Anxiety disorders are common among U.S. adults, but symptoms are often overlooked or misdiagnosed in primary care, potentially leading to lengthy delays in initiating treatment. New recommendations can help guide physicians on how to intervene.
The U.S. Preventive Services Task Force (USPSTF) now recommends routine anxiety screening for most adults—putting primary care physicians on the front lines of identifying and managing patients' mental health issues.
“For adults up to age 65, including those who are pregnant or postpartum, we found that screening is beneficial and should be conducted routinely in primary care,” said USPSTF member Gbenga Ogedegbe, MD, MPH, a professor of medicine and population health at NYU Grossman School of Medicine in New York. “A positive screen requires a follow-up appointment for a formal diagnostic assessment.”
The Task Force's statement, published online June 20 in JAMA, recommends screening for adults ages 64 years or younger, including pregnant and postpartum persons. It cites U.S. data from the early 2000s pegging the lifetime prevalence of anxiety disorders in adults at 26% among men and 40% among women. More recently, surveys conducted by the CDC's National Center for Health Statistics show that the percentage of adults reporting symptoms of anxiety disorders spiked to 37% during the height of the pandemic before tapering off to 27% as of July 2023.
“It's been 20 years since the Task Force first recommended routine screening for depression, and now is the right time to add another important mental health presentation that primary care can address,” said Bradley Gaynes, MD, MPH, head of global mental health at the University of North Carolina School of Medicine in Chapel Hill and senior author of the evidence review supporting the recommendations.
“A large percentage of complaints in primary care are either caused by anxiety or have anxiety as a driver of their presenting symptoms,” he said. “It makes sense for primary care physicians to identify these disorders and decide how best to manage them.”
Initial screening identifies patients with common anxiety-related risk factors, such as stressful life events, smoking and alcohol use, other mental health conditions, and family history of mental disorders. The Task Force recommends using an evidence-based screening tool, such as the Generalized Anxiety Disorder-7 (GAD-7), in all adults who have not been screened previously, then using clinical judgment to determine if additional screening is needed for high-risk patients.
“Routine screening is critical because only a minority of patients who have an anxiety disorder present with anxiety as a symptom,” said Heidi Combs, MD, MS, associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine in Seattle. “It's much more common to present with somatic complaints, such as fatigue, sleep disturbance, gastrointestinal distress, or pain.”
The GAD-7 asks patients how often they experienced feelings of nervousness, restlessness, irritability, or fear over the past two weeks and to rate the degree to which those issues interfered with their daily activities. Patients are assigned scores on a 21-point scale, with scores of 0 to 4 indicating the lowest risk and 15 to 21 suggesting high risk.
Screening for anxiety should be done in parallel with a clinical workup, noted Dr. Combs. The results offer another clue for physicians when investigating the cause of a patient's symptoms.
“There can be many reasons that a patient might be experiencing symptoms such as fatigue or GI distress,” she said. “Screening tools help the internist start to think about potential psychiatric causes of these complaints while they're simultaneously making sure they're not missing another medical diagnosis, such as an iron deficiency or congestive heart failure.”
Evidence-based screening helps physicians differentiate between healthy or appropriate responses to stress and a disorder, said Jaesu Han, MD, clinical professor of psychiatry and family medicine at the University of California, Irvine. He recommends paying special attention to how patients answer the final question on GAD-7: “If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?”
“You can't just look at the GAD-7 score and assume that a patient needs treatment,” said Dr. Han. “It's more important to know what sort of functional impairment or problems the anxiety is causing in their life.”
A positive screening test should trigger a follow-up appointment to discuss the results and clarify the type of anxiety diagnosis, said Dr. Gaynes. The GAD-7 assesses anxiety symptoms over the prior two weeks, but symptoms of a generalized anxiety disorder need to last at least six months, and symptoms of panic disorder need to involve at least one panic attack followed by persistent concern about additional attacks for at least one month. Physicians should take the time to confirm that the patient's symptoms persisted over a long enough period and resulted in severe distress or functional impairment, such as problems performing at work, school, or home.
“If a patient meets both the time period and functional impairment criteria, there's a good chance they have an underlying anxiety diagnosis,” Dr. Gaynes said. However, a positive diagnosis does not rule out other medical causes of the patient's symptoms.
“It's not always an either-or,” he said. “Someone could present with clinically distressing symptoms such as heart palpitations that are a manifestation of their anxiety but also have an underlying medical cause, such as a cardiac condition.”
In general, people with chronic medical conditions have a higher prevalence of depression and other psychiatric disorders. In a 2011 study cited by the USPSTF, 67% of people with a depressive disorder also had an anxiety disorder.
“This is a patient population that is going to have a higher burden of total illness, including psychiatric illness,” said Dr. Combs. “It's more the rule than the exception that patients will have comorbidities, and understanding the whole picture of what a person is struggling with will be very helpful in making treatment decisions.”
Once anxiety has been identified as a driver of the patient's symptoms, physicians must probe further to make a specific diagnosis, such as generalized anxiety disorder or obsessive-compulsive disorder, said William Salazar, MD, FACP, professor of medicine and psychiatry at the Medical College of Georgia in Augusta.
“The modalities of treatment differ for each type of anxiety syndrome,” he said. “Once you know the specific type, you can tailor the treatment to the anxiety.”
The GAD-7 also identifies patients with post-traumatic stress disorder, which was reclassified from an anxiety to a trauma and stressor-related disorder in the latest Diagnostic and Statistical Manual of Mental Disorders, according to an editorial accompanying the USPSTF statement. Accordingly, physicians should be prepared to ask about traumatic experiences during the follow-up visit.
It can be helpful to give patients the diagnostic criteria for different types of anxiety so they can read them on their own before a follow-up appointment, said Dr. Combs. This allows patients to familiarize themselves with different diagnoses and identify criteria that seem most applicable to their situation.
“I like to have some patient-friendly information available in the exam room with the names and diagnostic criteria for various anxiety disorders,” she said. “Some patients really like spending a little time with that information on their own to see what fits … it allows them to take some ownership over what they're experiencing.”
Diagnosing and treating anxiety add other elements to an already long checklist during a typical wellness exam. However, experts noted that many of the recommended treatments are the same as those prescribed for depression.
“Internists have been screening for and diagnosing depression for years, and most are very comfortable with initiating treatment,” said Dr. Gaynes. “The antidepressants commonly used to treat depression, selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs), can also be very effective in treating anxiety disorders.”
Still, while there is significant overlap between anxiety and depression, not all medications are indicated for both. For example, bupropion, a norepinephrine and dopamine reuptake inhibitor, does not work for anxiety, Dr. Gaynes said. Additionally, physicians may consider prescribing buspirone, an anxiolytic, for anxiety, he noted. He also said that while FDA-approved medications for anxiety are considered safe for pregnant and postpartum patients, they may not be well tolerated, and physicians and patients should carefully review the potential risks and benefits of use during the first trimester of pregnancy.
In general, antidepressants should be started more gradually for anxiety disorders compared to depression, said Dr. Han. Prescribe half of the typical starting dose for the first one to two weeks, he said, because patients with anxiety tend to be much more sensitive to side effects than patients with depression only.
“You increase the likelihood that a patient will stick with a medication by taking it a little bit slower and lower at the beginning to make sure that they're tolerating it,” he said. “Also, make sure patients understand that these medications are not to be taken as needed when they feel anxious. They work when they're taken consistently every day.”
Common side effects include gastrointestinal issues, nausea, and either jitteriness or sedation, he said. He noted that there is no one preferred SSRI or SNRI for generalized anxiety disorder—escitalopram (Lexapro) and sertraline (Zoloft) are two of the most commonly prescribed—but switching to a different option is often considered when patients experience intolerable side effects or aren't seeing results in the first couple of months.
Experts noted that antidepressants and psychotherapy, especially cognitive behavioral therapy, are equally effective in treating anxiety, especially in the short term. Following a diagnosis, it's reasonable to start a patient on one or both, depending on patient preference and availability. Research suggests that patients do better over time with the combination, said Dr. Gaynes.
“One of the potential long-term benefits of psychotherapy is that you learn about tools to manage your anxiety as opposed to relying on medication to do the bulk of the work,” he said. “The likelihood of having another problem with anxiety is less if a patient has those tools at their disposal and can apply them when they experience problems.”
Barriers and challenges
The Task Force recognizes significant challenges to starting treatment, said Dr. Ogedegbe, including access to affordable care and a national shortage of mental health practitioners, although these factors were outside the scope of the recommendations.
Fewer than half of individuals who experience mental illness receive appropriate care, the Task Force noted, and stronger connections between mental health and primary care are needed. Other issues include high treatment costs and lack of insurance, which tend to have a greater impact on Black and Hispanic/Latino patients versus White patients, the Task Force said.
“We are not ready to screen everyone unless we develop better systems to connect primary care to mental health,” said Dr. Salazar. “If we only do the screening without having the systems in place to make referrals, it will become more and more frustrating for physicians to manage anxiety and other mental health conditions.”
While working in New York City, Dr. Salazar established an outpatient psychiatric liaison service that connected primary care teams with psychiatric specialists for routine consults. Such programs can help reduce psychiatric referrals, he said, by helping general internal medicine physicians become more comfortable diagnosing and managing anxiety on their own.
That said, referrals are sometimes necessary, such as when patients have multiple anxiety and depressive disorders or may be struggling with substance abuse or suicidality, said Dr. Combs. A patient with complex bipolar disorder who is very unstable, for example, should be referred to a specialist.
Better systems are also needed to address disparities in access to screening, said Dr. Salazar, who runs a free clinic in Augusta. He is currently developing a program to facilitate access to screening and test the effectiveness of current evidence-based tools in the clinic's mostly low-income Hispanic patient population.
As noted in the JAMA editorial, there aren't enough mental health specialists to care for all of the patients with anxiety disorders, and even fewer are accessible to low-income populations.
To counter such obstacles, primary care physicians may want to offer alternative resources, said Dr. Combs. For example, anxiety workbooks or smartphone apps are low-cost options that can help patients develop strategies to manage anxiety on their own.
Additionally, many insurance plans now cover virtual therapy, which gives patients in remote and rural areas access to a larger pool of clinicians, said Dr. Gaynes.
Despite current barriers to treatment, expanding screening for anxiety is an important step toward recognizing its impact and providing needed treatment, said Dr. Combs.
“Primary care physicians understand that depression can significantly impair people's function but may not realize that anxiety also can cause significant disability,” she said. “These recommendations are fantastic in that they raise the focus on identifying patients at risk and sorting out the best way to move forward.”