Practice Dilemma - Patient refuses medication review

The Dilemma Mrs P has a history of recurrent depression and has, on two occasions, been admitted to a psychiatric unit. She continues to take citalopram 40mg daily. She puts in a request for more citalopram but, rather than prescribing it, you diligently look at her records and note she was last seen six months ago. The record stated she was clinically stable and that she should be reviewed in two months' time. You ask the receptionist to ring her and arrange an appointment to discuss her medication. The patient refuses to come in, saying she is too busy and would just like more citalopram. What should you do?

A telephone consultation may give clues to the patient’s mental state
A telephone consultation may give clues to the patient’s mental state

A GP's view
Dr Judy Duckworth is a salaried GP in Cornwall

Mrs P is at risk of relapse of depression or psychosis. Her reluctance to attend would concern me as it may be a warning sign that she is unwell again.

Her medical notes should show whether she is reviewed by the psychiatric team, or whether she has been discharged to the practice. If one particular GP has been reviewing Mrs P, their insight could be invaluable and I would discuss my concerns with them before contacting her by telephone.

A telephone consultation may give clues to her mental state, and the presence of suicidal ideation or psychotic symptoms. I would be supportive, and ask about any symptoms of depression or side-effects of medication. I would explain that while antidepressants are important in preventing relapse, regular review is essential.

I would offer an appointment at a convenient time, with a doctor of her choice. If she declined, I would explore fears about attending surgery. A home visit may be the only option for safe assessment.

Continued refusal would be unusual and would raise concerns about mental capacity. I would aim to obtain her consent for assessment by the mental health team. I would issue weekly citalopram scrips while awaiting their advice.

This case should be discussed at a significant event meeting, with a review of repeat prescribing policy.

A medico-legal opinion
Dr Jim Rodger is head of professional services with the UK-wide medical defence organisation MDDUS

You cannot 'blackmail' Mrs P by refusing to renew her medication unless she makes an appointment to have her medication reviewed. You can only try to persuade her that this is important for her. You will have to gather sufficient evidence to support your need to see her regularly.

The patient has no doubt been seen by a psychiatrist and the medication started by them. It might help your argument to get advice on appropriate review intervals. This will depend on the social circumstances of the patient, for example if they are in full-time work or have a stable relationship.

You can also explore with the patient her reasons for not attending and try to negotiate a suitable review schedule. It may be that work or family arrangements make it difficult for her and you can try to circumvent the barriers to attending.

You cannot allow uncontrolled prescription of such medication in a patient with this history but the risk of stopping her medication probably outweighs the risk of not. How you achieve a safe way of doing so is a matter of joint decision making with the patient.

A patient's view
Gillian Whitehead is an expert patient

The GP should contact the patient and explain to her the reasons for the medication review.

Hopefully the patient will understand the importance of medication review and make time to attend. However, if the patient still says she is too busy, the GP should consider a telephone consultation. While this is not ideal, it may allow the GP to assess the patient enough to decide an appropriate course of action.

The GP may consider issuing a citalopram prescription for two weeks on the understanding that the patient makes an appointment within that time. This should allow sufficient time to plan her diary.

If the above suggestions fail, or are not appropriate for the patient, especially because of her medical history, the GP should consider asking the community psychiatric nurse to visit Mrs P at home.

The GP should review the practice procedure for issuing repeat prescriptions to avoid this situation recurring.

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