The Danish National Board of Health

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The manuals from the Danish National Board of Health are not good enough

Danilo was only 20 years old when he was prescribed the “happy pills” which 11 days later triggered his suicide. He was legally seen as an adult: old enough to vote and old enough to drive a car. Had he been 2 years younger, under 18, it would have been against the manual from the National Board of Health that a General Practitioner prescribed the medicine to him. Instead this would be done by a specialist in psychiatry. But, doesn’t the medicine have the same side effects whether you are 17 or 19? Does the medicine know about the adult limit that has been imposed by law? These are the questions which Danilo’s parents decided to investigate, and the answer soon became clear to them. It was to be found on the product description on Sertralin, the antidepressant that took away Danilo’s life. Here they learned that the risk of suicidal behavior is increased for adolescents under 25 years, and they quickly found out, that there are several adolescents in the age of 18 to 25 years who are on antidepressants, that try to commit suicide. The increased risk of suicide does not only count for Sertralin. Several large-scale investigations from the American FDA and from the European EMA have showed the same results.

Inexplicable age limit from the National Board of Health
The National Board of Health is the highest health and drug authority in Denmark. They are the ones who decide which medicine is approved for sale, who are responsible for the sale, and which doctors are allowed to treat the different patients. The National Board of Health thereby define which doctors have the necessary competences to treat the different diseases. As an example, a dermatologist is not allowed to treat a broken leg, and a psychiatrist is not allowed to prescribe pills for gout. It is therefore the National Board of Health who have decided that General Practitioners are allowed to diagnose and treat adolescents between 18 to 25 years – despite the fact that data shows that the risk of suicide is increased for adolescents up to 25 years. The Terrida Family did not understand why the limit was set at 18 years: why isn’t it doctors specialized in the area who treat adolescents up to 25 years, when the side effects can be so fatal for exactly this group.

The National Board of Health did not comply with time limits
The age limit, which was so incomprehensible to the Family, that Marianne and Denis decided to complain. They wanted the manuals to be changed, so that others would not end up in the same situation. By Spring 2014, two and a half years after Danilo’s death, the manuals were the same, and the family lawyer therefore complained to the Danish Parliamentry Ombudsman about the missing change in regulations. The complaint was forwarded to the National Board of Health who promised to take care of the complaint within the summer 2014. However, the family did not hear anything, and when they followed up in Fall 2014, the National Board of Health postponed their answer to November. By December, the family still had not received any answers and they followed up on again. This time, it became clear that the National Board of Health had just changed the manuals which the Terrida Family had complained about.

New manuals with loopholes
To great joy for Marianne and Denis, they found that in the new manuals, the age limit, for when a doctor specialized in psychiatry should treat adolescents with antidepressants, was now raised to 25 years. Therefore, it would today not be okay if Danilos own doctor prescribed the antidepressants. He would by the new manual have to refer Danilo to a Psychiatrist. However, further down in the manual, the family discovered what they see as a loophole for the doctors. It was here described, that if it was not possible for the adolescent to get a consultation with a psychiatrist before it was necessary to initiate the treatment, the General Practitioner could still prescribe the antidepressants – however, only when consulting a psychiatrist, and only on the condition that the patient is seeking a psychiatrist as soon as possible. The family does not understand why the loophole has not been closed in the new manual. According to them, the National Board of Health are well aware that the General Practitioners are using it, as surveys show that General Practitioners still prescribe a lot of antidepressants to adolescents, even under 18 years, despite this being highly illegal by the manual. Regarding the General Practitioners’ breaking the rules, previous Chief Supervisor at the National Board of Health, Anne Mette Dons, has stated that so many doctors are involved that the National Board of Health do not think they can intervene and punish all the General Practitioners. To Marianne and Denis, this seem like the National Board of Health are letting the General Practitioners do whatever they want, and let them get away with it, without consequences, if they violate the manuals. Therefore, Danilo’s parents are left with the feeling that the National Board of Health are gambling with the lives of adolescents when no one are following up and checking the doctors.

Incompetent General Practitioners.
Besides the fact that the General Practitioners, without consequence can violate the manuals from the National Board of Health, Danilo’s parents found out that a large part of the General Practitioners have not received any official training in psychiatry within the past five years. This is evidenced by a WHO report. Meanwhile, the officially approved manuals for the treatment of psychological disorders are not available at most of the medical clinics in Denmark. The source for this report is the National Board of Health themselves, and Marianne and Denis are wondering whether the National Board of Health is knowledgeable about the obvious deficiencies in the knowledge of the General Practitioners in psychiatry, and how they can still allow General Practitioners to treat young people with so dangerous medicine.

The General Practitioner is the one to decide whether suicide is a side-effect
However, it is not only the actions of the National Board of Health in relation to the manuals that causes Danilo’s parents to worry. In Spring 2012, the Editors of DR1 Dokumentar(a Danish National Television Channel), discovered that there had not been registered any suicides where antidepressants was involved, among adolescents under 25 years. The reason for this is that Danilo’s doctor did not report the suicide as a side effect, and thereby his death could have ended up as not counting in the statistics. However, when Danilo’s death received a lot of media attention, the National Board of Health chose to check up whether Danilo’s suicide should have been registered as a side effect of the medicine. But instead of going through the case themselves, they went directly to Danilo’s own Practitioner, who had prescribed the medicine, and later received criticism for not following up on Danilo’s treatment. He reached the conclusion that Danilo’s suicide was not a side effect, and therefore the National Board of Health ended up not reporting it. It is frustrating to Danilo’s parents that the doctor who received criticism, is the one who has the last word about how the Authorities consider Danilo’s death – they thought that the Authorities were working independently from the doctors. Danilo’s death was instead registered as a possible consequence of the drug.

Proper term support for patients
On top of the long and frustrating process with the National Board of Health, the Terrida Family chose to complain to the Danish Parliamentry Ombudsman, about the lack of intervention in the case. In Marianne and Denis’s opinion, Danilo’s death could have been avoided if the National Board of Health had taken the necessary precautions to enable the General Practitioners to offer proper treatment, so that they as a minimum are able to diagnose and distinguish between patients who are sad and patients suffering from a possible mental illness. The Terrida Family are convinced that a large part of the General Practitioners are not professionally capable of examining and medicating potentially mentally ill patients, as they are not educated to do it. Therefore, it is according to Marianne and Denis, irresponsible by the National Board of Health to impose on General Practitioners to take responsibility for these patients. According to the experience of the family, the General Practitioners should, when they are contacted by potentially mentally ill patients, refer the patients directly to specialists to prevent severe errors and secure the best possible treatment with respect for the security of the patient and the National Board of Health’ own vision about delivering the best possible treatment.

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