Discontinued antidepressants?!

[Schnicklefritz]

Name-changed for this, as people may need to know location.

My DH was diagnosed with Severe Treatment-Resistant Depression and Psychosis in 2013. Over the course of 6 years, he was put on loads of different medications and antidepressants, most of which didn't help in the slightest. Eventually he was put on a high dose of Bupropion as well as Modafinil, Lamotrigine, Omeprazole, Aripiprazole, Flupentixol, Levothyroxine, and Trazodone. For 4 years now, this has helped and DH is relatively stable. He was discharged from his psychiatrist in 2020.

Cut to last month:

DH went to the pharmacy to pick up his prescription and they didn't have the Bupropion in stock. Fine. Went back a week later, and still nothing. Advised to speak to GP. Went back to GP to have the prescription sent to another pharmacy. Nowhere has it in stock. GP investigates.

Bupropion is no longer on the market in the UK. The drug itself hasn't been discontinued, but no providers in the UK stock it anymore. And nobody thought to report it or notify the GP.

So now my DH is left without his high-dosage primary antidepressant. No GP will touch his cocktail of medication and he is being referred to the Mental Health team, but likely won't have an appointment for 4+ months.

He is going into withdrawal. His symptoms of depression are coming back in full force and is very concerned the psychosis will return if unmedicated. Our situation has changed and we now have 2 young children. While DH was not a danger to others last time, psychosis unpredictable and I am scared of what could happen to my children.

Does anyone know what we can do? An alternative medication to suggest? A charity to contact? I'm not from the UK (DH is) and don't know the NHS system at all.

Any help is very much appreciated.

If that’s the case why do you advise OP

Using it as an antidepressant is an unlicensed indication, which is often by consultants and experts. Therefore, you'd need to be seen by the same expert or a similarly qualified one who initiated the treatment to be able manage any changes to such complex needs

As you say yourself GP’s are not experts in MH prescribing for as you say comped cases.

Complex cases

^^ this re GPs and psychiatric drugs

speaking from experience as someone that works in mental health services and as a patient

GPs are more than capable of dealing with both psychiatric patients and polypharmacy; those two combined are probably the majority of their workload in the first place. In fact, it's usually the the specialists, in particular psychiatrists, who are utterly shit with managing multisystem polypharmacy because they are what are called SODs - single organ doctors. They don't care about anything that happens outside of their organ system so they often fuck things up for patients with multiple disorders. 9/10 times it's the GP who ends up picking up the pieces without either the specialist or the patient even noticing. Why do you think GPs need to do a review of notes and medications when signing repeat prescriptions? It's not a case of just print it out and sign in 15 seconds.

To add to that, using medicines outside of their licensed indication is a totally different scenario than standard management. That usually requires additional expertise; that's why hospital specialists exist in the first place, otherwise they wouldn't be needed. Doctors have very wide powers of prescription, we can prescribe anything we believe to be in the patient's best interest, in-licence, off-licence, or even totally unlicensed. However, you must be able to justify your decision based on your knowledge of the patient and your expertise. Some drugs are used off-licence very commonly so it wouldn't be a problem, e.g., use of some drugs in under 18s where there isn't a paediatric licence. However, others are more contentious, and only a specialist would be deemed to have sufficient expertise to be able make that prescribing decision. Just because you're legally allowed to do something doesn't necessarily mean that it is professionally or ethically acceptable.

That GPs don't usually prescribe medicines outside licensed indication in cases where standard therapy has failed (by definition making them complex cases) does not, in any way, shape or form, mean or imply that GPs are not capable of dealing with psychiatric drugs or polypharmacy. To claim that it does is a gross misrepresentation of what I have written.

GPs in my experience (professional and personal) wont touch anything that has been prescribed by the MH team or any other specialist, they want the patient to be referred back to that person/team.

Bupropion issues are caused by the manufacturing process being contaminated by an ingredient that could be carcinogenic (or something to that effect).

Apologies if this has already been said.

Well I’m glad you believe yourself to be specialised & experienced enough to treat complex psychiatric cases without psychiatric input, shared care & the additional monitoring that is required in cases like the OP’s DH. That would mean you would be likely operating outside of your local Trust’s shared care protocols then as well.

This patient is at clear risk of relapse & in urgent need of an psychiatric review before any prescribing of psychotropic drugs. He needs a formal mental health evaluation first before any changes to his medication. I’m surprised you think a GP is best placed to be able to do that

And despite your very clear competence & experience in prescribing all classes of drugs across all patient groups & all care settings, you are a general practitioner not a mental health specialist.

You may well have your views on psychiatrists but I doubt you have the required specialist knowledge, tapering knowledge & experience & psychiatric training to qualify you able to make the most informed & safest treatment plan for patients with psychiatric care needs.

Believe it or not patients don’t really like being prescribed psychotropic drugs in the absence of any overriding formulation for care & thorough assessment of their current needs & history in a rushed 5 at best 10 minute appointment with their GP who clearly is not best placed to be treating them.

Patients for too long have been suffering the fallout from this kind of practise, suffering adverse withdrawal effects, worsening mental health, horrific side effects, yet are routinely chopped & changed on heavy medication with little or no ownership or responsibility taken by the prescriber, for the damage that can be caused. Historically the patient is blamed, gaslit or told their symptoms have returned/just got worse/they need a higher dose when withdrawal is actually causing significant harm, along side often adverse side effects that can have devastating consequences.

Thankfully acknowledgement of withdrawal syndromes & their harms has started to be taken (www.nice.org.uk/news/nice-draft-quality-standard-depression-adults-update-2023 as just an example) as you will of course know but there is a huge gap in knowledge & skills when it comes to properly managing these.

Can you safely say you have unique knowledge & understanding of each psychotropic drug’s withdrawal signature & how that will impact the person in front of you? Or that you have the specialised knowledge & skills to be assess the continued suitability & efficacy of their respective cocktail of psychotropics in conjunction with a biopsychosocial assessment, their vulnerabilities, coping resources & strengths?

I am more than convinced you have the medical ability to prescribe pretty much anything. But that does not necessarily make it the best or safest or most suitable for a psychiatric patient without specialist input.

While 1 in 3 visits to primary care are for psychiatric related complaints, it’s no secret that primary care providers typically have very little specific training in psychiatry. And most GP’s psychiatric education after medical school & residency is delivered by pharmaceutical representatives. They can’t be expected to however know everything - it’s not possible. Or safe.

It’s true there is much that needs reforming in MH from the primary care setting & beyond.

But this patient, OP’s DH, is currently being failed by both.
Hence why a private psychiatric consultation may be the only option. IMO.

Last post for @UnicornsHaveDadsToo 👆

Yet more assumptions which are also completely wrong and demonstrate your total lack of knowledge and understanding of the issues. First of all, I never claimed that I was capable of treating complex psych cases, and neither did I say I was a GP. I'm neither. However, I am a trained cardiothoracic surgeon, who then went on to do a PhD in biochemistry, diploma and specialist training in pharmaceutical medicine, and has been working in the pharmaceutical industry for a decade, is a recognised expert on biological medicines and thus sits on a regulatory commission and expert advisory group appointed by the Department of Health, and as the medical director/chief medical officer of various pharmaceutical companies, has organised more educational meetings for doctors than he cares to remember.

it’s no secret that primary care providers typically have very little specific training in psychiatry. And most GP’s psychiatric education after medical school & residency is delivered by pharmaceutical representatives.

That's just a pathetic lie with absolutely no evidence or basis to make such a sweeping statement. For a start, most GP rotations include a psychiatry placement giving them exactly the same length of exposure that GP trainees have to any other specialty such as paediatrics, obs & gynae, general medicine etc. Following that, in the GP registrar year, a significant proportion of the patients the GP trainee sees will be MH patients giving them significant training and learning time with their supervising GP trainer. Furthermore, MRCGP exams have significant sections dedicated to psychiatric disorders. GPs receive a lot of formal psych training. The above is an often stated myth with absolutely no basis in fact.

Also, residency? We don't have that crap here, we have a totally different postgraduate medical education and career system to the US/European residency systems. We do not, and have never had, residents in the UK as a junior doctor grade. That's just another piece of evidence pointing towards the fact that you're pushing a certain agenda. You're finding snippets of junk information from the least reliable parts of the internet which specifically don't even apply to the UK, and spreading them to denigrate and disparage a group of people who are the exact opposite of what you claim them to be.

In UK, not only do we have a specialist training programme to be able to train as a GP after medical school, you need to sit and pass an exam to be able to even apply! That's not the case in many countries where GP/primary care is what a newly qualified doctor/a doctor without additional training is. Then we have a very well established, audited and regulated continuous medical education, annual appraisal and 5 yearly revalidation, even after completing all training, with minimum set training hours per year. That doesn't happen anywhere else, not Europe, not US, not anywhere. Therefore, useless surveys carried out in other countries with totally different systems have no meaningful relevance to UK primary care, especially if those countries have a system where primary care isn't a specialist area with a training programme.

In my very first post, I said that the OP's husband needed a specialist opinion and gave the reasons why, you then decided to unfairly attack a group of highly trained and dedicated professionals. As I mentioned above, I'm neither a GP nor an expert in mental health, but I cannot tolerate an unjustified condemnation of an entire group based on prejudice.