• Posted June 20, 2023

Screen All Adults Under Age 65 for Anxiety Disorders, Expert Panel Says

For the first time ever, the nation's top panel of preventive health experts has recommended that doctors routinely screen all adult patients under 65 for anxiety disorder.

Evidence now shows that anxiety screening can help those patients find peace of mind, the U.S. Preventive Services Task Force (USPSTF) said in recommendations that were published online June 20 in the Journal of the American Medical Association.

“The task force found that for the patients who are 19 to 64, what we call the general adult population, the evidence was robust on reducing their symptoms of anxiety. There was also benefit around general quality of life as well,” USPSTF vice chair Dr. Michael Silverstein said.

The task force also reiterated its longstanding recommendation that adults receive regular depression screening.

“We were able to identify effective practices to screen the adult population for common and serious mental health disorders,” Silverstein said. “The good news is that screening for depression and anxiety can identify these conditions early. When this screening is linked to quality mental health care, patients benefit.”

However, the task force did not recommend anxiety screening for seniors.

“In the population 65 and older, we didn't see the same quality of evidence that spoke to those outcomes,” said Silverstein, a professor of health services, policy and practice at the Brown University School of Public Health in Rhode Island.

The task force also said it could not recommend regular screening for suicide risk at this time, even though it is a leading cause of death among adults.

“There was just simply not enough evidence to recommend for or against screening adults without signs or symptoms,” Silverstein explained. “And that is an urgent call for more research in this area.”

The pandemic highlighted the importance of mental health care for Americans, said Dr. Petros Levounis, president of the American Psychiatric Association (APA).

The global prevalence of anxiety and depression increased by 25% in the first year of the pandemic, according to a 2022 scientific brief from the World Health Organization.

“Depression and anxiety disorders are prevalent in the United States — it's estimated that one in five people could have an anxiety disorder at any given point — and it's gotten worse since COVID,” Levounis said. “Often depression and anxiety disorders go undetected, and if a mental health disorder goes untreated it can get worse.”

An APA poll conducted in May found that 37% of Americans felt more anxious this year than at this time last year, representing an increase of 5%.

The USPSTF received a number of requests to evaluate the effectiveness of anxiety screening, prompting this review and set of recommendations, Silverstein noted.

“Anyone in the United States can suggest a topic, and the task force has a transparent process for selecting its reviews,” Silverstein said. “The task force felt it was a very important topic because anxiety disorders are so common in the adult population.”

Silverstein emphasized that the recommended screening would not be for patients who go to their doctor with specific complaints of anxiety or depression.

Rather, these screenings would be done by a person's family doctor as part of their regular checkup, using recommended questionnaires that have proven accurate in detecting mood disorders, Silverstein and Levounis explained.

“Generally, your doctor would ask you some general questions about how you were feeling, off a checklist,” Levounis said.

Evidence showed that two screening tools were accurate in screening for generalized anxiety disorder, the USPSTF said.

One of the tools, the GAD-2, contains just two questions. It asks if over the last two weeks a patient has been feeling nervous, anxious or on edge, and if they've not been able to stop or control worrying.

The other, the GAD-7, contains a list of seven similar questions.

Likewise, the depression guidelines cite several screening tools that are effective, ranging in length from two to 15 questions.

“Clinicians conducting screenings should have training so they can follow-up positive screens with a few questions, such as the duration of symptoms, degree of distress and impairment, and current or previous treatment history, to better determine clinical significance and the need for treatment,” Levounis said. “This initial assessment and treatment planning has been shown to improve outcomes.”

The APA differed with the task force in that it believes anxiety screening should also be performed for seniors, Levounis said.

“Given the prevalence of anxiety in the older adult population and the impact of untreated anxiety on general medical conditions and their quality of life, APA recommends starting with a short, standardized screening instrument such as the GAD-2,” Levounis said.

Levounis added that while screening everyone for suicide risk might not be useful, it would be good to perform such a test on people who screen positive for depression.

Such a follow-up could help identify depressed people at risk for suicide and provide information on the type of care they need — for example, immediate inpatient mental health services versus outpatient counseling, Levounis said.

“Overall, it seems that a recommendation for targeted suicide screening [e.g., those screening positive for depression] would have been a more balanced and reasonable recommendation than not screening for suicide risk,” Levounis said. “This is especially important in groups at high risk for suicide such as individuals over the age of 65.”

The USPSTF is an independent, volunteer panel of national experts in prevention and evidence-based medicine.

Although it operates independently, the task force's recommendations carry heavy weight throughout U.S. health care. For example, the Affordable Care Act requires that insurers cover for free any screenings recommended by the USPSTF.

More information

The U.S. National Institute of Mental Health has more about anxiety disorders.

SOURCES: Michael Silverstein, MD, vice chair, U.S. Preventive Services Task Force, George Hazard Crooker University professor, health services, policy and practice, Brown University School of Public Health, Providence, R.I.; Petros Levounis, MD, president, American Psychiatric Association, and chair, department of psychiatry, Rutgers New Jersey Medical School; Journal of the American Medical Association, June 20, 2023