Behavioral Health - Key Activity 9C

KEY ACTIVITY #9C:

Screen Adults for Anxiety

 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration.

Overview

This activity provides guidance on screening for anxiety for adults (e.g., those 18 and above, though this age cutoff may be site-determined).

Twenty years ago, the U.S. Preventive Services Task Force (USPSTF) introduced screening for depression for all adults and adolescents. In June of 2023, they added a recommendation (Grade B) to screen adults 18 to 64 years old for anxiety. Many practices choose to screen for generalized anxiety disorder.

Anxiety disorders are often unrecognized in primary care settings and patients with anxiety commonly experience yearslong delays in treatment initiation. Anxiety disorders include generalized anxiety disorder, social anxiety disorder, panic disorder, separation anxiety disorder, phobias, selective mutism, and anxiety not otherwise specified.

Anxiety disorders typically begin in childhood and early adulthood, and symptoms often decline with age. Large population-based surveys estimate that 33.7% of the United States population is affected by an anxiety disorder during their lifetime.[1]

Research in the past 10 years provides evidence of inequities in mental health treatment for people of color, including restricted access to mental healthcare and suboptimal mental health treatment.[2] Some of these inequities arise as a consequence of unmet social needs, including socioeconomic status, educational attainment, housing status, access to health insurance, and exposure to toxic environments. Research throughout the pandemic shows that the disparity in treatment between white and patients of color increased.[3] The percentage of respondents with unmet mental healthcare needs in 2020 to 2021 suggest that more Black, Hispanic, and Asian respondents had unmet care needs in comparison to white respondents.

In addition to racial and ethnic disparities, there are differences in the prevalence of anxiety between genders. One of the most widely documented findings in psychiatric epidemiology is that women are significantly more likely than men to develop an anxiety disorder throughout their lifespan.[4]

Implementation of systematic anxiety screening for all patients is one approach to more equitable delivery of anxiety treatment in primary care.

Risk factors for common mental disorders are strongly associated with social inequalities, whereby the greater the inequality, the higher the inequality in risk.[5] Consequently, anxiety should be considered a comorbidity when social needs are screened for and vice versa, and patient needs in both areas should be considered when designing appropriate interventions. See Key Activity 10: Develop a Social Needs Screening Process that Informs Patient Treatment Plans for more.

Technology can support screening for behavioral health conditions by delivering structured guidelines, protocols, and clinical decision support to care team members responsible for carrying out assessments. It can also help by incorporating standardized screening tools into EHRs and care management and care coordination applications. These screening tools can also be made available directly to patients through patient outreach and screening technologies.

Understanding the prevalence of behavioral health conditions assists in program and resource development to track impact on health outcomes and to incorporate into risk stratification. Health information technologies used to track referrals are also important in care management.

Action steps and roles

1. Select a validated tool appropriate for the local context.

Suggested team member(s) responsible: Representatives and leaders from medical and behavioral health teams, QI staff.

Most commonly, when screening for anxiety in adults, the GAD-7 is the most common tool. Additionally, there are tools that are specific to pregnant people and older adults.[6] At this time, we encourage integrated teams to choose and consistently use a validated tool with considerations for clinic setting, preferences, and populations served.
 

2. Decide frequency of tool administration and when screens will be conducted in the visit flow.

Suggested team member(s) responsible: Representatives and leaders from medical and behavioral health teams, QI staff.
 

3. Interpret screening results within the clinical context for the patient with workflows for low, medium, and high acuity and determine next steps.

Suggested team member(s) responsible: Medical and/or BH provider.

Next steps may include:

  • Watchful waiting.
  • Self-management.
  • BH referral.
  • Medication management, including a combination of the above.

 

4. Conduct training with all staff and providers to enhance the effectiveness of screening and assessment.

Suggested team member(s) responsible: Clinic director, CBHO, CMO.

Given that there is likely to be a high rate of positives in response to screening activities for anxiety, ensure training of the integrated team in distinguishing and appropriately responding to the range of disorders that may include symptoms of anxiety, such as generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), social anxiety disorder, panic disorder, separation anxiety disorder, phobias, selective mutism, and anxiety not otherwise specified.

Endnotes

  1. Bandelow, B., & Michaelis, S. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in clinical neuroscience, 17(3), 327–335.  
  2. Samander, L. J., & Harman, J. (2022). Disparities in Offered Anxiety Treatments Among Minorities. Journal of primary care & community health, 13, 21501319211065807.  
  3. Thomeer, M. B., Moody, M. D., & Yahirun, J. (2023). Racial and Ethnic Disparities in Mental Health and Mental Health Care During The COVID-19 Pandemic. Journal of racial and ethnic health disparities, 10(2), 961–976.  
  4. McLean, C. P., Asnaani, A., Litz, B. T., & Hofmann, S. G. (2011). Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. Journal of psychiatric research, 45(8), 1027–1035. 
  5. Allen, J., Balfour, R., Bell, R., & Marmot, M. (2014). Social determinants of mental health. International review of psychiatry, 26(4), 392–407.  
  6. O’Connor E, Henninger M, Perdue LA, Coppola EL, Thomas R, Gaynes BN. Screening for Depression, Anxiety, and Suicide Risk in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 223. Agency for Healthcare Research and Quality; 2022. AHRQ publication 22-05295-EF-1.