Screening for Anxiety Will Only Make Us More Anxious

In response to the country’s anxiety epidemic, an influential panel of doctors appointed by the U.S. Department of Health and Human Services recently published a new set of guidelines. All adults, they recommended, should now be screened for anxiety by their primary care physicians. As the founder of a large clinical practice focused on anxiety, I stand to benefit from increased referrals. And yet, I’ve been lying in bed at night with growing worries that this policy will compound our anxiety epidemic.

All of us experience anxiety, and it’s awful—but it is not a disease. Anxiety can become a disorder when persistently elevated levels cause significant distress and encumber life activities. Such anxiety disorders are common, with nearly one in five U.S. adults experiencing them each year. 

But there is a great difference between anxiety and anxiety disorders. The latter depend on how much distress and dysfunction anxiety causes. The mere occurrence of anxiety is nothing to be medically worried about.

All human emotions, whether positive or negative, serve a vital function, and anxiety is no exception. Common anxiety symptoms include a rapid heart rate, increased breathing, muscle tension, stomach upset and feeling on-edge or easily startled. All of these are physiological responses to surging adrenaline, which is how the body mobilizes to deal with perceived threats. Anxiety is an indicator that our fight-or-flight system is working, which is a good thing. Newborns who do not exhibit the Moro Reflex (startle response) typically have severe neurological or spinal cord damage, and most do not survive.

For all these reasons, it is impossible to assess whether high anxiety is problematic just by examining how anxious someone is at a given point in time. In some instances, high anxiety is expected, adaptive and not pathological at all. I disagree with Dr. Petros Levounis, president of the American Psychiatric Association, who recently commented that constant worry is itself a signal that one needs professional help. 

A current example: In Ukraine since the Russian invasion, residents who experience nervousness and uncontrollable worry nearly every day are probably better off than their neighbors who are less anxious. They are more likely to survive a military attack, since a stress response yields benefits such as greater situational awareness, quicker response time, and even constriction of blood flow in the event of injury. 

Granted, after the war, Ukrainians with high baseline anxiety may be at greater risk for Posttraumatic Stress Disorder. But when we decontextualize anxiety and simply assess its quantity, we risk pathologizing normal, even healthy aspects of the human emotional experience.

The new guidelines call upon physicians to use the two-item Generalized Anxiety Disorder screening tool (GAD-2), which asks patients how often they have felt anxious or unable to stop worrying over the past two weeks. Its clinical cutoff to distinguish between normal and abnormal anxiety is purposefully low. Anything more than a report of “not at all” for anxiety and worry triggers potential diagnosis and treatment for an anxiety disorder.

This creates a high risk of false positives: 32% of individuals identified by the GAD-2 as having clinically significant anxiety do not, in fact, have an anxiety disorder. That is because the tool only assesses the severity of anxiety, not whether symptoms cause distress or impairment, or whether there are situational factors that make anxiety a normal response.

Overdiagnosis of anxiety disorders is not inconsequential. The most widely used class of anxiety medications—benzodiazepines—are already overprescribed and have a known propensity for abuse and addiction. 

A bigger concern is that unduly focusing medical attention on anxiety when it does not impair life activities could exacerbate the anxiety. Many individuals with high anxiety are not bothered by their symptoms and function just fine day-to-day. Such individuals will now be told by their primary care providers that they have a diagnosis and need treatment, which may trigger a greater flow of adrenaline and increase the chances that they will develop an actual anxiety disorder.

We have been here before. The opiate crisis was initially borne from compassion, notwithstanding corporate greed on the part of pharmaceutical companies. Physicians sought to reduce the suffering associated with physical pain and eagerly posted the now ubiquitous row of emoji-like faces in their offices, ranging from smiling to grimacing, to provide a tool for gauging pain. Any patient report of significant pain intensity, even by way of a finger-point, could yield a prescription for opiate-based pain medications. The tragic results of this approach have made it clear that emotional, behavioral and other factors must be assessed prior to treatment of physical pain.

Similarly, diagnoses of attention-deficit hyperactivity disorder (ADHD) skyrocketed when the American Academy of Pediatrics recommended that pediatricians routinely screen for its symptoms. Physicians were encouraged to use a simple checklist, without analysis of any other demographic or clinical factors, and to prescribe Ritalin and other stimulants as a first-line treatment for any child over the age of six. 

Within a few years, there were signs of nationwide overdiagnosis and overprescription. This had a disproportionate impact on children whose birthdays happened to fall between August and December, since younger children within an age cohort are naturally less attentive and more impulsive than their same-grade peers.

To be clear, the GAD-2 is a valuable tool for mental health professionals. It encourages them to probe further about symptoms and to follow up with specific questions about whether patients are truly distressed, how much their symptoms affect them, and why they may be experiencing high anxiety. But its use as a stand-alone screener for already overburdened primary care physicians is an entirely different proposition.

Perhaps I’m just too anxious about overdiagnosis of anxiety disorders. After all, it is possible that screening will prompt physicians to be more attentive to emotional and behavioral health and to take the necessary time to determine when anxiety is truly problematic, as opposed to normal or even adaptive. Time will tell whether this well-intentioned initiative is helpful or harmful. In the meantime, my own nagging worries seem to be contextually normative and healthy.

David H. Rosmarin is an associate professor at Harvard Medical School, a program director at McLean Hospital, and the founder of Center for Anxiety. His forthcoming book is “Thriving with Anxiety: 9 Tools to Make Your Anxiety Work for You.”