|
Abstract
|
Mental disorders are a leading cause of disease burden worldwide, with anxiety disorders being the second most influential contributor, after depressive disorders, to global disability-adjusted life-years.1 Anxiety disorders are characterized by anxious mood and, often, phobic avoidance, which result in extreme distress, functional impairment, or both.2,3 The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) recognizes the following types of anxiety disorders likely to be seen in adults: generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, specific phobias, substance/medication-induced anxiety disorder, and anxiety disorder due to another medical condition.4 The latter 2 instances of anxiety are caused by identifiable and, mostly, treatable sources and should be considered "rule-outs" before concluding that one of the other anxiety disorders is present.
Anxiety disorders typically have onset early in life, hence the importance of screening for anxiety in children and adolescents when there is the opportunity to promptly intervene and prevent what can often be lifelong impairment.5 There are also 2 anxiety disorders that are encountered predominantly, though perhaps not exclusively, in pediatric settings: selective mutism and separation anxiety disorder.6 The US Preventive Services Task Force (USPSTF) recently recommended screening for anxiety in children aged 7 to 18 years,7 but it is too early to know the extent to which these guidelines are being implemented and far too early to know if they have had a positive impact.
In a new Recommendation Statement8 in this issue of JAMA, the USPSTF now recommends, based on an accompanying Evidence Report,9 that all adults aged 18 to 64 years be screened for anxiety. This is a B recommendation, stemming from adequate evidence that screening tools can accurately identify anxiety in this population and moderate evidence that efficacious treatments exist. The recommendation emphasizes the need to include persons who are pregnant or postpartum, an important consideration given that anxiety disorders are more common in women than men. The USPSTF did not find sufficient evidence to make a recommendation for or against screening in older adults. Below are some of the implications of these new recommendations.
The anxiety disorders are a heterogeneous group, sharing symptoms of anxiety and avoidance but differing in the foci of the fears associated with each disorder. That there are many anxiety disorders with distinct diagnostic criteria can make it more challenging for clinicians to ask the right questions to arrive at the correct diagnosis (or, often, diagnoses) and to apply or refer for the appropriate treatment. For example, despite the moniker "generalized anxiety disorder," there is nothing particularly generalized about the disorder. Rather, generalized anxiety disorder is a very specific anxiety disorder, characterized at its core by excessive worry about multiple parameters of daily living (eg, finances, job, health).10 Conversely, one of the commonly used screening measures, the 7-Item Generalized Anxiety Disorder (GAD-7) scale (or the briefer GAD-2), is not specific for generalized anxiety disorder but rather is also sensitive to several of the other anxiety disorders.11-13 This feature of the anxiety screening instruments has the potential beneficial effect of enabling the identification of many of the anxiety disorders, not solely generalized anxiety disorder. It may also be problematic, because positive screening results may unearth symptoms stemming from a broad array of anxiety-related conditions, some of which the clinician may be relatively unfamiliar with and unprepared to addres...
Language: en |