Martin Scurr for the Daily Mail
16:27 EST, 6 July 2015
17:19 EST, 6 July 2015
I have suffered from mild depression and compulsive overeating and, in the past, was prescribed fluoxetine. I wake up feeling tired and wanting chocolate and bread. The smallest thing can send me into a temper or tears, or cause to me worry obsessively about something someone said or a mistake I made. To cheer myself up, I plan snacks, or look forward to eating, sometimes excessively. However, I had a sister with severe depression, and mine by comparison is mild: I just overeat, avoid socialising and lack motivation, but still function. In the evenings, my appetite is reduced and my energy levels increase. I am 37. I feel a bit lost – please help.
Name and address withheld.
A 37-year-old patient overeats, avoids socialising and lacks motivation, but still functions
Your symptoms are suggestive of a significant mood disorder, and I am deeply sympathetic. Although you describe your depression as mild because you continue to function, you are still suffering.
I suspect there may also be other symptoms you hesitate to mention – loss of libido, fear of going mad, or concerns about failing memory.
There are no tests for depression. Instead, diagnosis is based on evaluation of symptoms. What are significant are your symptoms of morning fatigue, your irritability, the fact you cry easily and your obsessive brooding about negative comments or small mistakes.
Your poor motivation is also suggestive of depression, and you have another key feature, which is what experts call diurnal variation of mood – put simply, you start the day feeling awful and pick up towards evening. The fact you have a history of depression in your family is supporting evidence that it is depression.
Symptoms are suggestive of a mood disorder
Although you describe your sister’s illness as severe, that’s not a reason to discount your own symptoms, though they may be mild in some senses, and overshadowed by your tendency to compensate with binge eating.
Not everyone agrees about the best treatment for depression; there is no ‘one size fits all’ prescription.
If the fluoxetine (better known by the brand name Prozac) was helpful, then an antidepressant might be a good option. But you might need to take it for 12 or 24 months as relapse is likely if you stop too soon.
In the full version of your letter, you said you stopped fluoxetine for fear of taking it your whole life. This was probably the wrong thing to do – you would not stop taking insulin if you were a diabetic. And though some patients with depressive illness need lifelong treatment, most do not.
I would also suggest a course of cognitive behavioural therapy, known as CBT, with a specialist psychotherapist. This talking therapy aims to change the way patients think and behave.
Studies have shown this is as effective as antidepressant medication, and the two together are a powerful combination.
You also tell me that you have a two-year-old daughter, so I would ask you: did the changes in how you feel come about after her birth? If so, you may well have a type of postnatal depression – a matter to discuss with your GP.
I spend at least two hours a day walking, so when I started to get more out of breath I wanted to know why (I have asthma but it’s controlled). I had a heart health check at a private hospital last September and was told I had a dangerous build-up of calcium in my heart and should ask my GP to refer me to a cardiologist. The cardiologist dismissed this, although I was referred for a myocardial perfusion scan, which was normal. I am scared – who is right? I wake at night with pains in my neck and shoulders. My mental health is suffering as I’m expecting a heart attack. I am 63.
Annette Vernon, Coventry.
Your concern is understandable but hopefully what follows will put your mind at rest. A build-up of calcium in the blood vessels supplying the heart is a known risk factor for heart disease, something we’ve known for hundreds of years. The calcium is the result of the plaques of cholesterol in the arteries hardening or calicifyng over time.
More from Martin Scurr for the Daily Mail…
We now have the technology to accurately measure the calcium. This involves a CT scan, which produces multiple images of the beating heart. The amount of calcium present is recorded by what is known as the Agatston score.
This type of scanning is widely promoted in the independent sector and many people with no symptoms, or those who, like yourself, have a degree of breathlessness on exertion, undergo it and are found to have abnormal test results, causing anxiety.
However, experts generally agree that while an Agatston score of zero (no calcium in the coronary artery walls) is a strong indication that there is no coronary artery disease, raised scores do not necessarily mean there is significant narrowing in the arteries – this is the situation you are in. It is possible for the arteries to widen to compensate for the plaque, so you can have calcification and a high Agatston score without the coronary arteries getting blocked.
What is required is further evaluation of the blood flow. If the blood supply to the heart is found to be poor, it indicates that the arteries have narrowed significantly, with the risk of a clot forming and cutting off blood supply, causing a section of the heart to die; this is a heart attack.
Yet we know there is no problem with blood supply to your heart thanks to your normal myocardial perfusion scan. I can only conclude your breathlessness was, in some way, related to your asthma.
Your peace of mind has been disturbed by the emotive phrase ‘dangerous build-up of calcium in the heart’. Your task is to get on with life. Take daily exercise and pay attention to all cardiac risk factors: don’t smoke, lower your cholesterol through diet, maintain normal blood pressure and make sure you are not overweight.
The greater concern is your anxiety and I suspect your nagging pains are due to this tension, and once the anxiety comes under control this will abate.
I’d suggest you may benefit from a session with a clinical psycho-logist to help with your concerns about having a heart attack.
By the way… Prescription fees rip off patients
CONTACT DR SCURR
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Dr Scurr cannot enter into personal correspondence. His replies cannot apply to individual cases and should be taken in a general context. Always consult your own GP with any health worries.
Soon your medicine could carry a label telling you how much it actually costs the NHS.
That was the plan announced last week by Jeremy Hunt, and will affect medication valued at over £20. The scheme is designed to ensure the patient reflects on what they are receiving, hopefully nudging them into taking the drug exactly as prescribed.
I am reminded about the story I heard from our practice nurse who had discovered that her father, a retired naval officer, had been hoarding a vast collection of unopened packs of simvastatin.
When questioned, he explained that he was concerned about the side-effects of statins. Besides, he felt entirely well, and, in his late Eighties did not believe that he would gain any benefit from what was, in his case, preventative treatment. But he had great respect for his GP and had no intention of disappointing him, so he continued to receive his periodic repeat prescription.
Perhaps if he’d seen the true cost of all this, he might have at least been willing to talk to his GP abut stopping his ‘needless’ repeat prescriptions. All very sensible, but this new plan also masks a clever little earner for the NHS at patients’ expense.
When my son was at York University he saw a GP at the student health centre for treatment of infected eczema, then raging during hay-fever season. He was given a prescription for four items: an antihistamine, a cream, an antibiotic, and some eye drops.
The prescription charge back then was more than £7 per item, but nobody took the time to explain that three of the items could be bought over the counter for less than half of that amount; even on a private prescription, the antibiotic would also have been less than £7.
I think £28 is quite a lot for a 20-year-old student to find (not to mention the fact that if he’d been at university in Wales or Scotland there would have been no charge at all).
I wonder how many people would pay the current prescription charge of £8.20 per item for medication if they knew their medicine costs less than that?
Of course they will not know – the new labelling only applies when the value is more than £20.
I have no wish to rain on Jeremy Hunt’s parade, but it’s just a thought.