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Ann Am Thorac Soc. 2018 Jul 9. doi: 10.1513/AnnalsATS.201708-631OC. [Epub ahead of print]

Test Performance Characteristics of the AIR, GAD-7 and HADS-Anxiety Screening Questionnaires for Anxiety in Chronic Obstructive Pulmonary Disease.

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Bucknell University, 4517, Psychology, Lewisburg, Pennsylvania, United States.
Johns Hopkins Bloomberg School of Public Health, Epidemiology, Baltimore, Maryland, United States.
Manchester Metropolitan University , Health Professions , Manchester, United Kingdom of Great Britain and Northern Ireland.
Johns Hopkins University, Medicine, Baltimore, Maryland, United States.
Johns Hopkins University Bloomberg School of Public Health, 25802, Baltimore, Maryland, United States.
University of Vermont, Medicine/Pulmonary and Critical Care, Burlington, Vermont, United States.
United States.
Duke University Hospital, 22957, Durham, North Carolina, United States.
Duke University Medical Center, Medicine, Durham, North Carolina, United States.
University of California, San Diego, San Diego, California, United States.
University of California San Diego, medicine, San Diego, California, United States.
University of Arizona , College of Public Health , Tucson, Arizona, United States.
Johns Hopkins University School of Medicine, Medicine, Baltimore, Maryland, United States.
Baylor College of Medicine, Houston, Texas, United States ;



Anxiety is a common co-morbidity of Chronic Obstructive Pulmonary Disease (COPD) that is associated with higher morbidity and mortality. We evaluated three anxiety screening questionnaires, the Generalized Anxiety Disorder (GAD-7) questionnaire, the Hospital Anxiety and Depression Scale (HADS-A), and the Anxiety Inventory for Respiratory Disease (AIR).


Evaluate and compare thet test performance characteristics of 3 anxiety screening questionnaires using the Mini International Neuropsychiatric Interview (MINI) version 7.0 as the gold standard.


Individuals with COPD were recruited at 16 centers. The MINI interview and questionnaires were administered by trained research coordinators at an in-person visit and re-administered by telephone 2 to 4 weeks later. A composite score for the presence of any DSM-V anxiety disorder was computed based on the MINI as the gold standard compared to a participant screening positive on self report measures for these analyses.


220 eligible individuals with COPD were enrolled; 219 completed the study. 11% were identified as having a DSM-V anxiety disorder based upon 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 curve (AUC) was highest for the GAD-7 (0.78, 95%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). 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 the GAD-7 (77%, P<0.001) and the AIR (65%, P<0.001); the GAD-7 specificity was higher than the AIR (P<0.001).


Symptoms of anxiety among COPD patients as identified by screening questionnaires were common and significantly higher than the prevalence of anxiety disorder meeting by DSM-V criteria. The GAD-7, the HADS 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.

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