BRITISH BROADCASTING CORPORATIONÌý
RADIO SCIENCE UNITÌý
CASE NOTES - No.3 - Autoimmune DiseaseÌýÌý
RADIO 4Ìý
THURSDAY 24/08/04 2100-2130Ìý
PRESENTER:
MARK PORTERÌý
REPORTER:
CLAUDIA HAMMONDÌý
CONTRIBUTORS:
BRIDGET GRIFFITHS
ANDREW GOUGH
ANDREW KEAT
FERGUS ROGERSÌý
ANONYMOUS
TIM VYSEÌý
PRODUCER: HELEN SHARPÌýÌýÌý
NOT CHECKED AS BROADCAST
PORTER
The immune system is a highly evolved and complex collection of billions of cells that protect us from threats and invaders like bacteria and viruses. But it's not just unwelcome visitors that can feel its wrath.Ìý
Today's programme is about autoimmune diseases - conditions that result from damage inflicted by our own immune systems. What happens when the frontline soldiers turn on their countrymen, and start destroying their barracks?Ìý
We are going to be looking at three very different types of autoimmune disease. I'll be finding out about a relatively common cause of back pain that typically strikes in early adult life and which, if not properly diagnosed and managed, can lead to spinal deformity.Ìý
CLIP
I've had people quite frequently who are in their 40s and 50s just been diagnosed and they just put it down to their occupations or something.Ìý
Lumbago doctor.Ìý
Well let's right.Ìý
PORTER
I'll be discovering how a DNA database is helping doctors understand more about SLE, or lupus - potentially one of the more aggressive autoimmune diseases and how that understanding could lead to better treatments, and possibly even a cure.Ìý
CLIP
The type of lupus that I had was severe. I would be on very strong medication and there was no cure.Ìý
PORTER
But first, perhaps the best known of all autoimmune diseases - rheumatoid arthritis - a condition which affects as many as 1 in 50 people in the UK.Ìý
My guest today is consultant rheumatologist Dr Bridget Griffiths and she joins us from our studio in Newcastle.Ìý
Bridget, the joints face the brunt of the attack in rheumatoid arthritis but other parts of the body are involved too aren't they?Ìý
GRIFFITHS
Yes, that's very true. A few patients will get inflammation of the lungs, some patients will get dry eyes and dry mouth, as a result of their rheumatoid arthritis. Sometimes people get inflammation of the nerves so that it's difficult for them to lift up their hands because of the damage to the nerves.Ìý
PORTER
Who gets rheumatoid arthritis and typically when?Ìý
GRIFFITHS
Anybody can get rheumatoid arthritis - women and men - and anybody of any age can actually get it but it's probably most common in women during their 30s, 40s and 50s.Ìý
PORTER
There is a familial component, do we understand much about the genetics of rheumatoid arthritis?Ìý
GRIFFITHS
We don't really at this stage although it can run in some families.Ìý
PORTER
But the majority of people who develop the condition will or won't have a strong family history?Ìý
GRIFFITHS
Most people won't have a strong family history and it'll just come out of the blue for no apparent reason.Ìý
PORTER
And we don't know what might trigger that in the environment?Ìý
GRIFFITHS
No, no we just think that patients have a genetic predisposition - so they're born with a gene that may make them more prone to developing rheumatoid arthritis and then something happens - they may have an infection that triggers the arthritis.Ìý
PORTER
And what sort of infections do you mean?Ìý
GRIFFITHS
It could be something very minor - just a common cold - or may even be a viral infection that the patient's not aware that they've actually had, they've had very few symptoms.Ìý
PORTER
What about the classic telltale signs?Ìý
GRIFFITHS
The things we look for when we see a patient in clinic we look for swollen tender joints, particularly of the knuckles, we look for a history of stiffness in the joints in the morning, which is prolonged and then wears off as the day progresses, and we also look for inflammation in the blood tests.Ìý
PORTER
And looking at those blood tests is that a way that I, as a GP for instance, could confirm the diagnosis?Ìý
GRIFFITHS
It will help certainly, not all patients will have inflammation but most patients will and some patients, about two thirds of patients, will actually have an antibody related to rheumatoid arthritis in their blood.Ìý
PORTER
What about treatments - is there anything patients can do to help themselves?Ìý
GRIFFITHS
Yes it's important that when patients are having active disease, their joints have inflamed and painful and swollen, that they actually pace their activities and also take a significant amount of rest, so that they're not damaging their joints.Ìý
PORTER
If they push on through when they've got an inflammatory attack that will accelerate the damage will it?Ìý
GRIFFITHS
If they do too much exercise when they're having a flare up then it may cause some problems yes.Ìý
PORTER
What about relieving symptoms and pain and stiffness - how do we deal with that?Ìý
GRIFFITHS
Patients need to do exercises so that they keep their muscles strong but they're going to probably need tablets and the first tablets that a patient will try will be the anti-inflammatory tablets and then if those don't work and we have persistent symptoms then we need to start on some stronger disease modifying drugs.Ìý
PORTER
Well let's hear more about those disease modifying or suppressing drugs from Andrew Gough. He's a consultant rheumatologist at Harrogate and I asked about recent developments in both the types of suppressing drugs available, and the way in which they are used - developments that should have a significant impact on the long term outlook for people with more severe forms of the disease.Ìý
I started by asking him about the way in which we use the more established drugs.Ìý
GOUGH
Well there's quite a collection of these - there are probably six or seven in routine use. And I think perhaps the most important change amongst these drugs has been the institution and increasingly widespread use of Methotrexate and that's become, probably, our cornerstone drug in the management of rheumatoid patients who do have the progressive form of the disease.Ìý
PORTER
What's it actually doing in rheumatoid arthritis to help the patient?Ìý
GOUGH
Well Methotrexate is having an immunosuppressant role. We know that it was previously and initially started being used as actually a cancer drug and we're using it in very small doses, given intermittently, on a once a week basis, and by doing that we're effectively damping down and controlling the immune system better and so improving patients' symptoms.Ìý
PORTER
And patients would stay on this drug for life?Ìý
GOUGH
A lot of patients with rheumatoid arthritis have long-term disease and it would be fair to say that the majority will remain on it for many years once their disease is controlled. If they are or they remain in remission for a period of time, perhaps a year or two, then rheumatologists will often try and reduce the doses and sometimes even successfully discontinue it but that wouldn't be the majority.Ìý
PORTER
You mentioned that it has been used as a form of chemotherapy. What sort of side effects do patients get from it?Ìý
GOUGH
Well we used to see a lot of side effects and maybe that's one of the reasons it wasn't widely used until really the last 10 years outside of America and perhaps the Americans helped to bring that in here by showing very good results. One of the key things is that we now give a vitamin called folic acid as regular supplements and that seems to actually prevent a lot of the side effects we used to see frequently. These things would include things like mouth ulcers, hair loss, blood count problems, infections and a manner of other things. So those side effects have been greatly reduced by adding in folic acid supplements.Ìý
PORTER
So taking regular methotrexate or indeed an equivalent drug can actually improve your symptoms and make you feel better but also what effect does it have on the outcome of the disease, I mean in the long-term is it reducing the damage done by the disease?Ìý
GOUGH
Yes we have conclusive proof for methotrexate and for some of the other drugs that it does reduce and slow the progression of the disease as measured on x-rays, which is perhaps the gold standard for that.Ìý
PORTER
What about newer drugs?Ìý
GOUGH
Well the newer drugs have been a revolution, I think it would be fair to say. The majority of these, there are at least three in widespread use now, are called anti-TNF drugs and these are specifically designed and targeted to combat a particular molecule that's very important in inflammation. And by either removing or blocking the effect of that molecule it's had a profound effect, not only in rheumatoid arthritis but also in other conditions as well.Ìý
PORTER
But are they better than the standard drugs and should we be using them more widely?Ìý
GOUGH
Well that's a very important question mark. Clearly these new drugs are very expensive and as such, at the moment, we're reserving those - these drugs for patients who we're not able to treat using the normal treatment regimens open to us. But increasingly and we're involved in research locally looking at using these drugs much earlier to see if we can have an even bigger impact on the disease and more wide impact on more patients.Ìý
PORTER
Because they are relatively safe aren't they, they're fairly simple to take, it seems that the main hindrance to them is the cost which I gather can be somewhere between £10 and £15,000 per patient per year.Ìý
GOUGH
Yes, I think the figure would perhaps be around £9,000 and broadly speaking the three main anti-TNF drugs would all be around about that price. They are very well tolerated, as you say, but they're all given by injection and some patients naturally have some difficulty with that. But that aside I have not yet come across a patient who having done well on the drug is in anyway unhappy about giving themselves injections.Ìý
PORTER
With a department like yours in terms of looking at using expensive drugs, obviously there is the possibility that if we can - not only are we keeping people well by using the best drugs but we're hopefully limiting their disability later in life now that has a major economic effect for society as a whole but of course you don't get that back do you, as a department, paying for your costs of drugs on a monthly basis?Ìý
GOUGH
Well no that's true but of course the patients' interests are paramount and seeing people return to work and being able to live a normal life is not only fantastic for them but a great lift for those of us looking after them as well. It's fair to say that we probably reduce significantly the numbers of patients needing to come into hospital and probably in the long-term will greatly cut down the number of patients needing new joints and replacement surgery.Ìý
PORTER
Dr Andrew Gough there talking about anti-TNF drugs. As he said they're a very welcome addition to the armoury and as we'll be finding out later, they've revolutionised the treatment of other conditions too.Ìý
Bridget, given the range of treatments we now have what is the long-term outlook for the average person who's diagnosed perhaps in their early 20s?Ìý
GRIFFITHS
Now I would hope that a patient will actually be able to continue the activities that they want to do and have a good quality of life. We encourage patients to come to the hospital very early so that we can start treatment early because we have really now got drugs that can actually control the disease in the long-term.Ìý
PORTER
So the earlier you get to see them presumably the better the long-term outlook?Ìý
GRIFFITHS
Definitely. We've really got a window in which we really want to start treatment before a patient starts to develop damage in their joints.Ìý
PORTER
And typically I know - I mean there's no such thing as an average person with rheumatoid arthritis but looking at the long-term outlook will most people have minor disability or will most people be quite seriously affected as time goes by?Ìý
GRIFFITHS
It's hard to say really. Obviously to the patient it's very significant and often it may actually be difficult for them to carry on with their job and they may have to think of changing a career because if they're doing a heavy job that is manual it puts extra stress on their joints and that's obviously not good and may cause more damage. So sometimes patients need to think about a career change.Ìý
PORTER
What do you think about the role of diet in rheumatoid arthritis, is there any convincing evidence that it makes a difference?Ìý
GRIFFITHS
I don't think there's any real evidence that any particular diet is better than another diet for a patient with rheumatoid arthritis. What we tend to advise is patients should actually have a healthy diet. But obviously if they found that a particular item of food makes their arthritis worse then obviously they're free to actually omit it from their own diet.Ìý
PORTER
We've talked about treatments like methotrexate and the newer anti-TNF drugs, but what about the role of antibiotics? Not an obvious choice in an autoimmune disease but seemingly used with some success in the States according to one of our listeners, Parul Shah, who wants to know why they are not given more prominence here. Parul says in his e-mail:
I was diagnosed with rheumatoid arthritis in 1983 and have tried all sorts of treatment. Thousands of patients in America have been treated with antibiotics, like Minocycline, with great success. Why is it so difficult to get them here? Could it have something to do, he asks, with drug companies who have a vested interest in doctors using the newer, more expensive drugs?Ìý
Bridget, have you used antibiotics in your patients?Ìý
GRIFFITHS
Very occasionally. It's not commonly used by rheumatologists in the UK but we may use it in patients that are unable to take any of the other disease modifying drugs.Ìý
PORTER
Do we know how they're working?Ìý
GRIFFITHS
I don't think we do except we may think that they're altering the way we absorb substances from the gut that might trigger arthritis.Ìý
PORTER
According to the listener who sent the e-mail in they're used in the States, perhaps more widely than they are here, is there any evidence that's come out of the States that they're useful?Ìý
GRIFFITHS
There was a clinical trial published a couple of years ago that showed there was some benefit from Minocycline but that was really before we had these new anti-TNF drugs that are certainly effective.Ìý
PORTER
And in your experience of using Minocycline and related antibiotics any benefit?Ìý
GRIFFITHS
I've not used Minocycline and the few patients that I have seen on this drug have not really had dramatic improvements.Ìý
PORTER
Thank you Bridget.Ìý
Now onto a slightly different disease - ankylosing spondylitis or AS. It's a chronic inflammatory condition that principally affects the spine, leading to back pain, stiffness and deformity. It's not thought to be a true autoimmune disease in the sense that there is no evidence that directed attacks by the immune system are responsible for the inflammation. Although it is thought to be over-reactive in people with AS and, to go back to that metaphor of the cells of the immune system being like soldiers - in AS they become a bit trigger happy causing collateral damage by shooting at nothing.Ìý
AS is a common condition affecting as many as 1 in 200 people in the UK and men are more likely to get it. Dr Andrew Keat is consultant rheumatologist at Northwick Park Hospital and Fergus Rogers, Director of the National Ankylosing Spondylitis Society. Fergus has AS and I started by asking him how he first noticed he had a problem.Ìý
ROGERS
About the age of 23, which is the average age of disease onset, with horrendous pain in my sacrum - base of the spine - I was actually climbing a mountain in Italy one summer's afternoon and it seemed to start then. I was exceedingly fortunate by the fact that my GP suspected I had ankylosing spondylitis because his father had had it as well. I went to the London Hospital and was diagnosed immediately.Ìý
PORTER
Andrew, that's a pretty unusual story isn't it. Ankylosing spondylitis isn't top of the list for back pain when you're climbing a mountain.Ìý
KEAT
Yeah, the only common feature of this story is that it started in the early 20s, otherwise it's completely atypical. Most people's onset is much more gradual, so that symptoms come on slowly, often over a period of years. There are far more common causes of backache, especially acute back pain, and most doctors don't have it at the top of their diagnostic agenda at all.Ìý
PORTER
What's actually happening in ankylosing spondylitis?Ìý
KEAT
The fundamental problem is that there is inflammation both within the joints in the spine, especially the joints between the sacrum and the ileum, right in the back of the pelvis, and subsequently in the joints further up between the vertebrae and the spine. But also inflammation of the sites where the tendons and muscles that work the spine connect to the bones. So it's inflammation going on in the joints and in these muscle connections.Ìý
PORTER
Andrew my understanding has always been that this is a progressive condition that leads to deformity of the spine eventually.Ìý
KEAT
For many people it is progressive, not for everybody, some people have it and it lasts a short - well a few years and seems to stop being a problem. For some people it goes on for 10, 20 or 30 years and becomes less of a problem. For many people though it is progressive in the sense that the spine remains inflamed and becomes stiffer and unless people remain very active and take great care of their posture they tend to become stooped, hunched forward, which is something we really ought to prevent these days.Ìý
PORTER
Which brings us on to treatments. There haven't really been historically any effective treatments for ankylosing spondylitis have there?Ìý
KEAT
No. The two treatments that have been used and are better than nothing, since the '40s and '50s, is regular exercise, something people all find difficult to do but many patients with spondylitis have to get on with and non-steroid anti-inflammatory drugs. The first was phenylbutozone, aspirin, and now there are many others and they help a bit.Ìý
PORTER
They help with the inflammation and they help ease the pain.Ìý
KEAT
They help ease the pain and the stiffness for many people but they don't get rid of it and they don't stop the disease progressing.Ìý
ROGERS
But the exercise thing is very important. I was taught physiotherapy three times a week until I knew what to do and taking that lesson on board, when I took over the society 23 years ago I started forming branches all over the country, so now we've got about a 110 branches providing physiotherapy one night a week for about 2,000 people each week.Ìý
PORTER
Now Andrew I said historically there hasn't been an effective treatment, that's changed recently hasn't it.Ìý
KEAT
It has changed recently. This is really the introduction of the Tumor Negrosis Factor blocking drugs - the anti-TNF drugs. There are two drugs available for the treatment of this condition and there are others in development.Ìý
PORTER
And the response is fairly immediate?Ìý
KEAT
Within 6 to 12 weeks people feel hugely different. There's still 20 odd per cent of people who don't benefit and there are some people who experience side effects which stop them going on with taking it. So not everybody - it's not magic - not everybody dramatically gets better but most people do. The one thing we don't know - there are several things we don't know - but one thing we most want to know is whether it will really stop the process of stiffening up - the ankylosis - where the bones gradually fuse together and produce a permanent restriction. Now we don't know for sure whether it will stop that and we'll need several more years, I think, of study and documentation to know if that's the case. We all have our suspicions but we do not know.Ìý
PORTER
Rheumatologist Andrew Keat, and director of the National AS Society Fergus Rogers talking to me there at Northwick Park Hospital.Ìý
Bridget, there are no diagnostic blood tests at the moment for ankylosing spondylitis and back pain is a very common symptom in general practice. What would make you, as a rheumatologist, suspect AS and what should prompt GPs like me to refer on to you?Ìý
GRIFFITHS
The thing that I would particularly look for is the patient describing early morning stiffness that they feel at the bottom of their spine and it radiates into their buttocks. And they particularly find this is worse first thing in the morning and then it improves as the day goes on. And often these patients won't have had any sort of mechanical trigger that could explain these symptoms and it may be intermittent, that would certainly sort of make me think of an inflammatory arthritis rather than the mechanical problem.Ìý
PORTER
Because the picture of back pain in the mechanical one is one that it tends to come on during the day and it tends to be worse after activity isn't it.Ìý
GRIFFITHS
Yes that's absolutely true.Ìý
PORTER
And are there - I know there's no diagnostic blood test but is there any other blood test that a doctor could do that might raise the possibility of an inflammatory condition like AS?Ìý
GRIFFITHS
Yes there's some blood tests that may show a little bit of inflammation but it's often very minimal. But obviously if this blood test is positive then that helps to make the diagnosis. And sometimes we also do a genetic blood test that may make - if the result is positive then it may help to confirm the diagnosis.Ìý
PORTER
But essentially you're making the diagnosis on the clinical story?Ìý
GRIFFITHS
Definitely yes.Ìý
PORTER
Now, onto some promising new research into one of the nastier forms of autoimmune disease - systemic lupus erythematosus - otherwise known as SLE or lupus, a condition where the immune system can target almost any part of the body. Fortunately most cases are relatively mild, but it can be very severe, as Claudia Hammond found out when she spoke to OO.Ìý
ACTUALITY AT ANONYMOUS'S HOME
So how was it [indistinct word]?Ìý
Mine was quite busy this afternoon.Ìý
HAMMONDÌý
ANONYMOUS is 38, but after collapsing when she was alone at home, for the moment she's had to move back in with her mother. She was first diagnosed with lupus nine years ago.Ìý
ANONYMOUS
The first sign was swollen ankles and stiffness in my joints. It happened fairly suddenly and it was when I went to the GP, my GP at the time thought I had a kidney infection and then she referred me to the casualty unit. I was in hospital for about a week - blood test after blood test after blood test. So when they came back and told me I had this disease I was pretty frightened because I'd never heard of it.Ìý
HAMMOND
Lupus affects 1 in 2,000 people in the world, although amongst Europeans it is rarer. In lupus the immune system goes wrong and starts attacking various areas of the body. ANONYMOUS's consultant at the Hammersmith Hospital in London is rheumatologist Tim Vyse.Ìý
VYSE
There's no particular part of the body that's necessarily attacked and this actually leads to a very wide range of different sort of clinical symptoms that people can have with the disease and there's also a great spectrum in how severely it affects people. At the milder end it'll often give people joint pains or skin rashes and make people feel very rundown and tired, just due to sort of longstanding activity of the immune system. At the more severe end it can affect your kidneys, your central nervous system and your heart or your lungs. And the severity is very much related to which bit of your body gets targeted by the disease.Ìý
HAMMOND
ANONYMOUS was put on high-dose steroids to get the lupus under control and for a couple of years everything was fine. Then the lupus flared up so severely that ANONYMOUS had to have a mild form of chemotherapy to suppress her immune system and stop it attacking her body. The treatment seemed to work, but as so often happens with lupus a few years later it flared up again, meaning she had a big decision to make. She needed more chemotherapy but if she had the treatment it might well stop her from having children.Ìý
ANONYMOUS
But then again I had to weigh up the options, either it was a case of saving my fertility or risking having kidney failure. So I think when you're faced with that it's pretty obvious which choice I took.Ìý
HAMMOND
Kidney failure isn't the only reason why lupus can be fatal. Both the faulty immune system and the drugs which are given to suppress its over-activity can leave patients more susceptible to infection. At present there is no cure, but since it's more common amongst family members, Tim Vyse and his team have collected the world's largest bank of blood samples from patients with lupus.Ìý
Already he has some early data suggesting that although there are probably lots of genes involved in lupus - perhaps as many as 20 or 30 - one gene in particular caught the team's interest.Ìý
VYSE
What we noticed was that there are variants in this gene called C reactive protein and that individuals with lupus are more likely to carry the variants that mean that they don't make so much of this protein. This protein has a number of different functions, one of which is to bind to sort of cellular debris and promote its clearance. So our work suggests that if you can't make so much of this protein maybe you can't clear the sort of cellular debris that we all make as part of the sort of ongoing sort of functioning of our bodies and that this cellular debris carries many of the sort of proteins that are targeted by the immune system in lupus. So that if you can't get rid of it so efficiently and readily maybe it kind of hangs around more and that's a factor that actually allows the immune system to sort of see it inappropriately and one of the reasons why it may be targeted.Ìý
HAMMOND
So perhaps, and at the moment it is only perhaps, the immune system detects this debris and seeing it as something that shouldn't be there, starts turning on its own cells. To find out whether they're right, they need to carry on collecting blood samples both from patients and from their families.Ìý
VYSE
Our current collection comprises over 700 families, so these families are obviously patients with lupus, their parents and their brothers and sisters and you may think well that sounds like plenty to be going on with but the complexity of the disease and the fact that some genes will be playing a role in some people but not in others and that genes may influence how severely you get it, sort of what sub-type of it you get, mean that you can never really have too many families.Ìý
HAMMOND
And Tim Vyse is cautiously optimistic that eventually the genetic research could lead to the development of a drug which can target the genes and treat the disease.Ìý
VYSE
Ten years ago there is no way we could have really undertaken the genetic experiments on the scale that we're doing but with advances in technology for typing people's genes, which we can do thousands and thousands now in a week, which would have taken us months and months before. So that has sort of come on no end. And secondly, just the development of the human genome project with the availability of the sequence for most of the human genome and the identification of genes in the genome has aided our work immeasurably. Lots of groups are going to be asking these questions so one imagines that the technology will advance similarly, could be even quicker than we think.Ìý
HAMMOND
Meanwhile ANONYMOUS has qualified as a solicitor despite the disruption her illness has caused to her training. After eight years of living with lupus she became used to the idea that it would flare up every couple of years, but in February last year it came as a shock to find out just how ill she could get.Ìý
ANONYMOUS
I had a seizure in my bedroom and I fell and in total I spent two and a half months in hospital last year. Before I just knew oh I've got lupus, I had my bad and good times, but now I'm just thinking gosh my bad times can get to a stage where it's 50/50 whether or not I'll pull through but I just think well I've just got to get on with it really. I've always had the attitude I don't want the lupus to control me, it's the other way round.Ìý
PORTERÌý
ANONYMOUS talking to Claudia Hammond.Ìý
Bridget given that most cases of lupus are mild what sort of telltale signs should we be on the lookout for and does it really matter if there are people out there who've got lupus without knowing?Ìý
GRIFFITHS
I think it's important that lupus is diagnosed in everybody if they've got symptoms but obviously it can be very difficult and often patients will have had their symptoms for a number of years before they actually get a diagnosis. I think GPs should think about a diagnosis of lupus if patients have got lots of symptoms, for example, some joint pains, they feel tired, they again have stiffness in their joints in the morning, they may have the odd rashes and generally feel a little bit under the weather.Ìý
PORTER
What about the link with miscarriage?Ìý
GRIFFITHS
Quite a few patients may receive their diagnosis of lupus during pregnancy, for example if they have had a couple of miscarriages then we will do blood tests to look to see if they've got so-called sticky blood, which is an antibody that make them more prone to actually having a miscarriage and that can be common in patients with lupus.Ìý
PORTER
So if they have lupus and have had recurrent miscarriages what can we do to help them?Ìý
GRIFFITHS
Well the first treatment that we use is to use low-dose aspirin, just junior aspirin, everyday and that actually helps to improve the blood supply to the placenta and then hopefully the mother will actually go through the pregnancy.Ìý
PORTER
And to confirm a case of lupus - how would a GP do that?Ìý
GRIFFITHS
Yeah because the symptoms are very vague it's very difficult but what I would actually suggest is that the GP tests for inflammation and also does a very basic screen for one of the autoantibodies called antinuclear antibody and if this is positive then they may do other antibody tests that are more specific for lupus and give us a diagnosis.Ìý
PORTER
Dr Bridget Griffiths, thank you very much. That's it for today, that's all we have time for. Next week's programme is on depression - as many as 140,000 children in the UK are currently taking antidepressants but do they work in young people, and are they safe?Ìý
ENDS
|
ÌýPrint this page
