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NEW YORK CITY -- Almost a quarter of surveyed U.S. adults met criteria for generalized anxiety disorder (GAD), though the vast majority of them were undiagnosed, a retrospective cross-sectional study suggested here.

Out of 75,261 respondents to the online 2022 National Health and Wellness Survey, 23.3% screened positive for anxiety using the , Daniel Karlin, MD, chief medical officer of MindMed in New York City, reported here at the American Psychiatric Association annual meeting.

Of those who screened positive, 83.1% had never received a GAD diagnosis. Most (55.1%) of the individuals screening positive had moderate symptoms while 44.9% had severe symptoms.

Last year, the U.S. Preventive Services Task Force recommended that all adults up to age 64 be screened for anxiety in the primary care setting, including for GAD, in order to avoid delays in diagnosis and treatment. But Karlin explained that estimates of undiagnosed GAD had been outdated or based on small samples.

If the proportions identified by Karlin and his team were broadened to the entire U.S. population, it would represent around 59 million adults with GAD, 49 million of whom are undiagnosed.

"There are a lot of people walking around with symptoms that are severe enough for them to have moderate to severe GAD who've never been diagnosed," he told MedPage Today. "The burden of illness of undiagnosed GAD is remarkably high."

"These findings reflect something that we're missing as a healthcare system, that there are people who have this severe anxiety, they aren't sure what to do [or] what there is to be done about it," he said. "We need to be doing a better job of screening for anxiety disorders, and then intervening when we detect them."

Karlin said that for a long time there has been a greater focus placed on diagnosing and treating major depressive disorder (MDD), but GAD and MDD are "overlapping diseases," he noted.

"We need to continue to recognize that distress comes in different flavors, and that no single flavor is more important than any other," Karlin added. "Let's make sure we're paying attention to anxiety as well as depression."

A few characteristics stood out among adults with GAD who were undiagnosed. They were more likely to be younger, male, smokers, alcohol drinkers, employed, and have a higher income when compared with controls without GAD symptoms or those already diagnosed with GAD:

• Age: 37.5 vs 51.8 vs 42.1 years, respectively
• Male: 54% vs 49% vs 26%
• Current smoker: 36% vs 15% vs 23%
• Alcohol drinker: 72% vs 64% vs 65%
• Employed: 75% vs 55% vs 50%
• Income of $75,000 or higher: 59% vs 46% vs 26%

The group with undiagnosed GAD were also less likely to be white (51% vs 65% vs 69%, respectively) and less likely to have overweight or obesity (45% vs 62% vs 68%).

Karinn Glover, MD, MPH, a psychiatrist at Albert Einstein College of Medicine in New York City, wasn't surprised to see people with GAD report higher rates of alcohol use, pointing out how untreated anxiety is linked with substance use.

"I certainly wonder how many of those who screened positive for anxiety also have relied heavily on alcohol or cannabis to manage anxiety and to what extent that use might meet criteria for misuse or a disorder," Glover, who wasn't involved with the research, told MedPage Today.

In another poster presented here led by Karlin and colleagues, adults with undiagnosed GAD also tended to have a poorer quality of life. Compared with diagnosed adults, undiagnosed adults had significantly fewer healthcare provider visits in the past 6 months (3.0 vs 8.7) but had a significantly higher number of hospitalizations (1.2 vs 0.3) and emergency room (ER) visits (1.3 vs 0.5; P<0.001 for all).

The Work Productivity and Activity Impairment Questionnaire also showed that undiagnosed adults had scores for absenteeism, presenteeism, overall work productivity impairment, and activity impairment that were 3.1, 1.9, 1.9, and 1.6 times higher, respectively, than diagnosed adults (P<0.001 for all).

As for Physical, Mental, and Global Health Composite scores, undiagnosed adults trended toward lower but not significantly different physical (36.1 vs 39.6) and global health composite scores (32.3 vs 33.5), but higher mental health composite scores (32.8 vs 32.1).

Interestingly, adults with undiagnosed GAD were less likely to report certain comorbidities like depression (15% vs 79%) and pain (10% vs 44%) than diagnosed adults.

In order to catch more cases of undiagnosed anxiety, Karlin recommended healthcare providers screen patients using the 7-Item GAD Questionnaire. Agreeing, Glover said these findings support the use of the collaborative care model -- a brief anxiety screening at every primary care visit followed by a warm handoff to a clinician providing evidence-based treatment in the primary care setting for each patient who screens positive and is interested.

"Collaborative care decreases barriers like waitlists and avoids some of the stigma often associated with obtaining care in more specialized psychiatric settings," Glover said. "Additionally, screening in primary care has been shown to decrease healthcare costs like ER visits in the long run."