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. Author manuscript; available in PMC: 2024 Sep 16.
Published in final edited form as: J Psychiatr Res. 2024 Jul 3;177:31–38. doi: 10.1016/j.jpsychires.2024.07.003

Generalized anxiety disorder screening scores are associated with greater treatment need among Veterans with depression

KG Saulnier a,b,*, D Ganoczy c, PP Grau b,c, RK Sripada b,c, K Zivin b,c,d, JD Piette b,c,d, P N Pfeiffer b,c
PMCID: PMC11404397  NIHMSID: NIHMS2016552  PMID: 38971054

Abstract

Comorbid anxiety and depression predict a poorer prognosis than either disorder occurring alone. It is unclear whether self-reported anxiety symptom scores identify patients with depression in need of more intensive mental health services. This study evaluated how anxiety symptoms predicted treatment receipt and outcomes among patients with new depression diagnoses in the Veterans Health Administration (VHA). Electronic medical record data from 128,917 VHA patients (71.6% assessed for anxiety, n = 92,237) with new diagnoses of depression were analyzed to examine how Generalized Anxiety Disorder-7 (GAD-7) scores predicted psychotropic medication prescriptions, psychotherapy receipt, acute care service utilization, and follow-up depression symptoms. Patients who reported severe symptoms of anxiety were significantly more likely to receive adequate acute phase and continuation phase antidepressant treatment, daytime anxiolytics/sedatives, nighttime sedative/hypnotics, and endorse more severe depression symptoms and suicidal ideation at follow-up. Patients who reported severe symptoms of anxiety at baseline were less likely to initiate psychotherapy. The GAD-7 may help identify depressed patients who have more severe disease burden and require additional mental health services.

Keywords: Screening, Anxiety symptoms, Care utilization, Veterans, Comorbidity, Depression

1. Introduction

Depressive disorders are one of the most prevalent psychiatric conditions among Veterans (Trivedi et al., 2015). Anxiety is commonly comorbid with depression among Veterans (Pfeiffer et al., 2009; Trivedi et al., 2015), and comorbid anxiety is associated with functional impairment (Ziobrowski et al., 2021), suicide mortality (Pfeiffer et al., 2009), and all-cause mortality (Phillips et al., 2009). Comorbid anxiety with depression typically predicts poorer depression prognosis and treatment resistance compared to depressed patients without identified anxiety disorders (Coplan et al., 2015). Although recent U.S. Preventative Services Taskforce guidelines recommend routine screening for anxiety in addition to depression (US Preventive Services Task Force et al., 2023), whether anxiety screens obtained at the point of care can help identify treatment needs and illness burden among patients with depression is not known.

Irrespective of depression, anxiety disorders among Veterans are associated with increased use of various mental health services, including substance use disorder clinics (Milanak et al., 2013), hospitalizations (Trivedi et al., 2015), and emergency department (ED) visits (Trivedi et al., 2015). Among Veterans with depression, patients with comorbid PTSD utilize mental health services, both psychotherapy and medication, at greater rates than patients without PTSD (Chan et al., 2009; Kramer et al., 2003; Maguen et al., 2012; Nichter et al., 2019) indicating a greater burden of illness. Although PTSD and anxiety disorders differ slightly in symptom presentation, prognosis, and preferred treatment choice (Bandelow et al., 2017; Ginzburg et al., 2010; Rauch and Foa, 2006; Trivedi et al., 2015), it is likely that comorbid anxiety disorders also confer higher burden of illness and therefore greater treatment need, but this has not yet been determined.

When quantifying the impact of comorbid anxiety on care process and outcomes for patients with depression, previous Veterans Health Administration (VHA) studies have relied on anxiety disorder diagnoses reported in medical records. However, it is important to also examine self-reported anxiety symptoms, given patients may experience anxiety without a recognized diagnosis (Roberge et al., 2015; Wittchen et al., 2002) and anxiety symptoms fluctuate over time (Saulnier et al., 2022). The Generalized Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006) is a self-report measure that assesses generalized anxiety symptoms that is widely used in VHA (Liebmann et al., 2022). The GAD-7 has been well-validated as a screening measure for generalized anxiety disorder (GAD) as well as other anxiety disorders (Plummer et al., 2016; US Preventive Services Task Force et al., 2023). In non-VHA settings, findings are mixed regarding whether GAD-7 scores predict increased healthcare service utilization (Ruiz et al., 2011; Shippee et al., 2014) or are unrelated (Chikovani et al., 2015; Lowe et al., 2016; Sarkar et al., 2015; Springer et al., 2023). Regarding treatment outcomes, studies have found that higher GAD-7 scores are associated with increased depression symptoms (Kunkle et al., 2021; Shippee et al., 2014). However, no study has examined the influence of patient-reported anxiety symptoms on longitudinal markers of care receipt and outcomes among a national cohort of VHA patients with depression to inform screening practices and treatment guidelines.

We used data from a large national cohort of VHA patients with newly diagnosed depressive disorders to identify patient-level factors associated with the likelihood of completing a GAD-7. We then examined whether anxiety symptoms were associated with psychotropic medication receipt, psychotherapy receipt, acute care service utilization (i.e., inpatient psychiatric stays, ED visits), and depression symptom scores at follow-up (within eight months). We hypothesized that patients with more severe anxiety would have increased psychotropic medication receipt, psychotherapy utilization, acute care service utilization, and report more severe depression symptoms at follow-up.

2. Method

2.1. Data source

Data for this retrospective cohort study were obtained from the VHA Corporate Data Warehouse, which contains demographic information, medical record diagnoses, and treatment receipt information for all VHA patients. The study procedures were approved by the VA Ann Arbor Healthcare System’s Institutional Review Board.

2.2. Sample

VHA patients were included if they had a diagnosis of a depressive disorder (ICD-10 codes: F32.0–F32.5, F32.9, F33.0–F33.3, F33.40–F33.42, F33.9, F34.1) in outpatient or inpatient records between January 1, 2018 and December 31, 2020, and also received a Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) score indicating at least moderate depressive symptoms (score ≥10) within 30 days of their first depression diagnosis. Patients were assigned an index date corresponding to the first depression diagnosis date with a positive PHQ-9 score during the study period. Exclusionary criteria included a diagnosis of bipolar disorder or schizoaffective disorder with a bipolar-type specifier in the 12 months prior to the index date. To capture new episodes of depression, patients also were excluded if they had a depressive disorder diagnosis or received an antidepressant prescription in the 12 months prior to their index date, or had a positive PHQ-9 or PHQ-2 score (score ≥3) in the 12 months to 30 days prior to their index date. Finally, patients with >30 inpatient days during the acute or continuation phase of antidepressant use (defined below) were excluded.

2.3. Measures

2.3.1. Anxiety symptoms

Anxiety symptoms were assessed as part of routine outpatient care via the GAD-7 (Spitzer et al., 2006), a 7-item self-report questionnaire that assesses symptoms of generalized anxiety. Items are rated on a 4-point Likert-type scale ranging from 0 to 3. We used recommended GAD-7 cutoffs to identify patients with minimal anxiety (scores 0–4), mild anxiety (scores 5–9), moderate anxiety (scores 10–14), and severe anxiety (scores ≥15).1 GAD-7 administrations within 30 days of the patient’s index date were included. The first GAD-7 was used for patients who completed multiple GAD-7s.

2.3.2. Depression symptoms

Depression symptoms were assessed as part of routine outpatient care via the PHQ-9 (Kroenke et al., 2001), a 9-item self-report questionnaire that assesses depression symptoms. Items are rated on a 4-point Likert-type scale ranging from 0 to 3. Given that we excluded patients with less-than-moderate scores on the PHQ-9 (scores <10), we classified patients as having either moderate (scores 10–14) or severe depression (scores ≥15) based on recommended cutoffs.2

2.3.3. Measures of treatment process and quality

For patients who received the GAD-7, we evaluated the impact of anxiety symptoms on medication receipt, including antidepressants, daytime anxiolytics/sedatives, and nighttime sedative/hypnotics (see Supplementary Table 1). The quality of antidepressant care was evaluated using metrics presented in the Healthcare Effectiveness Data and Information Set (HEDIS). We examined adequate acute-phase treatment, defined as receiving an antidepressant prescription within 90 days of the depression diagnosis that provided medication for at least 84 of the 114 days following the initial prescription. We also examined adequate continuation-phase treatment, defined as continuing antidepressant medication for 180 of the 231 days following the initial prescription. We also examined daytime anxiolytic/sedative receipt initiated within 90 days of the index date that included at least 30 days of coverage. Prescriptions were excluded from the daytime anxiolytic/sedative variable if the instructions were for sleep or if the medication was to only be taken at bedtime. Nighttime sedative/hypnotics receipt was also examined and included sedatives initiated within 90 days of index depression diagnosis that included at least 30 days of coverage.

We examined psychotherapy receipt using quality-of-care measures developed to be conceptually similar to medication-based HEDIS measures (Levine et al., 2017). Psychotherapy initiation was defined as one psychotherapy encounter within 90 days of the index date (inclusive of all forms of psychotherapy). Psychotherapy engagement was defined as at least three psychotherapy sessions occurring in the 12 weeks following the first psychotherapy session (Pfeiffer et al., 2023). Psychotherapy visits were included if they had depression as a primary or secondary diagnosis. We limited psychotherapy stop codes to those consistent with clinics in which psychotherapy is commonly provided for affective disorders in VA, consisting of the general Mental Health Clinic (MHC), Primary Care - Mental Health Integration (PCMHI), and the specialty PTSD Clinical Team (PCT) settings.

Inpatient psychiatric stays and ED visits within 12 months of the index date were also examined. ED visits were limited to those that included a mental health diagnosis assigned during the encounter. Finally, changes in depression symptom scores were assessed using PHQ-9 scores collected during the 8-months following the index date using established criteria (Panaite et al., 2019). For patients who had multiple PHQ-9s during this period, the follow-up scores were prioritized in the following manner: 1) the first available PHQ-9 score during the 4–8-month period, and 2) the last available PHQ-9 score during the 1–4-month period. These procedures were used to assess depression symptoms during the time-period proposed by the National Committee on Quality Assurance for the HEDIS measure of depression symptom response. Patients who did not receive a follow-up PHQ-9 were excluded from analyses examining subsequent depression symptom scores. To evaluate the impact of anxiety symptoms on suicidal ideation, analyses separately examined predictors of overall scores and the ninth item of the PHQ-9 (reflecting suicidal ideation).

2.3.4. Covariates

Covariates extracted from the medical record included demographic characteristics (i.e., age, sex, race, ethnicity, rurality, service connection), comorbid mental health diagnoses in the year prior to the index date (PTSD, GAD, other anxiety, alcohol/substance use disorder), and medical comorbidities (using a modified Elixhauser comorbidity score after excluding mental health conditions; Elixhauser et al., 1998). Service connection is a disability rating, with Veterans who are service connected at ≥50% being eligible for no-cost healthcare and prescription medications. The clinical settings in which patients received care during the 12 months prior to the index date and/or the 30-days following the index date were also identified (i.e., primary care only, PCMHI, MHC, PCT). Finally, patients were assigned to a single VHA administrative parent facility in a hierarchical approach: 1) facility of their most recent mental health visit, 2) facility of their most recent primary care visit, 3) facility of most frequent VHA use in 2018–2020. Facility type included Veterans Affairs Medical Center (VAMC), community-based outpatient clinic (CBOC), and other sites.

2.4. Data analytic plan

All analyses were conducted using SAS Enterprise Guide version 8.3 (SAS Institute Inc, 2023). To identify patient characteristics associated with the receipt of a GAD-7, analyses were performed in the overall sample (N = 128,917) to compare patients who did and did not receive a GAD-7. For all other analyses, the sample was limited to patients who received a GAD-7 (n = 92,237).

Logistic regression models were used to examine the associations between anxiety symptoms and the receipt of the following services: 1) guideline concordant acute phase antidepressant, 2) guideline concordant continuation phase antidepressant, 3) daytime anxiolytic/sedative, 4) nighttime sedative/hypnotics, 5) any psychotherapy, 6) psychotherapy engagement, 7) psychiatric inpatient stay, and 8) ED visit. Linear regression models were also used to examine the associations between anxiety symptoms and 9) follow-up depression symptoms (PHQ-9 scores) and 10) follow-up suicidal ideation (PHQ-9 item 9 scores). Listwise deletion was used to handle missing data and resulted in dropping 84 (0.07%) of the initial sample. All models included baseline PHQ-9 scores and all covariates listed in Table 1. Given the large number of variables in the regression models, the Bonferroni procedure was used to control familywise Type I error rate for the omnibus tests, resulting in an adjusted p value of 0.003 (0.05/18). The full results from all logistic regression models can be found in Supplementary Table 2 and the full results from all linear regression models can be found in Supplementary Table 3.

Table 1.

Screening characteristics of patients with new onset depression in a Veterans Health Administration cohort.

Screened for anxiety (N = 92,237) Not screened for anxiety (N = 36,680)
Characteristic (continuous) M SD M SD Hedge’s G
Baseline PHQ-9 score 16.9 4.3 16.7 4.4 0.0a
Age (years) 46.8 15.6 47.7 15.9 0.1a
Characteristic (categorical) n % n % OR
Sex
 Male 75054 81.4 30365 82.8 ref
 Female 17183 18.6 6315 17.2 1.1a
Race
 White 55397 60.1 21715 59.2 ref
 American Indian/Alaskan Native 865 0.9 365 1.0 0.9
 Asian/Pacific Islander/Native Hawaiian 2944 3.2 1296 3.5 0.9a
 Black 24059 26.1 9911 27.0 1.0a
 Multiracial 1365 1.5 483 1.3 1.1
 Unknown 7607 8.3 2910 7.9 1.0
Ethnicity
 Hispanic 11929 12.9 4085 11.1 1.2a
 Non-Hispanic 80308 87.1 32595 88.9 ref
Geographic locality
 Rural 20911 22.7 10090 27.6 0.8a
 Urban 71256 77.3 26538 72.5 ref
Facility size
 VAMC 45907 49.8 18241 49.7 ref
 CBOC 35034 38.0 13652 37.2 1.0
 Other 11282 12.2 4785 13.1 0.9a
Service connection
 0% 30655 33.2 12492 34.1 ref
 <50% 36502 39.6 13607 37.1 1.1a
 ≥50% 25080 27.2 10581 28.9 1.0c
PACT only
 Yes 281 0.3 702 1.9 0.2a
 No 91956 99.7 35978 98.1 ref
PCMHI
 Yes 76608 83.1 17592 48.0 5.3a
 No 15629 16.9 19088 52.0 ref
MHC
 Yes 50209 54.4 27097 73.9 0.4a
 No 42028 45.6 9583 26.1 ref
PCT
 Yes 4440 4.8 5112 13.9 0.3a
 No 87797 95.2 31568 86.1 ref
PTSD diagnosis
 Yes 24580 26.7 13565 37.0 0.6a
 No 67657 73.4 23115 63.0 ref
GAD diagnosis
 Yes 7967 8.6 1993 5.4 1.6a
 No 84270 91.4 34687 94.6 ref
Other anxiety diagnosis
 Yes 33747 36.6 7705 21.0 2.2a
 No 58490 63.4 28975 79.0 ref
AUD/SUD diagnosis
 Yes 14533 15.8 6894 18.8 0.8a
 No 77704 84.2 29786 81.2 ref
Elixhauser comorbidity score
 0 45279 49.1 18515 50.5 ref
 1 22166 24.0 8101 22.1 1.1a
 2 12665 13.7 4872 13.3 1.1b
 ≥3 12127 13.2 5192 14.2 1.0c
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Note. Hedge’s G is a measure of effect size with higher values indicating larger group differences. Elixhauser comorbidity score was calculated after excluding mental health conditions. PHQ-9 = Patient Health Questionnaire. VAMC = VA Medical Center. CBOC = Community-Based Outpatient Clinics. PACT = Patient Aligned Care Team. PCMHI = Primary Care - Mental Health Integration. MHC = Mental Health Clinic. PCT = PTSD Clinical Team. PTSD = Posttraumatic stress disorder. GAD = Generalized anxiety disorder. AUD = Alcohol use disorder. SUD = Substance use disorder.

a

p < 0.001.

b

p < 0.01.

c

p < 0.05.

3. Results

3.1. Descriptive statistics

The study cohort included 128,917 patients with a new episode of depression who also received a baseline PHQ-9 from 2018 to 2020. In the year prior to their index date, 9960 patients had been diagnosed with GAD (7.7%), 1935 with panic disorder (1.5%), 349 with agoraphobia (0.3%), 379 with social anxiety disorder (0.3%), 225 with a specific phobia (0.2%), and 39,858 with an other/unspecified anxiety disorder (30.9%). Of those patients, 71.6% completed a GAD-7 within 30 days of their index date. Table 1 compares patients who did and did not complete a GAD-7. Patients who completed a GAD-7 were more likely to be female (OR = 1.1, p = 0.001), White (versus Black and Asian/Pacific Islander/Native Hawaiian; ORs = 1.1, p’s = 0.001), Hispanic (OR = 1.2, p = 0.001), reside in urban areas (OR = 1.3, p = 0.001), have a VAMC administrative parent facility (versus another facility type; OR = 1.1, p = 0.001), be service connected between 10 and 40% (relative to 0%; OR = 1.1, p = 0.001), receive additional VHA services above primary care (OR = 6.4, p = 0.001), receive PCMHI services (OR = 5.3, p = 0.001), be diagnosed with GAD (OR = 1.6, p = 0.001), be diagnosed with an anxiety disorder other than GAD (OR = 2.2, p = 0.001), and have an Elixhauser comorbidity score of 1 (OR = 1.1, p = 0.001) or 2 (OR = 1.1, p = 0.001) versus 0. Patients with MHC (OR = 0.4, p = 0.001) or PCT utilization (OR = 0.3, p = 0.001) were less likely to receive a GAD-7, as were patients diagnosed with PTSD (OR = 0.6, p = 0.001) and AUD/SUD (OR = 0.8, p = 0.001). Patients who completed a GAD-7 were somewhat younger (Mage = 46.8, SD = 15.6) and had higher baseline PHQ-9 scores (MPHQ-9 score = 16.9, SD = 4.3) relative to patients who did not complete a GAD-7 (Mage = 47.7, SD = 15.9; MPHQ-9 score = 16.7, SD = 4.4).

A total of 92,237 patients had a new episode of depression from 2018 to 2020 and completed a GAD-7. Of these patients, 3.5% reported minimal anxiety, 14.1% reported mild anxiety, 29.1% reported moderate anxiety, and 53.3% reported severe anxiety. There was a significant positive correlation between GAD-7 scores and baseline PHQ-9 scores (r = 0.5, p = 0.001).

3.2. Logistic regression models predicting medication and psychotherapy receipt

A total of 84 patients had missing rurality (n = 70) or facility (n = 14) data and were excluded, leaving an analytic sample of 92,153 for these analyses. Results of logistic models examining predictors of medication receipt (i.e., adequate acute and continuation phase antidepressant treatment, daytime anxiolytic/sedative, nighttime sedative/hypnotics) are presented in Table 2, after controlling for baseline PHQ-9 scores and other covariates. Patients with severe anxiety were significantly more likely to receive adequate acute phase antidepressant treatment (Wald χ2 = 108.8(3) = 0.001) relative to patients with minimal anxiety (OR = 1.2, p = 0.001). Patients with moderate (OR = 1.1, p = 0.04) and severe (OR = 1.2, p = 0.001) anxiety were significantly more likely to receive continuation phase antidepressants relative to patients with minimal anxiety (Wald χ2 = 69.0(3) = 0.001). For both daytime anxiolytic/sedative medications (Wald χ2 = 269.6(3) = 0.001) and nighttime sedative/hypnotics medications (Wald χ2 = 155.3(3) = 0.001), patients were more likely to receive prescriptions if they reported moderate (OR = 1.4, p = 0.001; OR = 1.2, p = 0.002, respectively) or severe anxiety symptoms (OR = 1.8, p = 0.01; OR = 1.4, p = 0.001, respectively).

Table 2.

Logistic regression predicting medication receipt following new onset depression (n = 92,153).

Predictors Acute phase antidepressant Continuation phase antidepressant Daytime anxiolytic/sedative Nighttime sedative/hypnotics
OR OR OR OR
Severe PHQ-9 (ref. moderate) 1.29a 1.23a 1.07b 1.22a
Mild GAD-7 (ref. minimal) 0.95 1.00 1.10 1.08
Moderate GAD-7 (ref. minimal) 1.06 1.10c 1.36a 1.18b
Severe GAD-7 (ref. minimal) 1.19a 1.21a 1.81a 1.41a
Age (continuous) 1.00a 1.00 1.00 1.00
Female sex (ref. male) 1.11a 1.13a 1.26a 1.08a
Black race (ref. White) 0.69a 0.58a 0.66a 1.21a
Other race (ref. White) 0.86a 0.80a 0.86a 1.03
Hispanic (ref. non-Hispanic) 0.97 0.97 0.82a 1.22a
Rural (ref. urban) 1.14a 1.15a 1.07b 1.02
CBOC (ref. VAMC) 0.96b 0.98 0.92a 0.97
Other facility (ref. VAMC) 1.01 1.05c 0.93c 0.98
SC ≥ 50% (ref. 0%) 1.14a 1.22a 1.08b 1.13a
SC <50% (ref. 0%) 1.02 1.07a 0.97 1.02
PACT only (ref. not PACT only) 0.83 0.66c 0.96 0.85
PCMHI (ref. no PCMHI) 1.12a 1.10a 0.81a 0.92a
MHC (ref. no MHC) 1.40a 1.39a 1.67a 1.60a
PCT (ref. no PCT) 0.98 1.01 0.90c 1.11b
PTSD (ref. no diagnosis) 0.93a 0.92a 1.15a 1.13a
GAD (ref. no diagnosis) 1.11a 1.14a 1.65a 1.13a
Other anxiety (ref. no diagnosis) 1.02 1.03 1.55a 1.06a
AUD/SUD (ref. no diagnosis) 0.77a 0.72a 1.25a 1.09a
Elixhauser score = 1 (ref. 0) 1.03 1.09a 1.00 1.01
Elixhauser score = 2 (ref. 0) 1.10a 1.22a 1.11b 0.98
Elixhauser score ≥3 (ref. 0) 1.04 1.16a 1.27a 1.07c
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Note. PHQ-9 = Patient Health Questionnaire. GAD-7 = Generalized Anxiety Disorder-7. VAMC = VA Medical Center. CBOC = Community-Based Outpatient Clinics. SC = Service connection. PACT = Patient Aligned Care Team. PCMHI = Primary Care - Mental Health Integration. MHC = Mental Health Clinic. PCT = PTSD Clinical Team. PTSD = Posttraumatic stress disorder. GAD = Generalized anxiety disorder. AUD = Alcohol use disorder. SUD = Substance use disorder.

a

p < 0.001.

b

p < 0.01.

c

p < 0.05.

Results from logistic regression models examining predictors of psychotherapy receipt (i.e., psychotherapy initiation, psychotherapy engagement) are presented in the left two panels of Table 3. Anxiety symptoms were significantly associated with psychotherapy initiation (Wald χ2 = 54.5(3) = 0.001), such that patients with severe anxiety were less likely to initiate psychotherapy relative to patients with minimal anxiety (OR = 0.9, p = 0.04). Patients with severe anxiety symptoms were also less likely to engage in psychotherapy relative to patients with mild (OR = 0.9, p = 0.001) and moderate (OR = 0.9, p = 0.001) anxiety symptoms (Wald χ2 = 40.7(3) = 0.001).

Table 3.

Logistic regression predicting other treatment received following new onset depression (n = 92,153).

Predictors Psychotherapy initiation Psychotherapy engagement Any inpatient psychiatric stay Any emergency department visit with MH diagnosis
OR OR OR OR
Severe PHQ-9 (ref. moderate) 1.27a 1.19a 1.45a 1.27a
Mild GAD-7 (ref. minimal) 1.08 1.07 0.75c 0.79c
Moderate GAD-7 (ref. minimal) 1.00 1.04 0.77c 0.83
Severe GAD-7 (ref. minimal) 0.92c 0.94 0.88 0.98
Age (continuous) 1.00 1.00 0.99a 0.99a
Female sex (ref. male) 1.03 1.09a 0.75a 0.85a
Black race (ref. White) 1.07a 0.93a 0.86b 0.95
Other race (ref. White) 1.02 0.99 0.89 0.88c
Hispanic (ref. non-Hispanic) 1.07b 0.99 0.72a 0.87c
Rural (ref. urban) 1.01 1.04 0.96 0.72a
CBOC (ref. VAMC) 1.11a 0.98 0.55a 0.48a
Other facility (ref. VAMC) 1.25a 1.08b 0.82b 0.64a
SC ≥ 50% (ref. 0%) 1.10a 1.11a 0.60a 0.77a
SC <50% (ref. 0%) 1.12a 1.11a 0.67a 0.78a
PACT only (ref. not PACT only) 0.13a 0.26a <0.01 0.40
PCMHI (ref. no PCMHI) 2.17a 1.01 0.55a 0.66a
MHC (ref. no MHC) 0.91a 1.19a 3.70a 2.24a
PCT (ref. no PCT) 0.91b 1.15a 1.09 0.87
PTSD (ref. no diagnosis) 0.71a 0.69a 1.11c 1.03
GAD (ref. no diagnosis) 0.84a 0.96 0.76a 0.93
Other anxiety (ref. no diagnosis) 1.08a 0.94a 0.80a 1.03
AUD/SUD (ref. no diagnosis) 0.77a 0.71a 2.63a 2.20a
Elixhauser score = 1 (ref. 0) 0.98 1.02 0.84b 0.85a
Elixhauser score = 2 (ref. 0) 1.01 1.04 0.82b 0.91
Elixhauser score ≥3 (ref. 0) 1.02 1.01 0.83c 1.14c
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Note. MH = Mental health. PHQ-9 = Patient Health Questionnaire. GAD-7 = Generalized Anxiety Disorder-7. VAMC = VA Medical Center. CBOC = Community-Based Outpatient Clinics. SC = Service connection. PACT = Patient Aligned Care Team. PCMHI = Primary Care - Mental Health Integration. MHC = Mental Health Clinic. PCT = PTSD Clinical Team. PTSD = Posttraumatic stress disorder. GAD = Generalized anxiety disorder. AUD = Alcohol use disorder. SUD = Substance use disorder.

a

p < 0.001.

b

p < 0.01.

c

p < 0.05.

3.3. Logistic regression models predicting acute care service utilization

Logistic regression results from models examining predictors of acute care service utilization (i.e., inpatient psychiatric stay, ED visit) are presented in the right two panels of Table 3. After adjusting for multiple comparisons, anxiety symptoms were not significantly associated with inpatient psychiatric service receipt (Wald χ2 = 10.4(3) = 0.02). Patients with mild anxiety were significantly less likely (Wald χ2 = 22.5(3) = 0.001) to visit the ED relative to patients with minimal anxiety (OR = 0.8, p = 0.03).

3.4. Linear regression models predicting depression symptoms and suicidal ideation scores after the index date

A total of 5417 patients did not receive a follow-up PHQ-9 and were excluded from analyses of follow-up PHQ-9 and an additional 87 patients did not have a follow-up PHQ-9 item 9. This resulted in a final analytic sample of 86,740 patients for overall PHQ-9 analyses and 86,653 patients for PHQ-9 item 9 analyses. In the linear regression model of depression symptoms (see the left panel in Table 4), patients with severe anxiety (B = 3.2, p = 0.001), moderate anxiety (B = 1.4, p = 0.001), and mild anxiety (B = 0.8, p = 0.001) had higher PHQ-9 scores at follow-up than did patients with minimal anxiety. For suicidal ideation (PHQ-9 item 9) analyses (see the right panel in Table 4), patients with severe anxiety (B = 0.2, p = 0.001) and moderate anxiety (B = 0.1, p = 0.001) at baseline reported higher item 9 scores than did patients with minimal baseline anxiety.

Table 4.

Linear regression predicting depression symptom scores following new onset depression.

Predictors PHQ-9 score (n = 86,740) PHQ-9 item 9 score (n = 86,653)
B B
Severe PHQ-9 (ref. moderate) 4.40a 0.30a
Mild GAD-7 (ref. minimal) 0.76a 0.03
Moderate GAD-7 (ref. minimal) 1.35a 0.06a
Severe GAD-7 (ref. minimal) 3.16a 0.19a
Age (continuous) −0.01a 0.00c
Female sex (ref. male) −0.16b −0.10a
Black race (ref. White) 0.60a 0.00
Other race (ref. White) 0.50a 0.05a
Hispanic (ref. non-Hispanic) −0.07 −0.04a
Rural (ref. urban) −0.12c −0.02b
CBOC (ref. VAMC) 0.17a 0.00
Other facility (ref. VAMC) 0.12c −0.02c
SC ≥ 50% (ref. 0%) 0.27a −0.04a
SC <50% (ref. 0%) 0.02 −0.06a
PACT only (ref. not PACT only) 1.26a 0.09
PCMHI (ref. no PCMHI) 0.26a 0.03a
MHC (ref. no MHC) 0.28a 0.10a
PCT (ref. no PCT) 0.09 0.01
PTSD (ref. no diagnosis) 0.60a 0.04a
GAD (ref. no diagnosis) −0.42a −0.10a
Other anxiety (ref. no diagnosis) −0.33a −0.08a
AUD/SUD (ref. no diagnosis) 0.05 0.03a
Elixhauser score = 1 (ref. 0) −0.20a −0.05a
Elixhauser score = 2 (ref. 0) −0.33a −0.06a
Elixhauser score ≥3 (ref. 0) −0.49a −0.08a
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Note. PHQ-9 score assessed symptoms of depression. PHQ-9 item 9 assessed suicidal ideation. MH = Mental health. PHQ-9 = Patient Health Questionnaire. GAD-7 = Generalized Anxiety Disorder-7. VAMC = VA Medical Center. CBOC = Community-Based Outpatient Clinics. SC = Service connection. PACT = Patient Aligned Care Team. PCMHI = Primary Care - Mental Health Integration. MHC = Mental Health Clinic. PCT = PTSD Clinical Team. PTSD = Posttraumatic stress disorder. GAD = Generalized anxiety disorder. AUD = Alcohol use disorder. SUD = Substance use disorder.

a

p < 0.001.

b

p < 0.01.

c

p < 0.05.

4. Discussion

This study examined whether anxiety symptoms, assessed via the GAD-7, are associated with differences in care and depression symptom outcomes when administered clinically to VHA patients with new diagnoses of depression. Across most outcomes, we found that anxiety symptoms significantly predicted greater care receipt and symptom severity. Therefore, administering the GAD-7 to measure anxiety may be a relatively low-cost way to identify illness burden and treatment need more accurately than depression symptom measures alone.

We found that anxiety symptoms were associated with increased receipt of antidepressants (across acute and continuation phases), daytime anxiolytic/sedatives, and nighttime sedative/hypnotics. This finding is consistent with prior studies suggesting that patients with depression and comorbid PTSD utilize mental health treatment at higher rates than patients with either disorder alone (Chan et al., 2009; Kramer et al., 2003; Maguen et al., 2012; Nichter et al., 2019) and extends that finding to generalized anxiety symptoms. Anxiety symptoms also predicted ED visits, similar to the effects of anxiety disorders on ED utilization among Veterans (Trivedi et al., 2015).

In addition to predicting increased service utilization, we found that patients who reported elevated anxiety also experienced more severe depression and suicidal ideation at follow-up. Thus, despite the increased service utilization among patients with depression and severe anxiety, these patients still reported more depression symptoms. Our findings are consistent with prior studies of Veterans that indicate that comorbid anxiety and depression are associated with a host of negative outcomes (Pfeiffer et al., 2009; Phillips et al., 2009; Scherrer et al., 2010; Ziobrowski et al., 2021). These findings suggest close attention and monitoring of anxiety symptoms may aid early identification of patients who are most in need of treatment.

We found that patients with severe anxiety were less likely to initiate psychotherapy relative to patients with minimal anxiety. Large-scale studies have found that patients with anxiety disorders rarely seek treatment (Roness et al., 2005), potentially due to anxiety-related avoidance. Given that several psychotherapy approaches effectively reduce anxiety symptoms (Andrews et al., 2018; Bandelow et al., 2015), understanding barriers to psychotherapy initiation is essential. One potential barrier to psychotherapy initiation in VHA is the lack of clinical guidelines and evidence-based psychotherapy (EBP) initiatives for patients with generalized anxiety or depression with comorbid anxiety (Ennis et al., 2023). EBPs for several psychiatric conditions have been implemented in VHA nationally (e.g., depression, PTSD; VHA Handbook 1160.01; Uniform Mental Health Services in VA Medical Centers and Clinics) and VHA publishes clinical practice guidelines for bipolar disorder, schizophrenia, suicide, major depressive disorder, PTSD, and substance use disorder. Evaluation data for existing EBP programs (e.g., prolonged exposure for PTSD) suggest that the initiatives are associated with positive patient and provider outcomes (Karlin et al., 2010, 2012). Despite the success of EBP initiatives, there are not clear guidelines for how to treat patients with anxiety disorders, including when comorbid with depression. National EBP initiatives for anxiety may allow mental health providers more flexibility in engaging in shared decision making, an approach found to increase treatment engagement among Veterans with PTSD (Mott et al., 2014). Since anxiety is among the most common conditions present in Veterans seeking mental health treatment (Adler et al., 2011), clinical practice guidelines and EBPs for anxiety may increase psychotherapy utilization among patients with depression and elevated anxiety.

Recognizing the deleterious impact of anxiety in the general U.S. population, as well as poor detection in primary care (Kroenke et al., 2007), the U.S. Preventative Services Task Force recommended routine screening for anxiety among all U.S. adults aged 18–64 on 6/20/2023 (US Preventive Services Task Force et al., 2023). There have been calls for VHA to implement routine clinical screening for anxiety (e.g., Ennis et al., 2023). This study provides the first evidence, that we are aware of, that the GAD-7 may assist in the identification of patients likely to have more severe and prolonged depression. We also found that the likelihood of GAD-7 receipt differed across patient subgroups (by age, sex, race, ethnicity, rurality, service connection), comorbid mental and physical health diagnoses, and care utilization (by administrative parent facility, PCMHI receipt, MHC receipt, PCT receipt). Differences in GAD-7 receipt across these groups highlights the opportunity for guidelines to improve the consistency of screening practices in VHA and other health systems.

Instituting standardized screening for anxiety may have limited benefits in the absence of improved access to anxiety-specific EBPs. In other health systems, randomized trials testing the impact of screening primary care patients for anxiety did not improve patient symptom outcomes (Fifer et al., 1994; Kroenke et al., 2018). However, studies have found that when patients are systematically screened for anxiety, 56% of all patients who reported elevated anxiety symptoms were not recognized as having anxiety disorders in their medical record (Mathias et al., 1994). The case of depression screening may offer a useful parallel. Prior to the wide scale adoption of universal depression screening, cost-utility analyses showed that screening for depression was unlikely to be cost-effective in routine primary care practices despite the high prevalence of depression. However, cost-effectiveness of screening was favorable if effective treatments, including psychotherapy, were highly accessible in primary care (Valenstein et al., 2001). VHA has subsequently instituted both depression screening (Veterans Health Administration and Department of Defense, 2022) using the PHQ-9 and increased access to depression treatments via PCMHI (Wray et al., 2012). Depression screening in primary care and same-day PCMHI service is associated with increased probability of patients receiving psychotherapy and antidepressant treatment (Szymanski et al., 2013). Future studies should examine if the benefit of screening for anxiety is improved when more intensive or anxiety-specific mental health services are clearly specified and accessible to patients who screen positive.

Study findings are limited by the inability to discern who received a routine GAD-7 versus those who selectively completed the GAD-7 after an initial assessment. Most of our sample reported moderate or severe anxiety (29.1% moderate anxiety, 53.3% severe anxiety). Therefore, it remains unclear if findings related to the likelihood of GAD-7 receipt are due to differences in symptom presentation across patient subgroups or provider variation in screening practices. Further, it is unknown whether the differences in care utilization were due to patient or provider preferences. For example, there is evidence that psychiatrists are more likely to recommend antidepressants as the preferred treatment option for patients with GAD (Latas et al., 2018). Future studies might benefit from using provider notes to identify whether the difference between antidepressant and psychotherapy utilization rates are due to patient preferences or the treatments recommended by providers. Additionally, this study used GAD-7 and PHQ-9 scores that were entered into structured data fields within VHA’s electronic medical record. Consequently, measures that were administered but not recorded in the medical record or only recorded within the free text of progress notes may have been under identified. Also, we used the ninth item of the PHQ-9 to assess suicidal ideation, which contains a double-barreled reference to both passive and active suicidal ideation (Williams et al., 2009). Future investigations of GAD-7 scores and suicide-related outcomes should use measures that better differentiate severity of suicidal ideation and behaviors, such as the Columbia Suicide Severity Rating Scale (Na et al., 2018). Finally, given this study consisted solely of VHA patients, it is unclear whether these results extend to other healthcare systems.

In conclusion, we found that among VHA patients with new episodes of depression, anxiety symptoms were significantly associated with mental health-related medication receipt, psychotherapy receipt, ED visits, and depression symptom scores at follow-up, but were not associated with inpatient psychiatric stays. Efforts to improve outcomes for patients with depression and anxiety may benefit from routine screening for anxiety and instituting EBP initiatives to provide standardized anxiety treatment. Additional consideration should be given to targeting transdiagnostic processes that contribute to both anxiety and depression (e.g., anxiety sensitivity, intolerance of uncertainty; Allan et al., 2018; Carleton et al., 2012; Dugas et al., 2001; Gentes and Ruscio, 2011; Naragon-Gainey, 2010; Olatunji and Wolitzky-Taylor, 2009; Saulnier et al., 2018, 2019), and testing transdiagnostic treatments among this population (e.g., Safety Aid Reduction Treatment; Raines et al., 2023). Healthcare systems should prioritize enhancing the benefits of screening and treatment for patients with comorbid anxiety and depression.

Supplementary Material

Saulnier Supplement

Acknowledgment

This research is supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment, the Ann Arbor VA Healthcare System, and the Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC).

Funding

This work was supported by the VA Health Services Research and Development Service IIR 14–345 (PI: Pfeiffer) and the VA Health Services Research and Development Service RCS 21–138 (PI: Zivin) and RCS 03–155 (PI: Piette).

The views expressed in this paper are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the US government.

Footnotes

CRediT authorship contribution statement

K.G. Saulnier: Writing – original draft, Methodology, Conceptualization. D. Ganoczy: Formal analysis, Data curation. P.P. Grau: Writing – review & editing, Conceptualization. R.K. Sripada: Writing – review & editing, Conceptualization. K. Zivin: Writing – review & editing, Funding acquisition, Conceptualization. J.D. Piette: Writing – review & editing, Funding acquisition, Conceptualization. P.N. Pfeiffer: Writing – review & editing, Supervision, Investigation, Funding acquisition, Conceptualization.

Declaration of competing interest

None.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpsychires.2024.07.003.

1

Analyses were also ran with continuous GAD-7 scores. There were no differences in the pattern of statistically significant results between outcomes and GAD-7 scores in the continuous and categorical models.

2

Analyses were also ran with continuous PHQ-9 scores. There were no differences in the pattern of statistically significant results between outcomes and PHQ-9 scores in the continuous and categorical models.

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