When you go to the doctor for an annual visit, you know they’ll check vital signs, like your blood pressure. An American health task force now recommends doctors add another step to routine check-ups for adults - anxiety screenings.
The U.S. Preventative Services Task Force says adults between the ages of 18 and 64 should be asked about anxiety. Millions of American adults will deal with it at some point in their lives.
Dr. Sarah Mallard Wakefield is the chair of psychiatry at the Texas Tech University Health Sciences Center School of Medicine. Our News Director Sarah Self-Walbrick recently talked with her about mental health.
This interview has been lightly edited for conciseness and clarity.
Sarah Self-Walbrick: Dr. Wakefield, first, what’s your reaction to this new anxiety screening recommendation?
Dr. Sarah Mallard Wakefield: I'm really excited that there is a new, official recommendation. But we've known for a very long time that anxiety affects many, many Americans and that it is a predominant and often unclear, not recognized symptom for many individuals presenting with stomach upset or other kinds of symptoms in the primary health care setting.
SSW: Tell us more about common anxiety disorders. How do these develop?
SMW: There are many different ones. I think that's why we think about anxiety as a very common symptom, because a lot of things are lumped in together when we say anxiety.
So one of the most common that we see is called generalized anxiety disorder. This is kind of what we think of as the “what if?” diagnosis. So what if this happens? What if I can't find a parking space? What if there's a tornado? So a lot of “what ifs” about a lot of different things. Also lumped into anxiety disorders are things like separation anxiety, or social phobias, or other kinds of phobias.
How do these develop? Well, like most illnesses they develop in a multifactorial way. A genetic predisposition is often part of what we see. Mom or dad had anxiety, or someone in the family also has this kind of predisposition to developing anxiety symptoms, and then something triggers it. That can be different for different people or different intensities. What we look at is a bio-psychosocial model. What's that biology? What's the social context? What are those psychological coping mechanisms that someone has or has been taught or has been modeled for them over their lives to help them deal with these symptoms? So really looking at a global perspective of someone's system and context and current symptoms.
SSW: What are some signs to consider?
SMW: If you start to see functionally impairing behaviors due to that anxiety, that is when we start to say that's developing into an illness or could be developing into that illness. It's about what kind of behavior is triggered by the anxiety. Do you start to isolate? Do you pull away from those social contexts or people who could be supportive of you? Or do you say, “oh, goodness, I'm feeling anxious, I need to go towards a social construct to help me feel more okay in this situation.” So I look at the behaviors that that anxiety causes, not so much the anxiety itself, because anxiety is a part of our normal function. Having some worry is protective.
SSW: Are there particular groups who are at a higher risk for anxiety?
SMW: Well, we think so. The baseline answer is yes. When we look at gender groups, more women have a diagnosis of anxiety, up to 40% of a lifetime prevalence of an anxiety disorder in women. But it's hard to know because sometimes that's because it's more okay in society for women to talk about their anxiety and to say these things. When we look at kiddos who have had past traumatic experiences or in utero drug exposures, those kinds of things, are much more likely to develop an anxiety disorder diagnosis down the road.
SSW: This new screening suggestion is specifically for adults younger than 65. Does age have much to do with anxiety?
SMW: Actually, as you get older, anxiety tends to get better kind of no matter what. That 65 year and up age range, the rates of anxiety were low enough and they felt that cohort may feel kind of OK enough saying if they're having anxiety, that screening, mass screening everybody no matter what the evidence, wasn't really there to support that in that age group. It really is anyone 64 and under should be screened as a rule. Not when they present for an anxiety complaint, not when they say I'm feeling nervous or I'm having trouble sleeping. But everyone in that group, that's the recommendation, should be screened as a rule during well visits, or when they present for other things that could be anxiety-related, like stomach upset, or heart palpitations, or these other things that we see as often comorbid are coexisting.
SSW: What’s the process for an anxiety screening?
SMW: At most, you're answering seven questions and they are pretty brief. They're not long-form essay questions. It shouldn't take much time. You can do this in the waiting room, while you're waiting on your appointment, you could do it in the clinic room while you're waiting on your clinician to come. The screeners are designed to be very brief, so that they're not disrupting the flow of clinic or causing you to be there longer. But they are increasing the understanding of where your symptoms might be originating.
SSW: If a doctor does determine that you have anxiety, what happens next? What are some treatment options?
SMW: First, we have a conversation. We say, “Hey, this is what it looks like, to me, does that sound like something that you're experiencing?” and we call that psychoeducation. This is how your thoughts can affect your behaviors, can affect the way your stomach works, it can affect if you have headaches, all of those things. So we have to say this is why. We are not undermining the idea that you are having stomach upset, of course you are. But we think that's related to serotonin, which is related to and produced in your brain and what's happening in your brain more than it's related to something that you're eating. Those are the kinds of things that we want to have a conversation about.
There are lots of treatments for anxiety. There are apps, mindfulness apps. Anxiety is usually about worrying about the past or worrying about the future. If we can redirect your brain to what's happening right this moment, usually, we can alleviate that anxiety for many, many people. That is a super effective technique. Then there's psychotherapy. It's a little bit more intense of a skill learning, skill-building coping mechanism. The kind of interaction where you get a coach to help you understand these skills and apply them in your life, in your context, and override that mechanism in your brain to say there's something to worry about. Then there is medication, and medication can be helpful to many people. But many people don't need medication to address their anxiety concerns. If you do, it can be immensely helpful, and often with very few side effects and huge benefits.
SSW: I’ve struggled with anxiety for years and recently started medication for it. It’s really helped and I wish I talked about this with my doctor sooner. But, honestly, I always thought it wasn’t bad enough for that. How can patients get past those feelings and prioritize their mental health?
SMW: I think this is just a stigma that we continue to have within our healthcare context, within our own minds. We will go to the doctor or tell somebody if we have a sniffle, or if we have a stomachache. But then we have these functionally impairing symptoms, and we say, “oh, I should be able to handle this.” And we give ourselves all of these different shoulds. Instead of saying, “I need to pay attention to me, I am experiencing this, and I need to go figure out what's going on and address it.”
My perspective is the earlier you address it, the less you have to address it, the less you have to intervene. The more you understand how your body and your brain work, then the better it is in the future. Start with the intervention that makes sense for you right now. And then rescreen, check again, see if that was effective and what next steps may be.
