• Task Force Recommends Screening Adults for Anxiety, Depression

    Evidence on Screening for Suicide Risk Remains Inconclusive

    July 5, 2023, News Staff — In another sign of increased awareness of the importance of mental and behavioral health, the U.S. Preventive Services Task Force recently issued two final statements that recommend, for the first time, that clinicians screen all adults ages 19 to 64 for anxiety disorders and screen all adults — including those 65 and older — for major depressive disorder.

    The task force assigned “B” grades to both recommendations, and emphasized that they also apply to pregnant and postpartum adults.

    At the same time, the USPSTF concluded there was insufficient evidence to recommend for or against screening for anxiety disorders in adults 65 years or older, or for suicide risk in all adults.

    “Amid the mental health crisis in the United States, the task force worked to provide primary care professionals and their patients with recommendations on evidence-based screening,” said Michael Silverstein, M.D., M.P.H., the task force’s vice chair, in a USPSTF bulletin. “Fortunately, screening all adults for depression, including those who are pregnant and postpartum, and screening adults younger than 65 for anxiety disorders is effective in identifying these conditions so adults can receive the care they need.”

    The recommendation on screening for anxiety disorders applies to adults ages 19 to 64, including those who are pregnant or postpartum, who do not have a diagnosed mental health disorder and are not showing signs or symptoms of anxiety disorders.

    Similarly, the recommendation on screening for major depressive disorder applies to individuals 19 or older who do not have a diagnosed mental health disorder or recognizable signs or symptoms of depression or suicide risk. This recommendation does not address screening for other depressive disorders, such as minor depression or dysthymia.

    The recommendation on anxiety disorders addresses a topic the USPSTF has not previously covered, while the second recommendation replaces two separate ones on screening for suicide risk and major depressive disorder.

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    Findings and Research Gaps

    The task force’s final evidence review applied to both sets of recommendations and relied on the following conditions listed in the Diagnostic Manual of Mental Disorders, Fifth Edition: generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, selective mutism, substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition and anxiety not otherwise specified.

    The USPSTF found that direct evidence on screening for anxiety was extremely limited and did not suggest a benefit; furthermore. In addition, the task force noted that many anxiety screening tools were initially designed for other purposes, and that these tools alone are insufficient to diagnose a person without diagnostic assessment and follow-up.

    In contrast, the task force found clear evidence of effective treatment options for anxiety, such as cognitive behavioral therapy, antidepressants and benzodiazepines. Antidepressants in particular appeared to be effective in helping individuals with generalized anxiety disorder, panic disorder and social anxiety disorder.

    Although there were no harms associated with screening for anxiety disorders, the task force noted that in 2020, the FDA issued a warning that benzodiazepines could lead to misuse, abuse and addiction, even when taken at recommended doses. The agency issued a separate warning several years earlier, notifying health care professionals and patients that combined use of benzodiazepines with opioid medicines and other central nervous system depressants, including alcohol, could result in breathing difficulties and death.

    With regard to depression, the task force found both direct and indirect evidence to support screening in the primary care setting. Common screening tools included the Patient Health Questionnaire (two- and nine-item versions), the Center for Epidemiologic Studies Depression Scale, the Whooley Questions for depression screening, the Edinburgh Postnatal Depression Scale (for pregnant patients) and the Geriatric Depression Scale (for older adults). Overall, the evidence review indicated that the tests demonstrated comparable accuracy in identifying patients with major depressive disorder, with sensitivity levels ranging from 81% to 94% and specificity levels from 67% to 88%.

    Both psychological and pharmacologic treatments for depression led to improvements in symptoms. Psychological treatments such as cognitive behavioral therapy improved depression scores and other outcomes, such as quality of life, anxiety symptoms, feelings of hopelessness and functioning in primary care patients, perinatal populations and older adults. Antidepressants such as fluoxetine demonstrated small but statistically significant short-term reductions in symptom severity, and increases in the odds of treatment response and remission.

    Direct evidence on the effectiveness of screening for suicide risk was lacking. In response, the task force called for additional studies to determine whether and how screening for suicide risk can improve health outcomes, including research on:

    • which tools to use and how to screen in primary care populations, and pregnant and postpartum patients;
    • whether more people with suicidal ideation detected through screening can be helped before they act;
    • potential harms of interventions; and
    • benefits and harms of targeted vs. general screening.

    The task force also called for more research to ensure that all patients receive depression screening equitably, and for studies to identify and address barriers to establishing adequate systems of care.

    Similarly, the task force noted several critical evidence gaps on anxiety disorders, and said research is needed on topics including the accuracy of screening tools in older adults, and in pregnant and postpartum patients; the direct benefits and harms of screening in primary care settings compared with no screening or usual care; the diagnostic accuracy of screening tools that are feasible for use in primary care settings; and the overall prevalence of anxiety disorders.

    Updates in the final recommendations in response to public comments on draft versions address barriers to screening, screening intervals, use of pharmacotherapy in pregnant and postpartum patients, lack of evidence concerning older adults, and harms of suicide interventions.

    Family Physician Perspective

    Jennifer Buckley, M.D., FAAFP, a member of the Academy’s Commission on Health of the Public and Science, told AAFP News that the recommendations provide further support to what many family physicians are already doing.

    “Family physicians are often the first contact that a patient has with the health care system, and if it wasn’t the first contact for the patient, it often is the first contact where mental health conditions can be discussed and treated,” Buckley said.

    “Specific to the updated USPSTF recommendations, it is extremely helpful to know what works for screening and what doesn’t, how to access those screening options and how to apply the screening options to a busy practice,” she added. “It is also important to recognize that these recommendations are referring to patients who do not already have a mental health diagnosis, and I appreciate that because it fits with our collective goal of reducing barriers and stigma associated with having a mental health condition because we — the family physicians and other health care professionals doing this work — are asking about it rather than a patient feeling like they have to bring it up first and thus contributing to the stigma, silence and isolation that can accompany these conditions.”

    While Buckley appreciated that the recommendations applied to screening for asymptomatic people, she also recognized important gaps.

    “If we are going to screen, we must have adequate treatment options,” Buckley said. “Right now, it is very difficult to get patients into therapy within a reasonable amount of time. Other services still haven’t fully recovered from the pandemic. When additional help is needed by psychiatry, there is also a long wait list, and emergency rooms and psychiatric hospitals are overflowing.

    “At times, our patients are really suffering and there is a significant lack of resources to help them outside of prescribed medication,” Buckley added. “We need to be thinking creatively, constructively and quickly to find solutions for these issues and how we — the entire health care system — can be working together collaboratively to help our patients.”

    AAFP Tools and Tips

    As concerns about mental and behavioral health grow, the AAFP has assembled a diverse blend of resources to help family physicians care for patients who may be experiencing anxiety, depression or suicidal thoughts. American Family Physician, the Academy’s peer-reviewed and evidence-based medical journal, has published numerous review articles on anxiety, depression and related conditions, and maintains a community blog focused specifically on anxiety disorders.

    Mental and behavioral health also feature prominently in the AAFP’s CME offerings, including a recently published FP Essentials monograph on mood and anxiety disorders. Other resources are on the Academy’s Depression & Mental Health webpage, and the AAFP’s patient-centered website, familydoctor.org, contains dozens of articles on depression, various anxiety disorders and related health concerns.

    Finally, the task force provided links to several new resources for clinicians and patients from the National Institute of Mental Health, the Community Guide, UMass Chan Medical School, the Substance Abuse and Mental Health Services Administration, the Suicide Prevention Resource Center, the Office of the Surgeon General, and JAMA (including patient handouts on anxiety disorders and depression and suicide risk in adults and a podcast on the recommendations).