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Which Antidepressant? Taking a Commonly Prescribed Antidepres- Even Candidates for the DGM Have a High Failure Rate in Questions on Biological Sir, Sant

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Which Antidepressant? Taking a Commonly Prescribed Antidepres- Even Candidates for the DGM Have a High Failure Rate in Questions on Biological Sir, Sant Letters We therefore strongly agree with Dr understood as one. There are almost no tioner trainee conference he attended, Kay's recommendation that the value of adverse effects from lofepramine and it is levelling the charge that diplomas repre- the simple measure of the administration commonly used. Trazodone is less sent nothing more than a convenient of 150 mg aspirin should not be overlook- popular, probably because of the priapism source of income to respective colleges. I ed in the management of all patients which it occasionally causes and is hard think this aspersion unworthy, even presenting to their general practitioner to treat. Mianserin can cause blood anomic. He did concede, however, that with acute cardiac chest pain. dyscrasias so full blood counts need to be diplomas were important if they carried out, at least initially. Overall, R BLAND represented experience and specialization. lofepramine emerges as the best of the I would like to express my views as I have H DOEDAR three. advocated the diploma in geriatric KISHOR VAIDYA Fluvoxamine was suggested for medicine since 1978 and am the only Royal Cornwall Hospital (Treliske) depressive disorders where obsessional examiner for both it and the MRCGP Truro, Cornwall TRI 3LJ symptoms predominate. Fluoxetine is put examination. in the same category but this drug is men- The high rate of interest in the DRCOG References tioned only once. I found this surprising reflects little more than its value at job in- 1. ISIS-2 collaborative group. Randomised trial as it has been an extremely popular anti- terviews - it is an anachronism now that of intravenous streptokinase, oral aspirin, depressant internationally and is becom- involved with both or neither among 17 187 cases of few general practitioners are suspected acute myocardial infarction. ISIS-2. ing increasingly so in the UK. Over three intra-partum care and much antenatal Lancet 1988; 2: 349-360. million patients have now been treated care is quite rightly delegated to an attach- 2. Grupo Italiano per lo studio della with the drug. I am sure readers were hop- streptochinasi: nell' infarcto miocardico ed midwife. The DCH is highly specializ- (GISSI). Effectiveness of thrombolytic ing to hear psychiatrists' views of the re- ed, and less relevant to general practice treatment in acute myocardial infarction. cent adverse publicity about fluoxetine. It than might be supposed, since questions Lancet 1986; 1: 397-402. to be an effective drug which is 3. Gold HK, Johns JA, Leinback RC, et al. A seems appear on rare diseases of childhood that randomised, blinded, placebo controlled trial relatively free of adverse effects. In are, in practice, cared for by paediatric of recombinant human tissue plasminogen particular it causes nausea much less activator in patients with unstable angina registrars. pectoris. Circulation 1987; 75: 1192-1199. frequently than fluvoxamine and many I would agree that diploma studies 4. Cairns JA, Gent M, Singer J, et al. Aspirin, psychiatrists consider that this makes it a should not disrupt the general practice sulphinpyrazone or both in unstable angina: superior drug to fluvoxamine. results of a Canadian multicentre trial. N year or specialty attachments. However, Engl J Med 1985; 313: 1369-1375. A recent television documentary sug- the MRCGP examination is a wide rang- 5. Lewis HD, Davis JW, Archibald DG, et al. gested that fluoxetine might cause some Protective effects of aspirin against acute to commit suicide by violent ing assessment in which it is highly unlike- myocardial infarction and death in men with patients ly the candidate will be asked much if unstable angina. N Engl J Med 1983; 309: means. However, there are no controlled 396-403. trials to prove that the phenomenon exists, anything about geriatric care, despite the 6. Basinski A, Naylor CD. Aspirin and fact that in the average practice 16Wo of fibrinolysis. Lancet 1988; 2: 1133-1139. only case reports and these can sometimes be misleading. Depressed people patients are over 65 years old. It was only sometimes commit suicide by violent in 1980 that the first question on the elder- means and some of them are bound to be ly was asked in the MRCGP examination. Which antidepressant? taking a commonly prescribed antidepres- Even candidates for the DGM have a high failure rate in questions on biological Sir, sant. If this is a real phenomenon, there are two possible explanations for it. The theories of ageing, tardive dyskinesia and I was interested to read the article on an- Candidates are now tidepressants by Matthews and Eagles less likely of the two is that there is emotional lability. for something about the drug that gives rise better informed on rehabilitation, though (March Journal, p.123). The criteria many show a surprising lack of acquain- choosing an antidepressant - efficacy, to a 'side effect' of violent suicide. More in overdose and likely is that patients' motivation picks up tance with everyday aids and appliances, adverse effects, toxicity and of what is meant by enduring power cost - could have included another, more quickly than their mood, making experience with the drug. the chance of suicide temporarily greater. of attorney, testamentary capacity, and the Amitriptyline may have irritating The answer may not be to stop using court of protection. From the examiner's adverse effects but it has been around for fluoxetine but to warn patients of this point of view, the great advantage of the a long time. It can be prescribed with con- danger and monitor them particularly DGM is the ability to see the candidate fidence, in the knowledge that its efficacy closely in the early phase of recovery from relating to a real patient, a limiting factor is undoubted and that new adverse effects depression. in the MRCGP examination. are unlikely to be discovered. The same M SLANEY General practitioner principals and cannot be said of some of the newer Psychiatric Division trainees make up a considerable propor- drugs. Sertraline (Lustral), for example, is Basingstoke District Hospital tion of the candidates for this successful being widely advertised in the general Park Prewett, Basingstoke diploma, for which enjoyment in par- practitioner press but I would not recom- Hants RG24 9LZ ticipation and widespread tributes to its mend it for use by general practitioners relevance are often expressed. The un- as psychiatrists have not yet got a feel for precedented biological trend towards it. I wondered why this and other new Diplomatosis longer life in developed countries makes drugs such as paroxetine and amoxapine the diploma in geriatric medicine an were not discussed in the Matthews and Sir, essential requirement for general practi- Eagles' article. Then I realized that it had According to Dr Brown (Letters, March tioners who attend the needs of 947o of been submitted in January 1990. Journal, p.128) the MRCGP examination the elderly population. The article advocated the use of represents an endpoint assessment leading THOMPSON trazodone, mianserin and lofepramine as him to question the value of diplomas in M KEITH first line drugs. It was not stated whether core subjects like child health and geriatric 28 Steep Hill this was intended to be an order of medicine. He also reports that diplomas Stanhope Road preference, but it may well have been were not welcomed at a general practi- Croydon CRO 5QS 260 British Journal of General Practice, June 1991.
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