HOW DO WE DECIDE WHICH ANTIDEPRESSANT IS BEST FOR US?
Voltaire’s famous aphorism of “doctors prescribing drugs of which they know little to patients of whom they know less” may seem unduly cynical but the sheer number of medicines available today (4,000) certainly poses a challenge. Which to choose between, for example, the 30 different antidepressants on offer, 25 anti-inflammatory drugs or 50 anti-hypertensives?
This apparent cornucopia of drugs is, in practice, somewhat deceptive as most are minor variations of a single compound (or indeed the same but under a different name). Pharmaceutical companies might spend much money attempting to prove their brand is superior to their competitors, but the general view is that the distinction tends to be negligible.
Nonetheless, a recent investigation from the rather different perspective of how patients “do” overall on those numerous antidepressant drugs suggests there is “a winner”. This entailed the massive task for Dr Katherine Musliner and her colleagues at Denmark’s Aarhus University of examining the medical records of almost 100,000 older citizens (75 and older) who had been prescribed one or other of the 10 most popular brands.
They noted first the numbers for whom it had to be, variously, discontinued, switched to another brand (because of lack of efficacy) or augmented with another type of medication.
They also collated further information on admissions to psychiatric hospitals, suicide and self harm and fall-related injuries. From this mountain of data they derived a “ranking score” headed by sertraline with – bottom of the league – mirtazapine and venlafaxine both of which had “a higher risk of adverse clinical outcomes”. Very useful to know.
Clenched teeth
The gentleman troubled with episodic bouts of jaw pain, as recently featured in this column, has prompted a trio of dentists to advise this is most likely to be the subconscious clenching and grinding of the teeth known as “bruxism” – usually brought on by stress or anxiety but if occurring at night may be a sleep-related movement disorder. The repetitive grinding tires the muscles of the jaw hence the pain. Relaxation techniques (such as yoga) can be of value but the definitive solution is wearing a mouth guard at night to prevent the grinding and protect the teeth.
A couple of readers whose experience of recurrent jaw pain was the first sign of the serious inflammatory disorder of blood vessels, giant cell arteritis (GCA) suggested this too could be a reason. The inflammatory process narrows the arteries, reducing the blood flow to the muscles including those involved in chewing, causing them to become tender and painful. GCA is a medical emergency as delay in diagnosis can result in blindness from involvement of the arteries to the eye. Thankfully this is preventable with high dose steroids.
Forget-me-not
Finally, and further to the very important issue of commonly prescribed medicines as a reversible cause of forgetfulness and cognitive impairment, an engineer writes to tell how, when still in his mid-50s, he found it increasingly difficult to recall the names of close colleagues and deal with even simple professional matters. He consulted a neurologist who organised a comprehensive series of investigations including a CT brain scan that all proved negative. The prospect of early retirement loomed but, almost as an afterthought, it was suggested he discontinue the blood pressure lowering beta-blocker atenolol, which he’d been taking, without problems, for 20 years. “Within a couple of months my memory was fully restored,” he writes and has carried on working ever since.
Meanwhile the cognitive impairment can be so subtle as only to become apparent when confronted by some intellectually challenging task – as it was for a guitar player from Devon. It usually takes him two hours to learn a new piece of music but this has recently stretched to several days. Prompted by the observations in this column on this matter, he discontinued his (recently prescribed) cholesterol lowering statin. Three weeks on he is pleased to report that having just “had a go” at learning a new piece, his previous facility has returned.
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2024-04-23T10:16:27Z dg43tfdfdgfd