Ask the doctor: Dr Martin Scurr answers readers’ questions
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My friend, age 73, is considering retiring, but every morning when she wakes she shakes with fear and cries, anticipating the loneliness and inactivity. She tends to improve as the day progresses, only to find the next morning she is destroyed by fear of emptiness in her life. Her doctor has prescribed medication, but it has made no difference. I hope to get her some valerian herb remedy. Have you any suggestions?
From what you describe, I think your friend has depression. Although it is the most common mood disorder, experts estimate as few as 50 per cent who have it are ever diagnosed.
Better training means GPs are more skilled at spotting the symptons these days, but it can still be missed, often when the feelings of depression are masked by more obvious other symptoms, such as feeling exhausted all the time.
Another reason so few people are ever diagnosed is that they don’t seek help, fearing the stigma of mental illness, possibly amplified by a feeling that depression is not a real illness. Nothing could be further from the truth: depression is a significant, real illness that can be treated and cured.
Dr Scurr advises someone on how to help their friend who may be depressed. From antidepressants to Cognitive Behavioural Therapy, Dr Scurr gives guidance on how to support loved ones
I suspect your friend may have had depression a long while, but it was kept in the background by the daily demands of work. Based on what you’ve said, it seems this depression has been ‘released’ by her dread about the future.
Depression is characterised by a number of symptoms, most obviously mood change, which can include feelings of emptiness, hopelessness, worthlessness or guilt. In addition they may lose interest or pleasure in aspects of life they previously enjoyed.
Other symptoms can include insomnia or the need to sleep constantly, fatigue, loss of energy, and an inability to concentrate. There are no tests to confirm diagnosis, rather we rely on taking a detailed history. Depression is largely genetic — which is why family history is so important for diagnosis.
The first step, often the hardest, is to persuade the patient that he/she has a genuine condition.
Tell her straight that you think she might be suffering from depression, or use the phrase ‘depressive illness’, and insist she sees her GP once again in order to explain that the medication has not proved effective so far.
It may be that an antidepressant has been prescribed and that the dose should be increased. It is important to note that antidepressants take about four or six weeks to show a benefit.
Another treatment is cognitive behavioural therapy (CBT), a form of talking therapy — studies have shown that for some it works as well as drugs. However, its availability does vary.
As for valerian, there is no evidence it works — what your friend needs is a formal diagnosis and proper treatment; the difficulty will be getting her to accept it.
For six years I’ve had recurring cellulitis. During an episode last December, a nurse gave me antibiotic Fucibet cream but three days later my legs were much worse, red and itchy. This spread all over my body and after seeing four different doctors I was given an antifungal steroid cream, Timodine, and an antihistamine, loratadine.
Over three weeks I was given a different antibiotic, which cleared the cellulitis, but the itching continued. My GP thinks I have allergies and referred me to a dermatologist. I haven’t had this appointment yet, although I do have cellulitis again. I have half a tube of Timodine left so I am using that but I don’t know what to do now. I am 88.
P. Horn, Sandy, Bedfordshire.
Cellulitis is a common infection in the deeper layers of the skin that most frequently affects the legs or face. But any site of the body can be involved: I have seen cellulitis where piercings have become infected in earlobes, eyebrows and tummy buttons.
The skin is an effective barrier against bacteria, and cellulitis is a bacterial infection; for it to take hold there must be a breach of the skin and some reduction in immunity. Cellulitis in legs does often seem to be recurrent, even when there’s no obvious reason.
The organisms involved are usually staphylococci, the bugs that cause other infections such as styes or boils. About ten per cent of us are colonised all the time by staphylococci without problems.
But some staphylococci are more aggressive than others, and our susceptibility to it varies, too — cellulitis may be more likely when someone is run down, for example post-chemotherapy, or after surgery or illness.
Cellulitis is treated with oral antibiotics, but in severe cases hospitalisation may be required so drugs can be given in greater quantities by intravenous drip.
Creams such as Fucibet or Timodine are rarely, if ever, effective used alone. They do not penetrate to the depth needed to kill off all the bacteria. In my opinion, oral antibiotics are essential. However, treatment for five or seven days is often inadequate, as even in patients treated for ten to 14 days there may still be recurrences.
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Replies should be taken in a general context and always consult your own GP with any health worries.
Flucloxacillin, a type of penicillin, is the first-line treatment, at 250mg or 500mg four times daily; clindamycin tends to be reserved for those allergic to penicillins. A major disadvantage of clindamycin is that, rarely, it can cause diarrhoea so severe that hospitalisation is needed. The usual dose is 150 to 300mg every six hours; double that for severe infections.
The itching may have caused some confusion. Itching typically accompanies cellulitis and may take some time to settle, persisting after the end of the two-week course of antibiotics.
I hope that, i
f you have further attacks, your doctor will agree to longer courses of oral antibiotics — I’ve had patients who’ve needed four or six weeks of continuous treatment. Nine times out of ten long-term antibiotics will cure it.
By the way… Red tape HASN’T improved hospital safety
Strictly speaking, the quality of care across hospitals should be improving — after all, doctors are now subject to annual appraisals aimed at ensuring high standards. On top of that, since 2009 we have had the Care Quality Commission (CQC), the inspectorate that takes great care to identify poor practice and poor systems in hospitals.
But I find myself asking whether these regulatory bodies are achieving anything — or have they failed in their task? For, when it comes to maternity care, things have not improved in a quarter of a century.
Strictly speaking, the quality of care across hospitals should be improving — after all, doctors are now subject to annual appraisals aimed at ensuring high standards
There are just as many babies being injured or permanently damaged now due to failings in maternity care as there were 25 years ago, according to a recent report from NHS Resolution, the litigation arm of the NHS.
The NHS paid out more than £800 million in compensation in the year 2016 to 2017. With payouts at that level clearly something is seriously wrong in the system somewhere.
Analysis of these claims found serious examples of failings: for example, midwives failing to understand the data from heart monitors and medics trying to deliver breech babies despite having had no training in how to do it.
When there are errors in medical care, safety and better outcomes will only result when these stimulate opportunities for learning and change. And yet it seems that what actually happens when problems are identified is that even more regulation is imposed. However, we practise evidence-based medicine these days: so is there any evidence that the vast burden of regulation has brought about any improvement in obstetric care?
Quite the reverse. Which begs the question: who, if anyone, is keeping an eye on the expensive regulatory framework? Last year the cqc’s budget was more than £230 million. I’d like to say those regulators are worth every penny. But I’m not convinced.