Doctor criticised for repeat antidepressant prescription

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A doctor has been criticised for issuing a repeat prescription for antidepressants without a second face-to-face consultation with the patient, a young man who later took his own life.

Health and Disability Commissioner Anthony Hill said the doctor, whom he did not name, had breached the code of patients' rights in the way he prescribed citalopram, a drug in the class known as SSRI's or selective serotonin re-uptake inhibitors.

At a face-to-face consultation in 2012, the doctor prescribed citalopram to the patient, aged in his early 20s, for mild depression. He was not having suicidal thoughts, although seven years earlier he had divulged suicidal thoughts to his school guidance counsellor and received cognitive behaviour therapy, but not medication.

The patient agreed to take a low dose of citalopram in 2012. His preference had been to resume counselling but he was not eligible for state-funded sessions with a psychologist because he was a casual patient, having enrolled with the practice only the day before the consultation. Enrolment, which brings state subsidies to a practice, can take several months to be implemented by the Ministry of Health.

Six weeks after the doctor wrote the initial, two-month prescription, the patient phoned the clinic to ask for a repeat prescription. A nurse printed out a new, two-month prescription, which the doctor signed without any further assessment of the patient.

Several weeks later, the patient committed suicide after a heavy drinking session.

In a report published yesterday, Mr Hill said the doctor recalled telling the patient to make an appointment for a review about five weeks after the initial consultation or to come in earlier if he felt worse or if any side effects arose.

Mr Hill, citing his medical adviser, said a patient who started on an SSRI should be reviewed within one to two weeks of the prescription being written, because of the risk suicidal thoughts and behaviour, even if there was no evidence of "suicidality" at the time of prescribing. That approach was consistent with the ministry's datasheet on citalopram and the NZ Best Practice Advocacy Centre's guidelines for doctors treating depression.

The guidelines state: "Early contact in the first week of treatment is important to enquire about suicidal ideation and about any increase in symptoms.

"In the first few days of treatment with an SSRI an increase in anxiety, restlessness or agitation may occur. This can be very distressing and may be associated with increased suicidality."

Mr Hill said, "The [ministry's] MedSafe datasheet similarly refers to the '... longstanding concern that some antidepressants may have a role in the emergence of suicidality in some patients'."

He said the doctor had reviewed the Best Practice Advocacy Centre's guidelines, issued in 2009, "and has undergone further professional training in this area". He had written an apology, to be forwarded to the patient's family.