"The last doctor gave me mirtazapine – I'm not depressed. I don't need antidepressant drugs".
I agreed with him. He wasn't exactly warm, but he didn't strike me as depressed.
"I can't sleep".
(Here we go...again) I got my volley in early. "Well of course we don't use sleeping drugs any more... but let me check what the last doctor was thinking".
"I don't want drugs", he offered.
Rather loudly.
He didn't want drugs. He mentioned that earlier.
I checked the notes. That last doctor had squeezed and forced every criteria to justify "depression", treated him for it (wrongly, with drugs alone), and started him on, well, let's say 6 to 9 months of brain altering drugs. (Isn't that the correct timeframe nowadays for these sort of drugs?)
She got the patient out of the room, managed to forget about telling him what the drugs were and the potential timeframe, and organised a review. But not with her of course. Because he is sitting in front of me. What we call in general practice, a perfect dispatch. A home run.
"I agree with you, you're not depressed. Let me tell you about my sleep hygiene booklet".
"'I'm not reading no booklet. It is a waste of time".
"But it's the correct treatment", I pleaded.
(His elbows went up, his volume went up).
"How is your reading I ventured?", conjecturing he may be illiterate, although as far as I could tell all his tattoos were spelled (spelt) right (my Dad's favourite joke!)
"It's fine, I'm not reading no booklet".
"Good. I don't want you to read it, I want you to live, to rehearse it, to breathe it", I performed.
"You don't get better from booklets". (In principle I agreed with him, in another universe we could have been friends).
So if you don't want drugs and you don't want the correct behavioural treatment I'm looking to offer you and facilitate, and we both agreed that last doctor gave you antidepressants was well...liberal, what the Engelbert Humperdinck do you want?
The voice went up, his elbows went up, his volume went up.
He stormed out happily to explete to whoever would listen.
About me, of course.
He got away from me but I was close, so close. I nearly had him. I'd nearly broken through but the previous GP had left me a mountain to climb.
I never did discover what he wanted. (It's drugs by the way. I think the ingester prefers to call them tablets but I don't like to make it that easy for them to acquit their choices. You just hope to be able to save a few from themselves along the way).
But how much longer can I stick to the white line in the middle-of-the-road, not give up where my colleague (not my term) had sentenced him to brain altering drugs for no good reason before she was rumbled in absentia by her own patient?
I wouldn't have written this today (because it's one of a thousand similar occasions) except that Liam Farrell in the BMJ told a similar tale and it reminded me that a lone soldier sometimes isn't alone. His example was the good old legend of the sore throat.
Dishing out dubious medications doesn't bother the Americans, the French, the nurse practitioner (I could go on but I'm sticking to evidence-validated information).
It is left to the GP to avoid prescription and replace it with something. Clinical acumen maybe? Honed consultation skills? Starburst?
But you can't visualise the human brain.
It is just unfortunate that there are so many situations that, unlike Liam, means I can't call after my angry patient and scream helpfully "But it's only a virus".
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