This is the first installment of a 6-part series on mental health issues exacerbated by the COVID-19 pandemic. In this installment, we will discuss identifying and treating anxiety disorders in children and adults in primary care.
The COVID-19 pandemic brought to light the growing mental health crisis in America, which has affected patients of all ages. Before 2020, mental health disorders were among the leading causes of the global health-related burden, with depressive and anxiety disorders being the most disabling.1 The ongoing pandemic has exacerbated many determinants of poor mental health. As a result, rates of anxiety and depression among US adults were 4 times higher between April 2020 and August 2021 than in 2019 (Figure).2,3 Men, Asian Americans, young adults, and parents with children in the home had the greatest increases in rates, according to Centers for Disease Control and Prevention (CDC) data.3
The COVID pandemic further highlighted the need to monitor children’s mental health as well. The 2020 National Survey of Children’s Health (NSCH) examined 5-year trends in children’s well-being, including potential effects of the COVID-19 pandemic. Between 2016 and 2020, significant increases in the rates of children diagnosed with anxiety (from 7.1% to 9.2%) and depression (3.1% to 4.0%) were found along with decreases in daily physical activity (24.2% to 19.8%) and in caregiver mental health (69.8% to 66.3%; trend P <.001 for all comparisons).4
The Truth About Anxiety
Anxiety disorders are the most common mental illness in the US and affect 40 million adults (or 19.1% of the population) every year.5 Anxiety disorders are highly treatable, yet only 36.9% of those diagnosed with these disorders receive treatment.5 Lack of access to mental health providers and limited insurance coverage prevent patients from obtaining proper treatment, and poor psychological health is linked to an increased risk for physical illness.1,2,5
People with anxiety disorders are 3 to 5 times more likely to go to the doctor and 6 times more likely to be hospitalized for psychiatric disorders than those without anxiety disorders.5 Anxiety develops from a complex set of risk factors, including genetics, brain chemistry, personality, and life events.5 Depression is a common comorbidity in patients with anxiety with approximately 50% of those diagnosed with depression also diagnosed with an anxiety disorder.5
Anxiety disorders affect 31.9% of children between the ages of 13 and 18 years.4 Children with untreated anxiety are at higher risk of performing poorly in school, missing important social experiences, and engaging in substance abuse (often as self-medication).4,5 Anxiety disorders in children and adolescents also often co-occur with other disorders such as depression, eating disorders, and attention-deficit/hyperactivity disorder (ADHD).4,5 Identifying anxiety disorders at an early age may be important because childhood onset of some psychiatric disorders has been linked to a worse prognosis compared with adult onset.6
In older adults, generalized anxiety disorder (GAD) is the most commonly diagnosed anxiety disorder.5,7 Anxiety disorders in this older population are frequently associated with traumatic events such as a fall (or fear of a fall), safety, or onset of illness.
When symptoms of anxiety become pervasive, are consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, and affect the patient’s ability to function, the presumed diagnosis is an anxiety disorder (Table 1).5,7,8
Table 1. Common Types of Anxiety Disorders Treated in Primary Care5,7,8
|Generalized anxiety disorder||· The most common anxiety disorder|
· Chronic disorder involving excessive, long-lasting anxiety and worries about nonspecific life events, objects, and situations that occur more days than not for at least 6 months about several different events/activities
· People with this disorder are not always able to identify the cause of their anxiety and find it difficult to control their worry
· Women are twice as likely as men to be affected
· Often occurs with MDD
· Physical symptoms include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance
· Hallmark signs: excessive, persistent, out-of-control worry about various domains
|Panic disorder||· Includes recurrent brief and sudden attacks of intense terror and apprehension |
· ≥1 attack has been followed by ≥1 month of persistent concern about additional attacks or their consequences and/or a significant maladaptive change in behavior related to attacks
· Attacks may be expected (response to a typically feared object) or unexpected (occurs for no apparent reason)
· Panic attacks tend to occur and escalate rapidly, peaking after 10 minutes (however, a panic attack may last for hours)
· Hallmark signs: shaking, sweating, palpitations, fear of dying, confusion, dizziness, nausea, and breathing difficulties
|Social anxiety disorder||· The fear of negative judgment from others in ≥1 social situation or of public embarrassment|
· Includes a range of feelings such as stage fright, fear of intimacy, and anxiety around humiliation and rejection
· Can cause people to avoid public situations and human contact to the point that everyday living is rendered extremely difficult
· Fear, anxiety, or avoidance is persistent and lasts for ≥6 months Equally common among men and women
· Onset is typically around age 13 years
· Many patients will wait 10 years or more before seeking help
· Hallmark sign: fear of being scrutinized
Diagnosing Anxiety in Adults
Anxiety disorders can negatively impact a patient’s quality of life and disrupt important activities of daily living. Thus, regular screening for anxiety in primary care is essential. Sample questions to ask include the following8:
- Over the past 2 weeks, how often have you been bothered by either feeling nervous, anxious, or on edge?
- Have you been unable to stop or control your worrying?
- Please tell me a bit more about the difficulties your anxiety is causing you in terms of how you are functioning in your daily life at work and at home
The Generalized Anxiety Disorder 7-item Scale (GAD-7) is a free self-administered questionnaire that can be used to support diagnosis and as a severity measure for GAD. The tool can be introduced to patients by saying “Please complete this form so I can get a bit more information on the nature of your worries. It won’t take very long, there are only 7 questions, and it will help me to work out how best to help you.” In addition to assessing a person’s symptoms and associated functional impairment, consider how the following factors may affect the development, course, and severity of the person’s presenting problem7,8:
- History of any mental health problem
- History of a chronic physical problem
- Any past use of, and response to, treatments
- Quality of interpersonal relationships
- Living conditions and social isolation
- Family history of mental illness
- History of domestic violence or sexual abuse
The rates of underdiagnosis and misdiagnosis of GAD and panic disorder in primary care are high, with symptoms often ascribed to physical causes.8,9 Careful evaluation of an anxious patient will help to determine if the cause of the anxiety is organic (Table 2) or psychological. Establishing the cause will help direct medical therapy (Table 3).9-11
Table 2. Disease States Associated With Anxiety9
|Chronic obstructive pulmonary disease|
|Congestive heart failure|
|Hyper- or hypothyroidism|
|Vitamin B12 deficiency|
Clinical guidelines for pharmacologic treatment of anxiety in adults recommend a selective serotonin reuptake inhibitor (SSRI), such as paroxetine and escitalopram, as first-line treatment.12 Use of benzodiazepines for the treatment of anxiety disorders in primary care is not recommended except as a short-term measure during crises. Current treatment guidelines also discourage the use of antipsychotics for the treatment of anxiety in primary care.12
Table 3. Medications Used to Treat Anxiety Disorders Among Adults in Primary Care10,11
|Antidepressants||· Antidepressants are typically first-line treatment for anxiety, particularly SSRIs|
· SSRIs take 6-8 weeks to be fully effective
· SSRIs are not addictive
· Examples include paroxetine, sertraline, fluoxetine, and escitalopram
· Some serotonin and norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine and duloxetine, are indicated for anxiety
|Benzodiazepines||· Have largely replaced barbiturates in the treatment of anxiety as they are |
safer and more effective
· Work quickly, often within 1 hour
· Typically prescribed no more than 1 month when used for GAD, panic disorder, and social anxiety disorder
· Addiction/abuse is possible and withdrawal symptoms may occur if stopped suddenly; important to taper off when discontinuing use
· Safe for short-term use with antidepressants
· Examples include alprazolam, clonazepam, lorazepam (preferred in the elderly), and diazepam
|Azapirones||· Weak dopamine D2 receptor blocking action. |
· Does not produce antipsychotic or extrapyramidal side effects
· Buspirone is commonly used to treat GAD; this agent does not produce significant sedation or cognitive impairment
· Often prescribed with an antidepressant
· Have little potential for producing tolerance or physical dependence; no abuse liability
· Slow onset of action; not suitable for an acute episode of anxiety
· Avoid use in patients with renal or hepatic impairment
|Sedative antihistamine||· Hydroxyzine is used for short-term treatment of anxiety and tension symptoms as well as to treat allergic reactions|
· Acts quickly by rapidly absorbing into the stomach, and begins working as soon as 15-30 minutes after administration
· Most common side effect is sleepiness; this agent is also commonly used to treat insomnia
|β-blockers||· Many symptoms of anxiety (heart palpitations, increase in blood pressure, shaking, tremors) are caused by sympathetic overactivity|
· Propranolol and other nonselective beta-blockers can help with these symptoms
· Do not affect psychological symptoms such as worry, tension, and fear but are valuable in acutely stressful situations (examinations, public speaking)
Anxiety Disorders in Children and Adolescents
The median age of onset of anxiety disorders in children is approximately 11 years of age and onset typically occurs during a specific developmental phase such as specific phobias in the school-age years; social anxiety in the early adolescent years; and GAD, panic, and agoraphobia in the later adolescent/young adult years.13 While no universal recommendation for screening for anxiety disorders in children and adolescents exists, free screening tools such as the GAD-7 and the Screen for Child Anxiety Related Disorders (SCARED) are readily available to identify anxiety concerns.
Pharmacologic and nonpharmacologic treatment guidelines for children are similar to those for adults. The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that SSRIs be offered to patients 6 to 18 years old with social anxiety, GAD, separation anxiety, or panic disorder.13 All SSRIs have a boxed warning for suicidal thinking and behavior through age 24 years with the rate for suicidal ideation across all antidepressant classes reported to be 1% compared with 0.2% for placebo.13 Despite the low apparent risk, the US Food and Drug Administration (FDA) recommends close monitoring of children for suicidality, especially during the first months of treatment.11,12
Nonpharmacologic Treatments for Adults and Children With Anxiety
Low-intensity psychological interventions for anxiety disorders include psychoeducation groups and individual guided self-help with written or electronic materials of appropriate reading age.12 High-intensity treatment recommendations include 12 to 15 weekly sessions of cognitive behavioral therapy (CBT) delivered by trained and competent practitioners.12 Adult CBT usually combines several different interventions such as psychoeducation, worry exposure, applied relaxation, problem-solving, cognitive restructuring, and interpersonal psychotherapy.12 The AACAP recommends that CBT be offered to patients 6 to 18 years old with social anxiety, GAD, separation anxiety, specific phobia, or panic disorder.13 Cognitive behavioral therapy in children is aimed at both the child and parents with a focus on learning positive self-talk, coping skills training, and thought challenging.13
Because primary care settings often serve as the only point of contact for individuals experiencing mental health problems, primary care providers (regardless of their specialty) play a crucial role in the diagnosis, treatment, and management of mental disorders.5,6 Given the marked increase in anxiety rates among both adults and children during the COVID-19 pandemic, primary care clinicians should ask patients about anxiety symptoms and use simple screening tools such as the GAD-7 at regular visits.
The next installment in the mental health series will be a focused case study on depression.
Jennifer Allain, DNP, MSN, APRN, FNP-C, is the NP program coordinator and master teacher of mental health psychiatric nursing at The LHC Group, Myers School of Nursing of the University of Louisiana at Lafayette College of Nursing and Health Sciences.
Shirley Griffey, DNP, PMHNP, is a psychiatric nurse practitioner at Baton Rouge General Medical Center and an instructor at Southeastern Louisiana University School of Nursing in Baton Rouge, Louisiana.
Christy Cook-Perry, DNP, PMHNP, ANP, is an assistant professor at Southeastern Louisiana University College of Nursing and Health Sciences.
- COVID-19 Mental Disorders Collaborators. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet. 2021;398(10312):1700-1712. doi:10.1016/S0140-6736(21)02143-7
- Terlizzi EP, Schiller, JS. Estimates of mental health symptomatology, by month of interview: United States, 2019. National Center for Health Statistics. March 2021. Accessed June 18, 2022. www.cdc.gov/nchs/data/nhis/mental-health-monthly-508.pdf
- National Center for Health Statistics. Household pulse survey — anxiety and depression. Centers for Disease Control and Prevention. Accessed June 21, 2022. www.cdc.gov/nchs/covid19/pulse/mental-health.htm
- Lebrun-Harris LA, Ghandour RM, Kogan MD, Warren MD. Five-year trends in US children’s health and well-being, 2016-2020. JAMA Pediatr. 2022 Mar 14:e220056. doi:10.1001/jamapediatrics.2022.0056
- Facts and statistics. Anxiety and Depression Association of America. June 18, 2022. Accessed June 21, 2022. https://adaa.org/understanding-anxiety/facts-statistics
- Scheeringa MS, Burns LC. Generalized anxiety disorder in very young children: first case reports on stability and developmental considerations. Case Rep Psychiatry. 2018;2018:7093178. doi:10.1155/2018/7093178
- National Institute for Health and Clinical Excellence. Common mental health problems. Clinical case scenarios for primary care. May 2012. Accessed May 27, 2022. https://www.nice.org.uk/guidance/cg123/resources/clinical-case-scenarios-pdf-version-pdf-181726381
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
- Chen JP, Reich L, Chung H. Anxiety disorders. West J Med. 2002;176(4):249-253.
- Stahl MS. Stahl’s Essential Psychopharmacology. 4th ed. Cambridge University Press; 2011.
- Stahl MS. Stahl’s Essential Psychopharmacology: Prescriber’s Guide. 6th ed. Cambridge University Press; 2017.
- National Institute for Health and Care Excellence. Generalized anxiety disorder and panic disorder in adults: management. Updated June 2020. Accessed June 27, 2022. https://www.nice.org.uk/guidance/cg113
- Walter HJ, Bukstein OG, Abright AR, et al. Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2020;59(10):1107-1124. doi:10.1016/j.jaac.2020.05.005