1 Task Force on the Development of a Common Instrument to Measure Health States: Measuring Anxiety Cameron N. McIntosh; Julie Bernier; Jean-Marie Berthelot;

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1 Task Force on the Development of a Common Instrument to Measure Health States: Measuring Anxiety Cameron N. McIntosh; Julie Bernier; Jean-Marie Berthelot; Sarah Connor Gorber; Michael C. Wolfson Statistics Canada Ottawa, Ontario, Canada Working Paper No.3 Add.3 22 November 2005 STATISTICAL COMMISSION andSTATISTICAL OFFICE OF THE UN ECONOMIC COMMISSION FOREUROPEAN COMMUNITIES EUROPE (EUROSTAT) CONFERENCE OF EUROPEAN WORLD HEALTH STATISTICIANS ORGANIZATION (WHO) Joint UNECE/WHO/Eurostat Meeting on the Measurement of Health Status (Budapest, Hungary, November 2005) Session 3-Invited paper

2 Issues in Measuring Anxiety Issues in Measuring Anxiety above all, it was determined that the Anxiety domain (i.e., worry, nervousness, fear) should be assessed completely separately from that of Affect (i.e., happiness – depression) above all, it was determined that the Anxiety domain (i.e., worry, nervousness, fear) should be assessed completely separately from that of Affect (i.e., happiness – depression) a review of existing measurement tools showed that Anxiety is often assessed using double-barreled questions, for example (e.g., EQ-5D): a review of existing measurement tools showed that Anxiety is often assessed using double-barreled questions, for example (e.g., EQ-5D): 1. I am not anxious or depressed 2. I am moderately anxious or depressed 3. I am extremely anxious or depressed while depression and anxiety are often co-morbid, they are conceptually and empirically distinguishable aspects of mental health while depression and anxiety are often co-morbid, they are conceptually and empirically distinguishable aspects of mental health

3 Issues in Measuring Anxiety Issues in Measuring Anxiety The World Health Survey (WHS) uses the following two distinct items to measure Affect and Anxiety: The World Health Survey (WHS) uses the following two distinct items to measure Affect and Anxiety: Overall in the last 30 days, how much of a problem did [name of person] have with feeling sad, low, or depressed? Overall in the last 30 days, how much of a problem did [name of person] have with feeling sad, low, or depressed? 1 None 2 Mild 3 Moderate 4 Severe 5 Extreme 1 None 2 Mild 3 Moderate 4 Severe 5 Extreme Overall in the last 30 days, how much of a problem did [name of Overall in the last 30 days, how much of a problem did [name of person] have with worry or anxiety? person] have with worry or anxiety? 1 None 2 Mild 3 Moderate 4 Severe 5 Extreme 1 None 2 Mild 3 Moderate 4 Severe 5 Extreme similarly, assessing Anxiety and Affect separately on the common instrument could provide further refinement in the assessment of mental health. similarly, assessing Anxiety and Affect separately on the common instrument could provide further refinement in the assessment of mental health.

4 Proposed Items for Anxiety: Set A Preamble: “The next few questions ask about [your/his/her] feelings of anxiety, that is, [your/his/her] feelings of worry, nervousness, or fear. When answering these questions, please take into account any medication you may be taking in order to relieve feelings of worry, nervousness, or fear. Preamble: “The next few questions ask about [your/his/her] feelings of anxiety, that is, [your/his/her] feelings of worry, nervousness, or fear. When answering these questions, please take into account any medication you may be taking in order to relieve feelings of worry, nervousness, or fear. ANX-1A. Generally speaking, how often [do/does] [you/he/she] have feelings of worry? ANX-1A. Generally speaking, how often [do/does] [you/he/she] have feelings of worry? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 None of the time 1 None of the time 2 A little of the time 2 A little of the time 3 Some of the time 3 Some of the time 4 Most of the time 5 All of the time 4 Most of the time 5 All of the time 1, Don’t Know, Refusal (Skip to ANX-3A) 1, Don’t Know, Refusal (Skip to ANX-3A) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

5 Proposed Items for Anxiety: Set A ANX-2A. Generally speaking, how intense are [your/his/her] feelings of worry? ANX-2A. Generally speaking, how intense are [your/his/her] feelings of worry? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 mild 1 mild 2 moderate 2 moderate 3 severe 3 severe 4 extreme 4 extreme Don’t Know, Refusal (Go to next question) Don’t Know, Refusal (Go to next question) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

6 Proposed Items for Anxiety: Set A ANX-3A. Generally speaking, how often [do/does] [you/his/her] have feelings of nervousness? ANX-3A. Generally speaking, how often [do/does] [you/his/her] have feelings of nervousness? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 None of the time 1 None of the time 2 A little of the time 2 A little of the time 3 Some of the time 3 Some of the time 4 Most of the time 5 All of the time 4 Most of the time 5 All of the time 1, Don’t Know, Refusal (Skip to ANX-5A) 1, Don’t Know, Refusal (Skip to ANX-5A) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

7 Proposed Items for Anxiety: Set A ANX-4A. Generally speaking, how intense are [your/his/her] feelings of nervousness? ANX-4A. Generally speaking, how intense are [your/his/her] feelings of nervousness? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 mild 1 mild 2 moderate 2 moderate 3 severe 3 severe 4 extreme 4 extreme Don’t Know, Refusal (Go to next question) Don’t Know, Refusal (Go to next question) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

8 Proposed Items for Anxiety: Set A ANX-5A. Generally speaking, how often [do/does] [you/his/her] have feelings of fear? ANX-5A. Generally speaking, how often [do/does] [you/his/her] have feelings of fear? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 None of the time 1 None of the time 2 A little of the time 2 A little of the time 3 Some of the time 3 Some of the time 4 Most of the time 5 All of the time 4 Most of the time 5 All of the time 1, Don’t Know, Refusal (Skip to next section) 1, Don’t Know, Refusal (Skip to next section) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

9 Proposed Items for Anxiety: Set A ANX-6A. Generally speaking, how intense are [your/his/her] feelings of fear? ANX-6A. Generally speaking, how intense are [your/his/her] feelings of fear? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 mild 1 mild 2 moderate 2 moderate 3 severe 3 severe 4 extreme 4 extreme Don’t Know, Refusal (Go to next question) Don’t Know, Refusal (Go to next question) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

10 Proposed Items for Anxiety: Set B Preamble: The next few questions ask about [your/his/her] feelings of anxiety, that is, [your/his/her] feelings of worry, nervousness, or fear. When answering these questions, please try and focus only on [your/his/her] feelings of anxiety during the past ___ days. Please also take into account any medication you were taking in order to relieve feelings of worry, nervousness, or fear. Preamble: The next few questions ask about [your/his/her] feelings of anxiety, that is, [your/his/her] feelings of worry, nervousness, or fear. When answering these questions, please try and focus only on [your/his/her] feelings of anxiety during the past ___ days. Please also take into account any medication you were taking in order to relieve feelings of worry, nervousness, or fear. ANX-1B. Overall during the last __ days, how often did [you/he/she] have feelings of worry? ANX-1B. Overall during the last __ days, how often did [you/he/she] have feelings of worry? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 None of the time 1 None of the time 2 A little of the time 2 A little of the time 3 Some of the time 3 Some of the time 4 Most of the time 5 All of the time 4 Most of the time 5 All of the time 1, Don’t Know, Refusal (Skip to ANX-3B) 1, Don’t Know, Refusal (Skip to ANX-3B) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

11 Proposed Items for Anxiety: Set B ANX-2B. Overall during the last __ days, how intense were [your/his/her] feelings of worry? ANX-2B. Overall during the last __ days, how intense were [your/his/her] feelings of worry? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 mild 1 mild 2 moderate 2 moderate 3 severe 3 severe 4 extreme 4 extreme Don’t Know, Refusal (Go to next question) Don’t Know, Refusal (Go to next question) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

12 Proposed Items for Anxiety: Set B ANX-3B. Overall during the last __ days, how often did [you/he/she] have feelings of nervousness? ANX-3B. Overall during the last __ days, how often did [you/he/she] have feelings of nervousness? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 None of the time 1 None of the time 2 A little of the time 2 A little of the time 3 Some of the time 3 Some of the time 4 Most of the time 5 All of the time 4 Most of the time 5 All of the time 1, Don’t Know, Refusal (Skip to ANX-5B) 1, Don’t Know, Refusal (Skip to ANX-5B) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

13 Proposed Items for Anxiety: Set B ANX-4B. Overall during the last __ days, how intense were ANX-4B. Overall during the last __ days, how intense were [your/his/her] have feelings of nervousness? [your/his/her] have feelings of nervousness? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 mild 1 mild 2 moderate 2 moderate 3 severe 3 severe 4 extreme 4 extreme 1, Don’t Know, Refusal (Go to next question) 1, Don’t Know, Refusal (Go to next question) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

14 Proposed Items for Anxiety: Set B ANX-5A. Overall during the last __ days, how often did [you/he/she] ANX-5A. Overall during the last __ days, how often did [you/he/she] have feelings of fear? have feelings of fear? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 None of the time 1 None of the time 2 A little of the time 2 A little of the time 3 Some of the time 3 Some of the time 4 Most of the time 5 All of the time 4 Most of the time 5 All of the time 1, Don’t Know, Refusal (Skip to next section) 1, Don’t Know, Refusal (Skip to next section) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

15 Proposed Items for Anxiety: Set B ANX-6A. Overall during the last __ days, how intense were ANX-6A. Overall during the last __ days, how intense were [your/his/her] feelings of fear? [your/his/her] feelings of fear? [INTERVIEWER: Read categories to respondent] [INTERVIEWER: Read categories to respondent] 1 mild 1 mild 2 moderate 2 moderate 3 severe 3 severe 4 extreme 4 extreme Don’t Know, Refusal (Go to next question) Don’t Know, Refusal (Go to next question) Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

16 Proposed Items for Anxiety: Set C Preamble: “Now we are going to ask you to about [your/his/her] feelings of Anxiety during the past ___ days, that is, [your/his/her] feelings of worry, nervousness, or fear. For answering this set of questions, you will be asked to use a rating scale that goes from 0 to means that [you/he/she] were not worried, nervous, or fearful at all, and 100 means that [your/his/her] you were as worried, nervous, or fearful as you could possibly imagine. When answering these question, please try and focus only on [your/his/her] life during the past ___ days. Please also take into account any medication you may be taking in order to relieve feelings of worry, nervousness, or fear. Preamble: “Now we are going to ask you to about [your/his/her] feelings of Anxiety during the past ___ days, that is, [your/his/her] feelings of worry, nervousness, or fear. For answering this set of questions, you will be asked to use a rating scale that goes from 0 to means that [you/he/she] were not worried, nervous, or fearful at all, and 100 means that [your/his/her] you were as worried, nervous, or fearful as you could possibly imagine. When answering these question, please try and focus only on [your/his/her] life during the past ___ days. Please also take into account any medication you may be taking in order to relieve feelings of worry, nervousness, or fear. ANX-1C. Overall during the past ___ days, how would you describe [your/his/her] level of worry? ANX-1C. Overall during the past ___ days, how would you describe [your/his/her] level of worry? [INTERVIEWER: Present scale to respondent and say: “Please choose the number from 0 to 100 that best describes describe [your/his/her] level of worry during the past ___ days”] [INTERVIEWER: Present scale to respondent and say: “Please choose the number from 0 to 100 that best describes describe [your/his/her] level of worry during the past ___ days”] not worried at all as worried as I could possibly imagine not worried at all as worried as I could possibly imagine |____________________________________________________| |____________________________________________________| Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

17 Proposed Items for Anxiety: Set C ANX-1C. Overall during the past ___ days, how would you describe [your/his/her] level of nervousness? ANX-1C. Overall during the past ___ days, how would you describe [your/his/her] level of nervousness? [INTERVIEWER: Present scale to respondent and say: “Please choose the number from 0 to 100 that best describes describe [your/his/her] level of nervousness during the past ___ days”] [INTERVIEWER: Present scale to respondent and say: “Please choose the number from 0 to 100 that best describes describe [your/his/her] level of nervousness during the past ___ days”] not nervous at all as nervous as I could possibly imagine not nervous at all as nervous as I could possibly imagine |____________________________________________________| |____________________________________________________| Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

18 Proposed Items for Anxiety: Set C ANX-1C. Overall during the past ___ days, how would you describe [your/his/her] level of fear? ANX-1C. Overall during the past ___ days, how would you describe [your/his/her] level of fear? [INTERVIEWER: Present scale to respondent and say: “Please choose the number from 0 to 100 that best describes describe [your/his/her] level of fear during the past ___ days”] [INTERVIEWER: Present scale to respondent and say: “Please choose the number from 0 to 100 that best describes describe [your/his/her] level of fear during the past ___ days”] not fearful at all as fearful as I could possibly imagine not fearful at all as fearful as I could possibly imagine |____________________________________________________| |____________________________________________________| Relevant ICF Categories: b152 (Emotional Functions) Relevant ICF Categories: b152 (Emotional Functions)

19 Broad Questions Broad Questions Are both frequency and intensity items necessary to adequately assess Anxiety? Are both frequency and intensity items necessary to adequately assess Anxiety? Are any of the three approaches (i.e., no recall period, specific recall period, VAS) obviously superior, or is it worthwhile to subject all three to cognitive testing? Are any of the three approaches (i.e., no recall period, specific recall period, VAS) obviously superior, or is it worthwhile to subject all three to cognitive testing?