By Delvina Miremadi-Baldino, PhD, EdM, CAPP; Jonathan Adler, MD, MS, FACEP; Deryk Van Brunt, DrPH; Nick Beard, MB BS, MSc

The U.S. Preventive Services Task Force (USPSTF), a major nongovernmental agency that often guides healthcare screening practices, may finally recommend screening patients for anxiety. While this is a needed step, you can do more to help the population you serve, whether they are employees, community residents, or healthcare plan members. Many in your population are suffering, resulting in lost productivity and greater care costs. 

Screening for anxiety is long overdue, but due to the reactive mental health system in the U.S., the recommended screenings would result in care only for those with severe symptoms. You can take steps to serve the larger group of those who would benefit from self-help, early intervention, and prevention.

More people than ever are struggling with their mental health and anxiety in particular. According to the National Alliance on Mental Illness (NAMI), anxiety disorders, which cause persistent and excessive fear and worry about routine activities or events, affect more than 19 million American adults.[1] However, although anxiety is the most common mental health concern in the U.S., only one in ten people with an anxiety disorder receive the treatment they need.[2] It’s a growing mental health crisis that has been exacerbated in the last few years by many factors, including the COVID-19 pandemic, political divide, racial unrest, and even concerns over existential threats such as climate change.[3],[4]

Thankfully, the USPSTF is stepping up, and for the first time ever, issued a draft recommendation that all adults between the ages of 19 and 64 be screened for anxiety disorders by their primary caregiver. The USPSTF is an independent panel of experts who make evidence-based recommendations about preventive screenings, services, and medicines. While their advice is not mandatory, their recommendations wield a great deal of influence and often change how doctors and other caregivers approach patient care. Though it’s not yet clear which screening tool will be implemented, the USPSTF conducted a systematic review and found several questionnaires that are effective in identifying people at high risk of an anxiety disorder. 

How all of this plays out in the real world remains to be seen. The clear upside is that anxiety disorders, which are underdiagnosed in primary care with a staggering median time for initiating treatment of 23 years, can now be easily detected early through a brief screening tool.[5] Additionally, no harm was associated with screenings in their evidence review.

Any large-scale population screening intervention is fraught with consequences, both intended and unintended. In this case, it is intended that screening is implemented by a questionnaire. Several were evaluated, and the best evidence was found for the GAD-2 and GAD-7, both of which assess for general anxiety disorder (GAD). It is implied that patients whose scores suggest severe symptoms be considered for treatment. The USPSTF evaluated treatments as well, finding good evidence for “psychological interventions” and pharmacotherapy in primary care patients. For psychological interventions, they note that the most data exists for cognitive behavioral therapy (CBT). For medications, they note that venlafaxine or escitalopram showed beneficial outcomes. 

The recommendation has some limitations:

• Our greatest concern is that only patients scoring in the “severe” range of symptoms, those with an active anxiety disorder, will be offered care. There is no clear path for intervention for all but those with the most severe anxiety score. 
• GAD-2 and GAD-7 assess only for general anxiety disorder. Screenings may miss those with social anxiety disorder or other more specific syndromes.
• The recommendation does not include adolescents. The systematic review commissioned by the USPSTF was limited to asymptomatic adults. The National Institute for Mental Health estimates that 32% of adolescents experience clinical anxiety between ages 13 and 18 and that 8.2% have “severe impairment.”[6]
• It does not address the challenge that the reactive mental health system in the U.S. is already overburdened and understaffed, making it difficult for patients who need resource-intensive intervention (CBT and/or medication) to obtain the medically indicated care. According to a 2016 Health Affairs report, more than half of U.S. counties have no psychiatrists, and almost all counties (96%) have a shortfall of prescribers. The projected shortfall of mental health providers is expected to reach 250,000 by 2025. 

We fully support the USPSTF draft recommendation to screen adults for anxiety disorder. This is a long-overdue triage for early detection and intervention. If it’s widely adopted, many people with severe symptoms may receive care many years earlier. While this is an excellent first step toward population mental health, it doesn’t go far enough. Screening should be for more mental health concerns than just general anxiety disorder. 

For example, Monterey County, CA, has collaborated with the State of California and CredibleMind to create WellScreen Monterey, an internet-based mental health assessment covering eight mental health areas (anxiety, depression, postpartum depression, PTSD, eating disorders, bipolar disease, psychosis, and substance misuse). The tool uses validated scales, and the assessment is available to anyone with internet access. This has changed the traditional paradigm of residents needing to visit county offices and deal with paperwork to find out if they are eligible for services. Instead, residents sitting in their living rooms can quickly assess on the phone what their risk levels are and find out if they are eligible and where to go for help. The tool has added more than 500 new screenings by Monterey County Behavioral Health in the first month of operation.

• Screening as recommended squanders an opportunity for early identification and intervention for anxiety among the majority of symptomatic patients who have mild to moderate anxiety. A true population mental health approach would include identification and intervention for those with symptoms who are at risk of developing an anxiety disorder and those with active symptoms that are not yet so severe that immediate treatment with medication or counseling is indicated. Specifically, for the GAD-7 screening tool, a patient with quite significant symptoms could score in the “mild” or “moderate” range and receive no intervention. CredibleMind has spent the past several years developing a platform that matches the level of intervention that is indicated for a person’s screening result—and links the patient to appropriate resources. We strenuously suggest that such patients in the “mild” to “moderate” range should be offered evidence-based self-help resources as an intervention to prevent progression to a clinical syndrome requiring intensive resources.

Stated frankly, directing only patients with severe symptoms to counseling and/or dispensing medications isn’t a good strategy when there aren’t enough qualified providers and when other evidence-based interventions exist for those with less severe symptoms. Instead, there is a tremendous opportunity to provide self-management approaches to the majority of symptomatic patients who have mild to moderate anxiety. This is where preventive approaches should come into play in mental health. An equivalent in population medicine would be identifying patients with pre-diabetes but offering no education or intervention until they progress to becoming full Type II diabetics.

While this recommendation will identify more people with an anxiety disorder, the task force members recognize that there are still many challenges in proper diagnosis and treatment. There are long wait times to access mental health care and significant gaps in availability that don’t fully address the social determinants of mental health. We echo the perspective of the task force that initiating anxiety screening is necessary but not sufficient. Task force members are hopeful that these screening recommendations will not only increase early detection but also highlight treatment gaps and elevate awareness and the need for action. 

Significant changes are needed in systems and policies to address this mental health crisis. Not only is there a need for early disease recognition and treatment for those with a severe anxiety disorder but also an opportunity to identify the larger number of patients with mild or moderate symptoms across many mental health conditions for whom early intervention with evidence-based resources can prevent progression of symptoms and move them from their current state to thriving.

You can provide a platform with broad screening and provide evidence-based resources to your population, improving their mental health and productivity and lowering the costs of expensive reactive care.

• Dr. Adler, Dr. Van Brunt, and Dr. Beard are affiliated with CredibleMind, Inc.
• Dr. Miremadi-Baldino is the Resilience Strategy and Impact Director at Maine Resilience Building Network.
• Dr. Adler is Clinical Assistant Professor at Tufts University School of Medicine and Chief Medical Officer at CredibleMind, Inc.
• Dr. Van Brunt is a Clinical Professor at the University of California, Berkeley School of Public Health and founder of CredibleMind, Inc.
• Dr. Beard is a Non-Executive Director at the National Centre for Atmospheric Science, University of Leeds England, and serves on CredibleMind’s advisory board.

CredibleMind provides an evidence-based platform to health plans, employers, hospitals, health departments, and others for the early intervention and prevention of mental health. This evidence-based mental wellbeing information system covers all mental health topics where users can identify and learn what they can do to improve their mental health.

Discover how CredibleMind can supercharge your mental health strategy!

• For healthcare employers/organizations and public health departments  schedule a demo or contact Scott Dahl, scott@crediblemind.com
• For non-healthcare employers schedule a demo or contact Kathy Carlton, kathy@crediblemind.com or Ginny Sedberry, ginny@crediblemind.com

[1] (n.d.). Anxiety Disorders. National Alliance on Mental Illness. Retrieved November 23, 2022 from www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Anxiety-Disorders

[2] Alonso, J., Liu, Z., Evans-Lacko, S., Sadikova, E., Sampson, N., Chatterji, S., Abdulmalik, J., Aguilar-Gaxiola, S., Al-Hamzawi, A., Andrade, L. H., Bruffaerts, R., Cardoso, G., Cia, A., Florescu, S., de Girolamo, G., Gureje, O., Haro, J. M., He, Y., de Jonge, P., … the WHO World Mental Health Survey Collaborators. (2018). Treatment gap for anxiety disorders is global: Results of the World Mental Health Surveys in 21 countries. Depression and Anxiety, 35(3), 195–208. https://doi.org/10.1002/da.22711

[3] Reuben, A., Manczak, E. M., Cabrera, L. Y., Alegria, M., Bucher, M. L., Freeman, E. C., Miller, G. W., Solomon, G. M., & Perry, M. J. (2022). The interplay of environmental exposures and mental health: Setting an agenda. Environmental Health Perspectives, 130(2), 025001. https://doi.org/10.1289/EHP9889

[4] Schwartz, S. E. O., Benoit, L., Clayton, S., Parnes, M. F., Swenson, L., & Lowe, S. R. (2022). Climate change anxiety and mental health: Environmental activism as buffer. Current Psychology. https://doi.org/10.1007/s12144-022-02735-6

[5] Wang, P. S., Angermeyer, M., Borges, G., Bruffaerts, R., Tat Chiu, W., DE Girolamo, G., Fayyad, J., Gureje, O., Haro, J. M., Huang, Y., Kessler, R. C., Kovess, V., Levinson, D., Nakane, Y., Oakley Brown, M. A., Ormel, J. H., Posada-Villa, J., Aguilar-Gaxiola, S., Alonso, J., … Ustün, T. B. (2007). Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 6(3), 177–185.

[6] (n.d.). Any Anxiety Disorder. National Institute of Mental Health. Retrieved December 9, 2022 from https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder

[7] (2020, January 23). National Coalition on Mental Health and Aging Webinar Series – Solutions to Behavioral Health Workforce Shortages and Lack of Funding. National Council on Aging. Retrieved January 23, 2023 from https://www.ncoa.org/article/national-coalition-on-mental-health-and-aging-webinar-series-solutions-to-behavioral-health-workforce-shortages-and-lack-of-funding