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Contrary to new recommendations by the U.S. Preventive Services Task Force, health-care 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 U.S. primary care doctors should regularly screen all adults under 65 for anxiety using standardized questionnaires like the generalized anxiety disorder (GAD) scale.
The panel argues that anxiety disorders are highly prevalent in the U.S. – occurring in 26.4 per cent of men and 40.4 per cent of women – but that they are often unrecognized in primary care settings, leading to years-long 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 persons, has a moderate net benefit,” the document reads. “(There is) adequate evidence that psychological interventions to treat anxiety are associated with a moderate magnitude of benefit for reduced anxiety symptoms in adults, including pregnant and postpartum persons.”
However, doctors and psychiatrists with three major mental health research institutions in Canada warn the risks of implementing a routine anxiety screening program here would likely outweigh the benefits.
Dr. Eddy Lang is a member of the Canadian Task Force on Preventive Health Care and department head for emergency medicine at the University of Calgary’s Cumming School of Medicine.
Dr. David Gratzer is a medical doctor and attending psychiatrist at the Centre for Addiction and Mental Health.
Dr. Keith Dobson is a principal investigator for the Mental Health Commission of Canada’s Opening Minds program and faculty professor emeritus in clinical psychology at the University of Calgary.
All three told CTVNews.ca they have concerns around 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 by their U.S. counterparts, but are unconvinced universal screening would actually lead to better outcomes for patients.
“The evidence cited in these draft recommendations is actually questionable,” he told CTVNews.ca in a phone interview on Thursday. “It shows you can detect more anxiety but it doesn’t show patients will be better off at the end of the day because they are identified or labelled as a person with an anxiety disorder.”
Lang said the observational evidence supporting the recommendations only demonstrates that screening leads to a higher rate of diagnosis, but that it doesn’t measure whether patients are less likely to be hospitalized, less likely to miss work, or other indicators of wellbeing. In order to draw those conclusions, he said, the U.S. researchers would have to conduct a randomized study.
He said the Canadian task force is also concerned standardized screening could lead to overdiagnosis and misdiagnosis.
“These surveys that are being proposed, they’re far from perfect. They have very high false positive rates, and false negatives, too,” he said. “You could be labelled with a condition that would not ever have harmed you and that you would be better off not knowing about.”
Dobson agrees.
“The range of anxiety problems is large, so screening may identify many people who probably don’t need care,” he told CTVNews.ca in a phone interview on Wednesday. “There are a lot of people who deal with anxiety on a day-to-day basis and don’t need intervention.”
Finally, Lang said false positives can have major implications for patients, especially when doctors prescribe potentially addictive medications like Benzodiazepines, or medications with moderate or severe side effects.
INADEQUATE RESOURCES
Lang, Dobson and Gratzer also worry about how a mental health-care system that already struggles to serve patients with obvious anxiety symptoms could accommodate a new influx of anxiety disorder diagnoses.
“The danger with a screening program like this, potentially, is that you’re adding burden to an already strained system and taking away the opportunity to help those who are in true need,” Lang said.
“There are already prolonged delays to getting referred to mental health specialists and it’s not going to get better if we start a universal screening program and send more patients, many with false positives, over to psychologists who are already dealing with prolonged wait times and waiting lists for patients who need their help.”
Lang said a universal anxiety screening program would also add to the workload of primary care physicians in Canada, many of whom are already overburdened.
“We know physicians are closing offices, pulling back, leaving for other kinds of work. To now say you have to screen for anxiety in your patients is only going to put more work load onto family physicians,” he said.
Dobson thinks a routine anxiety screening program could be beneficial in a less-fragmented health-care system than Canada’s. For it to work here, he said the provinces and federal government would need to co-operate to deliver the program consistently across the country.
“For screening to be done well, it needs to be done nationally, it needs to be available easily, and there needs to be a clear linkage to appropriate services for people who screen positive,” he said.
“A significant issue may be that national screening might identify people who would benefit from services, but health care is delivered provincially, so finding services might remain a challenge. Also, the standards and mental health services are variable across 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 anxiety screening program.
“Ultimately, we don’t necessarily need screening. We need better care,” he told CTVNews.ca in a phone interview on Thursday. “If we had really well-funded cognitive behavioural therapy at point-of-use in Canada, the way they do in the United Kingdom, it would be different.”
Canada spends approximately nine cents of every health-care dollar on mental health-care funding, 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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