Why to screen for anxiety

Primary care physicians should more routinely screen for anxiety in women to better identify and alleviate the symptoms, which may otherwise linger for years without discerning the underlying cause, according to a new recommendation from the Women's Preventive Services Initiative (WPSI).

That screening should include all female patients ages 13 years and older, according to the recommendation, published July 7, 2020, in Annals of Internal Medicine. The clinical recommendation, which the WPSI describes as the first devoted to anxiety screening, doesn't specify how often patients should be screened, citing limited research in that area. But the authors advised that given the high prevalence of anxiety disorders in women and adolescent girls, screening should be part of routine practice, much like depression screening has become.

Roughly 40% of adult women develop some type of anxiety disorder during their lifetime compared with 26.4% of men, according to prevalence data published in 2012 in the International Journal of Methods in Psychiatric Research. Another study, which looked at using a screening tool in 965 male and female primary care patients, found that one in five had at least one anxiety disorder. Nearly half (41%) reported no current treatment, according to the findings, published in March 2007 by Annals of Internal Medicine.

Anxiety can fly under the radar when it becomes intertwined with other conditions and symptoms that may be more immediately recognizable, such as stomach problems or migraines, said Heidi D. Nelson, MD, MPH, MACP, a member of the WPSI advisory panel and lead author of the accompanying evidence review. “It's often a quiet suffering,” she said. “The person with anxiety may not be able to identify it or advocate for their health.”

Heidi Combs, MD, a psychiatrist and associate professor at the University of Washington School of Medicine in Seattle, agreed that too much misery is being missed. “It's very common that people come in not realizing that their physical symptoms are a downstream effect of their anxiety.”

Dr. Combs acknowledged that it's a “big ask” to add routine anxiety screening to already jam-packed primary care visits. But incorporating a few questions, asked in the waiting room or by a medical assistant, could save the physician time over the long haul, she said.

“These patients have distress, and they will come and see you over and over and over again until you figure out what's going on,” Dr. Combs said. “Because they're ill, and they're coming to you for help.”

Improving diagnosis

It's unclear precisely why anxiety disorders emerge more often in women, said Kurt Kroenke, MD, MACP, a professor of medicine at Indiana University in Indianapolis as well as a longtime researcher of anxiety and depression. There are likely a few possible influences, he said, including hormonal differences between men and women, genetics, and perhaps a greater cultural willingness among women to acknowledge difficulties with anxiety.

Screening for depression, which also is more common in women, has been recommended since 2016, when the U.S. Preventive Services Task Force issued guidance for all adults to be screened starting at age 18 years. Depression may have gotten more attention given its closer link to suicide, Dr. Kroenke said, but anxiety, which often coexists with depression, can be disabling on its own. He cited data published in April 2018 by JAMA indicating that anxiety disorders ranked No. 7 on a list of 25 physical and mental health conditions causing the most disability and injury in 2016. Major depressive disorder ranked No. 2.

Both anxiety and depression often emerge in women during times of hormonal flux, including puberty, the postpartum period, and the menopause transition, said Lisa Larkin, MD, FACP, a Cincinnati-based general internist who specializes in women's health. But all too often, these concerns are ignored or neglected for various reasons, including limited medical education about women's health, especially for primary care clinicians, as well as the time constraints and problem-focused nature of office visits, she said.

The recent WPSI recommendation supports screening all women starting at age 13 years who have not already been diagnosed with an anxiety disorder, including pregnant and postpartum women. The authors don't provide an optimal timetable, writing that “clinical judgment should be used to determine frequency.”

Studies to date haven't looked at how often anxiety screening should be performed, said Dr. Nelson, a professor of health systems science at the Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, Calif. The easiest route would be to screen for anxiety at the same visit as depression, such as during an annual visit or other clinical encounter, Dr. Nelson said. “Some of the tools screen for both.”

The recommendation, based on a systematic review that evaluated 27 screening tools, reported that in the general adult population, the three different versions of the Generalized Anxiety Disorder (GAD) scale, as well as the anxiety module of the Patient Health Questionnaire, demonstrated moderate to high accuracy (as did several others that are less known among internists, Dr. Nelson noted).

While the guidelines focus on women, primary care physicians should look for anxiety in both men and women, according to Dr. Kroenke, who is among the creators of the GAD-7 scale. The two- and seven-question versions of the GAD scale are similarly effective in terms of screening, Dr. Kroenke said. But if anxiety has been identified with the two-question scale, he recommends asking patients to then take the GAD-7, as it includes additional questions to gain a more nuanced baseline snapshot of their anxiety level. Then the GAD-7 can be administered again moving forward to determine any changes, regardless of whether the patient has chosen treatment or watchful waiting, he said.

During these pandemic times, research continues to indicate that people are struggling more with anxiety, as well as depression. As of last June, 25.5% of people screened positive for symptoms of an anxiety disorder, roughly three times higher than the 8.1% prevalence during the second quarter of 2019, according to data reported Aug. 14, 2020, in MMWR.

While some women may be biologically inclined to develop anxiety, such external factors as a job loss or the death of a loved one can cause those symptoms to flourish, Dr. Combs said. So can the angst that surrounds a global pandemic, she added. “If you are someone who is very anxious and worries a great deal, it's sometimes hard to block out those things that are happening around you.”

Treatment discussions

While scores on the screening tools are helpful, they shouldn't by themselves determine a patient's care, Dr. Kroenke said. “Don't simply treat to the score,” he said. It's important to ask the patient how troubling the anxiety is and how long symptoms have been present, he said.

Another approach, Dr. Combs said, is to ask the patient, “Do you think your worry affects your function in any way? Tell me how.” When a patient's score on a screening tool doesn't meet diagnostic criteria but symptoms impair daily life, then Dr. Combs will often advise treatment.

When screening for anxiety, physicians should watch out for other underlying causes, such as hyperthyroidism, said Kim G. Smolderen, PhD, a health psychologist and associate professor of medicine at Yale University School of Medicine in New Haven, Conn., who coauthored an editorial accompanying the WPSI recommendation. Epidemiological studies have also shown a link between anxiety or depression and later risk for heart disease, she said. The reasons are multifactorial, with health behaviors among those pathways that play a role, she said. With these mood disorders, “People tend to smoke more, not have a good diet, and not be so active,” said Dr. Smolderen.

Anxiety often doesn't exist in isolation, Dr. Combs said, so once physicians identify one anxiety disorder, they should screen for other anxiety disorders, as well as post-traumatic stress disorder, substance use disorder, and depression.

The WPSI recommended therapy, most typically cognitive behavioral therapy, for initial treatment. Women who can't meet with a therapist, either due to financial or other access reasons, can learn the techniques through online modules, said Dr. Combs, adding that patients will periodically require refresher training to keep their skills current.

“The beauty about cognitive behavioral therapy is there's not a lot of side effects,” she said. “It changes the tape that plays in your head, and that changes how you feel.”

But some patients resist therapy and prefer to take a pill, Dr. Combs said. In addition, Dr. Nelson noted, “Sometimes cognitive behavioral therapy just isn't enough and patients need medication, or there is coexisting depression that needs treatment.” In cases where medication is prescribed, the WPSI recommended selective serotonin reuptake inhibitors (SSRIs) or selective serotonin and norepinephrine reuptake inhibitors (SNRIs). The accompanying evidence review advised against prescribing benzodiazepines, except in acute crises. Given that SSRIs or SNRIs aren't without potential side effects, such as gastrointestinal or sexual dysfunction, Dr. Combs suggested asking the woman if someone in her family has previously taken one of the drugs and tolerated it well. “There is a better chance she will also tolerate the medication given shared familial drug metabolism,” she said.

Starting an SSRI or SNRI may initially worsen a woman's anxiety, something that occurs in about one-fourth of patients, Dr. Combs said. She prefers to start patients on half of the dose of the medication typically started for depression, warning them that their anxiety may temporarily rev up but encouraging them to ride out that stretch and not give up on the drug.

In addition, Dr. Combs stresses to patients that it can take as long as six weeks, and for many even longer, for the full anxiety-reducing benefits to kick in. “I have seen countless patients who tell me, ‘I'm totally treatment-resistant. Medications don't work for me,’” she said, but further questioning about the patient's prior experience may reveal that she only stuck with the medication for a few weeks.

The surge in anxiety and other mental health symptoms, as well as heavier alcohol consumption, has been notable since the COVID-19 pandemic began, Dr. Larkin said. Among women who haven't had prior anxiety difficulties but are coping with some symptoms, Dr. Larkin said that she's not immediately prescribing medication.

“I'm doing a lot of supportive counseling,” she said. “Honestly, I tell patients that it's been hard for me, too.”

But if a woman admits to drinking more heavily at day's end to blunt her anxiety, Dr. Larkin is more prone to suggest a prescription. “I really believe that using SSRIs or SNRIs is a far better option to help them with their anxiety than letting them self-medicate with alcohol.”

More routine screening of women, though, doesn't necessarily help them get care, said Dr. Smolderen, citing access issues ranging from cost to limited clinicians in some regions, such as rural communities, although she noted that “The telehealth evolution could help open up access to care.”

In her editorial, Dr. Smolderen discussed some of the potential downsides of medication, such as the risks of addiction and misuse associated with short-acting benzodiazepines. Another consideration is that women diagnosed with anxiety may already be living with other conditions requiring drugs that don't interact well with SSRIs/SNRIs, she wrote. For instance, antiplatelet therapy warrants “caution because of the enhanced risk for bleeding events.”

Nor will all patients agree to treatment, Dr. Kroenke pointed out. When patients score in the mild to moderate range on screening, the physician could try watchful waiting for a stretch, similar to when a patient has a high blood pressure reading in the office, he said. The patient could be asked to repeat screening four to six weeks later at home, either on paper or through an electronic portal.

If a patient continues to score high on screening and acknowledges that anxiety impairs ability to cope daily, Dr. Kroenke suggested advocating harder to get help. Try to get more insight into what's holding the patient back, in case any misconceptions can be addressed, he said.

As the pandemic extends into 2021, new cases of anxiety will no doubt continue to emerge, Dr. Kroenke said.

“It's going to be a time to even have a heightened sensitivity to say, ‘There are going to be more of these patients in my practice. If I were not a screener before, maybe for the next year to a year and a half I should be,’” he said, “because there are going to be higher rates of anxiety and depression out there.”