Screening for Anxiety in Adolescent and Adult Women: A Systematic Review for the Women's Preventive Services Initiative

The Effects of Echinacea (EP107TM) on Anxiety: A Comparison of Anxiety Measures in a Randomized, Double Blind, Placebo-Controlled Study

Background/Objectives: Echinacea extracts with unique alkamide profiles (EP107™) have been shown to affect upper respiratory tract infections and reduce anxiety in both animals and humans. However, a recent study found that a similar extract did not reduce anxiety more than a placebo, although it did enhance well-being and produced antidepressant-like effects. We hypothesized that the discrepancy arose from the differences in the anxiety assessment methods used. The study that observed no effects used the Clinically Useful Anxiety Outcome Scale, which focuses on physical symptoms, while earlier studies used the State-Trait Anxiety Inventory, which focuses on psychic symptoms. Methods: To investigate the influence of the anxiety measure on the detectability of anxiolytic effects, we examined the effects of Echinacea EP107TM using the Hospital Anxiety and Depression Scale-anxiety subscale (HADS-A), which focuses on psychic symptoms, and the Hamilton Anxiety Rating Scale (HAM-A), most items of which involve physical symptoms. The study was placebo-controlled, double-blind, and multicenter. Results: The extract significantly alleviated anxiety compared to placebo when measured with HADS-A. HAM-A total scores did not show significant treatment effects. However, Echinacea was superior to placebo in three psychic anxiety items on the HAM-A. Conclusions: These findings suggest that Echinacea EP107TM reduces psychic anxiety without affecting somatic symptoms. This indicates that the extract may be useful in mild or early-phase anxiety when somatic symptoms are not prominent.

Sex differences in cognition, anxiety-phenotype and therapeutic effect of metformin in the aged apoE-TR mice

BACKGROUND

Apolipoprotein E4 (ApoE4) is associated with an increased risk of Alzheimer's disease (AD), depression, and anxiety, which were reported to improve after the administration of metformin. However, sex influence on the effect of ApoE4 and metformin on cognition and mental health is poorly understood.

METHODS

ApoE3-TR and apoE4-TR mice of both sexes were randomly assigned to the normal saline and metformin groups from 13 months to 18 months of age. Behavior tests (MWM, EPM, OFT, TST, FST) were conducted to assess cognition, anxiety, and depression-like behaviors. The mice's blood glucose was also recorded.

RESULTS

Male aged apoE4-TR mice are more vulnerable to cognitive decline than females. Metformin improves the spatial memory of female, but not male apoE3-TR mice and female apoE4-TR mice while aggravating the cognitive impairment of male apoE4-TR mice. The anxiety-like phenotypes in male apoE4-TR mice are more severe than in male apoE3-TR mice, while metformin ameliorates the anxiety-like behaviors in the male apoE4-TR mice but not in male apoE3-TR mice. In addition, metformin alleviates depression-like behaviors in male and female apoE4-TR mice. The hypoglycemic effect of metformin is insignificant in both male and female apoE4-TR mice.

CONCLUSIONS

Male sex exacerbates APOE4-related cognitive impairment and anxiety in aged mice and is insensitive to the cognition improvement effect of metformin in the aged apoE3 mice. Male sex with APOE4 may experience more severe cognitive impairment after treatment with metformin while sensitive to the anti-anxiety effects of metformin. These findings identify sex-specific effects on ApoE4-based dementia, anxiety prevention, and therapy, emphasizing the importance of further sex dimension analyses in vivo and clinical studies.

Increasing Maternal Anxiety in the Pre- to Postpartum Transition Predicts Infant Feeding Practices and Beliefs

OBJECTIVE

Anxiety symptoms increase for some mothers in the perinatal period. Little is known about how increasing anxiety relates to infant feeding beliefs or weight-for-length. We examined relationships between clinically meaningful increases in maternal anxiety symptoms and perceptions of infant feeding behaviors and weight-for-length.

METHODS

Participants were 237 mothers with singleton pregnancies enrolled from obstetric care between 2015 and 2020 who completed the Infant Feeding Questionnaire (IFQ) at 6 months. Anxiety symptoms were measured during pregnancy (M = 24.6 weeks, SD = 6.3) and 6 weeks postpartum using the PROMIS-6A. Linear regression was used to test associations of prenatal, postpartum, or clinically meaningful increases in anxiety symptoms (ie, 3T-score increase) with two outcomes: IFQ (seven factors) and infant weight-for-length at age 6 months.

RESULTS

Prenatal symptoms were unrelated to IFQ factors. Postpartum symptoms predicted IFQ factors related to worry, such as concern for infant undereating/becoming underweight (B = 0.012, P = .02). Increasing symptoms predicted worry-related concerns as well as concern for infant hunger (B = 0.60, P ≤ .01) and greater preference for feeding on a schedule (B = 0.65, P ≤ .01). In a model including both increasing symptoms and postpartum symptoms, increasing anxiety symptoms drove associations with IFQ factors (eg, preference for feeding on a schedule, (B = 0.81, P = .01). Anxiety was unrelated to infant weight-for-length at 6 months.

CONCLUSIONS

Clinically meaningful increases in anxiety symptoms were associated with feeding beliefs related to worry. Increasing anxiety was a better predictor of feeding beliefs than the presence of pre- or postpartum symptoms alone. Mothers with increasing anxiety may benefit from support establishing health-promoting infant feeding practices.

Identification of depression and anxiety during pregnancy: A systematic review and meta-analysis of test accuracy

INTRODUCTION

Depression and anxiety are significant contributors to maternal perinatal morbidity and a range of negative child outcomes. This systematic review and meta-analysis aimed to review and assess the diagnostic test accuracy of selected screening tools (Edinburgh Postnatal Depression Scale [EPDS], EPDS-3A, Patient Health Questionnaire [PHQ-9]-, PHQ-2, Matthey Generic Mood Question [MGMQ], Generalized Anxiety Disorder scale [GAD-7], GAD-2, and the Whooley questions) used to identify women with antenatal depression or anxiety in Western countries.

MATERIAL AND METHODS

On January 16, 2023, we searched 10 databases (CINAHL, Cochrane Library, CRD Database, Embase, Epistemonikos, International HTA Database, KSR Evidence, Ovid MEDLINE, PROSPERO and PsycINFO); the references of included studies were also screened. We included studies of any design that compared case-identification with a relevant screening tool to the outcome of a diagnostic interview based on the Diagnostic and Statistical Manual of Mental Disorders, fourth or fifth edition (DSM-IV or DSM-5), or the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). Diagnoses of interest were major depressive disorder and anxiety disorders. Two authors independently screened abstracts and full-texts for relevance and evaluated the risk of bias using QUADAS-2. Data extraction was performed by one person and checked by another team member for accuracy. For synthesis, a bivariate model was used. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

REGISTRATION

PROSPERO CRD42021236333.

RESULTS

We screened 8276 records for eligibility and included 16 original articles reporting on diagnostic test accuracy: 12 for the EPDS, one article each for the GAD-2, MGMQ, PHQ-9, PHQ-2, and Whooley questions, and no articles for the EPDS-3A or GAD-7. Most of the studies had moderate to high risk of bias. Ten of the EPDS articles provided data for synthesis at cutoffs ≥10 to ≥14 for diagnosing major depressive disorder. Cutoff ≥10 gave the optimal combined sensitivity (0.84, 95% confidence interval [CI]: 0.75-0.90) and specificity (0.87, 95% CI: 0.79-0.92).

CONCLUSIONS

Findings from the meta-analysis suggest that the EPDS alone is not perfectly suitable for detection of major depressive disorder during pregnancy. Few studies have evaluated the other instruments, therefore, their usefulness for identification of women with depression and anxiety during pregnancy remains very uncertain. At present, case-identification with any tool may best serve as a complement to a broader dialogue between healthcare professionals and their patients.

Routine assessment of anxiety among adolescents in a primary care clinic

BACKGROUND

Approximately 20% to 25% of all adolescents experience significant symptoms of anxiety, but only half of those adolescents are diagnosed and treated. Recent clinical guidelines recommend routine assessment of adolescent anxiety symptoms in the primary care setting to improve the rates of identification and treatment of anxiety in this population. The objective of this project was to increase early identification and referral for treatment of adolescent anxiety during primary care visits.

METHODS

This project used the Generalized Anxiety Disorder-7 screening tool to assess anxiety symptoms in adolescents in a school-based primary care clinic. Upon arrival to the clinic, adolescent patients completed the brief self-assessment. The provider then used the assessment score to determine the need for further assessment and referral for treatment.

RESULTS

Of the 51 participants, 21.6% were referred to a mental health provider following assessment, compared with 1.2% of adolescent patients seen in the 6-month period immediately preceding the project.

CONCLUSION

The results indicate that screening for symptoms of anxiety in adolescents using a brief self-assessment survey is an effective method for achieving the desired outcome of increased identification and referral for treatment of anxiety symptoms in this population.

Women's Clinical Preventive Services: Closing the Gaps and Implementing in Practice

Evidence-based clinical preventive services have the potential to reduce morbidity and mortality and optimize health. The Affordable Care Act mandates coverage without cost-sharing for several clinical preventive services. The Women's Preventive Services Initiative (WPSI) has worked to and continues to identify gaps in recommended preventive services for women. The WPSI Well-Woman Chart and the accompanying Clinical Summary Tables can be used at the point of care to ensure women are offered and receive all the preventive services recommended for their age and circumstance.

Predictive validity of the Edinburgh postnatal depression scale and other tools for screening depression in pregnant and postpartum women: a systematic review and meta-analysis

PURPOSE

To compare the predictive validity of the Edinburgh Postnatal Depression Scale (EPDS) and other tools for screening depression in pregnant and postpartum women through a systematic review and meta-analysis.

METHODS

An electronic search of MEDLINE, EMBASE, CINAHL, and PsycArticles databases was conducted using the following keywords: depression, perinatal-related terms, and EPDS. Quality Assessment of Diagnostic Accuracy Studies-2 was used to assess the risk of bias in diagnostic studies.

RESULTS

The search identified 823 articles, of which 17 studies met the inclusion criteria. In 1831 pregnant women from nine studies, pooled sensitivity and specificity of the EPDS were 0.81 and 0.87, respectively, with summary receiver operating characteristic (sROC) curve of 0.90. In 515 postpartum women from six studies, pooled sensitivity, specificity, and sROC were 0.79, 0.92, and 0.90, respectively. We then compared the EPDS with other tools using three or more studies. The sROC curve of the Patient Health Questionnaire-9 was 0.74, which was lower than that (0.86) of the EPDS. The sROC curve of the Beck Depression Inventory and the ten-item Kessler Psychological Distress Scale was 0.91, similar to that of the EPDS (0.90 and 0.87). However, in comparison with the Postpartum Depression Screening Scale (0.98), the sROC curve of the EPDS was 0.54.

CONCLUSION

As a tool specialized for screening depression in pregnant and postpartum women, the EPDS showed excellent performance. Thus, the EPDS can be used in preference to other tools to screen for depression in perinatal women at a primary care setting or a midwifery center.

Screening for Anxiety in Pediatric Primary Care: A Systematic Review

CONTEXT

Anxiety is common, screening tools are available, and treatment can be effective. Recently, anxiety screening has been recommended for adolescent girls beginning at 13 years of age.

OBJECTIVE

To evaluate the evidence regarding anxiety screening test accuracy in primary care for children and adolescents and assess the effectiveness of treatment of individuals identified through screening.

DATA SOURCES

We searched PubMed, the Cochrane library, and references to potentially eligible studies cited in other articles.

STUDY SELECTION

Screening studies were included if they were conducted in primary care or a similar population and employed a reference standard based on DSM criteria. Treatment studies were included if subjects were identified through screening and there was at least 1 comparator intervention or a placebo arm.

DATA EXTRACTION

At least 2 reviewers evaluated each identified reference.

RESULTS

Two screening studies (1 with low risk of bias and 1 with high risk of bias) and 1 treatment study with a low risk of bias were included. The screening study with a low risk of bias reported a sensitivity of 56% and specificity of 80%. The treatment study found individual cognitive behavioral therapy to be effective for screen-detected adolescents with social phobia.

LIMITATIONS

This review only included screening or treatment studies with clear evidence that the study populations were derived from an unselected population reflective of typical primary care. Relevant studies not indexed in PubMed or the Cochrane library could have been missed.

CONCLUSIONS

There are significant gaps in evidence related to anxiety screening in the primary care setting.

GAD-7, GAD-2, and GAD-mini: Psychometric properties and norms of university students in the United States

OBJECTIVE

The Generalized Anxiety Disorder (GAD-7 & GAD-2) scales are reliable and valid instruments for assessing generalized anxiety symptoms in the general and clinical populations. However, little attention has been given to the psychometric qualities of GAD-7 and reduced length versions in a diverse sample of young adult college students stratified by sex. Thus, the aims for this study are to test psychometric properties and normative values of GAD-7, GAD-2, and GAD-Mini scales.

METHOD

U.S university students (N = 4128; females n = 2527, males n = 1601) ages 18-26 years completed an online survey composed of the GAD-7, Patient Health Questionnaire (PHQ-2), and demographic questions.

RESULTS

Exploratory principal components analysis yielded a one factor solution for GAD-7 across sexes. In reducing scale length, iterative confirmatory principal components analyses stratified by sex revealed a two-item scale (GAD-Mini) with high factor loading items, internal consistency (α ≥ 0.85), and construct validity with PHQ-2 (r ≥ 0.55). Normative data indicate that regardless of whether GAD-7, GAD-2, or GAD-Mini scores were considered, about three-quarters of men and two-thirds of women scored below the reasonable cut-points in screening for GAD.

CONCLUSION

Findings from this study may help health care providers and researchers better understand the interpretation of these scales among university students when screening for GAD.

Screening for perinatal depression with the Patient Health Questionnaire depression scale (PHQ-9): A systematic review and meta-analysis

OBJECTIVES

Perinatal depression (PND) is a prevalent and disabling problem both during pregnancy and the postpartum period. The legacy screening measure has been the Edinburgh Postnatal Depression Scale (EPDS). This systematic review examines the validity of the PHQ-9 as a screener for PND.

METHODS

The following databases were searched from January 2001 (when the PHQ-9 was first published) through June 2020: MEDLINE, Embase, and PsychInfo. Studies that compared the PHQ-9 to a criterion standard psychiatric interview were used to determine the operating characteristics of sensitivity, specificity and area under the curve (AUC). Studies comparing the PHQ-9 to the EPDS and other depression scales evaluated convergent validity.

RESULTS

A total of 35 articles were eligible for criterion (n = 10) or convergent (n = 25) validity. Meta-analysis of the 7 criterion validity studies using the standard PHQ-9 cut point ≥10 showed a pooled sensitivity, specificity and AUC of 0.84, 0.81 and 0.89, respectively. Operating characteristics of the PHQ-9 and EPDS were nearly identical in head-to-head comparison studies. The median correlation between the PHQ-9 and EPDS was 0.59, and categorical agreement was moderate.

CONCLUSIONS

The PHQ-9 appears to be a viable option for perinatal depression screening with operating characteristics similar to the legacy EPDS.

Screening for Anxiety in Adolescent and Adult Women: A Recommendation From the Women's Preventive Services Initiative

DESCRIPTION

The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives, developed a recommendation on screening for anxiety in adolescent and adult women to improve detection; achieve earlier diagnosis and treatment; and improve health, function, and well-being. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care to women, particularly in primary care settings. This recommendation applies to women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women.

METHODS

The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness of screening, accuracy of screening instruments, and benefits and harms of treatments in adolescent girls and adult women. No studies directly evaluated the overall effectiveness or harms of screening for anxiety. Twenty-seven screening instruments and their variations were moderately to highly accurate in identifying anxiety (33 individual studies and 2 systematic reviews; 171 studies total). Symptoms improved and relapse rates decreased with psychological therapies (246 randomized controlled trials [RCTs] in 5 systematic reviews) and with selective serotonin reuptake inhibitors or selective serotonin and norepinephrine reuptake inhibitors (126 RCTs in 3 systematic reviews). The WPSI also considered the effect of screening on symptom progression and identification of associated and underlying conditions, as well as implementation factors.

RECOMMENDATION

The WPSI recommends screening for anxiety in women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. Optimal screening intervals are unknown, and clinical judgment should be used to determine frequency. When screening suggests the presence of anxiety, further evaluation is necessary to establish the diagnosis and determine appropriate treatment and follow-up.