falls to 70%.

What it can detect: Although the GAD-2 was designed for generalized anxiety, it also performs reasonably well as a screen for three other common anxiety disorders: panic disorder, social anxiety disorder, and posttraumatic stress disorder. It’s least sensitive for PTSD, so a negative GAD-2 shouldn’t replace a PTSD screen when trauma is a concern.

How results are used: A score of 3 or higher is a positive screen and should be followed by the full GAD-7 or a clinical assessment. A 2016 review of multiple studies concluded the GAD-2 had acceptable accuracy for identifying generalized anxiety disorder at a cutoff of 3. Like the PHQ-2, the GAD-2 is a screening tool, not a diagnosis, and it doesn’t measure how severe anxiety is over time.

Performance as Screening Tool for Anxiety Disorders
(Using GAD-2 Score Cut-off of ≥3)

How results are used: A score of 3 or higher is a positive screen. Patients who screen positive should be further evaluated with the GAD-7 to determine whether they meet criteria for an anxiety disorder. A score below 3 is a negative screen, but it doesn’t rule out anxiety if other concerns are present. The GAD-2 also has no question about suicide or self-harm, so it can’t be used to assess safety. When there’s concern, follow up with the GAD-7 and PHQ-9 or a clinical assessment.

Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007 Mar 6;146(5):317-25.

The GAD-2 was based on the GAD-7, which was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.