What Primary Care Anxiety Screening Means for Mental Health Practitioners

Anxiety disorders are the most common psychiatric disorders, with approximately 30% of U.S. adults experiencing an anxiety disorder in their lifetimes. Despite these rates, most people do not receive treatment. 

As a clinical psychologist with a specialty in health and addiction, most clients I have worked with did not receive specialty mental health care until they were years into their mental health symptoms. 

Clients have shared with me their struggles of knowing when the problem was “problem enough” to seek out behavioral health treatment and not knowing where to go when they knew they needed help. 

To close this gap and ensure people are receiving proper mental health care, the United States Preventative Task Force (USPSTF) recently drafted a guidance that recommends anxiety screening in primary care settings for all U.S. adults. 

This guidance is the right direction to reduce stigma and normalize mental health as part of one’s overall well-being, while getting people into treatment earlier. 

What Does the Task Force Recommendation Mean?

First, what exactly is the USPSTF?

The USPSTF is a committee of non-governmental medical experts who review existing medical research to determine best practices in prevention. 

The USPSTF guidelines range broadly from screenings for visual impairments to screenings for behavioral health concerns, but all guidelines focus on preventative services that can increase early detection of physical and behavioral health problems in primary care settings. The guidelines set a benchmark for best practices that should be followed to improve prevention of health problems. 

What’s more, the drafted guidance shows that there is evidence to support that anxiety can be screened effectively in primary care, that there are relatively low risks, and that there are effective medication and behavioral treatments for both youth (ages 8 to 18) and adults (ages 18 to 64).

Some primary care providers already screen for anxiety as a regular part of their practice, and these guidelines will not change their practice.

It is important to note that the USPSTF guidance is a recommendation—and not a requirement for all providers. 

However, that said, these recommendations have the potential to positively change treatment, reimbursement, and integration of care.

 

Why Do We Need Primary Care Anxiety Screening? And, Why Now?

While many people are struggling with anxiety/anxiety disorders, most will not receive appropriate care and treatment.

People are more likely to see their primary care providers than to seek specialty mental health care directly.

Some individuals experience physical symptoms that may distract and mask the underlying anxiety when they seek help in medical settings, and others may be dealing with mental health stigmas.

At times, clients are not aware that the symptoms they are experiencing are anxiety. Whereas other times, clients might not feel hope that there are effective treatments. 

Because of these reasons, and many more, individuals who show up to medical care can experience misdiagnosis, unnecessary medical treatments, or no treatment at all. 

Addressing anxiety as a best practice in primary care means more people have the chance to talk, which, in turn, has a ripple effect of normalizing talking about anxiety, even beyond the individual patient. 

What Anxiety Screening in Primary Care Means for the Community

When primary care doctors ask patients routine questions about anxiety it can reduce stigma by normalizing mental health as a piece of overall wellness.

Reducing stigma for anxiety, and mental health more broadly, is one of the most important things we can do to improve the psychological well-being of all of our communities. 

The divide between mental and physical health has decreased, but a sizable gap remains. 

This gap is created by systemic, professional, and personal barriers. 

As a consequence, when it comes to mental health, voices of people who need care are silenced, treatment is delayed or never received, and the psychosocial impacts of untreated anxiety continue to increase.

This USPSTF guidance is a significant step forward in reducing that gap, and making mental health a more equitable partner in overall health and well-being. 

It also means that more people who need help with anxiety will get help, and will get it earlier. 

Earlier intervention means less negative impacts and often a more time-limited treatment course. 

Many times, people experiencing anxiety know something is wrong, but our mental health system can be challenging to navigate. 

Primary care providers are a first point of contact and able to guide next steps. 

What Primary Care Anxiety Screening Means for Behavioral Health Practitioners

Much of our U.S. healthcare system is overloaded, and many mental health practitioners already have long waiting lists, if they are even accepting new clients at all. 

The most recent Mental Health America (2022) report shows that the ratio of individuals needing help with anxiety to mental health providers is 350 to one. 

You might be wondering: “Will primary care screening simply lead to more demands on our already overburdened mental health system?” 

If we simply look at the number of individuals seeking anxiety treatment, this guidance may very well increase that number. 

Two important notes, though: 

1. Some primary care providers already do screen for anxiety in routine care, and this guidance will help to standardize the recommendations across all providers
2. This is an opportunity to define a new path forward for anxiety and anxiety treatment. 

As mental health practitioners, we have some immediate opportunities to define who we want to serve, to collaborate across disciplines, and to evaluate new ways we may want to provide treatment for individuals with anxiety. 

Defining who we serve requires establishing our general guidelines for both referral agents and for potential clients. 

In this case, if you often receive referrals from primary care providers, there is an opportunity to share guidance on what types of anxiety symptoms or experiences would benefit most from your level of care. 

With clients, it means being able to get creative about how we evaluate need and appropriate level of intervention before someone begins treatment. 

Collaboration across disciplines may include opportunities to provide psychoeducation to local primary care providers whom you have connections with. 

You might be able to share information on effective anxiety screening, as we all know that the tools are only one piece of effective screening. 

It might also include offering clients psychoeducation on very brief interventions that can be provided, such as offering skills like links to breathing exercises, mindfulness exercises, or psychoeducation on anxiety. 

Collaboration might also involve discussions around the complicated decisions related to when medications can be helpful or harmful to behavioral treatment.  

New approaches to treatment might be considering your training and interest in offering time-limited anxiety interventions via group, identifying short-term, focused treatment plans for anxiety, and keeping up on short-term evidence-based interventions for anxiety. 

Anxiety symptoms are typically one of the more responsive sets of diagnoses to treatment—when the treatment is effectively targeted. 

As we have seen continued growth of evidence-based interventions for anxiety across recent years, right now is also a great time to consider continued professional development.

What Are Some of the Sticking Points?

These guidelines are important, but they are only one part of solving the larger puzzle. 

Anxiety screening does not fix the struggles many patients face in accessing mental health care. 

Increased screening does not fix insurance struggles, access to mental health care in underserved communities, nor does it increase available appointments for mental health providers. 

Additionally, screening without any follow-up discussion during a medical visit could be experienced as more dismissive of a client’s symptoms than not doing the screening at all. 

Even when discussion happens, a primary care physician might not have the training to provide brief advice or intervention and in underserved communities, there might not be access to any mental health providers to partner with or to refer clients. 

These sticking points provide a starting point for developing policies and advocating for reforms. 

What Can Mental Health Practitioners Do Right Now?

It feels like we are at one of those key turning points in mental health care. 

There is, of course, the chance that this will increase identification of anxiety, without enough providers and resources to answer the call. 

However, I’m actually quite excited and hopeful about what may come from here, with some thoughtfulness and innovation. 

The time spent now to make things work feels well worth it when balanced with the continued step toward reduced stigma, increased identification of anxiety, and bringing mental health one step closer to an even playing field with physical health. 

New Approaches to Anxiety 

The great thing is, mental health screenings in primary care are not a new thing—some prior recommended screenings have included alcohol use, opioid use, depression, and postpartum depression. 

Anxiety screening is another important and needed step forward for mental health, and we can rely on lessons learned from earlier mental health screening recommendations. 

One successful approach that I am immediately struck by comes from my specialty area in substance use disorders. 

A model that has been successfully integrated into medical practice (and beyond) has been Screening, Brief Intervention, and Referral to Treatment (aka, SBIRT). 

In SBIRT, individuals are screened, at locations such as a primary care or an emergency room, for alcohol and other drug use. Screenings determine current risk level, which guides the intervention used. Interventions might  include no intervention, brief intervention, and all the way up through specialty addiction care. 

Appropriate targeting of treatment based on risk and severity level leads to better outcomes, whereas a higher level of intervention can lead to detrimental outcomes if it is not matched to the client’s risk level. 

In many ways, increased screening is an opportunity to make sure that the right people are making their way to the right treatment–those who really need a course of treatment with specialized care. 

Right now, some individuals who find their way to a mental health provider on their own, might have been better served by brief interventions or technological based interventions. 

An important point here is that effective intervention does not always mean a referral to a therapist. 

For some patients, a brief psychoeducational or skills based intervention within a medical setting can lead to significant improvements in anxiety. 

With effective screening, as we have seen with SBIRT for alcohol and other drugs, we can ensure people who are most appropriate for specialized/mental health treatment are the ones who actually make it into treatment.

Steps Mental Health Practitioners Can Take 

As mental health practitioners, we have an opportunity to take some steps right now. 

If you already work closely with primary care providers in your area as a referral source, you can start reaching out to share psychoeducation and define who is appropriate for anxiety referrals to your practice. 

If you do not already have training in brief interventions for anxiety, now is a great time to start. 

It’s also a great time to revisit your own approach to intake and planning for a treatment course to make sure it is working for you and your clients. 

It may also be a time to get creative about brief interventions you might offer in collaboration with primary care providers and/or ways to provide group based interventions within your own practice, if you do not already. 

Regardless of your current approach and what goals you might have for your own preparation, it is a great time to assess and plan what will work for you.

Anxiety screening is new for many medical professionals in primary care settings, however as mental health practitioners, we have the long-standing expertise to guide the implementation—now is the time to use our voices to educate and advocate for what we know will work. 

In conclusion, increased screening for anxiety in primary care settings will likely increase the number of individuals identified as having difficulty with anxiety. 

We know that the mental health system is already stretched to its limits, however there is hope that this guidance could be a first step towards increased funding, training, and access to many who need it. 

This guidance could also provide an opportunity to make sure that those who would most benefit from care are the ones who actually make it in the mental health professionals’ doors. 

Finally, and, most importantly, this guidance is one more step forward in reducing the divide between mental and physical health, and reducing the stigma related to mental health diagnosis and treatment. 

Building a Focused Approach to Anxiety in Behavioral Health

Behavioral health clinicians have an opportunity to set the stage for these changes. 

There are opportunities for clinicians and practices to consider their training and interest in offering time-limited anxiety interventions via group, identifying short-term, focused treatment plans for anxiety, and keeping up on short-term evidence-based interventions for anxiety. 

Anxiety symptoms are typically one of the more responsive sets of diagnoses to treat–when the treatment is effectively targeted. 

However, many clients never receive evidence-based treatment models when seeking therapy. 

As a broader mental health system, we need to ensure that there is accessible training available for clinicians seeking to advance their expertise in targeted treatments. 

I currently lead clinical strategy at SimplePractice, an electronic health record (EHR) SaaS platform used by over 200,000 mental health practitioners nationwide. 

We offer webinars and other clinician resources, including free anxiety worksheets clinicians can use with their clients.

As individual clinicians, it is a good time to review our processes for screening and treatment planning to ensure an approach for all risk levels (including those who might not need traditional treatment and those who need higher levels of care). 

Interdisciplinary Collaboration Between Physical Health and Mental Health Practitioners

These guidelines also represent a need to further strengthen the relationships between providers in physical healthcare and those in mental healthcare.

Now is the time for clinicians to build those relationships in their communities if they do not already exist. Collaboration across disciplines is mutually beneficial.

Behavioral health clinicians are able to share information on effective screening tools and approaches. They might also be able to provide psychoeducation on very brief interventions that can be provided, such as offering skills like links to breathing exercises, mindfulness exercises, or psychoeducation about anxiety. 

For some patients, a brief psychoeducational or skills based intervention within a medical setting, and sometimes even without a mental health provider present, can lead to significant improvements in anxiety. 

Primary care physicians can establish partnerships with behavioral health providers to make referrals for patients who do need specialty care. If we do this right, these collaborations should continue throughout a client’s course of care, which can lead to better client connection to care and clinical outcomes. 

In Conclusion

While the divide between mental and physical health is decreasing, a sizable gap still remains. 

Of course, these new screening guidelines are not sufficient to fix our growing mental health struggles. For example, they do not fix mental health insurance coverage struggles or access to mental health care in underserved communities.

Nor does this increase the number of mental health practitioners with available appointments for new clients in their schedules. 

However, all that said, these guidelines are progress towards our ability to develop policies and advocate for reforms that make mental health care more accessible. 

Resources/Further Reading:

USPTF Anxiety Screening Draft Guidelines

SBIRT If you want to learn more about the SBIRT model, the Substance Abuse and Mental Health Services Administration is a great place to start. 

References:

Jetty, A, Petterson, S., Westfall, J. M., & Jabbarpour, Y. (2021). Assessing primary care contributions to behavioral health: A cross-sectional study using medical expenditure panel survey. Journal of Primary Care & Community Health. 12.  doi:10.1177/21501327211023871

ttps://journals.sagepub.com/doi/full/10.1177/21501327211023871

Haftgoli, N., Favrat, B., Verdon, F., Vaucher, P., Bischoff, T., Burnand, B., & Herzig, L. (2010). Patients presenting with somatic complaints in general practice: depression, anxiety and somatoform disorders are frequent and associated with psychosocial stressors. BMC Family Practice, 11, 1-8.

https://link.springer.com/article/10.1186/1471-2296-11-67

Gates, K., Petterson, S., Wingrove, P., Miller, B., & Klink, K. (2016). You can’t treat what you don’t diagnose: An analysis of the recognition of somatic presentations of depression and anxiety in primary care. Families, Systems, & Health, 34(4), 317.

https://psycnet.apa.org/buy/2016-42696-001

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