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The Pharmaceutical Journal Vol 267 No 7169 p505
13 October 2001

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Feeling depressed? Anxious? Wait till you take these!

By David Barbanel

Last week I visited a friend at home. She had called me for some advice on her newly prescribed medication. She appeared to be extremely agitated, and I asked if I might visit her, rather than try to ascertain what was wrong over the telephone. On arrival, I asked her what was troubling her. She had started a new medicine the day before (not dispensed by me) and was feeling unwell. Her symptoms included extreme anxiety, palpitations, sweating, nausea and diarrhoea. In her words, she thought she was having a nervous breakdown. She had been unable to contact her general practitioner, and so she telephoned me. Without looking at her medicine, I thought she may have been prescribed a selective serotonin reuptake inhibitor, and this was confirmed when she showed me her pack of paroxetine.

I have dealt with this situation several times before, and now feel fairly confident that my communication skills are reasonable enough to get across to the patient, in the most empathetic way, the key messages I believe they should know. Another professional listening in may not agree with me, however, as it is difficult to know just how much information to give, and when to terminate the consultation. I am not a psychiatrist and so I try to listen rather than lecture.

I asked her, in confidence, why she had initially visited her GP. She described classic symptoms of depression and anxiety. She was sleeping badly and waking early. Recently she cried more, and was unable to concentrate. Annoying situations that you and I would find little more than normal daily events had become enormous problems for her, fraught with anxiety. She had lost her libido and occasionally had morbid thoughts. She did state that her GP was caring and sympathetic, however.

So, nothing wrong with diagnosis and choice of drug, you might say. I agree, but quite simply, it should not end there. Depressive illness is not like a skin rash. You cannot just prescribe a course of treatment and the condition disappears, without any problems along the way.

People who have never suffered may find it difficult to comprehend and empathise with such patients. Only when you see the total disintegration and desperation of sufferers can you begin to realise just how dreadful a condition this must be. I used to look at people and ask myself why on earth they were so low and needed medication to function normally. Often they appeared to be in loving relationships, with successful careers and no apparent money problems. So how come they were depressed? Well, it is obvious to me now that it is not as simple as that. If serotonin and other neurotransmitters in the brain are responsible for well-being, then low levels of these chemical transmitters cause real and distressing symptoms, in exactly the same way that low levels of thyroxine or insulin cause other classic “hypo” symptoms.

Leaflets poor

My friend’s tablets did have a patient medication leaflet included, and she had read some of it. However, I think the leaflets are poor in the way they minimise the side effects, implying that such reactions are rare. My experience in community practice indicates that such side effects are extremely common and often of unpleasant intensity. The leaflets should be modified to state that it is quite common and expected to have side effects initially, but these usually resolve after the first one to two weeks. Informing patients of what they may expect in the first few weeks of treatment will generally not put them off taking the medicine.

I recently counselled another patient who felt unwell after the first few doses of venlafaxine prescribed from her local hospital. Sadly, no patient information leaflet was included with her medicine and no verbal advice was given at the time of dispensing. She likened her symptoms to “having a stroke” and with no information to guide her about the possible range of side effects she might expect initially, she was extremely worried. In most cases, side effects seem to intensify the symptoms for which the patients originally seek medical help.

I think pharmacists have a real responsibility to counsel such patients at the time of dispensing. This is pharmaceutical care at its most basic and beneficial level. For patients taking SSRIs and related drugs for the first time, I make a point of inviting them into the counselling area for a chat. I try to include the points set out below.

Counselling points for patients taking selective serotonin reuptake inhibitors

Depression and anxiety are extremely common, but usually respond well to medication.

They are due to a chemical imbalance, and are nothing to feel embarrassed about.

The medication is not effective immediately, and it usually takes a couple of weeks before you notice an improvement.

Initially, the symptoms you needed help with may well appear to worsen, but this should resolve within one to two weeks.

It is quite common to experience some other side effects, such as nausea, sweating dizziness, palpitations, dry mouth, etc (please read the enclosed leaflet in full) but again if you do experience any of these they should resolve within one to two weeks.

Always speak to your pharmacist or doctor if you feel your symptoms are severe or troublesome.

In some cases it may be necessary to change your medication if you are not feeling any better after a month. Do not give up, but tell your GP and he will probably suggest another preparation, or alter the dose.

It is probable that if the medication helps you, you will need to continue treatment for six to nine months.

When you and your doctor decide it is time to stop taking this medicine, it should not be stopped abruptly, but reduced gradually over a period of one month. Your doctor or pharmacist will advise you how to do this.

Regular exercise should also help your condition. Speak to your doctor or pharmacist if you have another medical condition that could limit your activity.

Try to get out into daylight for at least an hour each day. It does not have to be bright sunshine to be of benefit. Try not to eat your lunch at your desk at work.

Admittedly, most of these points are covered to some degree in the patient information leaflets. However, they are often amid columns of writing almost too small to be legible to older or poorly sighted patients. Pharmacist reinforcement of these messages is essential and, in my experience, is received well by patients. They are thankful that you have taken the time and trouble to explain their medication to them.

David Barbanel is a pharmacist in Woodford Green, Essex