Anxiety in Adults: Screening

Anxiety disorders are commonly occurring mental health conditions. Anxiety disorders include generalized anxiety disorder, social anxiety disorder, panic disorder, separation anxiety disorder, phobias, selective mutism, and anxiety not otherwise specified.¹ Anxiety disorders are often unrecognized in primary care settings and years-long delays in treatment initiation occur.^1-4 Anxiety can be a chronic condition characterized by periods of remission and recurrence. However, full recovery may occur.^1,5

According to U.S. data collected from 2001 to 2002, the lifetime prevalence of anxiety disorders in adults was 26.4% for men and 40.4% for women.⁶ Generalized anxiety disorder has an estimated prevalence of 8.5% to 10.5% during pregnancy and 4.4% to 10.8% postpartum.⁷ The natural history of anxiety disorders typically begins in childhood and early adulthood, and symptoms appear to decline with age. Some community-based epidemiology studies indicate that rates of anxiety disorders are lowest in adults ages 65 to 79 years, but these data are outdated.^1,5

The USPSTF concludes with moderate certainty that screening for anxiety in adults, including pregnant and postpartum persons, has a moderate net benefit.

The USPSTF concludes that the evidence is insufficient on screening for anxiety in older adults. Evidence on the accuracy of screening tools and the benefits and harms of screening and treatment of screen-detected anxiety in older adults is lacking, and the balance of benefits and harms cannot be determined.

See the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.⁸

Patient Population Under Consideration

This recommendation applies to adults (age 19 years or older), including pregnant and postpartum persons, who do not have a diagnosed mental health disorder or are not showing recognized signs or symptoms of anxiety. Older adults are defined as age 65 years or older.

Condition Definitions

Anxiety disorders are characterized by greater duration or intensity of impairment of a stress response over everyday events. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, recognizes the following types of anxiety disorders: 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.⁹

Assessment of Risk

Risk factors for anxiety disorders include sociodemographic factors (female sex, non-Hispanic ethnicity, African American race, marital status of widowed or divorced, or poverty), psychosocial factors (stressful life events or smoking and alcohol use), and physical and mental health factors (presence of other mental health condition or parental history of mental disorders).^1,10 In addition, anxiety and depression often overlap. One cohort study found that 67% of individuals with a depressive disorder also had a current anxiety disorder, and 75% had a lifetime comorbid anxiety disorder.^1,11

Screening Tests

Brief screening tools have been developed that may screen for anxiety and are available for use in primary care. Selected screening tools that are widely used in the United States include versions of the Generalized Anxiety Disorder (GAD) scale, Edinburgh Postnatal Depression Scale (EPDS)-Anxiety subscale, Geriatric Anxiety Scale (GAS), and the Geriatric Anxiety Inventory (GAI).¹ Some instruments that are used for screening for anxiety were initially developed for purposes other than screening, such as supporting diagnosis, assessing severity, or evaluating response to treatment. Additionally, anxiety screening tools alone are not sufficient to diagnose anxiety. If the screening test is positive for anxiety, a confirmatory diagnostic assessment and followup are needed.

Screening Intervals

There is little evidence regarding the optimal timing for screening, and the optimal interval for screening for anxiety is unknown. More evidence is needed to identify ideal screening intervals for all populations. A pragmatic approach in the absence of data might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted.

Treatment or Interventions

Treatment for anxiety disorders can include psychotherapy (e.g., cognitive behavioral, interpsonal, family, and acceptance and commitment therapy) and pharmacotherapy (e.g., antidepressants, antihistamines, beta-blockers, anticonvulsant medications, or benzodiazepines). Anxiety treatment may also include relaxation and desensitization therapies. Transdiagnostic treatment approaches have also been developed for use with patients who have anxiety, depression, or both conditions because of the overlap between depression and anxiety.¹

Additional Tools and Resources

The Community Preventive Services Task Force recommends mental health benefits legislation in increasing appropriate utilization of mental health services for people with mental health conditions.¹² More information about the Community Preventive Services Task Force is available on its website (https://www.thecommunityguide.org). 

Implementation

Adequate systems and clinical staff are needed to ensure that patients are screened and, if they screen positive, are appropriately diagnosed and treated with evidence-based care or referred to a setting that can provide the necessary care.

Potential implementation barriers of screening include provider knowledge and comfort level with screening, provider access to effective screening instruments, and impact on care flow. Clinicians should aim to develop a trusting relationship with patients by being sensitive to cultural issues and free of implicit bias.¹ Many individuals who may be screened for mental health conditions do not receive adequate treatment. Less than half of individuals who experience a mental illness will receive mental health care.¹³ Systemic barriers, such as lack of connection between mental health and primary care, patient hesitation to initiate treatment, and nonadherence to medication and therapy, also exist.^14,15

Racism and structural policies have contributed to wealth inequities in the United States, which also affects mental health in underserved communities.¹⁶ For example, wealth inequities may result in barriers to receiving mental health services, such as treatment costs and lack of insurance, which tend to have a greater impact on Black persons and other racial and ethnic groups than on White persons.¹⁷ The misdiagnosis of mental health conditions occurs more in Black and Hispanic/Latino patients compared with White patients.^18-20 Black patients are also less likely to receive mental health services than White or Asian American patients.^21,22

Suggestions for Practice Regarding the I Statement 

Potential Preventable Burden

Anxiety disorders often have onset during childhood and adolescence (median age, 11 years). Prevalence of anxiety disorders usually decreases in the middle and older adult years and is the lowest among adults ages 65 to 79 years.¹ Anxiety disorders have long-term effects that include impaired quality of life and functioning and sizeable economic costs.

Potential Harms

Potential harms of screening questionnaires include false-positive screening results that lead to unnecessary referrals, treatment, labeling, unease, and stigma. Some anxiety screening tools used in adults emphasize sleep and other somatic symptoms that are also results of aging. These screening instruments could erroneously identify older adults as having anxiety disorders. Pharmacologic interventions may result in adverse events, while psychological interventions are likely to have minimal harms.¹ Evidence on harms of screening and treatment in older adults is limited.

Current Practice

There is a lack of evidence on screening rates for anxiety.¹ Underdetection appears to be common. This may be because patients with anxiety disorders present with other complaints, such as sleep disturbances or somatic complaints.¹ One study found that only 13.3% of primary care patients with generalized anxiety disorder presented with anxiety as the chief complaint; more common complaints in these patients were somatic complaints (47.8%), pain (34.7%), and sleep disturbance (32.5%).²³ Delays in treatment initiation also commonly occur. Only 11% of American adults with an anxiety disorder started treatment within the first year of onset; the median time to treatment initiation was 23 years.^3,4 A U.S. study of 965 primary care patients found that only 41% of patients with an anxiety disorder were receiving treatment for their disorder.^1,24

Other Related USPSTF Recommendations

The USPSTF has recommendations on mental health topics pertaining to adults, including screening for depression and suicide risk (in progress), preventive counseling interventions for perinatal depression,²⁵ screening for unhealthy drug use,²⁶ and screening and behavioral counseling interventions for alcohol use.²⁷

Scope of Review

The USPSTF commissioned a systematic review¹ to evaluate the benefits and harms of screening for anxiety disorders in asymptomatic adults. The USPSTF has not previously made a recommendation on this topic. Conditions reviewed included generalized anxiety disorder, social anxiety disorder, panic disorder, and anxiety not otherwise specified. 

Accuracy of Screening Tests

Ten studies (n=5,935) evaluated the accuracy of screening for anxiety with the GAD, GAS, EPDS-anxiety subscale, or Patient Health Questionnaire-panic disorder instruments to detect generalized anxiety disorder, panic disorder, social anxiety disorder, or any anxiety disorder.¹ Two studies were in older adults (age 65 years or older), three studies were in pregnant patients, and the remaining studies were conducted in adults from primary care. Mean ages ranged from 29 to 75 years.¹ Women were represented in higher proportions than men in the studies (57% to 100%). Race was reported in six studies: three studies in primarily White participants (79% to 91%); one study in South Korean participants (100%); one study in Hispanic/Latino participants (76%); and one study in White participants (53%) and Black participants (32%).¹

The most commonly studied instruments were the GAD-2 and GAD-7. There was limited evidence for other instruments and other anxiety disorders. Only the GAD-2 and GAD-7 were reported by more than one study.

The GAD-2 and GAD-7 demonstrated adequate sensitivity and specificity to detect generalized anxiety disorder.¹ Three studies among general adult populations reported the test accuracy of the GAD-2 to detect generalized anxiety disorder.¹ At a cutoff of 2 or greater, the pooled sensitivity to detect generalized anxiety disorder was 0.94 (95% CI, 0.90 to 0.98; I²=0%) and the pooled specificity was 0.68 (95% CI, 0.64 to 0.72; I²=94.5%). At a cutoff of 3 or greater, the pooled sensitivity was 0.81 (95% CI, 0.73 to 0.89; I²=28.8%) and the pooled specificity was 0.86 (95% CI, 0.83 to 0.90; I²=84.5%).¹

Three studies reported test accuracy for the GAD-7 at a cutoff of 8 or greater, 9 or greater, and 10 or greater.¹ At a cutoff of 10 or greater, the pooled sensitivity to detect generalized anxiety disorder was 0.79 (95% CI, 0.65 to 0.94; I²=77.3%) and the pooled specificity was 0.89 (95% CI, 0.83 to 0.94; I²=94.8%). Sensitivity among the three studies ranged from 0.67 to 0.89 and specificity ranged from 0.82 to 0.95. At lower cutoffs (≥8, ≥9), sensitivity increased and specificity decreased. In general, the GAD-7 performed as well or better than the GAD-2.¹

In a study among pregnant women (n=9,750) using a cutoff of 1 or greater, the sensitivity of the GAD-2 to identify generalized anxiety disorder was 1.0 (95% CI, 0.99 to 1.0) and the specificity was 0.60 (95% CI, 0.60 to 0.61). At a cutoff of 3 or greater, the sensitivity to detect generalized anxiety disorder was 0.69 (95% CI, 0.64 to 0.73) and the specificity was 0.91 (95% CI, 0.90 to 0.91).¹ The screening instrument used in this large study of pregnant persons had similar performance characteristics to the screening instrument used in all adults younger than age 65 years. As a result, the USPSTF extrapolated the evidence on accuracy in younger adults to pregnant and postpartum persons.

The evidence on older adults is lacking. Few of the studies provided accuracy data for screening tools in older adults. A small study of older adults (N=110) evaluated the GAS using a cutoff of greater than 9 to greater than 16. Sensitivity to detect any anxiety disorder at a cutoff of greater than 9 was 0.60 (95% CI, 0.31 to 0.83); specificity was 0.75 (95% CI, 0.66 to 0.82).¹ Furthermore, the anxiety screening tools used in adults emphasize symptoms that are natural signs of aging. As a result, these screening instruments could incorrectly identify older adults as having anxiety disorders because of aging.

Benefits of Early Detection and Treatment

The USPSTF found two randomized, controlled trials (RCTs) (n=918) that directly evaluated the benefits of screening for anxiety disorders in an adult population in primary care settings. Both trials found no group differences in anxiety, depression symptoms, or global severity at 13 to 22 weeks of followup. Absolute differences in change ranged from -1.5 to 0.3 on 16- and 40-point scales.¹

Twenty-one RCTs (N=4,929) and eight evidence synthesis reviews (ESRs) (~144 RCTs; N≈11,030) assessed the benefits of treatment of anxiety disorders with psychological interventions. Thirteen of the trials were conducted in mixed populations of persons with anxiety or depression, and eight were conducted in persons with anxiety only.

Trial participants included adults of all ages and perinatal populations: 16 studies included general adult populations, four studies were limited to older adults, and one study was limited to perinatal patients.¹ The mean age was 46.1 years, and 74% of participants were women. Seven trials were conducted in the United States and 14 trials were conducted outside of the United States.¹ Among the seven trials conducted in the United States, there were 68.5% White participants, 16.3% Hispanic/Latino participants, 15.3% Black participants, 1.5% percent Asian American or Native Hawaiian/Pacific Islander participants, and less than 1% Native American/Alaska Native participants. In the remaining studies that reported race and ethnicity, the percentage of White participants ranged from 56.6% to 81.8%.¹

Psychological interventions showed a small but statistically significant reduction in anxiety symptom severity in primary care patients with anxiety (standardized mean difference [SMD], -0.34 [95% CI, -0.48 to -0.20]; 8 RCTs [n=1,894]; I²=4.2%), but not among mixed populations of patients with anxiety or depression (SMD, -0.13 [95% CI, -0.32 to 0.06]; 11 RCTs [n=1,814]; I²=56.6%). In the ESRs (not limited to primary care patients), psychological treatment was associated with reduced anxiety symptoms. SMDs at posttreatment among broad adult populations were -0.80 and larger (e.g., SMD among persons with generalized anxiety disorder, -0.80 [95% CI, -0.93 to -0.67]; 23 RCTs; N and I² not reported). Psychological treatment (cognitive behavioral therapy) was also associated with improved depression symptom severity and quality of life. More limited evidence suggested a benefit in older and perinatal patients as well.

There were only two RCTs of pharmacotherapy in primary care patients, addressing venlafaxine and escitalopram, and both showed a benefit. Broad ESRs (i.e., not limited to primary care patients) reported improved anxiety and other outcomes for persons taking antidepressants and benzodiazepines compared with person taking placebo. For example, among patients with generalized anxiety disorder, the SMD for change in anxiety symptom severity with selective serotonin reuptake inhibitors was -0.66 (95% CI, -0.90 to -0.43; 31 studies; N and I² not reported). For antidepressants, benefits were seen for a variety of anxiety outcomes among persons with generalized anxiety disorder, social anxiety disorder, and panic disorder. Limited evidence suggested that antidepressants and benzodiazepines may improve anxiety symptoms in older adults, but evidence in perinatal patients was lacking. Improvements were also seen for depression and social functioning outcomes with pharmacotherapy.¹

Harms of Screening and Treatment

The two trials (n=918) that directly evaluated screening of anxiety did not report harms, and there was no pattern of effects indicating harms.¹ None of the RCTs or ESRs of psychological treatment reported on adverse events. Three RCTs (N=669), 10 ESRs (~112 RCTs; N≈29,674), and two case-control studies (N=262,3780) addressed the harms of pharmacologic treatment. Most evidence occurred in general adult populations. Evidence demonstrated an increase in nonserious harms (defined as any adverse events and withdrawals due to adverse events). Serious adverse events were rare and data were insufficient to determine whether pharmacotherapy increased the risk of serious harm. Although no eligible evidence on the risk of addiction or misuse of benzodiazepines was identified, the U.S. Food and Drug Administration has issued a warning for these potential harms, even when taken at recommended dosages. Case-control studies found an association between benzodiazepine use and suicide death. The inability to fully match cases and controls on severity of mental health symptoms and other health behaviors is a limitation. There was very limited observational data on specific serious harms in older adults and pregnant persons.

There are several critical evidence gaps. Studies are needed that provide more information on the following.

• More research is needed on accuracy of screening tools in screen-detected older adults and in pregnant and postpartum persons.
• Evidence is needed in other populations defined by sex, race and ethnicity, sexual orientation, and gender identity.
• More RCTs are needed on the direct benefits and harms of screening for anxiety in primary care settings (or similar settings) compared with no screening or usual care.
• More studies are needed on the diagnostic accuracy of screening tools that are feasible for use in primary care settings, tested among primary care patients or similar populations, using valid reference standards, and determining (and replicating) optimal cutoffs for any anxiety disorder.
• More evidence is needed on the effectiveness of anxiety treatment in older adults and in pregnant and postpartum persons

The American College of Obstetricians and Gynecologists and the Center of Perinatal Excellence recommend anxiety screening for perinatal or postpartum persons.^28-29 The Women’s Preventive Services Initiative recommends that screening for anxiety should include all female patients age 13 years or older not currently diagnosed with an anxiety disorder, including pregnant and postpartum women.³⁰

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