Contrary to new recommendations from the US Preventive Services Task Force, health professionals in Canada are warning against routine anxiety testing for adults.
The American health guidelines panel released a draft recommendation earlier this week that said US primary care physicians should regularly screen all adults under the age of 65 for anxiety using standardized questionnaires such as the of generalized anxiety disorder (GAD).
The panel argues that anxiety disorders are highly prevalent in the US (occurring in 26.4 percent of men and 40.4 percent of women), but often go unrecognized in primary care settings, leading to years of delays in treatment. Misdiagnosis rates are higher among black and Hispanic/Latino patients compared to white patients, the draft recommendation states.
“The USPSTF concludes with moderate certainty that screening for anxiety in adults, including pregnant and postpartum individuals, has a modest net benefit,” the paper reads. “(There is) adequate evidence that psychological interventions to treat anxiety are associated with a moderate magnitude of benefit for reducing anxiety symptoms in adults, including pregnant and postpartum people.”
However, doctors and psychiatrists from three major mental health research institutions in Canada warn that the risks of implementing a routine anxiety screening program here are likely to outweigh the benefits.
Dr. Eddy Lang is a member of the Canadian Task Force on Preventive Health Care and head of the department of emergency medicine at the University of Calgary Cumming School of Medicine.
Dr. David Gratzer is a physician and assistant psychiatrist at the Center for Addiction and Mental Health.
Dr. Keith Dobson is Principal Investigator of the Canadian Mental Health Commission’s Opening Minds program and Emeritus Professor of Clinical Psychology at the University of Calgary.
All three told CTVNews.ca they are concerned about the evidence supporting the draft recommendation, the outcomes of patients automatically screened for anxiety, and how a similar program would be implemented in Canada.
These are some of the concerns they shared.
Lang said the Canadian Task Force on Preventive Health Care is aware of the preliminary recommendations from their US counterparts, but they are not convinced that universal screening actually leads to better patient outcomes.
“The evidence cited in these draft recommendations is actually questionable,” he told CTVNews.ca in a telephone interview Thursday. “It shows that more anxiety can be detected, but it doesn’t show that patients will be better off at the end of the day because they identify or label themselves as having an anxiety disorder.”
Lang said the observational evidence supporting the recommendations only shows that screening leads to a higher rate of diagnosis, but does not measure whether patients are less likely to be hospitalized, less likely to miss work or other indicators of well-being. To draw those conclusions, she said, US researchers would have to conduct a randomized study.
He said the Canadian task force is also concerned that standardized screening could lead to overdiagnosis and misdiagnosis.
“These proposed surveys are far from perfect. They have very high rates of false positives and false negatives as well,” she said. “You could be tagged with a condition that would never have harmed you and that you’d be better off not knowing about.”
“The range of anxiety issues is wide, so screening can identify a lot of people who probably don’t need care,” he told CTVNews.ca in a phone interview on Wednesday. “There are many people who deal with anxiety on a daily basis and don’t need intervention.”
Finally, Lang said that false positives can have important implications for patients, especially when doctors prescribe potentially addictive drugs like benzodiazepines or medications with moderate or severe side effects.
Lang, Dobson and Gratzer are also concerned about how a mental health care system already struggling to care for patients with overt anxiety symptoms might adapt to a new influx of anxiety disorder diagnoses.
“The danger with a screening program like this, potentially, is that you’re adding a burden to an already overloaded system and taking away the opportunity to help those who really need it,” Lang said.
“There are already long delays in being referred to mental health specialists and it’s not going to get any better if we start a universal screening program and send more patients, many with false positives, to psychologists who are already dealing with long wait times and waiting lists. of patients who need your help.”
Lang said a universal anxiety screening program would also add to the workload of primary care doctors in Canada, many of whom are already overburdened.
“We know that doctors are closing practices, retiring, and leaving for other types of work. Saying now that you have to assess anxiety in your patients is only going to add more workload to GPs,” she said.
Dobson believes that a routine anxiety screening program could be beneficial in a health system that is less fragmented than Canada’s. For it to work here, he said the provinces and the federal government would have to cooperate to implement the program consistently across the country.
“For screening to be done well, it needs to be done nationally, it needs to be readily available, and there needs to be a clear link to appropriate services for people who test positive,” he said.
“A major problem may be that the national assessment can identify people who would benefit from services, but health care is provided at the provincial level, so finding services can still be a challenge. Also, mental health standards and services are variable in this country, unfortunately.”
Gratzer agrees that the federal and provincial governments need to address these gaps in mental health care before they can take steps to create a massive anxiety screening program.
“Ultimately, we don’t necessarily need screening. We need better care,” he told CTVNews.ca in a phone interview Thursday. “If we had really well-funded point-of-use cognitive behavioral therapy in Canada, like they do in the UK, it would be different.”
Canada spends about 9 cents of every health care dollar on funding mental health care, Gratzer said, compared to 15 cents of every health care dollar in the United Kingdom.
“We need to think about health care funding and mental health care funding,” he said.
“Many people are falling through the cracks in our system. They should get care, they would benefit from care, and yet they can’t get the care they need.”
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