To the Editor:

In their recent editorial, Thombs, et al., explained why they disagree with the US Preventive Services Task Force (USPSTF) recommendation to screen adults for anxiety with questionnaires.¹ The USPSTF recommendation statement is based on a systematic review that likewise describes physicians having limited time during primary care visits to discuss anxiety issues with patients.²

We draw the opposite conclusion. Given limited physician time with patients, screening questionnaires provide clinical benefit backed by good evidence and have been recommended for a variety of wellness encounters.^3,4 Patients may not recall all of their concerns in the examination room, but questionnaires can be completed in advance of their office visit. Furthermore, some patients are more comfortable reporting issues in a questionnaire than during a face-to-face encounter with their physician.

Thombs, et al., also advocate that time is better spent on a focused, in-depth discussion as opposed to administration and interpretation of a questionnaire. Indeed, a complete diagnostic mental health assessment is ideal but often not possible or necessary, and understanding the degree and temporality of anxiety may make reassurance and a tincture of time the best remedy. However, one cannot have it both ways: a focused discussion is not as feasible without the guidance of a questionnaire. Primary care clinicians are well-placed to initiate such conversations.

In Reply:

It is the task of screening guideline developers to carefully review evidence and recommend screening only when there is credible evidence of sufficient benefit to justify resources and harms incurred. These recommendations should rely on well-conducted randomized controlled trials (RCTs) when such trials are feasible, as is the case with questionnaire-based screening for anxiety.¹ The USPSTF guideline did not meet this standard, and suggesting that others also recommend using screening questionnaires does not constitute evidence.

Untreated anxiety is a critical problem in patient health care, but there is no evidence that the addition of screening to already time-constrained primary care visits saves time or improves care. The USPSTF recommendation cited two trials that enrolled patients who had already received positive screening results for anxiety with only triage and treatment to implement, yet neither showed improvement in health outcomes.²

Members of our author group previously reviewed USPSTF, Canadian Task Force on Preventive Health Care (CTFPHC), and United Kingdom National Screening Committee (UKNSC) questionnaire-based screening guidelines, which were all based on systematic reviews.³ However, we did not find any trials among these that randomized patients to be screened, provided participants in screened and unscreened trial arms with similar care options when identified as needing care, and determined that screening improved health outcomes. The CTFPHC and UKNSC have consistently recommended against questionnaire-based screening; the USPSTF recommends questionnaire-based screening for unhealthy use of alcohol and drugs, intimate partner violence, depression, and anxiety, all without RCT evidence of benefit and despite several well-conducted, large RCTs that did not find benefit.³

The hypothesis that screening may be better than standard care due to time constraints, or because patients might forget to discuss some of their health concerns once with their doctor, is unsupported by evidence. Unlike subclinical conditions like early-stage cancer, patients are very aware of their anxiety and can be forthcoming about their symptoms.

A major reason the United States spends more on health care than other high-income countries and achieves worse outcomes is the provision of low-value and no-value health services.⁴ The USPSTF's questionnaire-based screening recommendations contribute to this problem by reducing the time physicians have to provide effective care and adding to documentation and compliance burdens without demonstrated benefits.⁵