October 17, 2022
We are pleased to have the opportunity to express our views about the U.S. Preventive Services Task Force (USPSTF) on the Screening for Anxiety in Adults: Draft Evidence Review.
The National Center for Health Research (NCHR) is a nonprofit think tank that conducts, analyzes, and scrutinizes research on a range of health issues, with a particular focus on which prevention strategies and treatments are most effective for which patients and consumers. We do not accept funding from companies that make products that are the subject of our work, so we have no conflicts of interest.
We have concerns about the USPSTF recommendation of screening for anxiety in all adults up to age 64. The task force described the direct evidence as “extremely limited and did not suggest a benefit.” And yet high-quality direct evidence is what USPSTF usually requires and should require as the basis for their recommendations. The USPSTF also found problems with screening tools, because of the types of anxiety they measured and the lack of information about diagnostic accuracy.
Although we agree with USPSTF that “If tools identify patients with other conditions that need treatment as well as anxiety disorders, there could still be a net value of screening,’ that is not the standard of evidence that the USPSTF should require, especially since there are risks for most treatments that are likely to be prescribed by the primary care physicians who are doing the screening and may also do the prescribing. Screening for post-traumatic stress disorder, obsessive-compulsive disorder and attention deficit hyperactivity disorder makes sense, but there are many other causes of anxiety that are shorter term and less debilitating; that is why USPSTF should require evidence that the screening for anxiety as diagnosed by the screening tools will not be misconstrued by the patient or the physician doing the screening, and that the likely treatment has benefits that outweigh the risks.
Treatment for anxiety disorder usually includes cognitive behavioral therapy (CBT), medication, or a combination of these. One study cited by USPSTF, which included patients with a wide range of anxiety symptoms including PTSD, reported that 63% of patients receiving one or both of these treatments experienced at least a 50% reduction in symptoms by 12 months, compared to 45% for the control group1 . This is a statistically significant difference, but also suggests that almost half of the patients with anxiety disorder are improving without special treatment, making the risk-to-benefit ratio especially important. Although cognitive behavioral therapy is considered by experts to be the most effective longterm treatment for depression and anxiety, most diagnosed patients are prescribed medication instead. The most common treatments are antidepressants and benzodiazepines. All of these pharmacologic treatments have serious risks and should be used with caution and with very close monitoring due to possible adverse reactions, side effects and interactions with other medications. For example, benzodiazepines which are specifically indicated for treating anxiety, are effective when used appropriately over a short period of time; however, when used in increasing amounts as tolerance develops, they can cause physical dependence and addiction2. Benzodiazepine addictions can involve both physical and a psychological dependence on the drugs, resulting in withdrawal when doses are stopped or reduced. For that reason, the USPSTF should require better evidence that screening has benefits and will not result in treatments that do more harm than good.
An estimated 20% of pregnant women have at least one anxiety disorder3. Prenatal anxiety has been associated with pre-eclampsia, pre-term delivery, and low birth weight. However, there are risks to the fetus as well as the mother of taking prescription drugs for anxiety. Based on a systematic review, cognitive-behavioral therapy (CBT) is recommended as a first line treatment for pregnant and breastfeeding women with anxiety disorders, and there are no known contraindications of CBT in pregnancy3. Randomized controlled trials comparing pharmacological and psychological interventions for anxiety disorder indicate that CBT is safe and as effective or superior to medication. The researchers point out that CBT is time-consuming and expensive and should be made more widely available and affordable, especially for pregnant and postpartum women. Given the limited availability of CBT, USPSTF should provide evidence that screening pregnant women will likely result in such safe treatments and therefore would have benefits that outweigh the risks.
As is the case for pregnant women, anti-anxiety medications have risks for breastfeeding infants and USPSTF has not provided direct evidence that screening will result in CBT or other treatments where the benefits outweigh the risks.
We agree that further research is needed in adults 65 and over. About 27% of older adults who are under the care of an aging service provider showed anxiety symptoms that may impact their everyday experiences4. The task force did not find sufficient evidence to recommend screening for anxiety in this age group. Available screening tools may not accurately identify anxiety disorders in older men and women. Symptoms that are commonly seen as we age such as changes in sleeping patterns and loss of energy may lead to over-diagnosis for adults over age 64. Older adults are also more likely to have multiple medical conditions and take several medications making the diagnosis of anxiety disorder more complicated5. While we agree that USPSTF did not find strong data to suggest that screening and subsequent treatment leads to better outcomes for older adults, that lack of scientific evidence is also true for adults under 65.
1. Roy-Byrne P, Craske MG, Sullivan G, et al. Delivery of Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care: A Randomized Controlled Trial. JAMA. 2010;303(19):1921-1928. doi:10.1001/jama.2010.608
2. Semel Institute, UCLA. Benzodiazepine Addiction. Accessed October 17, 2022. https://www.semel.ucla.edu/dual-diagnosisprogram/Conditions_Treated/Benzodiazepine_Addictions
3. Fawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM. The Prevalence of Anxiety Disorders during Pregnancy and the Postpartum Period: A Multivariate Bayesian Meta-Analysis. J Clin Psychiatry. 2019;80(4):18r12527. doi:10.4088/JCP.18r12527
4. Mental Health America. Anxiety in Older Adults. Mental Health America. Accessed October 17, 2022. https://www.mhanational.org/anxiety-older-adults
5. Balsamo M, Cataldi F, Carlucci L, Fairfield B. Assessment of anxiety in older adults: a review of self-report measures. CIA. 2018;13:573-593. doi:10.2147/CIA.S114100