How to Screen Primary Care Adults for Anxiety Severity
How should clinicians in underserved primary care settings systematically screen adults for anxiety severity and related psychosocial burden using the measures applied in this study?
Adults presenting to underserved primary care clinics may have substantial anxiety symptoms even without a prior GAD diagnosis or current psychiatric pharmacotherapy. This guide applies to community-based adult patients similar to those in the study and focuses on identifying anxiety severity and the accompanying factors most strongly associated with greater symptom burden.
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Identify appropriate adults for screening
Screen adult patients aged 18 years or older in primary care. In the study, the screened population excluded patients currently receiving psychiatric pharmacotherapy and those with a prior diagnosis of GAD, so the workflow is best interpreted for undiagnosed, untreated adults rather than patients already in psychiatric treatment.
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Rate anxiety symptoms with the HAM-A
Administer the 14 HAM-A symptom domains used in the study: anxious mood, tension, fear, sleep disorders, intellectual disorders, depression, muscular symptoms, sensory symptoms, cardiovascular symptoms, gastrointestinal symptoms, respiratory symptoms, genitourinary symptoms, vegetative symptoms, and observed behavior at the time of the survey. Score each item from 0 to 4, where 0 is absent and 4 is very severe, for a total score from 0 to 56. Interpret scores as less than 17 for mild symptoms, 18 to 24 for mild-to-moderate symptoms, and greater than 25 for moderate-to-severe symptoms.
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Measure psychosocial stress with the PSS
Add the 10-item Perceived Stress Scale because psychosocial stress was common and showed the strongest association with anxiety severity in the study. Use the study's thresholds: 13 or less indicates absent or low stress, and 14 or more indicates moderate to severe stress. Patients with stress were much more likely to have moderate-to-severe anxiety, so this step helps identify those needing closer follow-up.
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Elicit lifetime anxiety episodes and panic attacks
Ask directly whether the patient has ever had anxiety episodes and whether they have had at least 1 lifetime panic attack. In the study, 85.7% of patients with moderate-to-severe anxiety reported anxiety episodes and 90.0% reported panic attacks, so these histories can help prioritize diagnostic clarification when current symptom scores are high.
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Ask about the correlates linked to higher severity
Include focused yes-or-no questions on family history of anxiety, family history of depression, alcohol consumption, unbalanced eating habits including skipping 1 or more daily meals, and prior SARS-CoV-2 infection. Each of these variables was significantly associated with higher anxiety severity in this sample, whereas smoking, illicit substance use, personal history of depression, traumatic childhood events, and medical comorbidities were not significantly associated.
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Interpret the pattern as association, not causation
Use the combined findings to identify patients with heavier anxiety burden, especially those with HAM-A scores above 25 plus psychosocial stress or the associated clinical correlates found in the study. At the same time, interpret these factors as markers associated with severity rather than proven causes or independent predictors, because the study was cross-sectional and the largest odds ratios for anxiety episodes and panic attacks likely reflect strong co-occurrence and conceptual overlap.
Clinical Considerations
- This workflow is derived from a single cross-sectional study in one underserved Venezuelan primary care clinic, so generalizability may be limited.
- The study's odds ratios reflect association rather than risk or causation because of the cross-sectional design.
- Very large odds ratios for anxiety episodes and panic attacks should be interpreted cautiously because of sparse cell effects and conceptual overlap with anxiety severity.
- The study excluded adults already receiving psychiatric pharmacotherapy or with a prior GAD diagnosis, so the workflow does not directly represent treated or previously diagnosed populations.
Bottom Line
In underserved primary care adults, pairing HAM-A symptom scoring with PSS stress screening and targeted questions about prior anxiety or panic symptoms, family history, alcohol use, eating habits, and SARS-CoV-2 history is the most source-supported way to identify patients with the greatest anxiety burden.
