Final Research Plan
Screening for Anxiety in Adults
August 27, 2020
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
This new topic incorporates and updates the evidence related to screening for and treatment of anxiety disorders while adding evidence related to screening for and treatment of depression and suicide risk and combination approaches that address more than one of these conditions.
- Do depression, anxiety, or suicide risk screening programs in primary care or comparable settings result in improved health outcomes in adults, including pregnant and postpartum persons?
- Does returning depression, anxiety, or suicide risk screening test results to providers (with or without additional care management supports) result in improved health outcomes?
- Do instruments to screen for depression, anxiety, or high suicide risk accurately identify adults, including pregnant and postpartum persons, with depression, anxiety, and high suicide risk in primary care or comparable settings?
- What are the harms associated with screening for depression, anxiety, or suicide risk in primary care or comparable settings in adults, including pregnant and postpartum persons?
- Does treatment (i.e., psychotherapy, pharmacotherapy, or both) of depression, anxiety, or high suicide risk result in improved health outcomes in adults, including pregnant and postpartum persons?
- What are the harms of treatment (i.e., psychotherapy, pharmacotherapy, or both) of depression, anxiety, or high suicide risk in adults, including pregnant and postpartum persons?
Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.
- What is the differential effect of screening for depression, anxiety, or suicide risk separately compared with screening for one or more of these conditions at the same time?
- Does screening improve process outcomes such as identification and appropriate diagnosis of persons with depression, anxiety, or suicide risk; appropriate followup and referrals; and mental health treatment engagement and retention?
- What health care system supports (e.g., collaborative care) can help ensure appropriate diagnosis and followup, treatment engagement and retention, and improved outcomes?
- How well do suicide risk screening instruments predict future suicide attempts?
- What is known about the validity of the most commonly used or recommended instruments to screen for depression, anxiety, and suicide risk in U.S. racial/ethnic minority patients?
The Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the key questions.
||Other mental health disorders (e.g., obsessive-compulsive disorder, posttraumatic stress disorder, psychotic disorders, bipolar disorder, cyclothymia, adjustment disorder with depressed mood, and other depressive disorders [persistent depressive disorder/dysthymia, disruptive mood dysregulation disorder,premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition], and other anxiety disorders [agoraphobia, specific phobias, separation anxiety disorder, selective mutism, substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition]).|
|Population||KQs 1–3: Adults (age ≥19 years), including pregnant and postpartum persons. Trials may include:
KQs 4, 5:
All KQs: A priori subpopulations of interest include pregnant and postpartum persons, individuals identified through population-based screening in primary care or comparable community settings, and subgroups based on age, sex or gender, race or ethnicity, sexual orientation, and socioeconomic status.
|Interventions||KQs 1, 3: Screening interventions with or without additional provider or patient-facing elements such as referral support, treatment guidelines, symptoms monitoring, and standardized treatment. Screening tools must be brief standardized instruments designed to identify persons with depression, anxiety, and/or high risk of suicide (i.e., recent or current suicidal ideation or behavior); self-report, clinician-administered, or electronically delivered (<5 minutes for clinician-administered instruments, <15 minutes for self-administered instruments).
KQ 2: Limited to the most widely recommended or used screening tools:
KQs 4, 5: Intervention to address depression, anxiety, and/or risk of suicide, including
|KQ 2: Other screening instruments.
KQs 4, 5:
|Comparators||KQs 1, 3 (Screening):
KQ 2 (Diagnostic accuracy):
KQs 4, 5 (Counseling):
KQs 4, 5 (Pharmacotherapy):
|Active intervention (i.e., comparative effectiveness).|
|Outcomes||KQs 1, 4:
KQ 2: Sensitivity, specificity, or data to calculate one or both.
KQs 3, 5:
KQ 5 (Pharmacotherapy only):
|KQs 1, 4: Rate of identification of persons with depression, anxiety, or high risk of suicide (e.g., trials of clinician training to identify persons at high risk of suicide that report no patient outcomes).|
|Outcome assessment timing||KQs 1, 3–5: ≥6 weeks after baseline, except for suicide death or self-harm (no minimum followup).
KQ 5 (Harms of pharmacotherapy): No minimum followup.KQ 2: Maximum of 2 weeks between screening and reference standard.
KQs 4, 5:
KQs 4, 5:
|Study design||KQs 1, 3: Randomized, controlled trials; controlled clinical trials
KQ 2: Systematic reviews and studies of diagnostic accuracy reporting sensitivity and specificity (or comparable statistics) compared with an independently assessed gold standard (structured or semistructured diagnostic interview or a nonbrief [>5 minutes] unstructured interview with mental health clinician) within 2 weeks of screening in populations that include a full spectrum of patient severity for the given setting (i.e., studies cannot limit the patient pool to only nondepressed and known/highly likely depressed patients).
|All KQs: All other study designs.
KQ 2: If unable to limit to existing systematic reviews, case-control studies will be used (i.e., studies that limit the study sample to only participants with and without known mental health symptoms).
|Study geography||Reviews and primary studies that primarily take place in countries categorized as “Very High” on the 2018 Human Development Index (as defined by the United Nations Development Programme) (published 2019).||Reviews in which >50% of included studies take place in countries not categorized as “Very High” on the Human Development Index.|
|Publication language||English||Any language other than English|
|Publication year||1980 or later||Prior to 1980|
|Quality rating||Fair or good-quality studies||Poor-quality studies|
The draft Research Plan was posted on the USPSTF website for public comment from May 7 to June 3, 2020. The USPSTF received comments regarding eligible populations, examination of subpopulations, outcomes, eligible settings, and requests for clarifications of language or approach. Commenters requested the inclusion of studies limited to persons with disabilities, medical conditions, and mental health conditions other than depression, anxiety, and increased suicide risk. In response, although studies limited to these participants will continue to be excluded, the USPSTF will include studies that enroll participants with the conditions listed above as part of an unselected, primary care population. Additionally, the USPSTF added a priori subpopulations of interest for detailed examination if data are available. The USPSTF added pregnancy outcomes, such as preterm birth, and a contextual question to address intermediate process outcomes such as appropriate diagnosis, treatment initiation, and treatment engagement. In response to comments, the USPSTF included studies in emergency department settings if the screening is broadly applied (e.g., not limited to persons in the midst of a mental health crisis). Finally, the USPSTF edited selected text for clarity.