The case for mak­ing an­tide­pres­sants Class C con­trolled sub­stances

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I WISH to re­spond to Alyne Duthie’s let­ter (Oc­to­ber 9), firstly with em­pa­thy and hu­mil­ity. De­pres­sion last­ing years is a dread­ful bur­den and no doc­tor should min­imise the toll that or com­pli­ca­tions of drug treat­ment takes on in­di­vid­u­als. GPs have the re­spon­si­bil­ity to di­ag­nose and treat many pa­tients with men­tal ill­ness with­out ref­er­ence to spe­cial­ists and need to be knowl­edge­able and able to com­mu­ni­cate ef­fec­tively and em­path­i­cally with those in front of them.

For ev­ery one pa­tient with per­sis­tent de­pres­sion, there will be many who, like me, have ex­pe­ri­enced short episodes of de­pres­sive ill­ness which, with the right pre­scrip­tion, has gen­er­ated im­prove­ment back to nor­mal within four weeks. For me, cour­ses of treat­ment have been ta­pered and stopped af­ter six months with no time off work.

Ta­per­ing doses of an­tide­pres­sants is the norm and the Bri­tish Na­tional For­mu­lary doc­tors’ guide states: “The dose should be ta­pered over at least a few weeks to avoid th­ese (with­drawal) ef­fects. For some pa­tients it may be nec­es­sary to with­draw treat­ment over a longer pe­riod, con­sider ob­tain­ing spe­cial­ist ad­vice if symp­toms per­sist.” That is not to say that we can also learn from pa­tient’s less good ex­pe­ri­ences, not helped when com­pa­nies such as Eli Lilly hid in­for­ma­tion about un­com­mon but mea­sur­able flu­ox­e­tine (Prozac) side ef­fects of activation, sui­ci­dal­ity and ag­gres­sion. Much of this is pre­sented and de­bated in med­i­cal jour­nals over years – the ma­jor editorial on dis­con­tin­u­a­tion/with­drawal ef­fects of se­lec­tive sero­tonin re­up­take in­hibitors (SSRIs) was pub­lished in the BMJ in the mid-1990s.

Pre­scrip­tions for pre­ga­balin in Eng­land have in­creased more than 11-fold in the last decade and the Govern­ment has now ac­cepted in prin­ci­ple that it should be re­clas­si­fied as a class C con­trolled sub­stance. Cur­rent con­cerns notwith­stand­ing, neu­ro­pathic pain treat­ment guid­ance from The Na­tional In­sti­tute for Health and Care Ex­cel­lence (NICE) in 2013, up­dated in Fe­bru­ary 2017 states: “Of­fer a choice of amitripty­line, du­lox­e­tine, gabapentin or pre­ga­balin as ini­tial treat­ment for neu­ro­pathic pain.”

A Cochrane ev­i­dence re­view pub­lished in June this year con­cluded that gabapentin “can pro­vide good lev­els of pain re­lief to some peo­ple with pos­ther­petic neu­ral­gia and pe­riph­eral di­a­betic neu­ropath”, but added: “Ev­i­dence for other types of neu­ro­pathic pain is very lim­ited… over half of those treated with gabapentin will not have worth­while pain re­lief but may ex­pe­ri­ence ad­verse events.”

Re­clas­si­fi­ca­tion as class C con­trolled sub­stance will em­pha­sise to doc­tor and pa­tients alike that re­view of the ef­fec­tive­ness and safety of gabapentin and pre­ga­balin is manda­tory. That will de­mand time and so­phis­ti­cated care as will the en­cour­age­ment in the Chief Med­i­cal Of­fi­cer’s Re­al­is­tic Medicine strat­egy urg­ing shared pa­tient/ doc­tor de­ci­sions at the out­set – pa­tients en­cour­aged to ask “is this the best pre­scrip­tion or only op­tion now and what are the pos­i­tive and neg­a­tive as­pects of that for me?” It re­mains to be seen whether the new Scot­tish GP con­tract to com­mence in April 2018 pro­vides that time in an era of a se­vere short­age of GPs.

Philip Gaskell,

Gen­eral prac­ti­tioner locum, Wood­lands Lodge, Buchanan Cas­tle Es­tate, Dry­men.

GAVIN Tait’s let­ter (Oc­to­ber 11) crit­i­cis­ing North La­nark­shire de­ci­sion to re­place Mon­k­lands Hospi­tal does not take into con­sid­er­a­tion the huge area, both ru­ral and ur­ban, it presently caters for. Ex­pect­ing Wishaw Gen­eral, Hairmyres or ,for that mat­ter, Glas­gow Royal In­fir­mary to cater for the pop­u­la­tion of North La­nark­shire is im­prac­ti­cal and frankly makes no sense. Pub­lic trans­port within the Mon­k­lands area serv­ing Wishaw, Cum­ber­nauld, and East Kil­bride is bad enough for the healthy and good­ness knows how bad it would be for the frail or the sick.

B Dun­can,

Rosedale Drive, Glas­gow.

IF ever there was a jus­ti­fi­ca­tion of an al­ter­na­tive use for the likely half­bil­lion pounds in­tended to be spent on a re­place­ment Mon­k­lands Hospi­tal it is to­day’s head­line in­di­cat­ing the clo­sure of many homes for the el­derly, which are con­sid­ered un­fit for ser­vice and not to be re­placed (“Fears for el­derly as char­ity aims to shut 12 care homes”, The Her­ald, Oc­to­ber 12). Where will present and fu­ture res­i­dents go?

To­gether with the in­creas­ing cost of the new In­te­grated Health and So­cial Care Board, the cost of care for the in­creas­ingly frail and el­derly pop­u­la­tion will bank­rupt La­nark­shire Health Board if a new Mon­k­lands is built.

The present sorry state of the fi­nances of Tay­side Health Board should be a warn­ing to all of the lack of imag­i­na­tion in health care plan­ning. Clin­i­cal and lo­cal vested in­ter­ests must be op­posed and ra­tio­nal think­ing en­cour­aged. No plan­ning ap­pears to have an­tic­i­pated that Hairmyres A&E would be­come the go-to unit for the south side of Glas­gow when the Vic­to­ria closed, not the new Queen El­iz­a­beth hospi­tal. Con­se­quently Hairmyres re­quires ma­jor en­large­ment.

We should not be build­ing a new acute hospi­tal when what is needed are mul­ti­ple care homes and lo­cal “cot­tage” hospi­tals, as Thomas Law (Let­ters, Oc­to­ber 12) sug­gests,

Gavin Tait,

37 Fair­lie, East Kil­bride.

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