Anxiety is commonly seen in primary care and associated with substantial burden.
To review the benefits and harms of screening and treatment for anxiety and the accuracy of instruments to detect anxiety among primary care patients.
MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022.
English-language original studies and systematic reviews of screening or treatment compared with control conditions and test accuracy studies of a priori–selected screening instruments were included. Two investigators independently reviewed abstracts and full-text articles for inclusion. Two investigators independently rated study quality.
Data Extraction and Synthesis
One investigator abstracted data; a second checked accuracy. Meta-analysis results were included from existing systematic reviews where available; meta-analyses were conducted on original research when evidence was sufficient.
Main Outcomes and Measures
Anxiety and depression outcomes; global quality of life and functioning; sensitivity and specificity of screening tools.
Of the 59 publications included, 40 were original studies (N = 275 489) and 19 were systematic reviews (including ≈483 studies [N≈81 507]). Two screening studies found no benefit for screening for anxiety. Among test accuracy studies, only the Generalized Anxiety Disorder (GAD) GAD-2 and GAD-7 screening instruments were evaluated by more than 1 study. Both screening instruments had adequate accuracy for detecting generalized anxiety disorder (eg, across 3 studies the GAD-7 at a cutoff of 10 had a pooled sensitivity of 0.79 [95% CI, 0.69 to 0.94] and specificity of 0.89 [95% CI, 0.83 to 0.94]). Evidence was limited for other instruments and other anxiety disorders. A large body of evidence supported the benefit of treatment for anxiety. For example, psychological interventions were associated with a small pooled standardized mean difference of −0.41 in anxiety symptom severity in primary care patients with anxiety (95% CI, −0.58 to −0.23]; 10 RCTs [n = 2075]; I2 = 40.2%); larger effects were found in general adult populations.
Conclusions and Relevance
Evidence was insufficient to draw conclusions about the benefits or harms of anxiety screening programs. However, clear evidence exists that treatment for anxiety is beneficial, and more limited evidence indicates that some anxiety screening instruments have acceptable accuracy to detect generalized anxiety disorder.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Elizabeth A. O’Connor, PhD, Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227 (firstname.lastname@example.org).
Accepted for Publication: May 1, 2023.
Published Online: June 20, 2023. doi:10.1001/jama.2023.6369
Author Contributions: Dr O’Connor had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: O’Connor, Henninger, Perdue, Coppola, Gaynes.
Drafting of the manuscript: O’Connor, Henninger, Coppola.
Critical revision of the manuscript for important intellectual content: Henninger, Perdue, Thomas, Gaynes.
Statistical analysis: O’Connor, Perdue, Gaynes.
Obtained funding: O’Connor, Gaynes.
Administrative, technical, or material support: Henninger, Perdue, Coppola, Thomas, Gaynes.
Conflict of Interest Disclosures: None reported.
Funding/Support: This research was funded under contract HHSA290201500011I, Task Order 75Q80119F32015, and contract 75Q80120D00004, Task Order 75Q80122F32005, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services.
Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.
Additional Contributions: We gratefully acknowledge the following individuals for their contributions to this project: Iris Mabry-Hernandez, MD, MPH, and Tina Fan, MD, MPH (AHRQ); current and former members of the US Preventive Services Task Force who contributed to topic deliberations; and Melinda Davies, MAIS, and Jill Pope, BA (Kaiser Permanente Center for Health Research) for technical and editorial assistance.
Additional information: A draft version of this evidence report underwent external peer review in October 2021 from 5 content experts (Ramin Mojtabai, MD, PhD, MPH, Pim Cuijpers, PhD, Tiffany A. Moore Simas, MD, MPH, Raquel Halfond, PhD, Bobbi Jo Yarborough, PsyD) and 3 federal partners (National Institutes of Health Office of Research on Women’s Health: Rebecca DelCarmen-Wiggins, PhD, Regine Douthard, MD, MPH, Shilpa H. Amin, MD, MJ, CAQ, Damiya E. Whitaker, PsyD, MA, Elena Gorodetsky, MD, PhD; Eunice Kennedy Shriver National Institute of Child Health and Human Development: Jackie Wallace, MD, MPH; Centers for Disease Control and Prevention: Erin M. Abramsohn, DrPH, MPH). Comments were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review.
Editorial Disclaimer: This evidence report is presented as a document in support of the accompanying USPSTF Recommendation Statement. It did not undergo additional peer review after submission to JAMA.
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