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Casebook: daughter demands antidepressantsfor elderly mum

Dr Melanie Wynne-Jones discusses

Case history

Janet comes to see you about her mother, who is 78. She says Margaret was apparently offended by your predecessor who suggested antidepressants, but Janet is worried because she keeps saying that life is no longer worth living. She asks you to insist that Margaret takes them.

Can you discuss Margaret's medical condition with Janet?

You must not breach confidentiality, but you must also show that you take Janet's concerns seriously; Margaret may be at risk and you have a duty to find out more.

Tell Janet you cannot reveal any details as you do not have Margaret's consent, but you are willing to listen. Do not promise to keep secrets or take action; you never know what third parties are going to tell you.

You can also offer to contact Margaret and ask for consent to discuss her medical details with Janet. Many patients are happy for GPs to speak to relatives, but they must not feel coerced. Margaret may be angry and refuse, or Janet may say she doesn't want you to tell Margaret she has spoken to you. This puts you in a difficult position if

Margaret is expressing suicidal ideas.

How could you arrange to see Margaret?

The simplest solution is to advise Janet to tell her mother she has been to see you because she is worried about her, that you could not give her any information, but you suggested that Margaret comes to see you or another doctor, with or without Janet. This often works, and creates no ethical dilemmas. Safety-net by asking Janet to tell you if her mother refuses to come. If this isn't acceptable, you need to consider whether Margaret may be sufficiently at risk for you to override Janet's wishes and make direct contact. Alternatives such as inviting Margaret in for a 'check-up', or calling round 'to see how she is' may not work, may arouse hostility towards you and/or Janet, and may not be ethical.

You should discuss options with your trainer, other partners who actually know Margaret or even your defence society, depending on what Janet told you.

How do we assess the severity of depression?

You need to take a relevant history asking about mood, motivation, concentration, sleep, diurnal variation, appetite, weight, and other cognitive or biological symptoms.

You also need to know about triggers such as life events, relationships, work, physical health, financial pressures, alcohol and substance use, coping strategies, support from others, and previous psychiatric problems and treatments. Always inquire sensitively about suicidal thoughts or plans.

Under the QOF, GPs are now expected to complete a depression-assessment questionnaire as well: 'Depression 2 indicator: In those patients with a new diagnosis of depression, recorded between the preceding 1 April to 31 March, the percentage of patients who have had an assessment of severity at the outset of treatment using an assessment tool validated for use in primary care.'

This is worth up to 25 points, with

payments staged according to 40-90 per cent compliance.

Three tools have been validated and accepted for use in the QOF, the Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory Second Edition (BDIII) and the Hospital Anxiety and Depression Scale (HADS).

The PHQ-9 has nine questions and takes around three minutes to complete; it uses DSM-IV criteria and recommends treatment depending on the 'depression score' – minimal (1-4), mild (5-9), moderate (10-14), moderately severe (15-19) or severe (20-27).

These tools can help GPs to make an objective assessment, and assist in deciding whether antidepressants are indicated. But they are not easy to use with an overwrought or slowed-down patient, can interfere with the natural flow of history-taking and add time to an already overrunning consultation.

What worries patients about antidepressants?

Even if you feel antidepressants are indicated, unless you identify and address Margaret's ideas, concerns and expectations about them, she is still likely to refuse. Many patients are frightened of or hostile towards antidepressants because they:

• Find it hard to accept they are ill enough to need them; not taking medication means they can reassure themselves that they are not so bad

• Fear they will become addicted

• Fear side-effects (genuine and perceived)

• Fear losing control over their own minds

• Fear negative reaction from family and friends

• Believe antidepressants are a crutch for the weak-willed and that 'it's up to them' to get themselves better

• Feel they're taking too many tablets

already

Time spent exploring these fears, correcting misinformation and reassuring them that they are genuinely ill and have a right to accept help may change their views.

Reframing the decision to take tablets as a positive step by them to take control of their own health, rather rather than a sign that they are giving in and being weak, helps many patients to accept treatment.

Unless the situation is urgent, giving them an information leaflet and encouraging them to come back when they have had a chance to think about it or discuss things with family and friends may be more effective than pressing a prescription on them.

What other options are there?

Assuming Margaret is not ill enough to justify compulsory psychiatric assessment, these will depend on her circumstances and personal wishes. They might include:

• Watchful waiting

• Referral for psychological therapy such as cognitive behavioural therapy

• Referral for counselling

• Strategies to deal with loneliness

• Interventions to deal with physical

symptoms such as pain or breathlessness

• Referral to social services for benefits, home services or rehousing

Melanie Wynne-Jones is a GP in Marple, Cheshire

Key points

• Concerns from third parties

must be evaluated and any risk assessed

• Confidentiality can only be breached when there is a clear duty to do so

• QOF requires the use of a depression questionnaires to assist treatment decisions

• Patients' concerns about antidepressants must be addressed before prescribing

• Alternative interventions should be discussed

References

1 Revisions to the GMS Contract 2006/7 Annex 1 www.ehiprimarycare.com/tc_domainsBin/Document_Library0282/2006_Revisions_to_GMS_contract_-_full.pdf

2 Patient Health Questionnaire (PHQ-9)

can be downloaded free from www.depression-primarycare.org/clinicians/ toolkits/materials/forms/phq9/questionnaire

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