pinkmada
08-21-2008, 04:51 PM
i don't seem to have any luck with GPs. the ones i've liked have all been locums so have left the practice months later.
i saw a new gp today because the anti-depressents have been giving me severe headaches. she was beyond useless. first she searched online the drug i am currently taking even though she had a bnf infront of her! then she told me that most of the anti-depressents available to me are of the same 'family' (she was also very patronising, though that could just be my perception since i didnt like her) so would probably cause the same side effects. then she told me about one (i cant remember the name) in a different 'family' but asked how my blood count has been recently because this drug lowers your WBC! so i told her i thought it was fine but didnt she have it on the comupter in front of her? she then asked what i thought about taking this drug and i responded (politely) that i don't know, i am not a doctor, but i would think she should consult my oncologist before prescribing me with the drug! she 'hmmmmed' at me and then said it was too much hassel so prescribed me with a similar SSRI which will probably have the same effetcs. and being a student nurse i have a bnf! it was a complete waste of time! so i definatly will not be seeing her again! this is why i always end up going to see my oncologist about stuff like this. she isn't stupid!
i'm also having a really bad day (and severe mood swings) which probably hasn't helped my feelings towards this morning!
and i keep forgetting to ask when i can have my hep b vaccines for work and uni. did you know that we are supposed to get all our old vaccines? (MMR, polio, tetanus etc) as daft as it sounds, i hate getting muscle injections! i think they hurt more than anything ever!
x
i saw a new gp today because the anti-depressents have been giving me severe headaches. she was beyond useless. first she searched online the drug i am currently taking even though she had a bnf infront of her! then she told me that most of the anti-depressents available to me are of the same 'family' (she was also very patronising, though that could just be my perception since i didnt like her) so would probably cause the same side effects. then she told me about one (i cant remember the name) in a different 'family' but asked how my blood count has been recently because this drug lowers your WBC! so i told her i thought it was fine but didnt she have it on the comupter in front of her? she then asked what i thought about taking this drug and i responded (politely) that i don't know, i am not a doctor, but i would think she should consult my oncologist before prescribing me with the drug! she 'hmmmmed' at me and then said it was too much hassel so prescribed me with a similar SSRI which will probably have the same effetcs. and being a student nurse i have a bnf! it was a complete waste of time! so i definatly will not be seeing her again! this is why i always end up going to see my oncologist about stuff like this. she isn't stupid!
i'm also having a really bad day (and severe mood swings) which probably hasn't helped my feelings towards this morning!
and i keep forgetting to ask when i can have my hep b vaccines for work and uni. did you know that we are supposed to get all our old vaccines? (MMR, polio, tetanus etc) as daft as it sounds, i hate getting muscle injections! i think they hurt more than anything ever!
x
Sponsor
lymphpre
08-23-2008, 12:04 PM
Hi Amanda,
Must be careful not to infringe any regulations here, so will give some information, but not advise.
I sympathise with you. I have a similar problem with my GP surgery, as there are around 10 names on the list, and you see whoever is available. I have yet to see the same one twice, most are locums, and they always have to look everything up.
I believe that not all SSRIs have the same side effect profile, otherwise everyone would get fluoxetine (prozac), which was the first widely used one. I thought they had stopped prescribing it, but spoke to someone the other day who has just been put on it. There is quite a lot of literature on these drugs, and when you read it carefully, it seems that only around 40% of patients report benefit from them. The benefits come at around the 3-6 week period, but the side-effects come immediately, which is why so many people discontinue them at an early stage: all the costs without the benefits. :(Which drug is prescribed is often down to the preference of the individual doctor, and not often not based upon anything other than their own anecdotal evidence. The same is also true of anti-psychotics.
If she is talking about another class of drug, that will either be a monoamine oxidase inhibitor (MAO), or a tricyclic. A MAO can be nasty, and you have to really watch what you eat: anything containing protein that is less than 100% fresh can give you headaches and heart palpitations. Without making a recommendation, I have to say I was on one as part of the ClVPP regime (procarbazine), and I would not want to go on one again. The anti-depressant which is similar to a tricyclic, and used quite a lot, is venlafaxine. This inhibits re-uptake of both serotonin and noradrenaline. A good friend of mine, with a long-term history of depression, switched to this after not getting on with SSRIs, and got on well with it in all respects.
A decent psychiatrist should know the pros and cons of the different SSRIs inside out. You do not need a referral to a psychiatrist over this, but a quick phone call for advice from your oncologist could be really helpful. I find that consultants in one specialism are often happy to approach a consultant from another specialism for advice, whereas the GP will either attempt to handle it themselves, or refer you on.
Best wishes
Simon
Must be careful not to infringe any regulations here, so will give some information, but not advise.
I sympathise with you. I have a similar problem with my GP surgery, as there are around 10 names on the list, and you see whoever is available. I have yet to see the same one twice, most are locums, and they always have to look everything up.
I believe that not all SSRIs have the same side effect profile, otherwise everyone would get fluoxetine (prozac), which was the first widely used one. I thought they had stopped prescribing it, but spoke to someone the other day who has just been put on it. There is quite a lot of literature on these drugs, and when you read it carefully, it seems that only around 40% of patients report benefit from them. The benefits come at around the 3-6 week period, but the side-effects come immediately, which is why so many people discontinue them at an early stage: all the costs without the benefits. :(Which drug is prescribed is often down to the preference of the individual doctor, and not often not based upon anything other than their own anecdotal evidence. The same is also true of anti-psychotics.
If she is talking about another class of drug, that will either be a monoamine oxidase inhibitor (MAO), or a tricyclic. A MAO can be nasty, and you have to really watch what you eat: anything containing protein that is less than 100% fresh can give you headaches and heart palpitations. Without making a recommendation, I have to say I was on one as part of the ClVPP regime (procarbazine), and I would not want to go on one again. The anti-depressant which is similar to a tricyclic, and used quite a lot, is venlafaxine. This inhibits re-uptake of both serotonin and noradrenaline. A good friend of mine, with a long-term history of depression, switched to this after not getting on with SSRIs, and got on well with it in all respects.
A decent psychiatrist should know the pros and cons of the different SSRIs inside out. You do not need a referral to a psychiatrist over this, but a quick phone call for advice from your oncologist could be really helpful. I find that consultants in one specialism are often happy to approach a consultant from another specialism for advice, whereas the GP will either attempt to handle it themselves, or refer you on.
Best wishes
Simon
harka
08-25-2008, 12:47 AM
Lymphpre,
With all due respect, this is a support board, and speaking so ill of GPs and psychiatrists the way you audaciously do is both rude and counterproductive. Especially considering doctor-patient relationships play a HUGE role for people who have an illness. Name-calling doesn't get anyone anywhere.
pinkmada, I sense you must be having a very difficult time. I take it you are on chemo?
Anyway, when your GP was talking about other "classes" of antidepressants, I will diverge slightly from lymphpre and say that she was very unlikely talking about MAOIs or tricyclic antidepressants. The former are a very old class with lots of side-effects and are rarely used anymore. The latter are only used now as tranquilizers as they can have serious cardioelectrophysiological side effects. (*edit: I see that the GP DID in fact prescribe a TCA which is VERY surprising to me given the many more safe options available! Simon, I apologize, you were correct!) She was likely speaking of the SNRIs (serotonin-norepinephrine reuptake inhibitors) such as venlafaxine (or Effexor), or...shoot...I forget the class...but an example in the class is called bupropion or Wellbutrin...and there is a final one and...shoot again, I forget the name of its class, but it is called mirtazipine or Remeron. Those three drugs are relatively new agents used for the treatment of depression which are NOT SSRIs.
As you know mentally fighting to stay positive is a huge part of getting through an illness. Depression is something which is definitely not just "in your head", and can seriously hinder the aforesaid process. Though I don't agree with lymphpre's comments about GPs and shrinks, I DO agree that it would likely be best for you to be seen by a psychiatrist who is not just experienced in the pharmacological treatment of depression, but also psychotherapy.
With all due respect, this is a support board, and speaking so ill of GPs and psychiatrists the way you audaciously do is both rude and counterproductive. Especially considering doctor-patient relationships play a HUGE role for people who have an illness. Name-calling doesn't get anyone anywhere.
pinkmada, I sense you must be having a very difficult time. I take it you are on chemo?
Anyway, when your GP was talking about other "classes" of antidepressants, I will diverge slightly from lymphpre and say that she was very unlikely talking about MAOIs or tricyclic antidepressants. The former are a very old class with lots of side-effects and are rarely used anymore. The latter are only used now as tranquilizers as they can have serious cardioelectrophysiological side effects. (*edit: I see that the GP DID in fact prescribe a TCA which is VERY surprising to me given the many more safe options available! Simon, I apologize, you were correct!) She was likely speaking of the SNRIs (serotonin-norepinephrine reuptake inhibitors) such as venlafaxine (or Effexor), or...shoot...I forget the class...but an example in the class is called bupropion or Wellbutrin...and there is a final one and...shoot again, I forget the name of its class, but it is called mirtazipine or Remeron. Those three drugs are relatively new agents used for the treatment of depression which are NOT SSRIs.
As you know mentally fighting to stay positive is a huge part of getting through an illness. Depression is something which is definitely not just "in your head", and can seriously hinder the aforesaid process. Though I don't agree with lymphpre's comments about GPs and shrinks, I DO agree that it would likely be best for you to be seen by a psychiatrist who is not just experienced in the pharmacological treatment of depression, but also psychotherapy.
pinkmada
08-25-2008, 04:10 AM
Hey Simon,
thanks for the reply. i was ranting. i do need to contact my onc again and let her know what my GP has pescribed me. the drug she tried to px me with that lowers my wbc is called lofepramine, a tricyclic) my psychologist is right, i do have severe trust issues when it comes to GPs and i question absolutely everything they do or say to me and this is why i almost always end up seeing my onc about anything that is wrong with me.
(i had the yucky stuff with my period again this month and my onc is referring me to see gynae asap. and i know that if i had went to see my GP about this then he'she would have given me antibiotics, and told me to 'wait and see'. at least with my onc, i get things seen to quickly.
i have not started to take the drug she prescribed (citalopram) and have continued to take the fluoxetine (and a lot of paracetamol) but i am almost out so i have to go back to my gps.
the first couple of weeks of me taking the fluoxetine i lost a few pounds but the headaches have only been the last few weeks (i have now been on them for 6 weeks) but i really havent noticed any difference with them. although my partner has told me that i have had a lot of mood swings recently.
i will ask my onc if she could even just arrange a phone call session with a psyciatrist. what is it they say? GPs no less and less about more and more and consultants know more and more about less and less? that makes sense.
Cgranulomatis, thanks for the reply, Simon wasn't being disrespectful, i have had a continuous struggle with my GPs as they never seem to listen to me. i am a year in remission and struggling with everything now. i am also a student nurse and my GP knows this but she was extrememly patronising when she was talking to me. (again, i can appreciate that she might not have been as patronising as i thought and it could just be my perception). the inverted commas around 'family' was just to emphasise that she was speaking to me like a child. but my gp googling the drugs i am on instead of using her bnf is a bit worrying when even nurses have bnfs (its like the pharmacy bible over here) and then telling me that i could take aspirin or ibuprofen with the paracetamol when it clearly states that you cant take these with fluoxetine and i cant take these anyway because of my haital hernia and then her prescribing me with a drug that will lower my blood count without consulting my oncologist i think is just careless and unprofessional and definatly not client centered care. she told me it was 'too much trouble' for her to contact my onc and prescribed me with a similar ssri even though she said it would probably cause the same side effects. anyways, i really just needed to rant about how incompetant my GP was being and how it seems to be a pattern with my GPs and really just say my feelings out loud. But thank you for the reply.
Simon, have you heard from resp medicine yet?
xxx
thanks for the reply. i was ranting. i do need to contact my onc again and let her know what my GP has pescribed me. the drug she tried to px me with that lowers my wbc is called lofepramine, a tricyclic) my psychologist is right, i do have severe trust issues when it comes to GPs and i question absolutely everything they do or say to me and this is why i almost always end up seeing my onc about anything that is wrong with me.
(i had the yucky stuff with my period again this month and my onc is referring me to see gynae asap. and i know that if i had went to see my GP about this then he'she would have given me antibiotics, and told me to 'wait and see'. at least with my onc, i get things seen to quickly.
i have not started to take the drug she prescribed (citalopram) and have continued to take the fluoxetine (and a lot of paracetamol) but i am almost out so i have to go back to my gps.
the first couple of weeks of me taking the fluoxetine i lost a few pounds but the headaches have only been the last few weeks (i have now been on them for 6 weeks) but i really havent noticed any difference with them. although my partner has told me that i have had a lot of mood swings recently.
i will ask my onc if she could even just arrange a phone call session with a psyciatrist. what is it they say? GPs no less and less about more and more and consultants know more and more about less and less? that makes sense.
Cgranulomatis, thanks for the reply, Simon wasn't being disrespectful, i have had a continuous struggle with my GPs as they never seem to listen to me. i am a year in remission and struggling with everything now. i am also a student nurse and my GP knows this but she was extrememly patronising when she was talking to me. (again, i can appreciate that she might not have been as patronising as i thought and it could just be my perception). the inverted commas around 'family' was just to emphasise that she was speaking to me like a child. but my gp googling the drugs i am on instead of using her bnf is a bit worrying when even nurses have bnfs (its like the pharmacy bible over here) and then telling me that i could take aspirin or ibuprofen with the paracetamol when it clearly states that you cant take these with fluoxetine and i cant take these anyway because of my haital hernia and then her prescribing me with a drug that will lower my blood count without consulting my oncologist i think is just careless and unprofessional and definatly not client centered care. she told me it was 'too much trouble' for her to contact my onc and prescribed me with a similar ssri even though she said it would probably cause the same side effects. anyways, i really just needed to rant about how incompetant my GP was being and how it seems to be a pattern with my GPs and really just say my feelings out loud. But thank you for the reply.
Simon, have you heard from resp medicine yet?
xxx
harka
08-25-2008, 12:42 PM
Hey again,
Yeah, it does sound like your doctor doesn't listen to you, and for sure that is not exactly going to help with your perception of her abilities. I can't believe she said "it would be too much trouble to contact your onc". Man! But I hope that doesn't soil your perception of all family docs, 'cause many of them are good. One thing is, doctors who are doing locums don't know you as well, and since they are transient, don't ever GET to know you well and develop a therapeutic relationship.
There is a huge discrepancy between what a doctor thinks (knows) is a good doctor and what a patient does. From a doctor's point of view, a good doctor is obviously someone who has very good clinical accumen in the realm of diagnosis and therapeutics. The icing on the cake would be a good bedside manner, but unfortunately with older docs, this is often not the case. Then you go to a patient's point of view (and there has been studies on this): showing that a patient is much more likely to view a doctor as a "good doctor" if they feel like the person's bedside manner is good, regardless of their clinical accumen.
To clarify, many doctors know of an eccentric older physician (lets' call him Dr. X) they work with who is one of the most brilliant people they've ever met, and if they ever got sick, would want Dr. X looking after them; HOWEVER, because Dr. X's bedside manner is atrocious, patients (who are not aware of what makes a good clinician from the knowledge and clinical accumen point of view) will uniformly say they hate Dr. X and don't trust him. The converse is true as well: there are plenty of doctors out there who are really nice and easy to get along with, but don't have the best clinical skills. Patients often trust anything this doctor says, and when another doctor gives a dissenting opinion, they are less likely to listen, even if doctor II is correct.
What am I trying to get at? Well, the optimal doctor would be someone who not only has a razor sharp clinical accumen, but also has amazing bedside manner. Wouldn't that be great eh?!
Soooooooooooooooooooooooo, in Canada, I don't think we have the bnf or whatever...we have something called CPS. While it is the "bible" so to speak of drugs, physicians often nowadays use things internet search engines first of all because it is way faster, and second of all because search engines help to find the medical databases (like Micromedex) that clinicians around the world use. The CPS (or bnf) is a great resource, yes, but the 'net can hook you up with electronic versions of that resource which saves a lot of time.
Finally, I mentioned a few medications like bupropion, mirtazipine and venlafaxine--did your doctor mention any of those?
Yeah, it does sound like your doctor doesn't listen to you, and for sure that is not exactly going to help with your perception of her abilities. I can't believe she said "it would be too much trouble to contact your onc". Man! But I hope that doesn't soil your perception of all family docs, 'cause many of them are good. One thing is, doctors who are doing locums don't know you as well, and since they are transient, don't ever GET to know you well and develop a therapeutic relationship.
There is a huge discrepancy between what a doctor thinks (knows) is a good doctor and what a patient does. From a doctor's point of view, a good doctor is obviously someone who has very good clinical accumen in the realm of diagnosis and therapeutics. The icing on the cake would be a good bedside manner, but unfortunately with older docs, this is often not the case. Then you go to a patient's point of view (and there has been studies on this): showing that a patient is much more likely to view a doctor as a "good doctor" if they feel like the person's bedside manner is good, regardless of their clinical accumen.
To clarify, many doctors know of an eccentric older physician (lets' call him Dr. X) they work with who is one of the most brilliant people they've ever met, and if they ever got sick, would want Dr. X looking after them; HOWEVER, because Dr. X's bedside manner is atrocious, patients (who are not aware of what makes a good clinician from the knowledge and clinical accumen point of view) will uniformly say they hate Dr. X and don't trust him. The converse is true as well: there are plenty of doctors out there who are really nice and easy to get along with, but don't have the best clinical skills. Patients often trust anything this doctor says, and when another doctor gives a dissenting opinion, they are less likely to listen, even if doctor II is correct.
What am I trying to get at? Well, the optimal doctor would be someone who not only has a razor sharp clinical accumen, but also has amazing bedside manner. Wouldn't that be great eh?!
Soooooooooooooooooooooooo, in Canada, I don't think we have the bnf or whatever...we have something called CPS. While it is the "bible" so to speak of drugs, physicians often nowadays use things internet search engines first of all because it is way faster, and second of all because search engines help to find the medical databases (like Micromedex) that clinicians around the world use. The CPS (or bnf) is a great resource, yes, but the 'net can hook you up with electronic versions of that resource which saves a lot of time.
Finally, I mentioned a few medications like bupropion, mirtazipine and venlafaxine--did your doctor mention any of those?
pinkmada
08-26-2008, 06:07 AM
Surprisingly i have had a good relationship with the doctors that have been locums. My first locum was the doctor that actually believed me that there was something wrong, instructed the hospitals to repeat the scans and then i was finally diagnosed. The doctor i saw last week wasn't a locum though she was very young.
I also requested my medical notes a few months back and discovered that it wasn't just my original GP that lied to me, it was every doctor I had seen before my diagnosis. Which again, doesn't help the trust thing.
I do understand that using the internet is easier and quicker than a book, however, the NHS have this amazing intranet thing called 'Trak' and everything a doctor needs to know (about anything) is on this. And there is also a website/search engine for the bnf. She didn't use either of these. she used googlee.
My gp didnt mention any of the drugs you have that I remember.
Thanks
x
I also requested my medical notes a few months back and discovered that it wasn't just my original GP that lied to me, it was every doctor I had seen before my diagnosis. Which again, doesn't help the trust thing.
I do understand that using the internet is easier and quicker than a book, however, the NHS have this amazing intranet thing called 'Trak' and everything a doctor needs to know (about anything) is on this. And there is also a website/search engine for the bnf. She didn't use either of these. she used googlee.
My gp didnt mention any of the drugs you have that I remember.
Thanks
x
lymphpre
08-26-2008, 08:20 AM
"Lymphpre,
With all due respect, this is a support board, and speaking so ill of GPs and psychiatrists the way you audaciously do is both rude and counterproductive. Especially considering doctor-patient relationships play a HUGE role for people who have an illness. Name-calling doesn't get anyone anywhere."
Looks like someone is up for a fight. Well, I am going to disappoint you. If I have caused offence with any of my posts, the only appropriate course of action is to apologise, and I shall do so immediately. It is not my intention to offend anybody, nor to violate the rules of the forum, and I appologise for having done so.
Hi Amanda,
how are you doing?
Still no sign of a high definition CT scan appointment, but have appointment with respiratory meds plus repeat of pulmonary function tests on Sept 18th. I would not say my breathing has got any better, but at least it seems stable at the moment, whereas it was definately getting worse a few weeks ago.
I am still wary of straying into dangerous territory by spending too much time discussing anti-depressants. As you know, medical treatment in the U.K. is constrained by the NICE (National Insitute of Clinical Excellence) guidelines, which, among other things, tell Drs. what they can and cannot prescribe. I believe the depression guidelines are due to be revised at the end of this year, but here is a link to the current guidelines, published in 2004, with an ammendment from 2006, to cover venlafaxine.
http://www.nice.org.uk/Guidance/CG23/Guidance/pdf/English
This is quite an information-packed document, which covers a fair amount of the evidence base for and against the different anti-depressants. The conclusions seem to be that there is little evidence that the various drugs differ in terms of efficacy/effectiveness. However, where the newer drugs tend to do better is in terms of side effect profiles, which makes them easier to tolerate.
It also contains guidelines as to who may prescribe what, and casts light on the suggestions made by the G.P. you saw. A regular G.P. may only prescribe an SSRI, or a tricyclic. Lofrepramine is the one recomended in the guidleines because of lower cardio-toxicity. Venlafaxine may only be prescribed by a specialist mental health practitioner (p.211). This can include a G.P., but only one with a special interest in mental health (i.e. who has done further training). Your oncologist will probably be similarly restricted in terms of which anti-depressants she can prescribe, but she might have better links with the psychiatrist/psychologist team, as I assume the connection there was via oncology?
Buproprion belongs to a class of drugs known as aminoketones. Its action is quite different to most anti-depressants, as it acts as a noradrenaline and dopamine reuptake inhibitor, and a nicotinic antagonist. It has been widely used as an anti-depressant in America since the mid-1980s. In the U.K, it has the brand name Zyban, and was licensed only for use in smoking cessation programs, and not as an anti-depressant. This may be something that is being reviewed, but is currently not commonly prescribed as an anti-depressant here, and is not mentioned at all in the current NICE guidelines on depression.
Mirtazepine is used as an antidepressant in the U.K., but like venlafaxine, needs to be prescribed by a specialist mental health practitioner. It is a noradrenergic and specific serotonin anti-depressant (NaSSA), sometimes referred to as a tetracylic antidepressent. Studies so far look promising in terms of better side effect profile than SSRI's. Again, this is psychiatrist territory at the moment.
Amanda, you did see a psychiatrist at some stage, or have I got confused? How did that referral come about? Some, but definately not all, U.K. oncology/haematology services have an affiliated psychology/psychological therapy/counselling service, but no psychiatric involvement. Did you see a liaison psychiatrist, or get a referral to the mental health services, or have I just got the whole thing mixed up?
The idea of a psychiatrist also trained in psychotherapy is something that you rarely get any more in the U.K. health system. A U.K. psychiatrist does not have extensive training in psychological therapies, although those with an interest may elect to do a very limited amount as part of their training. In the past, some psychiatrists took post-qualification training in psychotherapy, and incorporated this into their work, but that is pretty rare now. I doubt you will find many U.K. psychiatrists engaging in psychotherapy as part of their NHS work, for the simple reason that it is not a cost-effective use of a psychiatrist's time. Yes there are exceptions, e.g. Stirling Moorey at the Maudsley Hospital in London, but is makes far more sense to NHS managers to have time-consuming psychotherapy carried out by a psychologist, a counsellor, or increasingly a nurse who has undertaken further training in a psychological therapy (often CBT). You could probably get three of these for the price of one psychiatrist. Sorry, I digress into politics. My point is that there are reasons why UK practitioners expert in pharmacological treament of depression are rarely expert in psychological treatment, and vice versa.
Best wishes
Simon
With all due respect, this is a support board, and speaking so ill of GPs and psychiatrists the way you audaciously do is both rude and counterproductive. Especially considering doctor-patient relationships play a HUGE role for people who have an illness. Name-calling doesn't get anyone anywhere."
Looks like someone is up for a fight. Well, I am going to disappoint you. If I have caused offence with any of my posts, the only appropriate course of action is to apologise, and I shall do so immediately. It is not my intention to offend anybody, nor to violate the rules of the forum, and I appologise for having done so.
Hi Amanda,
how are you doing?
Still no sign of a high definition CT scan appointment, but have appointment with respiratory meds plus repeat of pulmonary function tests on Sept 18th. I would not say my breathing has got any better, but at least it seems stable at the moment, whereas it was definately getting worse a few weeks ago.
I am still wary of straying into dangerous territory by spending too much time discussing anti-depressants. As you know, medical treatment in the U.K. is constrained by the NICE (National Insitute of Clinical Excellence) guidelines, which, among other things, tell Drs. what they can and cannot prescribe. I believe the depression guidelines are due to be revised at the end of this year, but here is a link to the current guidelines, published in 2004, with an ammendment from 2006, to cover venlafaxine.
http://www.nice.org.uk/Guidance/CG23/Guidance/pdf/English
This is quite an information-packed document, which covers a fair amount of the evidence base for and against the different anti-depressants. The conclusions seem to be that there is little evidence that the various drugs differ in terms of efficacy/effectiveness. However, where the newer drugs tend to do better is in terms of side effect profiles, which makes them easier to tolerate.
It also contains guidelines as to who may prescribe what, and casts light on the suggestions made by the G.P. you saw. A regular G.P. may only prescribe an SSRI, or a tricyclic. Lofrepramine is the one recomended in the guidleines because of lower cardio-toxicity. Venlafaxine may only be prescribed by a specialist mental health practitioner (p.211). This can include a G.P., but only one with a special interest in mental health (i.e. who has done further training). Your oncologist will probably be similarly restricted in terms of which anti-depressants she can prescribe, but she might have better links with the psychiatrist/psychologist team, as I assume the connection there was via oncology?
Buproprion belongs to a class of drugs known as aminoketones. Its action is quite different to most anti-depressants, as it acts as a noradrenaline and dopamine reuptake inhibitor, and a nicotinic antagonist. It has been widely used as an anti-depressant in America since the mid-1980s. In the U.K, it has the brand name Zyban, and was licensed only for use in smoking cessation programs, and not as an anti-depressant. This may be something that is being reviewed, but is currently not commonly prescribed as an anti-depressant here, and is not mentioned at all in the current NICE guidelines on depression.
Mirtazepine is used as an antidepressant in the U.K., but like venlafaxine, needs to be prescribed by a specialist mental health practitioner. It is a noradrenergic and specific serotonin anti-depressant (NaSSA), sometimes referred to as a tetracylic antidepressent. Studies so far look promising in terms of better side effect profile than SSRI's. Again, this is psychiatrist territory at the moment.
Amanda, you did see a psychiatrist at some stage, or have I got confused? How did that referral come about? Some, but definately not all, U.K. oncology/haematology services have an affiliated psychology/psychological therapy/counselling service, but no psychiatric involvement. Did you see a liaison psychiatrist, or get a referral to the mental health services, or have I just got the whole thing mixed up?
The idea of a psychiatrist also trained in psychotherapy is something that you rarely get any more in the U.K. health system. A U.K. psychiatrist does not have extensive training in psychological therapies, although those with an interest may elect to do a very limited amount as part of their training. In the past, some psychiatrists took post-qualification training in psychotherapy, and incorporated this into their work, but that is pretty rare now. I doubt you will find many U.K. psychiatrists engaging in psychotherapy as part of their NHS work, for the simple reason that it is not a cost-effective use of a psychiatrist's time. Yes there are exceptions, e.g. Stirling Moorey at the Maudsley Hospital in London, but is makes far more sense to NHS managers to have time-consuming psychotherapy carried out by a psychologist, a counsellor, or increasingly a nurse who has undertaken further training in a psychological therapy (often CBT). You could probably get three of these for the price of one psychiatrist. Sorry, I digress into politics. My point is that there are reasons why UK practitioners expert in pharmacological treament of depression are rarely expert in psychological treatment, and vice versa.
Best wishes
Simon
harka
08-27-2008, 12:47 AM
"Looks like someone is up for a fight. Well, I am going to disappoint you. If I have caused offence with any of my posts, the only appropriate course of action is to apologise, and I shall do so immediately. It is not my intention to offend anybody, nor to violate the rules of the forum, and I appologise for having done so"
I'm not up for a fight--I just felt your comments were inappropriate. That's nice of you to apologize, but it's not me you need to apologize to.
I noticed your breakdown of each of the drugs I mentioned, and the comments at the end of your message mentioning a relative rarity of psychiatrists who do psychotherapy. I find that quite surprising, because that's not the case here in Canada. So if the psychiatrists aren't doing psychotherapy w/ or w/o psychopharmaceuticals, what types of therapy are they practicing? Is it more things like Cognitive Behavioural Therapy and other related modalities?
Additionally, I'm also very shocked that GPs can't prescribe venlafaxine and mirtazapine in the UK. Is that true for all parts of the UK?
I'm not up for a fight--I just felt your comments were inappropriate. That's nice of you to apologize, but it's not me you need to apologize to.
I noticed your breakdown of each of the drugs I mentioned, and the comments at the end of your message mentioning a relative rarity of psychiatrists who do psychotherapy. I find that quite surprising, because that's not the case here in Canada. So if the psychiatrists aren't doing psychotherapy w/ or w/o psychopharmaceuticals, what types of therapy are they practicing? Is it more things like Cognitive Behavioural Therapy and other related modalities?
Additionally, I'm also very shocked that GPs can't prescribe venlafaxine and mirtazapine in the UK. Is that true for all parts of the UK?
lymphpre
08-27-2008, 08:00 AM
The National Institute of Clinical Excellence (NICE) is intended to standardise treatment across the U.K., so yes, if use of a prescription drug such as those mentioned is restricted to mental health practitioners, then that restriction will apply to practitioners in all parts of the U.K.. Scotland can sometimes differ, but there are other factors at play there, largely related to the fact that they have a separate legal system. There are loopholes, and you still get situations where a particular drug is available under one health authority, but not another (rituximab, and herceptin being cancer-related examples which come to mind), but this was something the NICE guidelines were intended to prevent. NICE also attracts controversy because part of its remit is to evaluate cost-effectiveness, which means there are constant examples of clinicians being prevented from prescribing drugs deemed too expensive for the demonstrable gains. The examples which make the headlines are often forms of non-curative chemotherapy.
The healthcare system in the U.K. has undergone massive change in the last ten years, and this continues. All consultant medics, including psychiatrists, are very expensive, so their time is spread thinly. Their role is increasingly a consultancy role. Psychiatrists areas of expertise, in which no other mental health practitioner is fully qualified, are diagnosis, pharmacological treatments, and application of the Mental Health Act. They are also the only professions who can refer patients for treatments such as ECT and psychosurgery. A psychiatrist will oversee the care of a patient, and may refer them for psychological therapy (I include CBT in this umbrella term), but is unlikely to deliver that psychological therapy themselves. A psychological therapy might be prescribed in the same way as a pharmacological intervention. This has not always been the case, and, as I said, the system is in a constant state of change. But there is a big emphasis on cost-effectiveness, and "lean thinking". It is simply not cost effective for a psychiatrist to deliver CBT or any other psychological therapy, when a CBT-trained nurse therapist can deliver it for a third of the cost. I acknowledge there will be exceptions, but I think this has become the rule. There are also genuine concerns that some professions, such as psychologists, simply do not fit in with current NHS thinking about mental health service structure, and may cease to feature in many areas. This may change again though, as the new Mental Health act comes in soon, which will allow some other (cheaper) professions to carry out certain activities which were formerly the exclusive remit of psychiatrists.
The current NHS structure is far more complex than most people realise, as it is a mixture of NHS owned resources, alongside services bought in from the private sector. The New NHS: A Guide, by Alison Talbot-Smith and Allyson M. Pollock, covers it very well. But, beware, it is not light reading.
If we can get away with another post on this topic, I have some understanding of how American Healthcare works, which is radically different to the U.K., but I know nothing of the Canadian system. Would it be possible to say a few brief words about it?
Best wishes
Simon
The healthcare system in the U.K. has undergone massive change in the last ten years, and this continues. All consultant medics, including psychiatrists, are very expensive, so their time is spread thinly. Their role is increasingly a consultancy role. Psychiatrists areas of expertise, in which no other mental health practitioner is fully qualified, are diagnosis, pharmacological treatments, and application of the Mental Health Act. They are also the only professions who can refer patients for treatments such as ECT and psychosurgery. A psychiatrist will oversee the care of a patient, and may refer them for psychological therapy (I include CBT in this umbrella term), but is unlikely to deliver that psychological therapy themselves. A psychological therapy might be prescribed in the same way as a pharmacological intervention. This has not always been the case, and, as I said, the system is in a constant state of change. But there is a big emphasis on cost-effectiveness, and "lean thinking". It is simply not cost effective for a psychiatrist to deliver CBT or any other psychological therapy, when a CBT-trained nurse therapist can deliver it for a third of the cost. I acknowledge there will be exceptions, but I think this has become the rule. There are also genuine concerns that some professions, such as psychologists, simply do not fit in with current NHS thinking about mental health service structure, and may cease to feature in many areas. This may change again though, as the new Mental Health act comes in soon, which will allow some other (cheaper) professions to carry out certain activities which were formerly the exclusive remit of psychiatrists.
The current NHS structure is far more complex than most people realise, as it is a mixture of NHS owned resources, alongside services bought in from the private sector. The New NHS: A Guide, by Alison Talbot-Smith and Allyson M. Pollock, covers it very well. But, beware, it is not light reading.
If we can get away with another post on this topic, I have some understanding of how American Healthcare works, which is radically different to the U.K., but I know nothing of the Canadian system. Would it be possible to say a few brief words about it?
Best wishes
Simon
harka
08-27-2008, 11:17 PM
Sorry in advance mods, but I figure this post will be of support to lymphpre! :)
Yes, things are quite different here in Canada, and while parts of the health care system are compartmentalized (i.e. GP vs. specialists) there aren't any strict rules about what a GP can and can not do. For example, not that it would be recommended, but if a GP wanted to, s/he COULD technically prescribe, say, interferon to a patient with Hep C....i.e.... s/he could write the prescription; however, this rarely happens because 99% of GPs wouldn't feel comfortable with this, and even though Canada is manyfold times less latiginous than our southern neighbours, lawsuits are of concern.
I like the idea of prescribing something like CBT or "psychological therapy" as you put it, as like a "pharmaceutical", if you will....i.e. you prescribe it and someone else does it. Canada is starting to go that way in many areas, but I'm not sure if psychiatry has followed...e.g. in the ICU, docs used to look after the ventilators, but now that's almost all done by respiratory techs. There's examples of this ALL OVER medicine.
Oh, and in case you were wondering about the Canadian health care system in general, it is, on paper, a one-tiered system where everyone is supposed to have access to the same health care. Most people carry a health card which you present to the doctor's office when you go for a visit. The doctor takes down the card number, and with it bills the GOVERNMENT for services provided rather than the patient himself/herself. There are no restrictions on which doctor you see or which hospital you go to. The only real restrictions are to the access of specialists. The family doctors (GPs) are the gatekeepers. If they feel a patient needs to be seen by a specialist, they must first give a referral. In other words, a random patient from the street (usually) can't just walk in to an orthopedic surgeons office and ask for his/her broke ankle fixed....s/he first must enter the system through either a family or emergency doctor.
One other very important point: general internal medicine here is COMPLETELY different than family medicine. They are specialists and are accessed through referral from a family doctor as well. (That is somewhat different in the States).
Yes, things are quite different here in Canada, and while parts of the health care system are compartmentalized (i.e. GP vs. specialists) there aren't any strict rules about what a GP can and can not do. For example, not that it would be recommended, but if a GP wanted to, s/he COULD technically prescribe, say, interferon to a patient with Hep C....i.e.... s/he could write the prescription; however, this rarely happens because 99% of GPs wouldn't feel comfortable with this, and even though Canada is manyfold times less latiginous than our southern neighbours, lawsuits are of concern.
I like the idea of prescribing something like CBT or "psychological therapy" as you put it, as like a "pharmaceutical", if you will....i.e. you prescribe it and someone else does it. Canada is starting to go that way in many areas, but I'm not sure if psychiatry has followed...e.g. in the ICU, docs used to look after the ventilators, but now that's almost all done by respiratory techs. There's examples of this ALL OVER medicine.
Oh, and in case you were wondering about the Canadian health care system in general, it is, on paper, a one-tiered system where everyone is supposed to have access to the same health care. Most people carry a health card which you present to the doctor's office when you go for a visit. The doctor takes down the card number, and with it bills the GOVERNMENT for services provided rather than the patient himself/herself. There are no restrictions on which doctor you see or which hospital you go to. The only real restrictions are to the access of specialists. The family doctors (GPs) are the gatekeepers. If they feel a patient needs to be seen by a specialist, they must first give a referral. In other words, a random patient from the street (usually) can't just walk in to an orthopedic surgeons office and ask for his/her broke ankle fixed....s/he first must enter the system through either a family or emergency doctor.
One other very important point: general internal medicine here is COMPLETELY different than family medicine. They are specialists and are accessed through referral from a family doctor as well. (That is somewhat different in the States).
lymphpre
08-28-2008, 06:44 AM
Thank you for this information, and thank you moderators for tolerating our straying a little.
pinkmada
08-28-2008, 02:21 PM
Well saw my psychologist again today. She said that this is my second last or my second second last time of seeing her cause she's leaving. because every flippin doctor i end up trusting leaves. i'm now just waiting for my oncologist to leave and then i'll trust absolutely no-one. she is right though, i really don't trust most of them. i told her what my gp said and she told me that that was very irresponsible of her and she was glad that i called my oncologist. (i don't know if i said but i called her a couple of days ago to let her know what i'd been prescribed and thats all okay. oh and i can finally get my hep b vaccines) i felt a lot more comfortable there today than before. not really sure why. it actually quite a scary thought though that i wont see her again after the next month. like i've came to not depend on her but be comforted by the though that she will be there to talk to at the end of the week or fortnight. and i won't have that anymore.
lymphpre
08-29-2008, 08:44 AM
Hi Amanda,
I'm sorry to hear this, but I am pleased that things have gone well with her. I know you had reservations at the beginning. It really is difficult when you get no continuity with the Drs. you see. I so wish the system was not going this way. It is tricky with a therapist, because the nature of information you discuss can lead you to feeling dependent on them, and very let down when your time with them comes to an end.
If they are not referring you on to someone else, and you did feel you would benefit from more input, you could always ask for a referral via your GP: they often do have counsellors/therapists working in primary care, and sometimess psychologists. But maybe her input was the appropriate amount for where you are at the moment?
Look after yourself.
Simon
I'm sorry to hear this, but I am pleased that things have gone well with her. I know you had reservations at the beginning. It really is difficult when you get no continuity with the Drs. you see. I so wish the system was not going this way. It is tricky with a therapist, because the nature of information you discuss can lead you to feeling dependent on them, and very let down when your time with them comes to an end.
If they are not referring you on to someone else, and you did feel you would benefit from more input, you could always ask for a referral via your GP: they often do have counsellors/therapists working in primary care, and sometimess psychologists. But maybe her input was the appropriate amount for where you are at the moment?
Look after yourself.
Simon
pinkmada
08-29-2008, 11:34 AM
hey simon,
she has spoken to the psychologist at the maggies centre (do you have one in bristol? they are amazing) nd also discussed with me about going to the stress management course and then i can drop in whenever i feel like it just for a chat with one of the counsellors and they have an out of hours number/service too. i am also thinking about going to see the counselling people at uni when im not feeling so upset even just to touch base with them so that if i do feel stressed or upset i can go and see them without having to tell them everything from the beginning whe i am already upset. if that makes sense.
also, i have noticed yesterday and today about 2 hours after taking the citalopram i was shaking really badly. is that a usual side effect? im at uni just now so i will look it up when i get home. yesterday i thought it was maybe cause i didnt have breakfast but i did today and still had the same thing.
how are you doing?
amanda
xxx
she has spoken to the psychologist at the maggies centre (do you have one in bristol? they are amazing) nd also discussed with me about going to the stress management course and then i can drop in whenever i feel like it just for a chat with one of the counsellors and they have an out of hours number/service too. i am also thinking about going to see the counselling people at uni when im not feeling so upset even just to touch base with them so that if i do feel stressed or upset i can go and see them without having to tell them everything from the beginning whe i am already upset. if that makes sense.
also, i have noticed yesterday and today about 2 hours after taking the citalopram i was shaking really badly. is that a usual side effect? im at uni just now so i will look it up when i get home. yesterday i thought it was maybe cause i didnt have breakfast but i did today and still had the same thing.
how are you doing?
amanda
xxx
lymphpre
08-29-2008, 12:10 PM
Hi Amanda,
I don't know of anything called a Maggies centre. They have a psychology department as part of the Bristol Oncology Centre, but that felt a bit too close to home for me. Other than that, they offered to refer me to the hospice, which also has a counselling service. Let us know how you get on with this.
You know, accessing the counselling service at the Uni is an excellent idea. Some of their people are really well trained, and are particularly focussed on the problems that people go through whilst trying to get through a qualification.
Trembling is a possible side effect of citalopram. I just looked it up, as I was not sure how common. The best figure I could find was up to 10% of patients. Depending on how bad it is and whether the trembling continues, might be worth a return visit.
I'm doing about the same. Feeling quite down today, as I thought there might be some improvement now I'm in my third week post chemo, but no luck. My breathing has not improved at all, and I still feel devoid of energy. I know I need to be patient, as these things take time, but I cannot help feeling anxious in case this is as good as it is going to get.
Have a good weekend. Speak to you soon.
Simon
xxx
I don't know of anything called a Maggies centre. They have a psychology department as part of the Bristol Oncology Centre, but that felt a bit too close to home for me. Other than that, they offered to refer me to the hospice, which also has a counselling service. Let us know how you get on with this.
You know, accessing the counselling service at the Uni is an excellent idea. Some of their people are really well trained, and are particularly focussed on the problems that people go through whilst trying to get through a qualification.
Trembling is a possible side effect of citalopram. I just looked it up, as I was not sure how common. The best figure I could find was up to 10% of patients. Depending on how bad it is and whether the trembling continues, might be worth a return visit.
I'm doing about the same. Feeling quite down today, as I thought there might be some improvement now I'm in my third week post chemo, but no luck. My breathing has not improved at all, and I still feel devoid of energy. I know I need to be patient, as these things take time, but I cannot help feeling anxious in case this is as good as it is going to get.
Have a good weekend. Speak to you soon.
Simon
xxx
pinkmada
08-30-2008, 06:44 AM
hey,
the Maggies centre was first set up in edinburgh in 1996 by a woman who had ovarian cancer (she was some sort of doctor, i forget) and it is just a place to go and speak with others in a similar situation. they started building other centres around the uk over the years because it was such a huge success. every centre is different and you can drop in and have a cup of tea and sit in the garden and not speak to anyone if you want or you can join classes and support groups etc. they really are amazing. i think most of them are situated near a major cancer centre in the uk and it is just such a calming environment.
yes i understand what you mean about it being too close for home. i was coming out from seeing my psychologist and saw a girl in my year who is doing her placement in the cancer centre. thankfully she didnt see me, i just put my head down and walked out. i thought i would be 'normal' at uni and not have anyone who knew about it but i guess that is wishful thinking.
i will speak to the uni counselling people. i didnt think it would be available to me, i thought it was for students who were struggling with exams or having financial difficulties. but yes i will make an appointment sometime in the next week.
thanks i was just reading in the bnf that treomrs/trembling is a rarer side effect. i see my gp (or at least a different gp) next friday so will let them know if it is still a problem.
yea it really does take time. i just remember thinking everyweek that i should be fine now, i'd finished treatment so why was i still feeling so tired and have no energy. the last treatment was definatly the worst. i think i was in bed for about a week whereas i was normally only really tired for a few days after. i dont think i noticed a gradual improvement and then one day i just felt like i was full of energy again. i hope you feel better soon.
amanda
xxx
the Maggies centre was first set up in edinburgh in 1996 by a woman who had ovarian cancer (she was some sort of doctor, i forget) and it is just a place to go and speak with others in a similar situation. they started building other centres around the uk over the years because it was such a huge success. every centre is different and you can drop in and have a cup of tea and sit in the garden and not speak to anyone if you want or you can join classes and support groups etc. they really are amazing. i think most of them are situated near a major cancer centre in the uk and it is just such a calming environment.
yes i understand what you mean about it being too close for home. i was coming out from seeing my psychologist and saw a girl in my year who is doing her placement in the cancer centre. thankfully she didnt see me, i just put my head down and walked out. i thought i would be 'normal' at uni and not have anyone who knew about it but i guess that is wishful thinking.
i will speak to the uni counselling people. i didnt think it would be available to me, i thought it was for students who were struggling with exams or having financial difficulties. but yes i will make an appointment sometime in the next week.
thanks i was just reading in the bnf that treomrs/trembling is a rarer side effect. i see my gp (or at least a different gp) next friday so will let them know if it is still a problem.
yea it really does take time. i just remember thinking everyweek that i should be fine now, i'd finished treatment so why was i still feeling so tired and have no energy. the last treatment was definatly the worst. i think i was in bed for about a week whereas i was normally only really tired for a few days after. i dont think i noticed a gradual improvement and then one day i just felt like i was full of energy again. i hope you feel better soon.
amanda
xxx
lymphpre
09-01-2008, 07:16 AM
Hi Amanda,
Maggies centres sound like a really good idea. I shall look them up in a minute.
I had a bit of a rough weekend, feeling very weak and light-headed. My temperature has begun to settle now. For the last couple of months, it has permanently hovered between 37.3 and 37.8, never quite going over the 38 threshold. It is now hovering around 36.8, which feels a bit more normal. However, my blood pressure is now consistently low, currently at 96/55. I know that low blood pressure is not usually considered a cause for concern, but this might be one of the reasons that I am feeling light-headed so much of the time.
We shall see how this week pans out.
S
xxx
Maggies centres sound like a really good idea. I shall look them up in a minute.
I had a bit of a rough weekend, feeling very weak and light-headed. My temperature has begun to settle now. For the last couple of months, it has permanently hovered between 37.3 and 37.8, never quite going over the 38 threshold. It is now hovering around 36.8, which feels a bit more normal. However, my blood pressure is now consistently low, currently at 96/55. I know that low blood pressure is not usually considered a cause for concern, but this might be one of the reasons that I am feeling light-headed so much of the time.
We shall see how this week pans out.
S
xxx
pinkmada
09-03-2008, 07:08 AM
hey,
yes low bp will probably be the reason you are feeling weak and light headed. have you fainted at all? i know that being too hot or not drinking enough fluids and being dehydrated can all decrease bp and make a person feel light headed. what did your doc say about it? yes i know they dont worry too much over low bp as they do a high bp but it is still a significant change for a person and they should be running tests to figure out why.
my bp has always been 110/69 but when i was in hospital before i was diagnosed it was at 130/80 and they said it wasnt high so i couldnt be in as much pain as i said i was.
doctors should really listen to their patients. surely we know our bodies better than they do?
x
yes low bp will probably be the reason you are feeling weak and light headed. have you fainted at all? i know that being too hot or not drinking enough fluids and being dehydrated can all decrease bp and make a person feel light headed. what did your doc say about it? yes i know they dont worry too much over low bp as they do a high bp but it is still a significant change for a person and they should be running tests to figure out why.
my bp has always been 110/69 but when i was in hospital before i was diagnosed it was at 130/80 and they said it wasnt high so i couldnt be in as much pain as i said i was.
doctors should really listen to their patients. surely we know our bodies better than they do?
x