A collaborative of health organizations led by the American College of Gynecology is calling for routine anxiety screening for teen girls and adult women, despite insufficient evidence on the overall effectiveness and potential harms of screening and treatment.
In a directive released Monday afternoon, the Women’s Preventive Services Initiative (WPSI) recommended screening for anxiety in women and adolescent girls age 13 years and older who have not been previously diagnosed with anxiety disorders, including pregnant and postpartum women.
The WPSI writing group did not make a recommendation on optimal screening intervals, noting that they are unknown. And the recommendations call for clinicians to rely on their own judgment to determine screening frequency for individual patients.
“Although routine screening for depression is currently a standard of care in clinical practice, no (previous) recommendation for anxiety screening has been issued by guideline groups,” wrote Heidi D Nelson, MD, of Oregon Health & Sciences University, and colleagues in the Annals of Internal Medicine.
“The WPSI recommendation fills a long-standing gap in screening for women. Standardized screening for anxiety in routine clinical practice, particularly as part of a preventive health care visit in combination with depression screening, could identify adolescent and adult women with anxiety and initiate diagnostic evaluation and treatment.”
In a systematic review of anxiety screening in adolescent and adult women conducted for the WPSI, which was also published Monday in Annals, researchers concluded that “evidence on the overall effectiveness and harms of screening for anxiety is insufficient.”
The researchers noted that the prevalence of anxiety disorders is higher among women than among men, with roughly 40% of women experiencing anxiety disorder during their lifetimes and 23% experiencing them during the past year.
While the strength of the evidence for the accuracy of screening methods for identifying anxiety was high, the reviewers found no studies that evaluated the overall effectiveness or harms of screening for anxiety in adolescent girls and adult women.
The strength of the evidence for the effectiveness of treatment strategies for anxiety ranged from moderate to high. The strength of the evidence evaluating harms of treatment was low for cognitive behavioral therapy (CBT) and moderate for drug treatments.
The reviewers concluded that the studies support “a strong evidence base of moderate to highly accurate instruments for screening for anxiety that are applicable to clinical practices serving adolescent girls and adult women, including those who are pregnant or postpartum.”
The studies included in the review were published between 1996 and late 2019, and all included adolescent girls and/or adult women.
The review of 27 anxiety screening instruments, which included 33 studies and 2 systematic reviews, revealed that most of the instruments demonstrated moderate to high accuracy:
- Adults (Generalized Anxiety Disorder scale: sensitivity, 70% to 97%; specificity, 50% to 89%).
- Pregnant and postpartum women (Edinburgh Postnatal Depression Scale: sensitivity, 74%; specificity, 64%).
- Adolescents (Screen for Child Anxiety Related Emotional Disorders: sensitivity, 64% to 74%; specificity, 64% to 73%).
Anxiety symptoms improved with cognitive behavioral therapy (246 randomized controlled trials; 17,209 participants) and anti-anxiety medications (126 randomized controlled trials; 8,225 participants).
“Although trials of the overall effectiveness of screening for anxiety disorders are lacking, studies of the accuracy of screening methods and effectiveness and harms of treatment provide evidence supporting essential steps in the clinical pathway,” the reviewers wrote.
In an editorial published with the review and recommendations, Kim Smolderen, PhD, and Matthew Burg, PhD, of Yale University School of Medicine, New Haven, Connecticut, wrote that important questions need to be answered to successfully implement the newly proposed anxiety screening recommendations, including “Which of the 27 instruments that the WPSI reviewed should clinicians use for screening?”, “What threshold scores should indicate need for further evaluation?”, and “How frequently should screening be conducted?”
“Many of the candidate instruments reviewed showed moderate to high accuracy in detecting anxiety disorders and could be considered for implementation of the advisory, but clearer directives for how to approach screening would promote uptake of the guidelines in real-world clinical settings,” they wrote. “We encourage WPSI to include more specific, evidence-based implementation strategies in future guidance.”
The review authors and editorial writers’ expressed concerns about the lack of data on potential harms associated with screening for anxiety or the long-term side effects of drug treatments, especially in women who are pregnant or have recently given birth.
“Risks for abuse and addiction associated with short-acting benzodiazepines are real,” they wrote, adding that SSRIs and SNRIs, which are commonly prescribed for anxiety, can also have significant side effects.
Smolderen and Burg noted that disparities in access to care “further complicate this issue and disproportionately affect women; racial, ethnic, and sexual minorities; and people living in rural areas.”
“Implementation of mental health screening is more likely to be effective within a collaborative care context, in which well-organized paths are in place to care for those identified with a condition,” they wrote, adding that without this collaborative care “it is not apparent that the act of screening in itself would provide benefit.”
The Women’s Preventive Services Initiative (WPSI) recommended screening for anxiety in women and adolescent girls age 13 years and older who have not been previously diagnosed with anxiety disorders, including pregnant and postpartum women.
A systematic review of anxiety screening in adolescent and adult women conducted for the WPSI found that the evidence for the overall effectiveness and the harms of screening for anxiety is insufficient.
Salynn Boyles, Contributing Writer, BreakingMED™
The systematic review was funded by the Health Resources and Services Administration of the U.S. Department of Health and Human Services.
WPSI member and corresponding author Heidi Nelson, MD, reported receiving grant support from the U.S. Health Resources and Services Administration and ACOG.
Editorial writer Kim Smolderen, PhD, reported receiving grants from Terumo, grants from PCORI, other from Optum Labs, unrelated to this research. Editorial writer Matthew Burg, PhD, declared no relevant disclosures.
Cat ID: 925
Topic ID: 915,925,730,191,138,192,52,925