The dangers of GPs reviewing psychiatric medication

Birchy

Although I am no longer updating this blog, please keep your comments coming as I read absolutely all of them, and reply when I can.

Thanks for all your support over the past 18 months. Take care,

Birchy

I am just back from what should've been a routine trip to see my GP -- my twice-yearly medication review. In the past, this has been a rubber-stamping exercise. But now, with GP Commissioning, it's become a whole new ball game, and one which needs to be exposed. It began innocuously enough:

GP: "Have you been to see your consultant recently Ian?"

Ian: "Yes"

GP: "You are on an awful lot of medication, Ian. Was he happy with your medication?"

Ian: "Yes"

But then ...

GP: "I going to make some changes to your tablets today, Ian".

The reason -- none given but easily figured out once I'd rifled through my trusted copy of the British National Formulary (every mental health journalist has one -- most patients should too) -- to save the NHS money.

In the case of my anti-psychotic, swapping from a 6mg tablet to two 3mg tablets was enough to save around £20 a month, according to the BNF. That seems harmless enough -- it's more hassle for me and the chemist to deal with twice as many tablets, but no change to the medication or the dosage.

What came next, I wasn't prepared for.

GP: "Ian, I see you are on escitalopram 15mg. You have been on citalopram [a similar drug] in the past. I think 20mg of this would be the same thing. I am going to change you to that!"

Antidepressant medication blister strip

Shocked, stunned face - even 40mg citalopram left me suicidal!

Escitalopram is an "isomer", the purest form of citalopram. Is is from the same manufacturer, but it is far, far more powerful and the only antidepressant which has kept me from suicide over the past several years. Now I am a mental health journalist, my dad is the retired chief hospital pharmicist, and my mum is a retired former A&E and Intensive Care ward sister.

So he wasn't going to get away with this. I have already made a contemporaneous note to give to my consultant psychiatrist and care coordinator when I next visit the local CMHT clinic on Wednesday. This would have saved just £15 a month, or thereabouts, according to the BNF, yet put my life in danger.

What if I weren't clued up on psychiatric meds? If I were in relapse and unable to stand up for myself? If I came from a non-medical background and profession? If I trusted my GP to do what was right for me and not his commissioner's budget?

GP prescribing medication

Is my situation a one-off or could it happen to you?

It seems this is not an isolated case - I know of someone who relied on Z-drugs and had those removed without warning from their repeat prescription list. Again, GPs are trying to withdraw people abruptly from diazaepam and other benzos. Mine is an extreme example -- if you are unstable on medication and seriously unwell it is unlikely your GP would be carrying out a med review -- you'd be under the a CMHT -- so I don't want to cause alarm.

I would like you to help me out with this one for a possible future story. If your GP is now solely responsible for your medication, or reviews it aggressively, please let me know using the form below or email birch.ian@gmail.com. I am in meetings and appointments much of the week and on holiday next week but will endeavour to respond to you as soon as I possible can nevertheless -- I don't really do holidays(!).

The mental health community needs to take action now to ensure that GP Commissioning doesn't lead to a two-tier mental health service -- one in secondary care where consultants put patients first, and one in primary care where GPs put their budgets first. I am on a lot of medication -- some of which is extremely expensive still as it's proprietary -- my GP was happy to make his savings today but warned as I left the surgery: "One step at a time, Ian. We'll change them one step at a time." No, I thought, no you won't. So my consultant will be writing to him this week!

Over to you ...

Comments

Submitted by Charlotte Fantelli on Tue, 12/06/2012 - 10:03.

Very well said Ian. This really is something we must all be aware of, especially as the latest research shows that a very high percentage of GP's are in desperate need of more mental health awareness and training.

Thank you for flagging this up.

Charlotte

Submitted by Anonymous on Tue, 12/06/2012 - 15:06.

This is a dreadful but common example of GP's involvement in the side of medicine which really is specialised. My own experience happened about a year ago when I'd been on Venlafaxine (75mg twice daily) for a while but hated the side effects of the high dose I needed (sweats). I went to my GP as I was also not sleeping very well. He decided to change my med completely to a different type of med altogether - Mirtazapine (15mg once a day before sleeping) This med has a slight sedative effect therefore attempting to help my sleep problem. I had in the past switched directly from Citalopram to Venlafaxine without event and so he decided to do exactly the same with this med switch with terrible consequences. Having taken my last Venlafaxine that morning I was to take nothing until the following night when I was to take my first Mirtazipine. I did this but on the waking the morning after that I firstly felt unable to wake properly but once I was, I felt everytime I stood up I was tipping over and I would have dreadful brain shocks and odd sensations all over my body. I couldn't focus and was continually having brain shocks and a buzzing sensation in my head. I phoned my doctor and he said all should be ok once I'd had another dose of the new med and it was properly my body adjusting and to come back to him at the end of the week. I woke up the following morning in more of a state with panic setting in and a feeling of dread. I stood in my bedroom sobbing. For the first time in my life I didn't think I could or wanted to go on, and this was a med to help?? I was straight on the phone to him again and said there was no way I could live like this until the end of the week. He then said I had obviously gone is to serious withdrawal and he probably shouldn't of advised my to do a straight switch. He apologised and asked if I wanted to go back on Venlafaxine and wean off and then go on to Mirtazapine. With that frightening experience I said no and said I would try to manage with the lower dose of Venlafaxine which causes less side effects. I could not go to work that week and thankfully my husband an children were ok after seeing me go through that. I took a 37.5mg dose of Venlafaxine and I am completely honest when I say that within 20mins of that dose all withdrawal symptom stopped and I was back to 'normal' (!) I have remained on the lower dose (37.5mg twice daily) ever since and am managing my depression fairly well at the moment. My sleeping has improved although I am a little up and down regularly in mood. I have no concerns whatsoever with my GP and have every faith in him and trust him completely. However these meds are not to be messed with and I don't think GP's have the specialised training to understand their effects and the way they work. They are, after all General Practitioners and we can't expect them to know everything about all conditions. They have a first and second etc line of prescribing. This can never and shouldn't be in place of individual case prescribing but they are just not equipped to do this. If GP's are expected to manage these problems in the GP surgery setting the MUST be trained to a very high standard. Best wishes to all Natalie

Submitted by Birchy on Tue, 12/06/2012 - 18:00.

Hi Natalie

I'm really sorry to hear about your experience but very grateful to you for sharing it with us all. Venlafaxine and mirtazapine are similar drugs in that they both work on the serotonin AND noradrenaline receptors in the brain -- the chemical messengers, a lack of which, many psychiatrists and pharmacologists think are responsible for depression.

They are SNRIs (serotonin and noradrenaline reuptake inhibitors) which are more complex drugs than typical modern antidepressants like citalpram (SSRIs -- selective serotonin reuptake inhibitors).

I can well understand you having such a distressing experience with abrupt withdrawal from any SNRI even when taking the same class of drug as a substitute. To quote from the British National Formulary, latest edition, accessed online this afternoon:

"Withdrawal -- Gastro-intestinal disturbances, headache, anxiety, dizziness, paraesthesia, tremor, sleep disturbances, and sweating are most common features of withdrawal if treatment stopped abruptly or if dose reduced markedly; dose should be reduced over several weeks"

I too had an "instant improvement" with one drug -- unrelated I know -- diazepam -- after having clonezpam withdrawn abruptly. I remember vividly how terrifying the panic attack was and the way all the muscles in my body tensed up.

And this was a consultant's decision! I want to reassure you that with careful withdrawal it will be possible to come off the venlafaxine one day, should you want to, or have to, but it has to be done very gradually and at your pace.

Thanks again for sharing and I look forward to hearing other people's experiences. I think it's really true what Charlotte said above that many GPs have far too little experience and training in mental health generally although some are of course quite excellent. My GP is a single GP practice but when I move to a new flat next year in a nearby town, I'm going to ask around the service users I volunteer with there and make sure I have a mental health trained GP who is both knowledgeable and able to withstand pressure from commissioning fundholders.

Meantime, I have spoken to my care coordinator and my consultant is going to write to my GP so I should be safe for now!

Take care,

Ian

Submitted by Anonymous on Wed, 20/06/2012 - 19:08.

Hi. Great article. Thanks for sharing. I haven't heard of this happening in North America, but I'm sure it has for people on certain type of healthcare coverage. I'm really astounded to thing that a GP would substitute his/her own judgement for that of a specialist. It's the whole reason your seeing a specialist to begin with, after all, their expertise. If my doctor tried to do this I would throw an absolute fit. Thanks for bringing this to everyone's attention. - Natasha Tracy - Mental Health Writer - http://natashatracy.com

Submitted by Anonymous on Fri, 29/06/2012 - 23:34.

I have found this site ver interesting. I have been suffering with the below list daily for 11months. Dizzieness feeling of going to topple over when standing muscle spasmns muscle tightness all over pain in back neck and shoulders blurred vision sweats floaters in my eyes daily i have taken citralopram cipralex and sertraline. None to any avail. I have now stopped for 8days as these do not work for me. I have not seen my doc since jan. He just does my certificates for work on my reques along with tab perscriptions. I do not have a consultant or a care person. My doc is not very helpfull at all. After reading this site i am glad i stopped taking tabs recently.

Submitted by Anonymous on Mon, 27/08/2012 - 20:11.

My GP treats my mental health like a joke. I'm still trying to find the 'right' medication for me but it doesn't help when he prescribes me something I've tried before but initially fools me by calling it by a different name.