Test performance characteristics of the AIR, GAD-7, and HADS-anxiety screening questionnaires for anxiety in chronic obstructive pulmonary disease

Anna M. Baker, Janet T. Holbrook, Abebaw M. Yohannes, Michelle N. Eakin, Elizabeth A. Sugar, Robert J. Henderson, Anne S. Casper, David A. Kaminsky, Alexis L. Rea, Anne M. Mathews, Loretta G. Que, Joe W. Ramsdell, Lynn B. Gerald, Robert A. Wise

Research output: Contribution to journalArticlepeer-review

13 Scopus citations


Rationale: Anxiety is a common comorbidity of chronic obstructive pulmonary disease (COPD) that is associated with higher morbidity and mortality. We evaluated three anxiety screening questionnaires: the Generalized Anxiety Disorder 7-Item Scale (GAD-7), the Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A), and the Anxiety Inventory for Respiratory Disease (AIR). Objectives: To evaluate and compare the test performance characteristics of three anxiety screening questionnaires, using the Mini-International Neuropsychiatric Interview (MINI), version 7.0, as the “gold standard.” Methods: Individuals with COPD were recruited at 16 centers. The MINI and questionnaires were administered by trained research coordinators at an in-person visit and readministered by telephone 2–4 weeks later. A composite score for the presence of any Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) anxiety disorder was computed, based on the MINI as the gold standard, compared with a participant screening positive on self-report measures for these analyses. Results: Two hundred and twenty eligible individuals with COPD were enrolled; 219 completed the study. Eleven percent were identified as having a DSM-V anxiety disorder, based on the MINI. Elevated anxiety symptoms based on questionnaires were 38% for the AIR, 30% for the GAD-7, and 20% for the HADS-A. Area under the receiver operating characteristic curve (AUC) was highest for the GAD-7 (0.78; 95% confidence interval [CI], 0.69–0.87), followed by the HADS-A (0.74; 95% CI, 0.64–0.84) and the AIR (0.66; 95% CI, 0.56–0.76). The AUC for the GAD-7 was significantly greater than for the AIR (P = 0.014). Sensitivity was not statistically different among the questionnaires: 77% for the GAD-7, 63% for the HADS-A, and 66% for the AIR. The HADS-A had the highest specificity, 85%, which was significantly higher than that of the GAD-7 (77%; P, 0.001) and the AIR (65%; P, 0.001); GAD-7 specificity was higher than AIR specificity (P, 0.001). Conclusions: Symptoms of anxiety among patients with COPD as identified by screening questionnaires were common and significantly higher than the prevalence of anxiety disorder meeting DSM-V criteria. The GAD-7, the HADS-A and the AIR questionnaires had fair to moderate psychometric properties as screening tools for anxiety in individuals with COPD, indicating the need for improved measures for this patient population.

Original languageEnglish (US)
Pages (from-to)926-934
Number of pages9
JournalAnnals of the American Thoracic Society
Issue number8
StatePublished - Aug 2018


  • Anxiety
  • Chronic obstructive pulmonary disease
  • Psychometric properties
  • Test anxiety scale

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine


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