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Plan for follow-up of patient with depression; renewing a prescription without reviewing the patient (13HDC00015)

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(13HDC00015, 1 December 2014) 

General practitioner ~ Antidepressant medication ~ Renewing prescription ~ Appropriate plan ~ Suicide ~ Right 4(1)

A young man had a history of depression which was first recognised when he was a teenager. In his early twenties, he was assessed by a general practitioner (GP). The man told the GP that he had been finding it difficult to concentrate at work, and that he had experienced approximately seven years of low mood. The GP undertook a physical and psychological examination, and concluded that the man was experiencing mild depression. 

The man advised the GP that his preference was for counselling rather than medication. The man was not immediately eligible for fully funded counselling as he was not an enrolled patient at the general practice at that time. The GP and the man discussed the commencement of antidepressants, which the man agreed to. The GP prescribed a two-month course of the selective serotonin reuptake inhibitor (SSRI) antidepressant citalopram, at a light dose of half a 20mg tablet per day. The clinical notes record that a review was to take place six to eight weeks later. The GP recalls telling the man to come in earlier if he developed side-effects from the citalopram.

Six weeks later, the man telephoned the practice and asked for a same-day repeat prescription of citalopram. At that time, if the  man had been taking his medication as directed, he should have had two weeks' supply of citalopram remaining. A further two-month prescription for citalopram was signed by the GP. The GP was aware that he had not reviewed the man since the initial prescription was provided, but stated that he balanced his desire to review the man with his view that it would be unwise for the man to be without citalopram. Two weeks later the man committed suicide after a heavy drinking session.

Clinical guidelines state that, following an initial prescription of an antidepressant medication, patients should be reviewed within one to two weeks. This is because, even in adults with only mild depressive symptoms, suicidality can be an emergent symptom where a patient is prescribed antidepressant medication for the first time. A further review should then be carried out to assess the medication's efficacy and appropriate dosage.

The GP did not have in place an appropriate plan for timely follow-up of the man after the initial two-month prescription of citalopram. This was a breach of Right 4(1). The GP's provision of a further two months of citalopram without undertaking a review of the man was also a breach of Right 4(1).

The practice was not held to be directly or vicariously liable for the GP's breaches of the Code.

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