The US Health Guidelines Panel released a draft recommendation earlier this week that US primary care physicians should routinely screen all adults under 65 for anxiety using standardized questionnaires such as the Generalized Anxiety Disorder (GAD) scale ). 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 with white patients, the draft recommendation notes. “The USPSTF concludes with moderate certainty that screening for anxiety in adults, including pregnant and postpartum women, has a modest net benefit,” the paper states. “(There is) sufficient evidence that psychological interventions to treat anxiety are associated with a modest benefit for reduced anxiety symptoms in adults, including pregnant and postpartum women.” But doctors and psychiatrists with three major mental health research institutions in Canada warn that the risks of implementing a routine anxiety screening program here likely outweigh the benefits. Dr. Eddie Lang is a member of the Canadian Preventive Health Care Task Force and chief of emergency medicine at the University of Calgary’s Cumming School of Medicine. Dr. David Gratzer is a physician and psychiatrist at the Center for Addiction and Mental Health. Dr. Keith Dobson is a principal investigator for the Mental Health Commission of Canada’s Open Minds program and an emeritus faculty professor in clinical psychology at the University of Calgary. All three told CTVNews.ca they have concerns about the evidence supporting the draft recommendation, the outcomes of patients automatically screened for anxiety and how a similar program would be delivered in Canada. Here are some of the concerns they shared.
OVERDIAGNOSIS, MISDIAGNOSIS
Lang said the Canadian Task Force on Preventive Health Care is aware of the draft recommendations of their U.S. counterparts, but is not convinced that universal screening would actually lead to better patient outcomes. “The figures that are listed in these draft recommendations are actually questionable,” he told CTVNews.ca in a phone interview Thursday. “It shows that you can detect more anxiety, but it doesn’t show that patients will be better off at the end of the day because they are identified or labeled as having an anxiety disorder.” Lang said the observational evidence supporting the recommendations only shows that screening leads to a higher diagnosis rate, but that it doesn’t measure whether patients are less likely to be hospitalized, less likely to miss work or other indicators of well-being. In order to draw these conclusions, he said, the American researchers would have to conduct a randomized study. He said the Canadian task force is also concerned that standardized testing can lead to overdiagnosis and misdiagnosis. “These proposed investigations are far from perfect. They have very high rates of false positives, as well as false negatives,” he said. “You could be labeled with a condition that would never have harmed you and you would be better off not knowing.” Dobson agrees. “The range of anxiety problems is wide, so screening can pick up a lot of people who probably don’t need care,” he told CTVNews.ca in a phone interview Wednesday. “There are a lot of people who deal with stress on a daily basis and don’t need intervention.” Finally, Lang said false positives can have significant implications for patients, especially when doctors prescribe potentially addictive drugs such as benzodiazepines or drugs with moderate or severe side effects.
INSUFFICIENT RESOURCES
Lang, Dobson and Gratzer also worry about how a mental health care system already struggling to serve patients with overt anxiety symptoms could accommodate a new influx of anxiety disorder diagnoses. “The danger with a screening program like this, potentially, is that you add burden to an already strained system and take away the opportunity to help those in real need,” Lang said. “There are already long delays in referral to mental health specialists and it is not going to improve if we start a universal screening program and send more patients, many with false positives, to psychologists who are already facing long waiting and waiting times. lists for patients who need their help.” Lang said a universal stress screening program would also add to the workload of primary care doctors in Canada, many of whom are already overworked. “We know that doctors close practices, retire, leave for other types of work. Saying now that you have to screen for stress in your patients will put more burden on family doctors,” he said. Dobson believes a routine stress screening program could be beneficial in a less fragmented health care system than Canada’s. To make it work here, he said the provinces and the federal government would have to work together to deliver the program consistently across the country. “For screening to be done well, it needs to be done nationally, it needs to be easily available and there needs to be a clear link to the right services for people who test positive,” he said. “A major issue may be that national screening may identify people who would benefit from services, but health care is delivered provincially, so finding services may remain a challenge. Also, mental health standards and services vary 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 any steps toward creating a mass stress screening program. “After all, 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 nine cents of every health care dollar on mental health funding, Gratcher 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 funding,” he said. “A lot of people fall through the cracks in our system. They should get care, they will benefit from care, and yet they can’t get the care they need.”
