Monday, July 6, 2020

Should we screen all adolescent and adult women for anxiety?

- Jennifer Middleton, MD, MPH

At first glance, the question mark in that title might seem misplaced. Anxiety is prevalent among both women and men, and the current stress of the global COVID-19 pandemic is exacerbating those symptoms for many. A new recommendation statement making the lay press rounds urges us to screen all adolescent and adult women for anxiety, but the evidence behind that recommendation merits further examination.

The Women's Preventive Services Initiative (WPSI) is a "national coalition of women's health professional organizations and patient representatives" led by the American College of Obstetricians and Gynecologists (ACOG) which includes the AAFP and the American College of Physicians (ACP). The WPSI's "Screening for Anxiety in Adolescent and Adult Women" recommendation statement, published last month, describes the prevalence and scope of anxiety disorders in women and also reviews available treatment methods in detail. Its recommendation to adopt universal screening is based on a systematic review, published alongside the recommendation statement, which sought to "evaluate evidence on the effectiveness of screening for anxiety disorders in primary care in improving symptoms, function, and quality of life; harms of screening; accuracy of screening instruments; and effectiveness and harms of treatments." The systematic review's abstract transparently states that "[n]o studies evaluated the overall effectiveness or harms of screening;" it did identify valid screening instruments and confirm the treatment benefits of both cognitive behavioral therapy and anti-anxiety medications.

The WPSI is citing this systematic review, which found that "[e]vidence on the overall effectiveness and harms of screening for anxiety is insufficient," to justify its universal screening recommendation. While most physicians and patients would agree that patients with generalized anxiety disorder deserve recognition and treatment, screening initiatives that fail to justify the costs of doing so relative to their benefits, as well as fail to adequately consider potential harms, may not result in the health gains they promise. The WPSI's website states that "participation in the WPSI does not constitute organizational endorsement of the recommendations,"and it remains to be seen whether the AAFP and/or ACP will endorse this guideline.

In the meantime, you can find resources for diagnosing and treating anxiety disorders in the AFP By Topic on Anxiety Disorders.