Most adults in the US should be routinely screened for anxiety even if they don’t have symptoms, the US Preventive Services Task Force (USPSTF) recommended Tuesday. The recommendation applies to adults (19 years or older), including pregnant and postpartum women “who do not have a diagnosed mental health disorder and are not showing recognized signs or symptoms of anxiety disorders.” The task force found “insufficient evidence” to screen for anxiety in adults aged 65 and older.

This is the first time the panel has issued a final recommendation for anxiety disorder screenings in adults ages 19 to 64. Consistent with the task force’s 2016 recommendation, the new guidelines also continue to recommend that all adults be screened for major depressive disorder (MDD), including those who are pregnant or postpartum and older adults.

USPSTF’s recommendation, published in the journal JAMA, comes after a years-long rise in mental health conditions which surged during the pandemic as symptoms of anxiety and depression became more frequently reported. The panel’s decisions generally influence insurance plans and become standard medical practice, which means anxiety disorders could soon become better detected.

Anxiety: Women at twice the risk than men

Although depression and anxiety are different conditions, they can often occur together and such screening recommendations can help clinicians identify which patients may need treatment for both conditions or one versus the other.

“Anxiety disorders are common, and they can really impact people’s quality of life,” stated Dr. Michael Silverstein, vice chair of the USPSTF and director of the Hassenfeld Child Health Innovation Institute at Brown University. “What the task force found is that screening for anxiety disorders in the general adult population can lead to identifying these conditions early and then, if those people who are identified get linked up with appropriate care, they will benefit.”

According to the US National Institute of Mental Health, women are more than twice as likely as men to experience an anxiety disorder in their lifetime. The prevalence of anxiety in men was 26.4% and 40.4% in women between 2001-2002. In addition, generalized anxiety disorders had an estimated prevalence of 8.5% to 10.5% during pregnancy and 4.4% to 10.8% during the postpartum period.

Per the USPSTF, nearly 90% of adults with anxiety disorder don’t begin treatment within the first year of symptoms and the average time to initiate treatment is 23 years. The panel also cited a recent US study of 965 primary care patients which found that only 41% of patients with an anxiety disorder were receiving treatment for their disorder.

Depression debilitation

US data on depression is also sobering. According to 2019 statistics, 7.8% (n = 19.4 million) of adults in the US experienced at least 1 major depressive episode, with 5.3% (n = 13.1 million) experiencing a major depressive episode with severe impairment. MDD is defined as at least 2 weeks of mild to severe persistent feelings of sadness or lack of interest in everyday activities, according to the USPSTF. If left untreated, MDD “can interfere with daily functioning and can be associated with an increased risk of cardiovascular events, exacerbation of comorbid conditions, or increased mortality,” according to the USPSTF recommendation. Only about half of people with major depression are identified.

Depression in pregnant individuals can affect both the parent and the offspring. Research has shown that babies born to women who were depressed while pregnant have lower birth weights (Ecklund-Flores L. et al. 2017). Additional data revealed that depression during pregnancy is the primary risk factor for drinking alcohol as well as for smoking pot and tobacco—above education, income, or age (Brown, R.A. et al. 2019).

Evidence-based guidance for screening, not timing

The USPSTF’s recommendations were based on data from 2 evidence reports also published in JAMA. For the recommendations on depression screening, 105 studies were included in the panel’s review, including 32 original studies and 73 systematic reviews. For anxiety, 40 original studies and 19 systematic reviews were included in the evidence report.

Despite the USPSTF finding of a “moderate net benefit” to universal screening for anxiety and depression, there is currently little evidence on the optimal timing for such assessments with more evidence needed in both perinatal and general adult populations.

“In the absence of evidence,” the panel authors wrote, “a pragmatic approach might include screening adults who have not been screened previously and using clinical judgment while considering risk factors, comorbid conditions, and life events to determine if additional screening of patients at increased risk is warranted. Ongoing assessment of risks that may develop during pregnancy and the postpartum period is also a reasonable approach.”

The USPSTF emphasized that positive screening results should be followed by an assessment and mental health care. The panel also acknowledged potential barriers to patients receiving that screening or follow-up care such as financial burdens, lack of insurance, or access to a primary care physician.

Screening for suicide risk

Research suggests that anxiety disorders and depression may be associated with suicidal thoughts, suicide attempts, and other types of suicidal behaviors. In the new recommendations, the USPSTF calls for more research on suicide risks among people who are not showing signs or symptoms. However, consistent with its 2014 recommendation on the issue, the task force stopped short of advocating screenings for suicide risk.

For suicide risk screening, the panel concluded that data from 27 studies did not demonstrate improvement over standard care, highlighting one randomized clinical trial of a suicide risk screening intervention which showed no difference in suicidal ideation after 2 weeks between primary care patients who did and did not receive the screening.

An editorial that accompanied publication of the new recommendations in JAMA addressed the lack of the panel’s screening recommendations to extend to suicide. “Although not called out in the USPSTF Recommendation Statement, a positive screen result for anxiety should be immediately followed with clinical evaluation for suicidality,” wrote Murray Stein, MD, Professor of Psychiatry and Family & Preventive Medicine and Director of the Anxiety & Traumatic Stress Disorders Program at University of California, San Diego (UCSD), and Linda Hill, MD, Clinical Professor in the Department of Family Medicine and Public Health at UCSD.

“Anxiety screening will typically take place concurrently with USPSTF-recommended depression screening, which should prompt specific questions about suicidal ideation,” they counseled.

“The uptake of these new anxiety screening recommendations should provide an impetus and an opportunity for primary care clinicians to become more comfortable with diagnosing and treating anxiety disorders, which may require additional training,” Drs. Stein and Hill continued. “Anxiety disorders can be distressing and disabling, and appropriate recognition and treatment can be life-altering and, in some cases, lifesaving, for patients.”

Read the task force’s unabridged recommendation statement here and the accompanying editorial, “Are There Reasons to Fear Anxiety Screening?” here.

The contents of this feature are not provided or reviewed by NPWH.