GP dilemma - depression management

Get the advice of a GP, medico-legal advisor and an expert patient.

The dilemma

Your sister-in-law has recently been showing some features of clinical depression. She told you that her sleep has been poor, often with early morning waking. She is less interested in her job and she admits that she has put on weight recently as a result of comfort eating. She has been feeling low for the past three months.

You encourage her to see her GP, who also feels that she is depressed and prescribes fluoxetine. After taking this for three weeks she is already improving, but has become more anxious and a little agitated at times. You suggest that she asks her GP for an alternative antidepressant.

However, her GP decides to keep her on fluoxetine but gives her a prescription of diazepam to take at times when she is feeling more agitated.

You do not agree with this approach but find it difficult to disagree with a GP you have never met. Should you tell your sister-in-law about your concern?

A GP's response

Dr Raj Thakkar is a GP in Wooburn Green, Buckinghamshire

Although many GPs would be happy with the management plan outlined in this scenario, the dilemma is also about the underlying principles of confidentiality, dealing with colleagues and crossing the boundaries with family medical issues.

The first option is to do nothing and trust your sister-in-law's GP. Several factors favour this choice. You probably have not taken a formal history and it would be unethical to do so.

Given that the management plan is not entirely unreasonable and her GP is more likely to be objective than you, it may be better not to intervene. In addition, it may be prudent to do some reading on the management of anxiety to ensure your knowledge is up to date. It is important to bear in mind your sister-in-law is getting better and the fluoxetine has not been given enough chance to work.

The second option would be to suggest that your sister-in-law sees her GP and challenges the current management plan. This may serve to confuse her, increase her anxiety and damage the relationship she has with her GP.

A third option may be to offer to see the GP with her, but again this may further increase her anxiety and cause her to lose faith in her GP.

I would go for the first option and offer support as her family rather than her doctor, only give a considered opinion if asked, and be clear about not crossing boundaries.

A medico-legal view

Dr Janet Page is a medico-legal adviser at the Medical Protection Society

Although you may have your sister-in-law's best interests at heart, you should be careful not to say anything that might undermine her confidence in her GP.

GMC guidance states that you should not make unfounded criticisms of colleagues that might undermine a patient's trust in the treatment they receive or the judgment of those treating them.

You were not privy to the consultation and do not know exactly what discussions took place, so before taking matters further it would be sensible to find out more from your sister-in-law. Furthermore, as a relative, you may not be looking at the situation objectively. This is why the GMC advises doctors not to treat anyone with whom they have a close personal relationship.

Unless you consider the GP's advice seriously flawed and fear it may put your sister-in-law at risk, you should think twice before interfering. You may opt to keep an eye on the situation and encourage your sister-in-law to return to her GP if she fails to improve. If you have serious concerns, you may wish to discuss them with your sister-in-law's GP, but you would need her consent and must ensure you handle the discussion with the GP sensitively.

A patient's opinion

Danny Daniels is an expert patient

At this early juncture it might be confusing and potentially harmful to tell your sister-in-law your concerns. The case does not feature your alternative ideas for her care and my initial response is not to get involved.

The GP appears to be working on evidence-based treatment. It may be at odds with your preferred approach but it is not putting the patient at serious risk. There appears to be no attempt to determine the underlying cause for the condition.

Although you disagree with the treatment I feel it would be beneficial to your sister-in-law if you continue acting as a 'listening ear' and supporting her through her condition without becoming too embroiled in the prescribed treatment.

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