In 2020, the first year of the Covid19 pandemic, the global prevalence of anxiety and depression increased by up to 25%. The lockdown had taken a toll on people’s mental health, a sign of caution for healthcare providers and governments to follow mental health issues with vigilance. This provides the context today, when a panel of US physicians recently recommended that all adults between the ages of 16 and 65 should be routinely screened for anxiety — even if they’re not showing symptoms. This is one of the first official guidelines to recommend screening for mental illness – marking a shift in the way we approach mental health care.
The US Preventive Services Task Force has developed a set of guidelines for mental health screening that applies to young and middle-aged adults, including those who are pregnant and those who are postpartum. “When you go to your GP, they check you for many, many preventive conditions — blood pressure, heart rate, all sorts of things,” said Dr. Lori Pbert, Task Force Member and Professor in the Department of Population and Quantitative Health Sciences at UMass Chan Medical School.
“Mental illness is just as important as other physical illnesses, and we really need to treat mental illness with the same urgency as other illnesses.” The idea also blurs the rigid lines between mental and physical health in public health.
Anxiety is both prevalent and often misunderstood in the health discourse. It is believed that at least one in seven people in India is living with anxiety disorders and depression, but the true extent of the burden remains unrecognized. Dissemination does little to counteract the misconceptions—the cultural response is to disparagingly equate them with routine “stress” and “worrying,” as if anxiety weren’t a diagnosable psychiatric disorder. The “invisibility” of mental illnesses like anxiety and the many ways they present themselves also reinforces the stillness around them. According to one study, the delay in starting treatment for anxiety — from referral to a healthcare facility to arrival at the receiving connection health facility — is 23 years. But even in its supposed invisibility, anxiety levels have increased dramatically over the course of the pandemic – as adults experience an avalanche of stressors in the form of burnout, isolation, loneliness, relationship difficulties and abuse.
These recommendations reiterate that screening is helpful for those who do not have a diagnosed mental disorder or do not show any discernible signs or symptoms. Recommendations such as these are instructive for the broader public health discourse, because mental health care as part of routine visits to primary care physicians can change the way people think about anxiety, and even better, how it is treated.
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While the task force recommended using tools like questionnaires to ask people about fear, worry, or other disturbing emotions, it didn’t specify exactly how often screening should occur.
Over the years, it has been recognized that a preventative—rather than curative—treatment model for anxiety is needed. The evidence surrounding screening shows that it has helped in the early detection and treatment of anxiety. It serves the purpose of raising people’s awareness, educating them about signs and treatments outside of cultural bias, and legitimizing the experiences of millions of people. Viewing anxiety screening as something that is routinely part of a health check-up also breaks the cultural silence surrounding mental health care.
But there are notable risks that experts have pointed out before. Screening results may be inaccurate, there may be bias and ignorance on the part of healthcare providers, and follow-up may not always prove effective. “The most important thing is to realize that a screening test alone is not enough to diagnose anxiety,” Pbert said.
In this case, given the urgency of the mental health issues catalyzed by the pandemic, the panel found that the benefits of screening programs far outweigh the risks. “Anyone showing signs or symptoms of depression, anxiety, or suicidal risk should be associated with care,” said Dr. Pbert. In addition, screening could help people who are showing symptoms but may not recognize their experiences as signs of an underlying disease. It then relieves people of the burden of knowing, identifying and naming their fear in a culture where this is not always possible.
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Cultural contexts and access to healthcare play important roles in how anxiety disorders impact different settings. While routine screenings address the stigma and urgency of mental health, they still require a more robust, cushioned infrastructure that most countries do not currently have. Screenings require primary health care providers, but there is currently a shortage of physicians and nurses worldwide.
In India, there was a 7 percent shortage of doctors in primary health centers and a 57 percent shortage of doctors in community health centers, according to the Rural Health Statistics 2021. Some estimates include AYUSH doctors practicing homeopathy. Experts have warned against this inclusion; “Ayush doctors cannot be treated on an equal footing with MBBS doctors in total numbers,” said one.
Access to anxiety screening also comes with other logistical challenges — such as mobility, affordability, and geographic access to healthcare providers. Screening for physical diseases like cancer and tuberculosis is still a battle half won. Additionally, the stigma attached to mental health and anxiety would make it harder for people to access. This is all the more true for women and people with marginalized identities, who have limited economic options and are systemically excluded from health care due to gender roles and caste hierarchies. The psychological burden of anxiety disorders is significantly higher in women than in men.
There is arguably a need for early screening to address anxiety with an air of legitimacy and to validate people’s experiences and struggles. It is an incomplete but nonetheless important framework that must take into account cultural differences that limit access to quality healthcare.