Even before this Bill was proposed, several pharmacies, especially chain pharmacies (or pharmacies operating in chains), are already dispensing antidepressants and antipsychotic medications, with impunity. My patients told me that they have easy access to many psychiatric drugs, and only saw me when they needed medications which were not available at the pharmacies.
The problem is that some pharmacies are already enjoying such tremendous business selling medications that the pharmacists (or even dispensers) may not have the time to counsel patients about side-effects. For example, most antipsychotics can occasionally cause a low white blood cell count and low platelet count which may be lethal. We emphasise the need to do a full blood count or see a doctor should the patient develop high fever. Unfortunately, once the patients are sent to the pharmacies with a prescription, they are often lost to follow ups with doctors, with tragic consequences.
We counsel patients who are on antidepressants and antipsychotic medications about the need to avoid such medication preferably if they intend to get pregnant. We have to weigh the risk of treatment (first trimester foetal development) third trimester newborn delivery) to the child against the risk of no treatment (which may lead to recurrence of depression, schizophrenia or bipolar disorders that affect maternal health and infant bonding) to the mother and child. We also advise breastfeeding mothers to consider the effect of medication on the child, and may suggest stopping the medication for two to four weeks or not to breastfeed if medication is vital to her mental heath.
We have to be careful of mood stabilizers, used for bipolar disorders, such as lithium carbonate or sodium valproate and monitor blood levels regularly to ensure they do not cause toxicity. Such medication is strongly contraindicated in pregnancy because of the dangers of congenital deformities, but if is really necessary, regular blood monitoring is required.
Often we have patients with mental disorders, who are underweight due to poor appetite, so initially we prescribe medications which stimulate appetite, such as olanzapine for schizophrenia and mirtazapine for depression. When their weight is normal, we switch them to other medications which are less likely to stimulate appetite. Unfortunately, such patients who stop seeing doctors and get their prescriptions repeated at pharmacies may continue to do so until they have developed metabolic syndrome, including obesity and diabetes.
Often, doctors are faced with patients who demand high doses of tranquillizers or sleeping pills as they are addicted. We will help the patients to switch to other non-addictive medications including antipsychotics and antidepressants so that they can slowly wean off their addiction. If the proposed Bill is passed, then we are held hostage by the addicts to give in to their demands or face criminal charges!
We have come across patients who are addicted to 30 to 50 tablets of diazepam, dormicum and stilnox daily. They have successfully been helped to reduce their usage to just one tablet or stop entirely with the help of other psychiatric medication.
We monitor our patients on antidepressants or antipsychotics with regular blood tests to pick up SIADH (syndrome of inappropriate antidiuretic hormone), which causes severe low blood sodium, with dangerous effects. Patients are advised to check for glaucoma with ophthalmologists or optometrists as certain antidepressants and antipsychotics are not to be used if there is glaucoma. Will pharmacies continue to provide such advice once our patients are seeing them regularly after they are lost to our follow-ups?
Nowadays, antibiotic resistance due to antibiotic abuse is causing the emergence of super bugs that are resistant to all antibiotics, resulting in death. So in the medical profession, we have strict antibiotic protocols to ensure that the patient’s infected discharge is cultured and tested for antibiotic sensitivity and reviewed on the third and fifth day. Without this protocol, patients will just demand antibiotics from doctors, and we have to give in to them even though the patient is likely to have viral fever which does not respond to antibiotics. Similarly, patients may demand unnecessary or excessive pain killers like tramadol (used for severe pain within therapeutic limits) or pethidine (an opiate) injections and become addicted.
I hope the lawmakers in their wisdom will deliberate on the proposed Bill taking some of the above points for consideration.
DATUK DR TAN CHEE KHUAN
Past chairman, Malaysian Medical Association, Penang Branch and past president, Penang Medical Practitioners’ Society
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