A JAMA Internal Medicine review examined how anxiety disorders are managed in general practitioner (GP) offices and found that they remain underrecognized and undermanaged, despite being among the most common psychiatric conditions seen in primary care.

In an interview with Univadis Italy, part of the Medscape Professional Network, Gianluca Serafini, a psychiatrist and full professor at the University of Genoa and IRCCS Ospedale Policlinico San Martino, a research hospital, both in Genoa, Italy, confirmed that, worldwide, about 700 million people suffer from anxiety and depressive disorders, causing substantial disability and psychosocial impairment. The World Health Organization estimates that anxiety disorders affect roughly 3.6% of the general population. The importance of primary care in this context was also emphasized by Alessandra Taraschi, GP and vice-coordinator of the scientific area of ​​the Italian Federation of General Practitioners. “A relationship of trust is established between the patient and the family doctor, so much so that this doctor is often the first clinician with whom a person experiencing anxiety symptoms speaks. He or she is the closest, most accessible, and most trusted doctor,” she explained to Univadis Italy. Taraschi noted that, especially since the pandemic, there has been a significant increase in psychiatric disorders, particularly anxiety-related ones. “We deal with patients suffering from these disorders almost daily, and the exponential increase in their incidence means we are increasingly ready for early recognition,” she added.

First Step, a Correct Diagnosis

Correctly diagnosing anxiety disorders in the GP’s office is the first crucial step toward managing the problem, but this step isn’t always simple. The authors of the recently published review, led by Robyn L. Shepardson, PhD, US Department of Veterans Affairs Center for Integrated Healthcare, Syracuse, New York, noted that primary care clinicians still miss many cases; fewer than half of the anxiety disorders are correctly identified in general practice, and only about 40% of patients receive treatment deemed appropriate. Patients often present with somatic symptoms, such as palpitations, chest pain, or shortness of breath, without linking them to anxiety. Anxiety frequently co-occurs with depression or medical conditions such as chronic pain, cardiovascular disease, asthma, and cancer. These factors complicate diagnosis, which often involves subclinical forms of the condition. In the review and recent US Preventive Services Task Force guidance, Shepardson and colleagues recommend routine screening for anxiety in adults up to age 64, including pregnant and postpartum patients. Screening should be based on standardized tools such as the Generalized Anxiety Disorder 2-item questionnaire (GAD-2) and GAD-7, while also considering the medical history, physical examination, and any laboratory tests to rule out medical conditions that may cause or mimic anxiety. “In Italy, GPs are trained to recognize these symptoms: Anxiety disorder is a widely recognized condition that we experience in daily practice,” Taraschi told Univadis Italy.

One of the greatest advantages of a GP, according to Taraschi, is knowing the patient for many years, if not for entire generations. “Therefore, we can recognize the onset of pathological symptoms early, and we are often also aware of particularly serious events that can trigger the disease,” she said, reiterating that standardized tools are especially useful when clinicians are uncertain, but they do not replace a comprehensive clinical assessment.

According to Shepardson and colleagues, patients evaluated in primary care are more likely to receive a diagnosis under the generic label “anxiety, not otherwise specified” rather than a specific disorder. “Anxiety disorders are often confused with chronic stress disorders, which are actually the precursor to anxiety disorders but are also often overlooked because they are not considered sufficiently serious and worthy of treatment in primary care,” Serafini told Univadis Italy.

Treatment Approaches

Cognitive-behavioral therapy is the first-line psychological treatment. But comprehensive programs and brief integrated primary care interventions show clinically significant and long-lasting benefits. Digital mental health tools, online psychotherapy platforms, and cognitive-behavioral therapy-based apps can extend access and support symptom management. Regarding pharmacotherapy, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line medications, particularly for GAD, whereas the use of benzodiazepines is discouraged.

“In Italy, in recent years, there has been an increase in the use of anxiolytics and sedatives, particularly benzodiazepines, which are commonly prescribed antianxiety drugs. At least four million people use benzodiazepines,” commented Serafini. As the expert explained, low doses of benzodiazepines can be safe, whereas high doses and long-term use can cause dependence and tolerance.

“Overall, therefore, benzodiazepines remain effective, safe, and well-tolerated drugs when prescribed with clear clinical precautions that significantly improve the risk-benefit ratio,” he explained, convinced that the use of this therapeutic device should not be condemned outright. “These drugs must be combined with psychotherapy and accompanied by specific GP training programs on appropriate use,” he stated.

Collaboration for Optimal Management

The review highlights the effectiveness of integrated care models such as Collaborative Care Management that involve close collaboration between GPs, consulting psychiatrists, and case managers. According to the authors, greater adoption of screening and collaborative models could significantly improve the recognition and clinical outcomes of one of the most common and burdensome psychiatric conditions seen in daily practice.

“In our national context, there are fairly structured dialogue initiatives between GPs and mental health specialists, but for the consultation process to be truly effective, with a truly multidisciplinary approach, I believe a structured method of contact and response between local mental health departments and general practice is necessary,” Serafini explained, specifying that this should be part of specific liaison projects developed through the coordination of local health authorities.

The expert also offered some examples of such actions, such as 1) scheduled meetings, in which local psychiatrists update GPs on treatment protocols and discuss clinical cases; 2) establishing a direct line to contact specialists for specific, real-time advice; and 3) integrated specialist GP working groups.

“To improve the management of anxiety disorders in primary care, I would start by strengthening mental health services,” added Taraschi, who believes it is essential to increase staffing (including nursing and practice assistants) to reduce the administrative burden on GPs so that they can focus on diagnosis, initiating first-line treatment, and supporting medical practice.

This story was translated from Univadis Italy.