Primary care physicians are increasingly prescribing medications to treat depression and managing their patients’ antidepressant use. While there are many reasons for this, and it is generally beneficial for patients, it does open the door to potential lawsuits, as we see in this months’ case.
Dr C, a 49-year-old family practitioner, worked for a busy medical office and typically saw a steady stream of patients from shortly after he arrived in the morning until the end of the workday. His ‘free’ time was often spent returning calls to patients, insurance companies, and pharmacies.
When he exited his office, the receptionist handed him a note from the medical assistant and told him that Mrs J had called. Mrs J, 55, had been the doctor’s patient for the past 5 years. She had a history of depression for which Dr C had prescribed venlafaxine about 3 years ago. Mrs J reported to the medical assistant that she had stopped taking the venlafaxine because she thought it was causing side effects such as poor sleep, mental strain, spontaneous crying, and gastrointestinal problems. She reported not having ‘felt right’ for the last 3 months and having to take more sleeping pills to deal with sleep issues.
After reading the note, Dr C changed the patient’s antidepressant to escitalopram, wrote a referral to a gastroenterologist, and had the medical assistant call Mrs J and tell her that she could pick up samples and a prescription for escitalopram from the office. He did not ask Mrs J to schedule an appointment to see him.
Mrs J picked up the prescription and filled it that afternoon. The following day, she took the entire bottle of pills and then fatally hanged herself in her garage. She was found by her husband. Mrs J did not leave a note.
Dr C felt sorrow when he heard about Mrs J’s suicide. He certainly hadn’t anticipated it. But he didn’t feel that he had anything to do with it until he was served with papers notifying him that he was being sued by Mrs J’s widower. Shocked at the lawsuit, he immediately contacted a defense attorney to discuss the case.
The defense attorney made a motion for summary judgement, asking the judge to dismiss the case. He argued that Dr C owed no duty to prevent Mrs J from committing an unforeseeable suicide while she was not in his control. The attorney stated that even the patient’s family had been stunned by her unexpected suicide, so how was Dr C to have predicted it?
The plaintiff, on the other hand, alleged that Dr C had breached his duty of care in treating Mrs J and that her suicide resulted from that breach. The plaintiff introduced medical expert testimony from 2 experts who testified that given the patient’s history of depression and the information that she gave to the medical assistant, the standard of care required Dr C to see her and assess whether she was having suicidal thoughts, and to counsel her on the effects and side effects of escitalopram before prescribing it.
The judge sided with the defense and held that Dr C had no legal duty to prevent Mrs J’s suicide and the case was dismissed. The plaintiff appealed.
On appeal, the plaintiff argued that the lower court improperly characterized Dr C’s duty as a duty to prevent Mrs J’s suicide. Instead, the plaintiff argued that Dr C’s duty was to treat Mrs J according to the prevailing standard of care, and that he had failed to do so. And his failure was the proximate cause of the suicide. The plaintiff argued that the suicide was in fact foreseeable because Dr C admitted in a deposition that he knew that patients who stopped taking venlafaxine abruptly had an increased risk of suicide.
The higher court reversed the lower court’s dismissal of the case. It held that Dr C did have a duty – not the duty to prevent a suicide – but the duty to treat the patient with the standard of care required by law. The court remanded the case to trial court, where a jury will ultimately decide whether Dr C’s treatment failed the standard of care, and if that created the foreseeability of Mrs J’s suicide.
In order to prevail in a medical malpractice case, a plaintiff must prove 4 legal elements: 1) a professional duty to the patient, 2) breach of that duty, 3) an injury caused by the breach, and 4) damages. Dr C owed a duty to his patient, and it is likely that expert testimony will be able to show that he breached this duty by not counseling Mrs J or even calling her back to assess her situation himself before prescribing another antidepressant. The issue that the jury will ultimately have to decide is whether this breach was the proximate cause of her suicide.
When managing patients with depression, clinicians must always be cognizant that suicide is a possibility, and that sometimes the medications prescribed can actually exacerbate the situation. If a patient with depression mentions a worsening of symptoms it is wise to speak to or, better yet, see the patient so you can assess the situation. Consider referring patients with depression to a therapist, in addition to medication therapy. Proper counseling when prescribing antidepressants is essential as well.