Anxiety screening could be part of your next doctor's visit

Are we living in an age of anxiety?   

Anxiety is already one of the world's most common mental health conditions, especially in women. Approximately 26% of men and 40% of women in the United States will have an anxiety disorder during their lifetimes. And in recent years, the number of people reporting anxiety symptoms has been rising, exacerbated by the COVID-19 pandemic. 

Health professionals are grappling with how to help people with anxiety get the help they need.

Recognizing that the first step on the journey to recovery is awareness and detection, a national panel of U.S. medical experts is recommending anxiety screening for all adults under age 65, including pregnancy and post-partum persons. That's why routine anxiety screening could be coming to doctor's offices across the United States.   

The recommendation — still in draft form — is intended to close the anxiety treatment gap between the onset of symptoms and treatment, which can stretch to a decade or longer for some mental health conditions.  

The advisors behind the recommendation suggest that widespread screening will help improve the health and quality of life for people with anxiety. 

That's good news, right?   

Not so fast, say some experts, including Carmen McLean, a clinical psychologist at the Dissemination and Training Division of the National Center for PTSD in the Palo Alto VA Health Care System.    

"In theory, screening is a step in the right direction; detecting anxiety disorders earlier could help people get treatment sooner," says McLean. "However, screening alone won't impact public health if we don't have robust and accessible mental health resources to connect people with. Which we don't. We already have a demand for services that far exceeds capacity."  

So what is anxiety screening? What are the pros and cons associated with it? And who's likely to benefit? 

What is anxiety screening?   

It's important to know that mental health screening — for anxiety, depression, or any other condition — is not the same as a psychological assessment.   

Screening tests have been validated by years of research, but compared to a psychological assessment, they are brief and narrow in scope. 

Screening tests are used to identify a person at risk for a specific condition or disorder. They indicate whether or not a person should be evaluated for a mental health condition or would benefit from a preliminary intervention.   

In contrast, psychological assessments are more comprehensive. For example, they can identify mental health conditions, gauge their severity, and provide treatment recommendations.   

A standard screening tool for generalized anxiety disorder is the GAD-7. It also performs well for panic, social anxiety, and post-traumatic stress disorders. Like most screening tests, GAD-7 is a short questionnaire that can be administered during a routine doctor's visit or self-administered online.

There are other commonly used scales for various types of anxiety disorders:  

• Beck Anxiety Inventory (BAI)   
• Hamilton Anxiety Rating Scale (HARS) for GAD 
• Panic and Agoraphobia Scale (PAS) for panic disorder/agoraphobia 
• Liebowitz Social Anxiety Scale (LSAS) for social anxiety disorder   

The bottom line is that anxiety tools like GAD-7 alone are not sufficient to diagnose anxiety. A doctor will usually recommend a psychological assessment if the screening test is positive.  

Why are medical experts recommending screening for adults?   

Anxiety is one of the most common mental health conditions, especially among women who are 1.5 to two times more likely than men to receive an anxiety disorder diagnosis. Anxiety disorders are important to catch because they have a long-term impact on people's quality of life and overall functioning.    

Yet, according to the U.S. Preventative Services Task Force — the organization behind the recommendation — anxiety disorders often go undetected by primary care physicians. That is partly because patients don't necessarily complain to their doctors about anxiety itself. Instead, their complaints relate to things like sleep disturbances or physical discomfort or pain.    

Anxiety disorders are also undertreated. For example, only 37% of patients received treatment for their anxiety disorder, according to the Anxiety & Depression Society of America. Many people also go years without seeking help for their symptoms.  

The Task Force experts weighed the benefits and risks of screening for anxiety in adults. They concluded that screening has a "moderate net benefit in improving outcomes."

However, they stressed that the strength of the evidence for screening is only moderate and there are still many knowledge gaps, including whether screening benefits specific populations defined by sex, race and ethnicity, sexual orientation, and gender identity.  

What do the experts think?   

It's fair to say doctors and psychologists are divided over the Task Force's recommendation.    

The CEO of the American Psychological Association, Arthur C. Evans Jr., supports the recommendation. According to Evans, regular screening could help identify at-risk adults and help them receive care sooner. In a statement, he also said that making screenings part of routine check-ups sends "the message that your mental health is as important as your physical health." This could help normalize mental health and reduce the stigma surrounding mental health conditions.   

However, psychologist and anxiety researcher Carmen McLean cautions that screening adults for anxiety disorders will only create "increased demand for services from an already overburdened system." 

Carly Johnston, a medical student and mental health advocate, is another skeptic. She shares her personal journey with anxiety, along with tips and resources to help others, at Healing the Anxious Mind. 

"I think the basis of addressing mental health concerns like anxiety in our populations is extremely important, but I don't think the answer is in universal screening," says Johnston.    

"The difficulty with screening tests is that they need to cast a broad net in order to ensure we 'catch' people who truly do have an anxiety diagnosis. The problem with this is that many screening tests are great at ensuring people with a diagnosis of anxiety will screen positive, but they also have a large false positive rate. That means many people who do not have anxiety will also test positive." 

Johnston says screening and diagnosis aren't barriers that come up often when she speaks to others about their experiences with anxiety. Instead, stigma and access to treatment are common.   

Psychiatrists in the U.S. and Canada have also questioned how fragmented health systems with long wait times can deliver adequate mental health care.    

They cite other concerns, too, such as the strength of the evidence on which the Task Force's recommendation is based, the accuracy of screening tests for anxiety disorders, and the capacity of primary care physicians to conduct the screenings, communicate the results, and follow up with patients who screen positive.   

They also note that screening may lead to higher diagnostic rates. However, whether diagnosis translates into better patient outcomes such as less time off work or improved daily functioning and well-being is still unknown. 

 

What happens next?   

The Task Force collected public comments on the draft and is expected to finalize the recommendation this year.   

It is important to note that the final recommendation is still that: a recommendation not a requirement. Still, the U.S. Preventative Services Task Force is influential and its recommendation will likely promote anxiety screening in adults.   

What should you do if you think you have anxiety?   

If you think you have anxiety, don't delay talking to your doctor. Anxiety disorders are common, particularly in women and people from marginalized communities, and highly treatable.   

Johnston credits her relationship with her family physician as key to her diagnosis and treatment.

"It helped me open up much more than a screening tool may have, and I think her clinical experience and knowledge ultimately was what benefitted me on my own journey," she says.   

In terms of treatment, McLean says, "No approach will work for every person, but cognitive behavioral therapy has the best evidence supporting short- and long-term efficacy, so this is a great place to start."    

Other common treatments include: exposure therapy for specific phobias; complementary and alternative therapies such as stress management and relation techniques, meditation, and yoga; medications; and transcranial magnetic stimulation.  

McLean says finding the right type of care or provider can be challenging and recommends consulting the information, resources, and provider directories published by the Anxiety & Depression Association of America and the Association for Behavioral and Cognitive Therapies.

Similarly, Anxiety Canada offers a variety of anxiety tools, online courses, and group therapy programs. The Canadian Association of Cognitive and Behavioural Therapies also maintains a database of certified therapists.