The case for making antidepressants Class C controlled substances
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.
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.
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,
37 Fairlie, East Kilbride.