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GPs go forth

Wife sneaks SSRI into her depressed husband's tea

Case history

Peter has been attending for three weeks with a depressive illness. After discussing the options he agrees to a course of an SSRI. You give him a month's supply with one repeat for a further month when needed.

He phones you that night to say he doesn't want the antidepressants because he is not keen on their side-effect profile mentioned in the advice leaflet. He agrees to see you for weekly reviews and, apart from mild nausea of no obvious cause, he is getting steadily better.

Two months later his wife comes for a third month of Peter's tablets and tearfully admits that she has been putting them in his tea.

Dr Rupal Shah

'I will not be able to collude in prescribing for the husband without his consent'

Peter's wife has every reason to feel upset and guilty about what she has done. She probably realises she is putting me in a difficult situation and that I will not be able to collude with her in prescribing for Peter without his consent, even if the medication seems to be helping him. I must explain to her my dilemma of not being able to prescribe for Peter, yet needing to avoid withdrawing the drug abruptly.

In the circumstances, her only option seems to be to tell him what she has done so that all three of us can come to a decision together about whether to continue the medication. If she agrees to do this then the situation is fairly straightforward and I would offer her a double appointment to see her and her husband as soon as possible.

They will both need a lot of support in getting through this; the marriage must have been under tremendous strain anyway to induce Peter's wife to take the actions she has. Perhaps the depression was more serious than I first realised.

If, on the other hand, Peter's wife refuses to disclose to him what she has done in spite of being told about the dangers of stopping the antidepressant suddenly, and the dangers of relapse, the situation is more complicated.

If I am going to continue treating Peter for his depression I would feel obliged to tell him the truth about the medication he has been receiving; he needs to be in a position where he can make an informed choice about what to do next.

Dr Claire Bailey

'And I thought it was my skill that was making him better!'

Unbelievable. I thought it was my skilful weekly counselling that was helping Peter to get better!

Peter's wife is rather cunning. I can understand that she may think she is trying to help, but spiking her husband's tea is really the limit. I would explain very clearly that this was totally unacceptable and can be dangerous.

I would have to explore her ideas as to what she was trying to achieve. Then I would question her with regard to her understanding of the medication and its possible effects. Hopefully, this would lead to me being able to explain the indications and side-effects of SSRIs to her so she may realise herself why this could be a dangerous practice. There are of course some moral issues I would remind her of which she may wish to consider: how would her husband feel if he knew what had be going on?

I wouldn't overlook the fact that she may be very stressed or depressed with the situation at home, which, as it stands now, needs some careful consideration. Peter should be told his tea has been spiked and I think the best person to do this is his wife. I would not entertain the idea of collusion or letting her persuade me to tell him what's been going on.

Abrupt withdrawal of SSRIs is not advised so Peter needs to continue his medication, which seems to be having a beneficial effect. I would invite him to attend for an appointment to discuss his depression and explain that his improvement may be due to the SSRIs and also may explain his nausea.

Peter should be given the choice of whether he wants to continue the medication, and if he does not, he should be supported by a plan to wean him off slowly. I hope he will appreciate some of the benefits of antidepressants and decide to stay on them.

Dr Peter Harvey

'I would seek to recruit his wife for further input and support'

Although this scenario seems implausible it does raise issues of confidentiality and openness. Supposing Peter somehow had been taking the tablets unwittingly and I have been indirectly colluding with his wife, where do we go next?

The fact his wife was a party to his condition and the prescribed treatment implies she has been taken into his confidence over this; it is rare for a married couple not to accept full mutual disclosure and involvement when one of the couple is ill. For a depressed patient, a confiding relationship is an essential aid to recovery. I have no doubt his wife was acting with the best intentions ­ by her actions she was supporting my judgment and management.

I would say that taking an SSRI is only a small part in the overall recovery plan from depression ­ much more is the benefit from counselling, self-reflection and, above all, time. So my time invested with him and doubtless the absence from the stress of work as he'd be signed off, together with the support from his wife, have also contributed to his improvement, and maybe it wasn't even the effect of the SSRI in the first place.

So, I would not be alarmed at the possible breach of confidentiality and infringement of Peter's rights. On the contrary, I would build on his recovery and seek to recruit his wife for further input and support. I would simply suggest they came along together for the next appointment and that the truth be told, rather than leave it to the wife to confess at home. I'm sure I could act as both mediator and facilitator for the next phase of his recovery principally by emphasising all the positives that have come out of this. Sometimes the means does justify the end.

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