Fewer than half of anxiety disorder cases are correctly detected or diagnosed in primary care, and only 40% of affected US patients receive potentially adequate behavioral or pharmacologic treatment, according to a narrative review.

The review synthesized evidence from systematic reviews, meta-analyses, randomized controlled trials, and guidance from the US Preventive Services Task Force and multiple professional organizations, including National Institute for Health and Care Excellence and World Federation of Societies of Biological Psychiatry guidelines, wrote Robyn L. Shepardson, PhD, of VA Center for Integrated Healthcare, Syracuse VA Medical Center, and colleagues.

Detection Gap Driven by Clinical Presentation

Anxiety disorders affect 19.5% of adult primary care patients, with generalized anxiety disorder (7.6%), panic disorder (6.8%), and social anxiety disorder (6.2%) among the most common diagnoses.

Comorbidity is common: among primary care patients with an anxiety disorder, 57% have at least one additional anxiety disorder, and nearly two-thirds also have major depressive disorder.

The researchers emphasized that underdetection is driven in part by how anxiety presents in primary care. Patients frequently report somatic symptoms—including chest pain, palpitations, tachycardia, and shortness of breath—without identifying them as anxiety, requiring clinicians to distinguish psychiatric from medical causes.

Conditions such as hyperthyroidism, cardiac arrhythmias, and pheochromocytoma, as well as medications including corticosteroids and stimulants, may contribute to or mimic anxiety symptoms and should be considered during evaluation.

Screening and Assessment Pathway

The US Preventive Services Task Force recommends screening adults younger than 64 years, including pregnant and postpartum patients, for anxiety symptoms, while evidence remains insufficient for older adults.

The review supports a stepwise approach to evaluation. Initial screening with the 2-item Generalized Anxiety Disorder-2 should be followed by further assessment using the 7-item Generalized Anxiety Disorder-7 and clinical interview for patients with positive results. Assessment should incorporate symptom severity, functional impairment, and differential diagnosis.

Subthreshold anxiety symptoms are common and predictive of future anxiety disorder diagnoses, underscoring the importance of monitoring and early intervention.

Treatment Depends on Symptom Severity and Pattern

The review outlines a clinical decision framework distinguishing subthreshold or adjustment-related anxiety, for which behavioral and self-management approaches are recommended first, from diagnosable anxiety disorders, for which behavioral therapy, pharmacotherapy, or both may be appropriate.

The authors also provide a clinical flowchart outlining decision points from screening through stepped behavioral and pharmacologic management.

Behavioral Therapy and Integrated Care Models

Cognitive behavioral therapy is the first-line behavioral treatment, with first-line behavioral treatment demonstrated in randomized trials, although many studies used wait-list comparators.

Two integrated care models are highlighted:

• Primary Care Behavioral Health (PCBH): Embedded behavioral health clinicians deliver brief interventions, with clinically meaningful improvement reported after as few as one to two sessions.

• Collaborative Care Management (CoCM): Combines physician-prescribed medication, psychiatric consultation, and care management, and has been associated with greater reductions in anxiety symptoms compared with usual care, particularly for panic disorder.

Digital and self-guided cognitive behavioral therapy tools may also reduce symptoms, especially in panic disorder, social anxiety disorder, and generalized anxiety disorder.

Pharmacologic Treatment: Daily vs As-Needed Strategy

Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line pharmacologic treatments. Agents with US Food and Drug Administration indications for generalized anxiety disorder include escitalopram, paroxetine, duloxetine, and venlafaxine. Paroxetine and venlafaxine also carry indications for panic disorder and social anxiety disorder, and fluoxetine has an indication for panic disorder.

The review emphasizes tailoring treatment to symptom pattern: daily medications for persistent symptoms and as-needed medications for intermittent or situational symptoms. Examples include propranolol for performance-only social anxiety disorder and short-term use of hydroxyzine or benzodiazepines for acute symptom relief.

Benzodiazepines are not recommended for long-term management because of risks including dependence, particularly among older adults.

Special Considerations in Older Adults

The authors note that evidence is insufficient to support routine anxiety screening in adults aged 65 years or older. Several commonly used medications—including benzodiazepines, hydroxyzine, and pregabalin—appear on the American Geriatrics Society Beers Criteria and should be used cautiously or avoided in this population.

Prognosis and Treatment Impact

Untreated anxiety disorders often follow a chronic course, with only 40% of patients achieving full recovery over 2 to 5 years. In contrast, patients who received their preferred treatment demonstrated 64% response rates versus 45% with usual care, and 51% remission at 1 year versus 33% with usual care. These findings underscore the importance of shared decision-making, which the researchers associate with improved treatment engagement and outcomes.

Limitations

The review was narrative rather than systematic and did not include all potential treatments, such as complementary or emerging therapies. Many behavioral treatment trials relied on wait-list controls, most evidence is derived from disorder-specific studies rather than heterogeneous primary care populations, and the review was conducted in part within a VA integrated care context, and applicability to community-based primary care settings may vary.

Conclusion

"Clinicians should recognize common anxiety presentations and understand how to differentiate between anxiety and other psychiatric or medical conditions," the researchers wrote. Integrating behavioral therapy, appropriate pharmacotherapy, and collaborative care models may improve patient outcomes.

Disclosures

Dr Shepardson reported receiving a grant from the US Department of Veterans Affairs/Veterans Health Administration Office of Research and Development. No other disclosures were reported. The work was supported by VA Center for Integrated Healthcare resources. The funders had no role in the review, and the contents do not represent the views of the US Department of Veterans Affairs or the US government.

Source: JAMA Internal Medicine