The Allegation
A psychiatrist negligently failed to diagnose and treat the patient’s medical/psychiatric conditions, which resulted in his suicide and the death of his wife and two children.
Case Details
A 71 YOM (5’7”, 199 lb) patient presented to a psychiatrist with complaints of a six-month history of insomnia, low energy, depression, confusion, memory problems, headaches and a 50-pound weight loss. He reported that after a 50-year history of daily alcohol intake, he had stopped drinking a year ago. His medical and surgical history included a hiatal hernia, diverticulitis, arthritis, GERD, hyperlipidemia, BPH, basal cell cancer, prostate cancer, diabetes, forgetfulness, and chronic fatigue. The patient’s current medications included Lipitor 40 mg, Tricor 145 mg, and Protonix 40 mg. In the past, his primary care physician had prescribed Celexa, Zoloft, Paxil, Cymbalta, Klonopin and Xanax for depression and anxiety. The patient no longer took any of these psychiatric medications because they were either ineffective or caused nausea. The psychiatrist believed the patient met criteria for a major depressive disorder and anxiety. He prescribed Wellbutrin XL 150 mg daily and Ativan as needed if he had severe insomnia, anxiety, or panic attacks.
At the patient’s one month follow-up, the psychiatrist increased Wellbutrin to 450 mg and prescribed Restoril to aid with sleeping. Two weeks after that, however, the patient reported the Wellbutrin was not working, so the psychiatrist switched the patient to Brintellix. He added Abilify 5 mg at the next appointment because the patient was still struggling with depression. However, two weeks later, he discontinued the Abilify because it was making the patient groggy. The psychiatrist restarted the patient on Wellbutrin 150 mg daily. When the patient had been taking the Wellbutrin 150 mg for two weeks, the psychiatrist noted the patient was doing better with his sleep medication, but he was withdrawn and had low energy. Therefore, he increased the Wellbutrin to 450 mg and added Remeron 30 mg.
The patient’s mood continued to improve, and two months later, the patient’s wife and two children reported their husband and dad “was back.” The patient was smiling, positive, and making eye contact. Three months following that, the patient continued to improve and felt that his depression and memory loss were in remission. After he had been on the Wellbutrin 450 mg and Remeron 30 mg per day for almost a year, the patient called the psychiatrist’s office to report that he was self-tapering his Wellbutrin because he believed he no longer needed it. He only wanted to take one antidepressant. A staff member called the patient and left a message warning him of the risk of relapse if he was not taking his Wellbutrin as prescribed.
The psychiatrist saw the patient one month after he had stopped taking Wellbutrin. The patient reported his anxiety and insomnia had increased, so the Remeron was increased to 45 mg per day. A month later, the patient called the psychiatrist’s office to report he could not sleep, was nauseous, and had headaches. The psychiatrist prescribed Halcion 0.25 mg every night at bedtime. Two weeks after that, the patient was hospitalized and treated for GI issues, memory problems, and anxiety. Shortly after discharge, the patient called the psychiatrist stating he had extreme anxiety and wanted to change his treatment. The psychiatrist prescribed BuSpar and made an appointment for four days later. The day before the appointment, the psychiatrist received a fax from the patient’s daughter expressing concerns about her father and his increasing depression, anxiety, insomnia, and paranoia.
At the appointment, the psychiatrist, patient, his wife, and two children discussed the patient’s psychiatric care plan. They agreed that the patient was doing well until he weaned himself off Wellbutrin. The psychiatrist noted the patient currently had no suicidal or homicidal ideations, no hallucinations, and no overt delusions. The family members did not believe the patient was violent, suicidal, or needed hospitalization. The plan was to continue Remeron 30 mg and Restoril and restart Wellbutrin. The next day the patient shot and killed himself, his wife, and two of his children. Toxicology revealed temazepam (Restoril) 0.14 micrograms/ml and mirtazapine (Remeron) 0.33 micrograms/ml in his system.
At no time during the psychiatrist’s treatment of the patient, had he or his family (with whom he had presented at various times) expressed any concerns about past or current suicidal ideation or behavior, or violent or assaultive behavior.
The family members of the patient alleged that negligent failure to diagnose and treat his psychiatric condition caused his suicide and the murder of his wife and two children. They asked for $8-12 million in damages.
Expert Testimony
Plaintiff’s expert testified the psychiatrist negligently failed to: Intervene, hospitalize, send the patient for more intensive evaluation, arrange for around-the-clock supervision at home, address the family’s terror, and add a quick-acting low dose antipsychotic. Defense experts testified the psychiatrist could not have predicted or prevented the murder/suicide. The patient did not have a history of violence or suicidal behavior. There was no indication that the patient would harm himself or his family. They further believed the patient did not meet the criteria to be hospitalized at the last visit with the psychiatrist prior to the suicide/murder. Under the circumstances, the guidelines did not require the psychiatrist to ask the patient about a gun. The medications prescribed were within the standard of care and the decision to restart Wellbutrin was appropriate.
Resolution
The jury returned a verdict in favor of the defense.
Risk Reduction Strategies
While treating psychiatric patients can present many difficulties, the excellent documentation by the insured and his staff were instrumental in helping defend and win the medical negligence action filed by the patient’s family.
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