Solving one problem, creating another: New anxiety recommendations

This past June in the Journal of the American Medical Association (JAMA), one of the most prestigious medical journals, the US Preventive Task Force [1] issued a recommendation that primary care physicians screen adult patients for anxiety. This recommendation applies to adults (19 years and older).

This recommendation is good news. It acknowledges the burden of anxiety. It recognizes that many people who suffer from anxiety - whose condition has not been detected or treated - can be reached in the primary care setting.

In promising fashion, the Task Force goes on to say that clinicians should be aware of the risk factors, signs, and symptoms of anxiety, listen to any patient concerns, and make sure that persons who need help get it. This is all good news.

As a public health professional whose focus is prevention, I have always admired the US Preventive Services Task Force. They make evidence-based recommendations about preventive services such as screenings, behavioral counseling, and preventive medications. As they describe their work, these recommendations are “created for primary care professionals by primary care professionals.”

How common is anxiety?

People familiar with Easing Anxiety know what the challenges of anxiety are. But how many people are we talking about?

According to large population-based surveys, up to 33.7% of the population is affected by an anxiety disorder during their lifetime. [2] Of course the COVID-19 pandemic made anxiety worse. KFF, an independent health policy research, polling, and news agency, assessed the US Census Bureau’s Household Pulse Survey, and concluded that

…many adults reported symptoms consistent with anxiety and depression, with approximately four in ten adults reporting these symptoms by early 2021, before declining to approximately three in ten adults as the pandemic continued. — U.S. Census Bureau’s Household Pulse Survey

An estimated 31.1% of U.S. adults experience any anxiety disorder at some time in their lives.[3]

A good recommendation isn’t enough

So, I’m worried about this recommendation, not because it isn’t important or necessary but because screening isn’t enough. Several important considerations:

• What do busy, overtaxed primary care clinicians do when they find that an unexpected number of their patients screened positive for anxiety?

• What tools do they use to help these newly-diagnosed patients?

• What services are available for support and treatment?

• Where do they refer these patients?

I suggest that it isn’t enough to screen for a potential issue without appropriate and available follow-up services.

We know that anxiety is common, and therefore we need primary care clinicians to screen for this issue. That is the purpose of this new recommendation. However, to make this screening recommendation effective, clinicians must be provided with the tools to adequately treat their patients. Providers may not be familiar with effective treatments for anxiety such as cognitive-behavioral therapy or mindfulness strategies. And even if they are aware of these services, there may not be enough providers to provide services soon enough for most people.

An even worse outcome

But there’s also an unintended and very troubling outcome that I see on the horizon. We don’t want primary care clinicians to wind up prescribing - what might be considered an easier solution for a large number of newly identified patients – benzodiazepines (Xanax, Ativan, Klonopin, Valium).

The challenge that primary care clinicians and we face is trying to solve an immediate, pressing need – that of an increasing number of primary care patients identified with anxiety – without the ability of health and behavioral health care to adequately respond to these needs. The worst outcome would be another generation of people needing to taper off of benzodiazepines, continuing to struggle with anxiety, and perhaps suffering with BIND (benzodiazepine induced neurological dysfunction).

FDA boxed warning highlights the dangers of benzodiazepines

Many of us know that in 2020, the US Food and Drug Administration (FDA) issued a warning about benzodiazepines:

Physical dependence can occur when benzodiazepines are taken steadily for several days to weeks, even as prescribed. Stopping them abruptly or reducing the dosage too quickly can result in withdrawal reactions, including seizures, which can be life-threatening.

It isn’t clear whether most primary care clinicians know about FDA’s warning on the potential hazards of benzodiazepines. We certainly don’t want to solve one problem – identifying anxiety among primary care patients who could benefit from support and treatment – by creating another one.

As always, we'd love to hear your thoughts and ideas about this blog post.

References

1. Screening for Anxiety Disorders in Adults. US Preventive Services Task Force Recommendation Statement, US Preventive Services Task Force JAMA. 2023;329(24):2163-2170. doi:10.1001/jama.2023.9301

2. Borwin Bandelow & Sophie Michaelis (2015) Epidemiology of anxiety disorders in the 21st century,Dialogues in Clinical Neuroscience, 17:3, 327-335, DOI: 10.31887/DCNS.2015.17.3/bbandelow

3. Harvard Medical School, 2007. National Comorbidity Survey (NCS). (2017, August 21). Retrieved from https://www.hcp.med.harvard.edu/ncs/index.php . Data Table 1: Lifetime prevalence DSM-IV/WMH-CIDI disorders by sex and cohort .