Anxiety Disorders ____________________________________________________________________________
SCREENING FOR ANXIETY DISORDERS IN THE PRIMARY CARE SETTING Lifetime prevalence of anxiety in the general population is estimated 30%, and anxiety disorders are among the most common mental health syndromes encountered in general medical practice. In a study of 965 randomly selected patients across 15 primary care clinics, 19.5% had at least one anxiety disorder; of the four common disorders assessed in the study, 8.6% of patients had PTSD, 7.6% had GAD, 6.8% panic dis- order, and 6.2% had SAD [55]. Each disorder was associated with functional impairment that became more substantial as the number of co-occurring anxiety disorders increased. The GAD-7 diagnostic scale was seen to perform well as screening tool for all four anxiety disorders studied [55]. Other studies in primary care settings have found that the prevalence of co- occurring GAD is 68% for patients with panic disorder and 38.6% for those with a diagnosis of major depression [34; 122]. The American Academy of Family Physicians and other physi- cian groups have noted that rates of failed diagnosis of anxiety disorder and misdiagnosis of GAD and panic disorder are high in primary care settings, in part because of time constraints, lack of a defining presentation, and the resemblance of symp- toms to common somatic disorders [54; 55; 121]. Primary care clinicians have noted that patients with somatic complaints, sleep disturbance, or psychosocial distress are often unaware that anxiety disorder is the root cause of their symptoms. A study of older patients with GAD found that accurate referenc- ing of symptoms to the onset of anxiety was low (34%), as was the rate of anxiety disorder diagnosis (9%), despite a high level of healthcare utilization [123]. In the current managed care environment, anxiety is usually treated in primary care settings, and given the increasing time constraints imposed on primary care providers, it is not surprising that anxiety disorders are under-recognized and undertreated [70]. Many patients with anxiety and depressive symptoms do not seek help, and in those who do, anxiety symptoms are often not the presenting complaint. Patients and providers often have difficulty initiating discussion of emotional problems and distress. Primary care providers with greater sensitivity to nonverbal communications have been found more likely to detect and diagnose anxiety, while those tending to “blame” patients make fewer psychologic inquiries and are less accurate in detecting distress [3; 124]. SCREENING TOOLS The American Academy of Family Physicians suggests using diagnostic screening and monitoring scales, such as the Gener- alized Anxiety Disorder 7-Item Scale (GAD-7) and the Severity Measure for Panic Disorder, to aide in diagnosis and monitor response to treatment [121]. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was originally developed as a physician-administered screening tool for identifying mental disorders. It contained 12 different mental health disorder
modules and required lengthy administration time, limiting its clinical usefulness [133]. Developers of the PRIME-MD subse- quently crafted a self-administered version of the PRIME-MD, the Patient Health Questionnaire (PHQ). The PHQ includes mood, anxiety, alcohol, eating, and somatoform modules as covered in the original PRIME-MD [134]. In addition to its value in identifying anxiety and mood disorders, including depressive symptoms, panic disorder and other anxiety dis- orders, the PRIME-MD-PHQ is efficient for use in primary care settings; most clinicians can analyze the results in three minutes or less [134]. The GAD-7 scale is a brief, validated screening tool specifi- cally designed to identify anxiety disorders. The patient with symptoms is asked to rate severity and frequency of occurrence over the previous two weeks. Each item is rated on a four-point scale (0 to 3), yielding a maximum score of 21. A score of 10 or greater is the cut-off point for diagnosis of anxiety disorder (sensitivity 87%; specificity 82%) [135]. The degree of distress/ functional impairment varies directly with the total score. The GAD-7 scale is available online at https://adaa.org/sites/ default/files/GAD-7_Anxiety-updated_0.pdf. In theory, patients and providers should benefit from screening tools designed to detect anxiety disorders. However, regular use may require adjustments to practice structure, and it is uncertain to what extent routine screening (of all patients) and disclosure to “screened positive” patients improves clini- cal outcomes. In 2022, the U.S. Preventive Services Task Force recommended screening all children older than 7 years of age for anxiety [349]. Primary care providers can improve anxiety detection skills by first acknowledging patients may be reluctant to discuss psychological and emotional distress early in the physician- patient relationship. This can be offset with greater sensitivity to nonverbal expression of distress and by allowing repeated patient encounters and deepening understanding to develop the rapport required for exploring the presence and depth of anxiety symptoms [3]. Healthcare providers can create a more comfortable environ- ment for a patient of another culture by acknowledging the impact of culture and cultural differences on physical and mental health. The nature and expression of symptoms are influenced by cultural factors, and in some cultures anxiety is expressed through a heavy focus on somatic symptoms, such as musculoskeletal pain and fatigue. Providers may consider starting the clinical encounter by exploring such symptoms patiently and in greater depth. The concept of anxiety also varies across cultures, and patients may not seek medical treatment unless symptoms manifest as psychosis, conversion disorders, or significant physical ailments.
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