New OHSU study reveals low rates of routine patient screenings for anxiety and intimate partner violence across Oregon

National guidelines recommend a routine screening for anxiety and intimate partner violence in adolescent girls and women. But the screenings are rarely implemented across clinics in Oregon, according to a new study from Oregon Health and Science University.

The study cites reasons such as provider discomfort, lack of awareness and challenges to workflow as reasons these screenings aren’t being implemented. Amy Cantor, a researcher and OHSU family physician, was the senior researcher of this study. She joins us to share her findings and how the research led to new tangible tools that providers can use in the screening process.

Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.

Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. National guidelines recommend that women and adolescent girls get routinely screened for anxiety and intimate partner violence in their primary care visits. But according to a new study from Oregon Health and Science University, Oregon providers are rarely doing these screenings. Amy Cantor is a family physician at OHSU who specializes in primary care for women. She was a senior researcher on this study, and she joins me now. It’s great to have you on Think Out Loud.

Amy Cantor: Thanks for having me.

Miller: Where did the recommendations to ask about anxiety and intimate partner violence come from?

Cantor: Yes, one thing I want to say is that these are two separate screening recommendations that the Women’s Preventive Services Initiative put forth as the result of a systematic review of the evidence that demonstrated that screening is effective and there are effective treatments and follow-up for both of these conditions. The Women’s Preventive Services Initiative, or WPSI, is a cooperative agreement between HRSA, a federally funded Oregon branch, the Health Resources and Services Administration, and several professional organizations that specialize in women’s health and general health.

Miller: How long have these recommendations been in place?

Cantor: The recommendation for screening for anxiety came out in 2018. It was the first of its kind, and it was really unique and groundbreaking. That was part of the incentive and interest in evaluating this specific recommendation. There have been recommendations for intimate partner violence screening that came before this, by the U.S. Preventive Services Task Force, but the WPSI recommendation is more expansive, meaning that it includes all adolescents and women, whereas the USPSTF guideline is specific for women of reproductive health age.

Miller: How prescriptive are these recommendations? I mean, is it a very established set of specific questions, or is it more open-ended, like, it’s important to ask about anxiety or/and separately about intimate part violence, but you, the clinician, do it however you’d like?

Cantor: Sort of. I would say that it’s a balance between that. It’s not prescriptive because there are several validated clinical tools, meaning that there have been various tools as simple as two simple questions; or even for intimate partner violence, an opening question that opens the conversation. So it’s not that everyone should be asking this specific question, but there are several tools available that can be implemented in various clinical settings to answer those specific questions and offer that screening routinely.

Miller: I want to go back to what you said before. You said that the reason these were put forward as recommendations by these bodies is that they’re effective. What do you mean by that?

Cantor: It means that we know that screening works. That screening for a condition, and when it’s recommended specifically, we know that it can lead to effective treatment and ultimately result in better health outcomes for women. And when you think about screening recommendations in general, there’s a really strong foundation for doing these, and there’s a very high bar for the research that is used to establish those screening recommendations and inform them.

When we think about screening recommendations specifically for these conditions, we know that there are effective treatments in place, and we know that, when identified early, this can lead to better health outcomes.

Miller: Is that another way of saying that you know, and research has found, that when these questions are asked in the right way, they will yield accurate answers?

Cantor: Absolutely. That is what they mean. And when we say “a validated clinical tool,” different studies have taken different tools. For example, a screening for anxiety questionnaire that’s two simple questions that ask about anxiety symptoms, and by asking those questions you can identify people who are experiencing those symptoms effectively.

Miller: And then you can help them.

Cantor: Correct.

Miller: Which is, obviously, the reason to ask it in the first place.

Cantor: That’s the goal.

Miller: What are those two simple questions?

Cantor: It depends which tool you’re asking about, but the GAD-2 is the Generalized Anxiety Disorder screening questionnaire, and it started out as a seven-question screening tool and then was actually brought to two simple screening questions that asked about anxiety symptoms: “Do you experience anxiety symptoms,” and, “How often?”

There are ways to measure that, and there’s a threshold for then taking that on to ask more questions, but it’s that first step in the door that you can ask those questions to identify whether or not someone’s experiencing those symptoms. And if they’re not, great. You ask the questions, you screen, you move on. And if the person is positive for those, then you might want to ask more questions, or you can implement the next steps in the plan.

Miller: What about intimate partner violence questions?

Cantor: There are also various tools that are recommended. One thing that’s really interesting in the field of screening for intimate partner violence is that we’ve shifted to recommending universal education; meaning that, as part of screening, it’s really talking about and normalizing that you want to make sure resources are available. So the goal isn’t necessarily disclosure. You’re not screening to find out whether or not this is happening. You’re screening to make sure that someone knows that, if this is happening, the appropriate resources are in place that they can access when they feel safe and comfortable.

Miller: Is that different than the potential outcomes for asking about anxiety? Because you didn’t mention education first, there, and I’m wondering if there actually is a difference in the approach?

Cantor: Well, certainly, I think that with part of the perception and what we learned from our research is, both of these are considered sensitive topics; and when we were learning about what was either helping or getting in the way of this in clinical settings, when we talk to clinicians and clinic staff, we learned that there are things that make people worry about asking these questions.

And so you diffuse that, one, by normalizing it and then also by asking everyone, so it becomes universal. It becomes part of a routine question and protocol. So people feel comfortable, and you’re taking away the stigma and the concern that you might be doing something that makes someone uncomfortable.

Miller: All right, so this gets to the findings of this recent study. So, first of all, how did you go about finding out the extent to which these questions are being asked in various clinics around Oregon?

Cantor: We had some specific approaches. One was just to get a general assessment of, do you know that these screening recommendations exist? And then if you do, are you implementing them and in which patient population?

So those were the early questions. And then we conducted qualitative interviews, meaning that we had more extensive conversations with clinicians and clinic staff to learn more about, what are you doing in your daily practice? Is this part of the electronic health record? Is it routine in your system, and are there various clinic staff that are involved in the process? Five out of 12 clinics for the anxiety screening question had something in place that they were doing, but it wasn’t consistent and it wasn’t necessarily the same across all the clinics.

Miller: And seven of the 12 had nothing in place?

Cantor: They didn’t have a standard protocol in place. I would say that it wasn’t that there was nothing in place. But one thing that was interesting about anxiety screening is that they were often getting confused that depression screening was sort of a proxy for that. And there are different questions and clinical tools that you use for depression, separate from anxiety, that help identify those symptoms, although there is some overlap.

And ultimately, I can talk about that in a little bit, that led to some really important work that we did as a result of these questions, but helping them understand that there are distinct conditions and that there are different tools in order to identify those conditions.

Miller: Well, I’m glad you brought up depression. That’s another thing that health care providers, I think, can and often are asking about. I’ve been asked questions about, are there firearms in my home? Do kids have access to them, if so? How many alcoholic drinks do I have in the course of a week? How many minutes of exercise do I get?

A lot of questions, more so than I remember, I don’t know, 15 years ago, 20 years ago. How do you think about the full list of screenings that are on the plates of healthcare providers?

Cantor: Well, that was really interesting, some feedback that we received in this research. One of the barriers was screening fatigue. You hear that term and that – both for patients and clinicians – who are like, well, I ask about all these things, like the ones you just mentioned. It feels like a laundry list of things you’re supposed to ask about and how could you possibly get that done in a 10 to 15 minute visit?

So there’s several opportunities to make sure that’s happening, and part of that is helping normalize it, and part of that is clinical workflow. You may or may not have received those questions before you even stepped into the door of your clinician.

Miller: Yeah, sometimes they have me fill out things…

Cantor: Fill out the form.

Miller:…or they ask me to and I forget to.

Cantor: Sure, you got it online or you got it in your electronic mobile app or whatever it was, so you can preemptively get this information to then address the things that come back as positive screens.

Miller: Has research found any difference in whether these questions are asked and answered electronically or in person? Is there a difference in terms of the data you get?

Cantor: We didn’t look into that specifically. I’ve done other research on telehealth, specifically, and actually, telehealth for intimate partner violence services, and it turns out that asking them – for that study, not this study – was the same, in terms of the effectiveness of those screening opportunities. At that moment in time, and that was closer to when the pandemic was, telehealth actually showed similar outcomes.

Miller: I’m curious about one of the points that you mentioned a few times, and I think I understand it. You said that to normalize this is helpful and to universalize this. So it’s not up to clinicians to make guesses based on whatever potentially incorrect or biased assumptions they have about. Let me ask this person this question and not this person this question, so it makes perfect sense to have it be universalized and that can make it easier to ask questions.

But I guess I would have thought that healthcare providers, like physicians like you and nurse practitioners, other people, you ask all kinds of questions that other people wouldn’t have the professional reason or license to ask about. About sexual function, about intimate aspects of our health and lives, so why is it that doctors or nurses might be squeamish about asking these questions?

Cantor: I think we all come to our healthcare setting with our own biases, and we’ve seen that in other aspects of healthcare research, but you’re right that, if we normalize it and we destigmatize it, it is on the clinician to just say, yes, talking about sexual health is normal. Talking about intimate partner violence is normal.

Screening for anxiety, depression, cancer screening, all of these things, screening for HIV. I mean, there are several things that we do routinely, and we know that when we routinely adopt them and normalize them, we can diffuse that stigma.

Miller: As we mentioned briefly earlier, but it’s worth coming back to this, especially for both intimate partner violence and for anxiety, the point of the screening is not just to get an answer on a questionnaire, it’s to provide help to patients who might be dealing with these.

To what extent did the providers that you were talking to know what the next step would be if a patient says, “Yes, I’m dealing with anxiety,” or, “Yes, I’m dealing with intimate partner violence”? Did the providers that you interviewed, were they clear about what they should do next?

Cantor: Not always. There was some inconsistency in terms of comfort level and understanding of what happens next. I know from our research that was one of the barriers is feeling like, well, what if I don’t have the right resources in place? Or what if we don’t have that immediately?

But, you know, the answer isn’t to have all the answers in-house. It’s to know what resources… and out of this work our team created workflows and one-page resource documents that are actually available to anyone online currently. And they’re customizable so you can incorporate local resources, hotlines, national hotlines, and things that are available in your clinic, outside of your clinic and in your community so people can be connected to the right care.

Miller: Maybe this is obvious, but what’s at stake in this? What are the potential repercussions for these questions to not be asked?

Cantor: That’s really important. When we think about anxiety conditions that are undetected, that manifest into something more problematic, someone may present with symptoms that have gone beyond just their mood. It may present with physical symptoms, other stresses, and long-term impact. And we certainly see that in clinical research on the long-term impact of mental health conditions.

When we think about intimate partner violence, you can only imagine that if that goes undetected, that can turn into something more tragic. So if we’re screening early, we can identify problems before they become more concerning or long term are affecting bigger health outcomes. Effective screening can lead to effective treatments and offering resources to patients is really important.

Miller: What other solutions came forward for you, based on what you heard from these healthcare practitioners all across the state?

Cantor: The question isn’t whether or not screening works. I think everyone understands that. I think what people are trying to grapple with is, how do you provide all these services? And by creating workflows and making things smoother for them to understand, we are making sure that we have the right resources in place.

It’s not all on one person to do this. It’s building a system that works well together. That’s a better solution. No one individual can take this on, but by creating resources that help build a team and build a resource and a system that works effectively, then you can really help your patients.

Miller: Amy Cantor, thanks very much.

Cantor: Thanks so much for having me.

Miller: Amy Cantor is a family physician at OHSU and the senior researcher on this new study. It found that women and adolescent girls in Oregon are often not being screened for anxiety and intimate partner violence in their primary care visits.

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