Are GP's being encouraged or paid to prescribe antidepressants?

[FrolickingLemon]

Not sure if I'm being unreasonable, but here goes.

About 2 years ago a felt I had perimenopausal symptoms. Described about half a dozen or more symptoms over the phone to GP. I was almost 48 at the time. Her first answer was would I like to take an SSRI? No. I wasnt depressed. Joint pain was one of my symptoms, and apparently SSRI's can help with that. I countered that I was a sports Therapist and that many of my clients were on SSRI's for depression and anxiety, yet still they came to me with joint pain for muscle and joint pain. I also voiced my concerns about side effects and how difficult it can be to come off antidepressants. She said they were way better and safer than opiates and anti inflammatories. Still wasn't buying it.

A year later and I'm diagnosed with osteoarthritis. Was given codeine, but made to feel like shit for taking it. Like I'm some sort of drug addict. I totally get that some people get addicted to opiates, but that wasn't me.

At the same time, my Mum was absolutely shattered. Short of breath and it was getting her down. Lots of other symptoms and underlying problems. GP asks if she would like antidepressants? We visited the GP not long after this and long story short, my Mum was severely anaemic due to microscopic bleeding. Turned out to be bowel cancer. Mum had a big op just after lockdown and is recovering nicely.

I had another appointment today with GP regards to ongoing osteoarthritis pain and also further perimenipause issues (hot flushes- I'm now nearly 50) Again, she wants me to take SSRI's. I did a lot of research beforehand and read a lot of threads of MN in the menopause section. So many people say they had immediate joint pain relief from HRT. GP has said all along she is sceptical about this, but I'm edging closer to going on HRT.

But why the love of SSRI's? Sorry, this was longer than I intended. I've done family research too with regards to risks and benefits. Would be grateful for anyones personal experience.

It's because it's what they do.
They give out drugs.

There is really not that much in a GPs tool kit but despite this we continue to treat them like mini Gods and massively over pay them.

There is so much emerging evidence now about the damage the long term use of painkillers does and the over medication of the elderly and I think GPs are to blame for this.

Other professions have so much more to offer with regards to lifestyle therapies/fitness coaching and initiatives like social prescribing. We could appoint about 4 specialist nurses for the price of one GP.

GPs are still not doing home visits for the housebound and most vulnerable people in many areas, yet nurses, carers and community therapists have worked right through covid, seeing positive patients in their own homes.

I think the country is waking up to the Prima Donna's

@barcodescanner

I have a few chronic conditions, I have been considering asking my gp for antidepressants for my back pain. I was completely relaxed on Monday, more relaxed than I can remember and my back wasn't hurting - it always hurts!

I have taken antidepressants before, once when my mum died and the other for PND. I have no issues with taking them for reasons above.
I did however take exception to being asked at every gp visit if I was depressed when what I needed was more frequent b12 injections. I was not having depression on my notes for something that wasn't depression.

I had this with a Mirena coil. Every.fucking.time. No reason at all. I had a Mirena years before, after having DD2. It was a disaster. I had every single negative side effect in the book and ended up taking it out myself as they kept fobbing me off with 'It will settle'. I wasn't even on it for heavy periods, just contraception (it was great for that, I never stopped bleeding, ever, even with other tablets and my libido vanished). Yet kept being offered it every time I went in, no matter what it was for. Even though my h had had a vasectomy and the all-clear months later. I finally wrote a letter and had it put on my record that I NEVER wanted a Mirena, or needed one.

Am now menopausal. Whew.

Mitzik
That is shocking.

Maybe one day we'll be able to match the drug to the person.
I cannot take AD's, had too many bad experiences. But my body works well with diazepam, many years ago I'd have five tablets a year and use them every so often to help me focus when I was feeling wretched. A holiday from my anxiety 🤷‍♀️. Now you can't get them for love nor money.

maxnormal I’ll let you into a secret. We do think about what we prescribe.

Mintychoc1 it should be clear from this (and other) threads that people are having some extremely frustrating experiences with gps. I'm another that had something very serious dismissed as anxity for a long time.
I'm sure you are an excellent gp and prescribe thoughtfully, but it's clear that this is far from the case across the board.

Again, I do think it would be more useful for gps to take patients concerns on board rather than getting defensive.

@megletthesecond

Maybe one day we'll be able to match the drug to the person. I cannot take AD's, had too many bad experiences. But my body works well with diazepam, many years ago I'd have five tablets a year and use them every so often to help me focus when I was feeling wretched. A holiday from my anxiety 🤷‍♀️. Now you can't get them for love nor money.

Oh, yeah, the only place you can get those now are from street dealers.

Oh, yeah, the only place you can get those now are from street dealers.

This seemed to be said in reference to diazepam. Are you serious? Is this true?

Again, up until last year in the UK my gp prescribed these for my dental procedures. I can't manage actual dental work without - if it's just a check up I can cope with yoga breathing. I just had work done today and my primary care practitioner here in the US prescribed them for it because he understands the severity of the fear.

Have things changed massively in the UK over the last year? I find that incredibly alarming, how are people going to manage? LOADS of people have dental phobia thanks to shit experiences when young. What are they going to do now?

I'm not afraid of flying myself but I thought it was also quite common for people to get a couple of valium for flights if they are terrified? They didn't all end up hooked!

In the US, yeah, you'll probably get them. In the UK, not very likely but depends on the prescriber; in some cases, no chance.

Prescribing guidelines changed in the UK. Very difficult to be prescribed diazepam or zop sleeping pills.

YABU to think GP’s are paid to prescribe any group of drugs. They aren’t. UK Dr’s even allowed to accept a pen from drug rep without declaring it. I’m not a GP but am an NHS doctor.

Antidepressants do have multiple uses- for instance fluoxetine is often used for flushes/sweats in Perimenopause/menopause; amitriptyline and nortryptyline (Tricyclics antidepressants) as well as duloxetine (SNRI) are often used on chronic pain; both TCA’s and venlafaxine are sometimes used for migraine prevention. All these are used because there is evidence they work and are in guidelines both in the UK and in other countries. It’s perfectly reasonable to use them for a variety of reasons, not in any way related to depression or anxiety.

In the case of chronic pain and migraine, they are frequently used because they have been shown to be more effective for certain types of pain than many other classes of drugs. Their use can reduce the reliance on opiates, with the many serious issues with long-term use of that class of drugs- for instance as well as risk of tolerance (get used to drug so higher doses/stronger forms of opiate required to treat the pain effectively), dependence/addiction and in the case of migraines opiates can also make them worse/more frequent if used long-term.

Whilst I would not support the use of an antidepressant as a 1st line in mild depression and/or anxiety in the majority of cases, I imagine there are quite a few significant drivers for GP’s to offer them. The wait for counselling and psychological therapies are extremely lengthy (in our area it is currently about 18-20 weeks, longer for more specialised forms of therapy such as EMDR). Local 3rd sector organisations do offer counselling a little quicker, and you can access some support via organisations such as CRUSE, but their lists are growing too. Community mental health teams are stretched, and unless the patient has a “significant and enduring” mental illness they are declining the referral. Many GP’s are working close to capacity, if not understaffed, in some areas with significant pressure on appointments and the patient dissatisfaction that goes along with that. Patients do often have an expectation that “something will be done” and quite a few (in my experience in a different field, but it is not unusual to think patients may benefit from health psychology input) aren’t keen on the thought of therapy or cannot commit (for perfectly understandable reasons) to the frequent and lengthy appointments required (e.g. due to work commitments, childcare issues etc).

Taking these factors together, it is not very hard to see why there is a strong temptation to prescribe an antidepressant in order to do something to help within a reasonable timeframe and meet patient expectations. It also is a “quicker/easier fix” and this can be attractive to both patient and GP.

I do think antidepressant use should be monitored/followed up once started though.

Minty I’m sorry you’re finding this thread upsetting. It’s not aimed personally at you, and I for one do recognise that most GPs want to do their best for their patients, with very limited resources.

I expect you went into medicine wanting to help people. So I’d be interested to hear how it feels to you to be unable to prescribe anything that’s actually effective for pain relief to those who are really suffering?

You said If you don’t want tablets and you don’t want physio and you don’t want counselling, then don’t bother the GP. But the issue is that patients DO want the tablets (ie the pain killers that actually work, not ADs that mostly don’t), and they used to be able to get them, but they now find the rug’s been pulled out from under them and they’re left in agony.

Consider: Should Pam be left to suffer unrelenting pain because Trevor down the road might try and sell a few tablets on if he’s prescribed some?

How is it fair or ethical or humane to deny Pam pain relief because of what hypothetical unrelated others might do?

Why does our moral panic over street drugs (most of which are made specifically for selling rather than being diverted prescribed drugs in any case) trump our compassion for those in pain? And should it?

And if we think about the risk to Pam of addiction, maybe Pam would prefer this to being in pain, as the lesser of two evils. Given there’s no perfect solution for her anyway. Of course, this often, in any case, only becomes an issue for Pam if she suddenly can’t get her meds anymore (because the rug’s been pulled out from under her with no regard to her quality of life).

Why would we not have an adult conversation with Pam where we point out that X pain med may well help her, but comes with a risk of dependency and she needs to think carefully before taking it, making sure she is happy to take this risk on.
That if some miracle occurs and her condition suddenly gets a cure(!) and she no longer needs the meds, that she will have to wean down very slowly, over an extended period of time.

Why have we decided that it’s ok for people to live in pain?

minty you know as well as I do that the new offering isn’t as effective as what was allowed before. As a GP of course, you don’t have any power over the prescribing guidelines of CCGs etc, and have to toe the line. But I’d be interested to see how you feel it works for the patients you personally see.

Why does our moral panic over street drugs (most of which are made specifically for selling rather than being diverted prescribed drugs in any case) trump our compassion for those in pain? And should it?

This. Anyone who works in the field of criminality/law enforcement/legal is well aware of this.

@AbsentmindedWoman

Dr’s will only prescribe diazepam (or any other benzodiazepines or hypnotics such as zopiclone) for a limited number of reasons and even then not in large quantities or frequently. They will prescribe larger doses/long-term under the direction of specialist- e.g. psychiatrist or neurologist.

They may prescribe a small dose for the occasional one-off for dental treatments where it is clear that it is only used infrequently and for a documented reason.

The guidance states that benzodiazepines should not be prescribed for patients for fear of flying. It is also off licence. This is for flight safety reasons. Dr’s prescribing against guidance are leaving themselves in very vulnerable position medico-legally as it is both an off-license prescription and also goes against what is very explicit guidance not to prescribe for patients who take it for fear of flying. A minority may chose to do so, many (sensibly) will no longer do so.

@Badbadbunny

You are sadly misinformed. QOF no longer exists(in Scotland, anyway) and there was not a huge payout for prescribing antidepressants. There was only payment if mental health conditions, and related prescribing, were shown to be regularly followed up and monitored appropriately. So simply prescribing an Ssri and never seeing the patient again would not lead to payment under qof.

how dare you offer me antidepressant for pain relief when other pain relief hasn't worked, this isn't in my head

What patients are concerned about, what patients are already experiencing, is antidepressants and other psychiatric drugs being offered as the first choice when a patient presents with physical symptoms. And as mentioned, existing pain relief prescriptions that do work being withdrawn and refused renewal.

It's probably an unpopular opinion, but I think by these drugs not being prescribed it pushes people into the underworld. It creates crime and addiction, because people will not just live in pain indefinitely they will try to find a solution. The GP doesn't help? The antidepressants don't help? The physio/counselling waiting lists are far too long? The pain is unbearable, life is unbearable. Maybe some find naturopaths, but more find drug dealers or booze or suicide. Because pain sucks, we are genetically programmed to react to pain as a problem and do something about it. So if the right things don't work, eventually we do the wrong ones. Some people get their quicker than others, but everyone has the capacity to make desperate choices if the conditions are right. I would rather people eat painkillers like smarties than go through months of pain only to end up heroin addicts.

Doctors don't make people drug addicts. Drug addicts just like blaming other people. It's part of the denial that goes with the disease of addiction. The drugs aren't to blame, societies not to blame, the GP is not to blame, all of those things may have contributed to the conditions that lead that person to the domino effect of desperate choices that resulted in a dreadful addiction. But that's life. People who have never even been to a GP end up addicts all the time. Addiction is part of the human spectrum. It's just the way some people are wired and the effect life has further on their wiring.

So we shouldn't be contributing to those negative conditions for desperation, or punishing the whole for the effects on the few

Antidepressants are neuropathic painkillers. Cheaper and less addictive then other forms of pain medication.

If only that were actually true in practice Winterwollies.

This thread wouldn’t exist if it were.

Yup, I was fobbed off with ADs when I was on my knees with post natal hypothyroidism. Numbers off the charts by the time I finally got a diagnosis months later. All my symptoms were classic hypothyroidism but the GP latched onto the depression part and ‘treated’ that without bothering to do blood tests. Only after returning several times and eventually seeing a locum did I get a thyroid test and surprise surprise, been on meds for 20 years now.

I’ve tried ADs on 3 separate occasions and come out in a rash every time. DS also had some horrid side effects on them - I tried to convince him that his anxiety and depression were entirely natural given his difficult circumstances and not something that needed medicating, but a change of work and maybe some talking therapies. He eventually took himself off them as they messed him up even more.

Hate ADs. I know they help lots of people but I genuinely think most people’s depression is situational/circumstance related and could be helped by changing their life not their body.

I agree with Jades

@Badbadbunny

GP practices may not get extra funding for diagnosing certain conditions individually, but there is big money for them via the Quality and Outcomes Framework where they earn "points" for managing certain chronic conditions, one of which is depression. The more points they earn, the more money they get. So there is an incentive to diagnose and manage certain conditions.

I'd love to know where I am in my GP surgery / CCG tickbox matrix.

I suspect our views may differ.

Hate ADs. I know they help lots of people but I genuinely think most people’s depression is situational/circumstance related and could be helped by changing their life not their body.

I'd be dead without mine and my son's OCD would be crippling him. Glad they are there.

Mintychoc1 - I know it seems to be the bastion of acceptable bigotry but “junkie” really? If GPs think it acceptable to speak of people in this way what hope do we have? Surely, somewhere in your training you have taught how most people end up as “junkies” I genuinely believe if most of us had lived the lives many of these people had lived we would also be “junkies”

Re diazepam, I have experienced the increasing difficulty of getting it prescribed for fear of flying. When it has been prescribed, the tablets have been provided in the exact quantity needed for the flights. Whereas previously a prescription was for a full packet (so didn't need a new prescription for every flight) and also advised a higher dosage over the same period.

Now, I understand from this and other mn threads why this is, even if it's disappointing for me personally. But I do wish gps would be honest with patients. It's a bit insulting to be told that I may become catatonic if I take more than 2mg of Valium on a short-haul flight by the same doctor who has prescribed higher dosages without concern for over a decade. It clearly isn't about any risk to me as an individual, but because of changing guidelines. Fine - just say this!

Interestingly, I met a number of other nervous flyers on holiday last year, all taking diazepam. One was a man who had been prescribed it for the very first time at a dose far higher than I'd ever taken. Did make me wonder about the sexism angle people talk about on these threads.