Each of our patients is unique: the limits of biomedical entities

This is a thought-provoking article by Charles Todd. He states that “The term ‘Medically Unexplained Symptoms’ is widely used as an overarching dustbin category; its adoption represents a hubristic extension of the biomedical model.”

Our own ‘Patient Voice’ research¹ shows that “In this sample [158 cases] 25% of patients with antidepressant withdrawal presenting to their GP were diagnosed with ‘medically unexplained symptoms’ [MUS], a ‘functional neurological disorder’ [FND] or ‘chronic fatigue syndrome’. Many of the signs and symptoms associated with these medically unexplained disorders, captured in the often-used PHQ-15, overlap with the symptoms of antidepressant withdrawal, including insomnia, feeling tired, nausea, indigestion, racing heart, dizziness, headaches and back pain”.

The RCGP ‘Top Ten Tips’ for GPs states: “No 3. MUS account for up to 20% of GP consultations. 25% persist in primary care for over 12 months”.² The RCPsych estimate “About I in 4 people who see their GP have such symptoms” and “In a neurological outpatient setting, it is 1 in 3 patients or more”…“Another common term is ‘functional’ – the symptoms are due to a problem in the way the body is functioning, even though the structure of the body is normal”.³

We urge GPs to read our ‘Patient Voice’ paper,¹ to refer to the new 2020 NICE-endorsed RCPsych information about ‘stopping antidepressants’,⁴ and for the RCGP to urgently provide updated guidance for all prescribers reflecting this published and emerging evidence.

Stevie Lewis’s BJGP article ‘Guidance for psychological therapists: information for GPs advising patients on antidepressant withdrawal’ is relevant.⁵ Patients will increasingly be asking their prescribers to support their need for informed autonomy to manage and reduce their antidepressant burden so as to minimise further harm.

We urge individual prescribers to always raise, with their patients, possibilities such as antidepressant adverse effects and/or potential dose-change and withdrawal issues before initially prescribing an antidepressant for any patient – and before attributing patients’ subsequent development of ‘unexplained’ ‘functional’ symptoms to psychosomatic ‘medically unexplained’ or ‘functional’ syndromes and disorders. This is vital to the all-important doctor/patient relationship, to properly informed consent – and to reduce prescribed drug damage and resulting nervous system chaos.

References

1. Guy A, Brown M, Lewis S, Horowitz M. The ‘patient voice’: patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition. Ther Adv Psychopharmacol. January 2020. doi:10.1177/2045125320967183.
2. RCGP.  Mental Health Toolkit: Top 10 Tips MUS.  www.rcgp.org.uk/clinical-and-research/resources/toolkits/-/media/C7B311CF8F3C423F93F57C650BA42DE9.ashx.
3. Royal College of Psychiatrists.  Medically unexplained symptoms. www.rcpsych.ac.uk/mental-health/problems-disorders/medically-unexplained-symptoms.
4. NICE. Depression in adults: recognition and management. NICE 2009.  www.nice.org.uk/guidance/cg90/resources/endorsed-resource-stopping-antidepressants-8892174781.
5. Lewis S. Guidance for psychological therapists: information for GPs advising patients on antidepressant withdrawal. Br J Gen Pract 2020; 70(694):245. doi: 10.3399/bjgp20X709685.