In their CME article on generalized anxiety disorder, the authors claim that 45% of such disorders are not recognized in primary care. Leaving aside the fact that the study cited in support of this statement is 20 years old, and that the diagnosis and treatment of anxiety disorders have changed over these two decades—from a general practitioner’s perspective, a detection rate of 55% for anxiety disorders, which often present somatically, seems a good result in primary care.
The recommended drugs of first choice are SSRIs, SNRIs, and pregabalin. Among the SSRIs, escitalopram was favored. There are no scientifically proven differences in effectiveness between citalopram and the notably more expensive escitalopram as a levorotatory isomer. The authors did not discuss this in their article. However, the fact that the potential for addiction, which has been proven for pregabalin (1, 2), was not mentioned at all is almost criminal.
Both substances are among those whose prescription has been viewed as uneconomical, according to publications by the Associations of Statutory Health Insurance Physicians. Their use could be justified in case of medical benefits, but not where those are lacking.
Two years ago, the BMJ published a systematic review on the topic of generalized anxiety disorders (3), which was methodologically far more valuable than the results of a selective literature search presented in the CME article. The results: fluoxetine was the preferred drug in terms of effectiveness, sertraline in terms of tolerability. The authors did not mention this meta-analysis.
In sum, the published article does not merit the sign of approval of a CME article; rather, it carries a sense of one-sided presentation.
It is most welcome that authors publishing in Deutsches Ärzteblatt have to declare their competing interests. The comprehensive list reported by the authors of this article gives readers a clear idea of what might be the cause of the authors’ bias.
Dr. med. Günther Egidi
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Schwan S, Sundström A, Stjernberg E, et al.: A signal for an abuse liability for pregabalin results from the Swedish spontaneous adverse drug reaction reporting system. Eur J Clin Pharmacol 2010; 66: 947–53 CrossRef MEDLINE|
|2.||Caster O, Edwards IR, Noren G0N, Lindquist M: Earlier discovery of pregabalin’s dependence potential might have been possible. Eur J Clin Pharmacol 2011; 67:319–20 CrossRef MEDLINE|
|3.||Baldwin D, Woods R, Lawson R, Taylor D: Efficacy of drug treatments for generalised anxiety disorder: systematic review and meta-analysis BMJ 2011; 342: d1199 MEDLINE|
|4.||Bandelow B, Boerner RJ, Kasper S, Linden M, Wittchen HU, Möller HJ: The diagnosis and treatment of generalized anxiety disorder. Dtsch Arztebl Int 2013; 110(17): 300–10 VOLLTEXT|