Gemma Lewis and colleagues should be congratulated for conducting the PANDA trial, the largest drug trial of primary care patients with low mood. More importantly, they used the Patient Health Questionnaire, 9-item version (PHQ-9) and Generalised Anxiety Disorder Assessment 7-item version (GAD-7) measures of low mood and anxiety, which can be easily administered in primary care and are commonly used in New Zealand to assess baseline severity to qualify for funding for extended consultations. Therefore, the results of this study are immediately generalisable to a primary care population. The surprising finding in this study was the benefit for patients who had baseline scores of around 10 on the GAD-7, where the number needed to treat was 6·3 at 12 weeks, enabling primary care clinicians to easily relate the patients in PANDA to their own patients. The number needed to treat for a patient to enter remission in the PANDA trial on the Beck Depression Inventory (BDI) II at 12 weeks was 8·3 and the PHQ-9 was 12·5. These results are not unexpected, as Fournier and colleagues reported a number needed to treat of 16 for mild to moderate depression, 11 for severe depression, and 4 for very severe depression. The placebo response in the PANDA trial was 39% for the BDI and the effect size was 12%. Thus, a response at 12 weeks is 3·25 times more likely to be a placebo response than a medication response. Lewis and colleagues state that “[their] findings support the prescription of SSRI antidepressants in a wider group of participants than previously thought, including those with mild to moderate symptoms”. If we consider that advice in light of the PHQ-9 score in the placebo group at 12 weeks, many patients who would get better anyway would be medicated. The issue is when to prescribe antidepressants—straight away at the first visit or to wait and see what happens. A 2019 primary care study with similar baseline scores to the PANDA trial reported a number needed to treat of 3 for depression remission at 1 week with behavioural activation, which was done in primary care while the patient was waiting to see their primary care clinician. Antidepressant use is increasing in high-income countries, but in New Zealand we have been using the message “talk first prescribe later” when educating primary care clinicians. SSRI use in New Zealand increased up to 2017 and since then appears to be static or decreasing. SSRIs remain the most recommended antidepressant, but patients could get better treatment in primary care with a talk first prescribe later model (unless strong evidence to the contrary exists) than with increased use of antidepressants. This argument also applies to anxiety, for which at 12 weeks in the PANDA trial the placebo response was 42% in remission and the intervention response was 58% in remission, as there is considerable overlap between depression and anxiety in primary care settings.

中文翻译：

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舍曲林在初级保健中：对PANDA试验的评论。

应该对Gemma Lewis及其同事进行PANDA试验表示祝贺，该试验是对情绪低落的初级保健患者进行的最大药物试验。更重要的是，他们使用了9个项目的患者健康调查表（PH​​Q-9）和广义的焦虑症评估的7个项目版本（GAD-7）的情绪低落和焦虑测量，可以在初级保健中轻松实施，并且通常在新西兰用来评估基线严重性，从而有资格获得扩展磋商的资金。因此，这项研究的结果可立即推广到初级保健人群。这项研究中令人惊讶的发现是，GAD-7基线评分约为10的患者受益，在12周时需要治疗的人数为6·3，从而使初级保健临床医生可以轻松地将PANDA患者与自己的病人。在PANDA试验中，根据贝克抑郁量表（BDI）II的第12周，治疗需要进入缓解期的患者人数为8·3，PHQ-9为12·5。这些结果并不出乎意料，因为Fournier及其同事报告了需要治疗的16种轻度至中度抑郁症，11种严重的抑郁症和4种非常严重的抑郁症。在PANDA试验中，安慰剂的BDI应答率为39％，效应大小为12％。因此，第12周的反应是安慰剂反应的可能性是药物反应的3·25倍。Lewis及其同事指出：“ [他们的发现支持比以前认为的更广泛的参与者，包括那些具有轻度至中度症状的参与者，处方了SSRI抗抑郁药。” 如果我们根据安慰剂组在第12周的PHQ-9分数考虑该建议，无论如何，许多会好转的患者都将接受药物治疗。问题在于何时开出抗抑郁药的处方–初次就诊时立即服用或等待观察会发生什么情况。一项与PANDA试验相似的基线评分的2019年初级保健研究报告称，需要通过行为激活在1周内治疗3例抑郁症缓解所需的数字，这是在初级保健中进行的，而患者正在等待看望初级保健临床医生。在高收入国家，抗抑郁药的使用正在增加，但在新西兰，我们在教育初级保健临床医生时一直使用“先谈话后处方”的信息。新西兰的SSRI使用率一直持续到2017年，此后一直保持稳定或下降态势。SSRI仍然是最推荐的抗抑郁药，但是，与增加抗抑郁药的使用量相比，患者首先应通过谈话开出较晚的模型（除非有相反的有力证据）才能在初级保健中获得更好的治疗。该论点也适用于焦虑，在PANDA试验中，在12周时，安慰剂缓解率为42％，干预缓解率为58％，因为初级保健机构的抑郁和焦虑之间存在相当大的重叠。