Diagnosis of anxiety conditions in primary care: Part 1

Please note: This is the first article in a planned two-part series on anxiety conditions. Part 2 will outline more details on the treatment of anxiety conditions in primary care.

Disclaimer: The Ottawa Anxiety Algorithm is designed to assist health professionals in Canada by providing an analytical framework for evaluating and treating anxiety conditions. It is not intended to replace a clinician’s judgment or establish a protocol for all patients with a particular condition.

Author

Dr. Douglas Green (biography and disclosures)

Disclosures: Co-creator of https://ottawaanxietyalgorithm.ca. The free website was developed by Drs. Douglas Green, Asmat Khan and Michael Cheng, and the support of many colleagues at the University of Ottawa and beyond.

What care gaps or frequently asked questions I have noticed

Studies indicate that anxiety conditions (including generalized anxiety disorder, social anxiety disorder, panic disorder, post-traumatic stress disorder and obsessive-compulsive disorder) are often underdiagnosed and undertreated in primary care.¹ One reason for this is that patients do not always present with symptoms of anxiety but rather with issues with sleep or various physical symptoms.²

Even if anxiety is considered, I have observed that the diagnosis of the specific anxiety condition that may be responsible for it is not often made. This could be considered somewhat analogous to telling patients they have a “fever” without providing a diagnosis.

This article will focus on the diagnosis of anxiety conditions. In Part 2, I will discuss the management of these disorders.

Data that answers these questions or gaps

Anxiety conditions are extremely common in primary care, with a higher lifetime prevalence (as high as 31%) than mood disorders and substance use disorders.¹

In one study of anxiety conditions in primary care^, 19.5% of patients had at least one anxiety condition, 8.6% had post-traumatic stress disorder, 7.6% had generalized anxiety disorder, 6.8% had panic disorder and 6.0% had social anxiety disorder.³ Obsessive-compulsive disorder (OCD) is less common, with a lifetime prevalence of 1.0-2.3% and is frequently misdiagnosed.^1,4

Co-morbidity is very common, including with mood disorders, substance use disorders and psychosis. Significantly, at least one-third of patients with one anxiety condition are likely to have another one.³ This co-morbidity worsens the functional impact and other outcomes from these anxiety conditions.

The impact of these anxiety conditions can be quite significant, especially when they go untreated. They are associated with increased health care costs, loss of workforce productivity, greater unemployment, disability, higher divorce rates and decreased quality of life.² Having an anxiety disorder worsens the disability associated with a co-occurring physical health condition.³ Importantly they are also associated with an increased risk of suicide.

To try to mitigate these various impacts, their diagnosis and treatment is critical. While it is true that the treatment strategies employed to manage these various conditions are quite similar (usually antidepressants and/or psychotherapy in conjunction with lifestyle changes), the specific approach must be tailored for the individual condition. For example, using Selective Serotonin Reuptake Inhibitors (SSRIs) in OCD usually requires much higher doses used for longer time frames before effectiveness can be assessed, compared to other anxiety conditions.

Secondly, patients will benefit from knowing more about their specific condition and how they can manage it. For example, being told you have panic disorder (rather than just “anxiety”) may prevent further trips to the emergency room once you have a better understanding of your condition.

What I recommend (practice tips)

Routine screening for anxiety in primary care is not recommended in Canada at this point due to concerns about overdiagnosis and overtreatment, and unnecessarily further taxing an already overburdened health care system. However, in certain scenarios it may be worth screening for anxiety, including when a patient presents with anxiety symptoms, unexplained physical symptoms, depression or substance use problems. A history of trauma or extreme psychosocial adversity could also warrant screening.

Using rating scales such as the GAD-7 for anxiety symptoms and the PHQ-9 for depressive symptoms can assist with both screening and diagnosis.

Of course, management should also include ruling out organic conditions (e.g., anemia or hyperthyroidism), substance use disorders and other psychiatric disorders.

To help diagnose and manage anxiety conditions in primary care, we have created a free online tool called the Ottawa Anxiety Algorithm. It is designed to be evidence-based and practical, and contains guidance as to when and how to screen for and diagnose anxiety conditions. It also includes self-help resources that can be emailed to patients, links to community resources and treatment algorithms for the commonly used medications for these conditions.

Figure 1. Ottawa Anxiety Algorithm

It employs measurement-based care using the GAD-7 scale to help assess severity and response to treatment.

Two short videos (2-3 minutes each) at the top of the website provide instructions as to how to use the algorithm and how to use the medication section, the latter of which is quite extensive.

As this article is focused on the importance of screening for and diagnosing anxiety conditions, the relevant parts of the website would be contained in the two buttons located in the upper left section of the home page entitled “Concerns regarding anxiety” and “Confirm diagnosis of anxiety condition”. Clicking on the first button contains scenarios when screening for an anxiety condition may be considered, and tools and questions to assist with this. Clicking on the second button provides additional questions and scales to help diagnose specific conditions, and other information to help assess for co-morbid or alternative diagnoses.

An adapted version of the Ottawa Anxiety Algorithm is available on Pathways BC as the Anxiety Enhanced Care Pathway – Adults.

In Part 2, the focus will be on the self-management and treatment of these conditions and illustrate how the Ottawa Anxiety Algorithm can be used in these domains.

Resources

• Ottawa Anxiety Algorithm
• Anxiety Enhanced Care Pathway – Adults is an adapted version of the Ottawa Anxiety Algorithm for the BC-specific context
• GAD-7 for anxiety symptoms
• PHQ-9 for depressive symptoms
• eMental Health provides patients and family members with information and resources on mental health

References

1. Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress, and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(Suppl 1). doi:10.1186/1471-244X-14-S1-S1 (View)
2. Combs H, Markman J. Anxiety disorders in primary care. Med Clin North Am. 2014;98(5):1007-1023. doi:10.1016/j.mcna.2014.06.003 (View with UBC)
3. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317-25. doi:10.7326/0003-4819-146-5-200703060-00004 (View with UBC)
4. Stahnke B. A systematic review of misdiagnosis in those with obsessive-compulsive disorder. J Affect Disord Rep. 2021;6:100231. https://doi.org/10.1016/j.jadr.2021.100231 (View)

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