The U.S. Preventive Services Task Force (USPSTF) recommends that adults 19 to 64 years of age be screened for anxiety disorders, which include a number of disorders not commonly treated in primary care.1 Adding anxiety screening tests, as well as clinician review and interpretation, to an already time-constrained primary care visit takes time away from critical health care tasks, increases administrative burden, and is not likely to benefit patients compared with good standard care.
For anxiety screening to be effective, several elements are required. First, patients must give consent and receive a properly administered screening test; if the result is positive, a diagnostic mental health assessment is required. Then, if a disorder is diagnosed, they must receive treatment that reduces symptoms more effectively than the absence of treatment, with any potential benefit outweighing any treatment-related harms.2,3
The USPSTF did not identify any trials that fully tested anxiety screening in primary care.1 Rather, it cited two randomized controlled trials that tested part of the process by enrolling patients who had already been screened and had positive results; in one group, results were shared with physicians, and in the second group, they were not. Trials that test only part of the screening process should more easily find benefit, but neither randomized controlled trial found evidence of improved mental health.4,5
Treatment of generalized anxiety disorder (GAD), the most common anxiety disorder in primary care, mainly involves pharmacotherapy.6,7 The USPSTF cited two randomized controlled trials that were described as having tested pharmacologic treatment in primary care.8,9 One (n = 244) reported a small reduction in anxiety symptoms among patients randomized to venlafaxine XL compared with placebo,8 and the other (n = 177) did not find any difference based on standard intention-to-treat analysis.9 Neither trial included patients representative of a screened primary care population. GAD detected via screening in real-world primary care settings would presumably be less severe and less amenable to drug treatment than GAD among patients independently reporting symptoms or seeking treatment.10 One of the trials cited by the USPSTF required participants to have higher levels of anxiety than almost all other GAD treatment trials that have been conducted, even though most of these trials have been completed in specialty mental health settings.8,11 The other trial also restricted enrollment to patients with high symptom levels, and, contrary to the study's characterization by the USPSTF, most participants were not recruited from primary care settings.1,9
The USPSTF downplayed harms from anxiety screening.1 Increased prescriptions and use of anxiolytic medications can expose patients to adverse effects and drug-drug interactions related to polypharmacy, despite not having evidence of benefit in a screened population.12 Antidepressants are the most common treatment for GAD, with a mean prescription duration of more than 5 years.13 Benzodiazepines are also used long term for anxiety by many patients in primary care.14 Antidepressant and benzodiazepine use can lead to severe discontinuation effects and be difficult to deprescribe.15,16
The USPSTF added anxiety screening to other questionnaires it recommends routinely administering to screen for depression, unhealthy drug use, and intimate partner violence. Although these are significant concerns, there is no evidence that they are solvable by administering questionnaires. Neither the U.K. National Screening Committee nor the Canadian Task Force on Preventive Health Care recommends administering questionnaires to screen for these problems17,18; there have been at least 20 trials of screening with questionnaires for a range of conditions, and none have shown an improvement in health outcomes.19 For depression and intimate partner violence screening, several robust trials failed to find benefit.2,3,19,20
If implemented as intended, each of the questionnaire-based screening procedures recommended by the USPSTF, including anxiety screening, would substantially increase the time required to provide care and the burden of documenting that care.21 In addition to administering and scoring a screening test, anxiety screening would, at a minimum, require an initial evaluation of patients with positive results to evaluate the possible causes of symptoms. Among positive screens, some patients could have mild symptoms reflecting situational stressors or difficult life situations that are not resolvable through a diagnosis and prescription. Others could have symptoms due to a physical condition (e.g., thyroid disease) or lifestyle factor (e.g., caffeine intake).22 Some patients could have anxiety disorders that are not typically treated in primary care. The amount of time needed for this evaluation could easily fill the allocated visit time for many patients. Some could be referred to a mental health specialist after an initial evaluation is performed, although not enough specialists are available to assess and care for all patients with anxiety disorders, and most patients would require additional time for management in primary care.22
Too often, physicians enter the examination room with an ever-increasing checklist of items, making it difficult to hear and address the specific concerns of the patient. Rather than screening everyone with time-consuming questionnaires of unproven benefit, patients would be better served by being able to share their concerns, including those about mental health, with caring clinicians who take the time to talk with them, understand them as people, and help them access care options consistent with their needs, values, and preferences.3
Editor's Note: Dr. Thombs was supported by a Tier 1 Canada Research Chair. He was previously a member (2013 to 2021) and chair (2017 to 2021) of the Canadian Task Force on Preventive Health Care but did not serve as a voting member on mental health screening guidelines.
