A woman who was accidentally given angina pills instead of her usual antidepressant medication suffered a worsening of her depression.
The woman, aged 26 at the time, was travelling in 2014 and visited a GP to get a repeat prescription of her usual antidepressant, fluoxetine, sold under various brands including Prozac.
She took the prescription to a pharmacist who by mistake dispensed Duride, a heart medication used to prevent angina, according to a report published today by Deputy Health and Disability Commissioner Rose Wall.
The pharmacy's medication label, printed and stuck on the medication box, stated the contents were fluoxetine. However, the box and pill packets were marked "Duride". The woman did not question the name Duride on the box or pill packets as she had been given different drugs in the past.
She started taking the Duride.
"During the time she was not taking fluoxetine, Ms A experienced an exacerbation in her depression," Ms Wall says. "She started seeing a counsellor again and struggled to find a job owing to her feelings of inadequacy. Her relationship broke down and she suffered severe migraines, felt nauseous, experienced random heart palpitations, and was always fatigued."
She went to another GP for a further prescription and took with her the box from her existing medication. The GP told her the pills she had been taking for depression were not anti-depressants and alerted the pharmacy to the error.
The woman told the deputy commissioner's investigation: "Looking back, it made a lot of sense. My depression had taken a steep turn for the worse, and my quality of life was severely compromised for months. I started seeing a counsellor again. I struggled to find a job due to my intensified feelings of inadequacy and hatred that comes with depression. My relationship was lost also. I had - albeit accidentally - been taken off anti-depressants immediately, without my knowledge, after being on them for more than a year, for the second period of depression in my life."
Ms Wall says there are risks in stopping taking antidepressant medication suddenly: it can lead to flu-like or stomach upset symptoms, difficulty in thinking, and/or disturbing thoughts.
She says the pharmacist had failed to check the dispensed medication adequately against the prescription or the label. This was a failure to comply with both the pharmacy's established procedures, and with the pharmacy profession's standards. Consequently he had committed a breach of the code of patients' rights.
The pharmacist and the pharmacy have both apologised to the woman.
By Martin Johnston of the New Zealand Herald
