• WPSI Recommends Screening Women for Anxiety

    FPs Invited to Comment on Initiative's Draft Recommendation

    April 03, 2019 08:49 am Chris Crawford – The Women's Preventive Services Initiative (WPSI) from the American College of Obstetricians and Gynecologists (ACOG) has released a draft recommendation on screening for anxiety in adolescent and adult women.

    Available for public comment until May 1, the guidance released April 1 recommends screening women for anxiety, including those who are pregnant or postpartum, as a routine preventive health service.

    The draft recommendation stated that because optimal screening intervals are currently unknown, physicians should use their clinical judgment -- taking into account factors that include, but are not limited to, patient history, concerns and behavior -- to determine when screening is warranted.

    "Given the high prevalence of anxiety disorders, lack of recognition in clinical practice and multiple problems associated with untreated anxiety, clinicians should consider screening women who have not been recently screened," the recommendation said.

    WPSI is overseen by an advisory panel that includes representatives from ACOG, AAFP, the American College of Physicians and the National Association of Nurse Practitioners in Women's Health.


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    Implementation Considerations

    Clinicians may consider screening for anxiety in conjunction with screening for depression, which is a current standard of care, because of the frequent co-occurrence of anxiety and depressive disorders.

    However, Christopher Zahn, M.D., ACOG's vice president of practice activities, told AAFP News that although anxiety and depression may coexist, the impact on women's lives and therapeutic approaches to each disorder may be different.

    "Based on these considerations and the lack of consistent clinical guidance on this topic -- and since one of WPSI's missions is to address gaps in clinical guidance for women -- the program considered this to be an important women's health topic," he said.

    The WPSI recommendation said validated instruments that screen simultaneously for both anxiety and depression may be clinically efficient in practice settings, such as the Edinburgh Postnatal Depression Scale (specifically for pregnant and postpartum women), the Patient Health Questionnaire-4 and the Hospital Anxiety and Depression Scale (HADS) in adult women, and the Bright Futures Pediatric Symptom Checklist -- Youth self-report (Y-PSC) in adolescents and young women.

    Additional screening instruments that demonstrated moderate to high accuracy in identifying anxiety disorders in women were the Generalized Anxiety Disorder seven-item scale (GAD-7), HADS and the Beck Anxiety Inventory and -- for adolescents and young adult women -- the five-item Screen for Child Anxiety Related Disorders.

    The recommendation noted that although they haven't been specifically evaluated in research studies involving adolescents, the GAD-7 and Bright Futures Y-PSC are commonly used in clinical practice.

    Although the draft recommendation statement acknowledged that no studies have evaluated the benefits and harms of population screening for anxiety, it pointed to trials among patients with clinically diagnosed anxiety that support the effectiveness of managing the condition. Management may include cognitive behavioral therapy, individual therapy and medications for reducing symptoms.

    "Screening should ideally be implemented in conjunction with collaborative and team-based approaches to ensure accurate diagnosis, effective treatment and appropriate followup," the recommendation noted.

    Zahn said he would highlight to family physicians who provide women's health care that anxiety is a common issue that can greatly impact women's lives.

    "If we don't identify the problem and don't identify affected women, we can't intervene," he said. "Bottom line is: You can't treat what you don't diagnose."

    Family Physician's Perspective

    AAFP Commission on Health of the Public and Science member James Stevermer, M.D., of Fulton, Mo., told AAFP News that anxiety is more common in women (prevalence of 23 percent) than in men (14 percent). This same trend exists in adolescents (i.e., those ages 13-18), with girls having higher rates of anxiety (38 percent) than boys (26 percent).

    Additionally, Stevermer, who represented the AAFP on the WPSI steering committee, said anxiety can have significant comorbidities, is often associated with unhealthy behaviors and increased depression, and has adverse effects on both health and function.

    And that's aside from its effects on the health of the nation's economy; a 1999 estimate put the U.S. economic cost of anxiety at more than $40 billion dollars annually, he said.

    Still, Stevermer said he believes there are some open questions about screening for anxiety that remain to be answered, including about screening in this particular patient population.

    "By screening, we're looking to identify patients who've not otherwise come to attention for their anxiety," he said. "What proportion of these women will benefit from diagnosis and treatment for anxiety? What proportion could be harmed, for example by overdiagnosis, labeling or an adverse effect of therapy?

    "I'm particularly interested in the perspective of family physicians regarding these questions."

    Feel Free to Comment

    Family physicians can provide input on WPSI's draft recommendation and address Stevermer's specific questions during the public comment period.

    ACOG's Zahn said public comments also could be valuable in identifying research opportunities to address gaps that currently exist in women's health care recommendations, and he pointed to specific guidelines on how to leave constructive comments.

    The draft recommendation itself identified a need for research in a number of areas, including

    • studies of the overall effectiveness of screening for anxiety that report meaningful health and function outcomes;
    • research regarding potential harms of screening for anxiety, including labeling, misdiagnosis and overdiagnosis;
    • examination of optimal methods for screening, diagnosis, treatment and coordination of systems to support the clinical pathway; and
    • investigation into changes in the incidence and prevalence of anxiety over time and the influence of specific risk factors, triggers, mediators and moderators to focus screening and prevention on optimal times, intervals and population subgroups.

    According to Stevermer, WPSI also is interested in nominations of other topic areas in which the development of preventive recommendations would benefit women.

    "They are looking for any problems that have significant associated morbidity and mortality and have an evidence base to support preventive recommendations," he said. "The disease of interest may be specific to women, be more common or serious in women, or have some other difference in outcome or treatment."

    WPSI is interested in hearing the perspectives of all involved stakeholders, including patients and their physicians, Stevermer added.

    "I think that family physicians are uniquely suited to comment on this recommendation, as they care for women across the lifespan and routinely assist patients with management of their anxiety," he concluded.

    Related AAFP News Coverage
    USPSTF Final Recommendation
    Counsel At-risk Women to Help Prevent Perinatal Depression


    AAFP Joins Other Groups to Develop Well-Woman Resource
    Tool Recaps Age-based Preventive Care Recommendations


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