Thursday 9 August 2007


I'm a doctor. I've been trained to select, evaluate and prescribe medicines. I have an FP10 prescription pad which I carry around with me so I can provide medication to people I see where so ever I chance upon them.

It may seem curious, then, that the most frequent change I make to medication regimens is to stop a medicine rather than to start one.

Old medicines

Often folk have been prescribed a medicine that usually was wholly appropriate at that point, in the past, when it was initiated. Then when I see them the drug's causing side effects or it's working in unhelpful ways.

It's done it's job but it's now run it's course and can be stopped.

A common example would be antidepressants. Someone has something bad happen (like being told they have cancer) and their mood, naturally, drops. It stays low. An antidepressants is started to help them cope (and sometimes it's indicated, other times the person isn't depressed they're simply very sad 'cause life's awful). In any case, the medicine's used and time passes. When they're still feeling low and referred to me they're often at a stage where they're accepting that life's not peachy and they're coping well enough, but feel appropriately sad. Being sad because life's awful is a normal human emotion, it's not an illness and isn't depression. Antidepressants like fluoxetine are often started to "pep people up" with a bit of vim and vigour but the alerting qualities can make people restless. Having energy, but not purposeful, directed energy, makes people feel ill at ease and unable to relax. Stopping the antidepressant and giving explanation and support is usually more helpful than prescribing more.

Physical medicines

Often folks may be on medicine for other problems that start to affect their mental well being. If physically frail and losing health, losing energy, losing mobility so losing independence mood can, understandably, drop. Some medicines, like atenolol for blood pressure/heart problems, can not uncommonly lower mood. Opiate analgesics can cause mood disturbance. Often, stopping these medicines (and swapping to another if still needed) can help moods strikingly, along with other support.

I'm struck of late by how prescribing really isn't necessary for many folk much of the time.


Calavera said...

What a beautifully written post. I totally agree - I was on a Elderly Care rotation, and the polypharmacy going on there was unbelievable... My team were looking through the drug charts of patient's notes, and finally my consultant grabbed the chart and just scored through a whole lot of drugs, saying, "He doesn't need this anymore... Or this... Or this... Or this..."

It was ridiculous.

Calavera said...

PS: Thanks for the extra info on Harry Potter! And your thoughts. They were very entertaining to read through.

...Though I always thought that Hermione would become a famous author and write lengthy tomes...

Dr Andrew Brown said...

Ah, you consultants love stopping GP medication! Did you know that we start it deliberately just so you have something to do when you see the patient. :-)

I reviewed an elderly lady today who was in tip top condition. I was about to stop her paroxetine which cleared wasn't needed when I realised that her consultant had only just taken her off lithium!

The psycho-geri on our patch is truly wonderful. It's not you by any chance, is it? :-)

XE said...

Good post! Many of the patients I help out with are elderly and have ridiculously long pharm lists. Of course I'm just a health sci student, but I continually wonder if they really need all of those meds --- some prescriptions seem to keep being renewed without being re-examined to see whether or not they are still needed.

P.S. I know Cal already said it, but thanks for the HP7 info!

Advanced Practitioner said...

Excellent post

When i came to general practice three years ago, i was astounded too how many patients were still taking antidepressants, which had been prescribed many years ago, in some cases 8-9 years. I decided to review these patients and found like you, that they had been prescribed many times due to relationship breakdown, bereavement etc. It took me a while to convince these patients, mainly women that they no longer required the medication. The gp's now refer all patients they believe have mental health issues to me for further assessment and half the time they are just sad due to acute events and watchful waiting is often all they need.