Ms. F was a nurse practitioner working in a clinic that had a steady stream of patients. Ms. F, as well as the other NPs working at the clinic, had broad authority to examine and treat patients.
One day, Ms. C, aged 15 years, arrived at the clinic with her father. She had been seen two days earlier in the emergency department (ED) of the local hospital with complaints of nausea, abdominal pain and vomiting. The clinician in the ED attributed her condition to a virus and advised the young patient to follow up with her family physician if she did not improve in a few days. Ms. C did not have a family physician, so her father took her to Ms. F’s clinic when the teenager was still nauseated after 48 hours.
Ms. F examined the patient while the father waited in the reception area. Ms. C’s vital signs were normal, but the patient appeared fatigued and drained. She complained of nausea and reported that she felt “down.”
Ms. F watched the clock carefully. Her superiors frowned on appointments that lasted longer than 15 or 20 minutes, and she had violated this policy on more than one occasion.
“Explain what you mean when you say you are feeling down?” Ms. F asked the girl.
“You know, tired. Just sort of sad for no good reason,” responded Ms. C.
“How are you sleeping?”
“It seems like I either sleep too much, or I can’t sleep at all,” answered the patient.
Ms. F spent a few more minutes questioning Ms. C, and then remembered the packed waiting room and knew she had to wrap up the exam.
“I’m giving you two prescriptions,” said Ms. F. “One is for an antinausea drug to help with the queasiness, and the other is an antidepressant to help with feeling down. Come back in four weeks so we can see how you’re doing.” Ms. F wrote prescriptions for the antinausea medication and for fluoxetine (Prozac, Rapiflux, Sarafem, Selfemra) on a pad that had been pre-signed by the supervising physician, and handed them to the patient.
“I’ll see you in one month,” she told her, and the girl and her father left. Ms. F noted in the patient’s file which drugs had been prescribed and that the fluoxetine was for depression.
Ms. C scheduled an appointment for four weeks later, but never showed up. Three weeks after her appointment with Ms. F, Ms. C attempted to hang herself. She was discovered by her mother and was rushed to the hospital, but she had already suffered catastrophic brain injury and would now require permanent around-the-clock care.
Ms. F was shocked and troubled when she heard the news, but as time passed she began to forget about Ms. C, whom she had only seen once.
Ms. C’s parents were heartbroken and distraught, but eventually their sorrow turned to anger. A friend mentioned to them that he had heard on the news that antidepressants were known to cause suicidal thoughts in teenagers. The girls parents decided to contact a plaintiff’s attorney and see whether they might have a case.
The attorney studied the medical records and then asked the father whether Ms. F had spoken to him about prescribing an antidepressant for his daughter.
“No,” replied the father, “but I knew she was taking it because I filled the prescription for her.”
“But the clinician never told you to watch your daughter for signs of worsening depression?”
The attorney accepted the case and filed a malpractice lawsuit against Ms. F, her supervising physician, and the clinic.
Ms. F quickly scheduled a meeting with her defense attorney. The attorney looked at the records and asked Ms. F why she had prescribed the fluoxetine. Ms. F explained that the girl was exhibiting signs of clinical depression, which she’d noted in the file, and she thought it was the proper treatment.
The case moved toward trial. Depositions were taken, records were produced, and experts were hired. In the meantime, Ms. C passed away from her injuries (two years after the suicide attempt). More than ever, her parents were anxious for what they considered to be justice.
At trial, the parents tearfully testified about their love for their daughter and the impact her loss had on the family. The jury was obviously moved by their testimony. Experts testified that fluoxetine was known to cause suicidal ideation in children and adolescents, which is why the FDA had mandated a black-box warning on the packaging.
The defense argued that the medication was legitimately prescribed for clinical depression, as Ms. F had noted in the patient’s file. Using information gained during depositions, the defense contended that Ms. C’s attempted suicide was caused by an argument with her father and a breakup with her boyfriend, not by the medication prescribed by Ms. F.
After deliberating for several hours, the jury found Ms. F, the physician, and the clinic liable, and awarded more than $3 million in damages to the family.
A jury is made up of ordinary people, and sympathy for the plaintiff can sway jurors, even if it should not. In this case, the jurors heard about a suicide attempt by a teenage girl. They saw the impact this had on the family and heard testimony that the medication prescribed by Ms. F was known to be dangerous for a small subset of patients (a group that included Ms. C).
The defense’s tactic of trying to blame the suicide attempt on an argument with the father or a breakup with a boyfriend actually might have worked against Ms. F by making her appear unsympathetic. While it is reasonable to expect and hope that jurors can be unbiased, the fact is that they may be moved by the tragedy of the situation.
Ms. F probably should not have prescribed fluoxetine to Ms. C. She had no history with the patient and could only make an assessment based on a 15- or 20-minute appointment. The medication does have significant warnings regarding its use in children and young adults, yet Ms. F never spoke to the patient’s father to make sure he was aware of a possible worsening of the condition.
Most teenagers feel depressed at one point or another, but these feelings often resolve in time. Ms. C had not gone to the clinic for depression; she had been seeking treatment for a stomach virus. Even if Ms. F believed the teen was depressed, a far safer course of action would have been to have her return to the clinic in two weeks and reassess her for depression at that time.
If Ms. F suspected clinical depression, she should have referred the teenager to a psychiatric professional rather than try to make such a quick assessment after having just met the patient. Even if Ms. C did suffer from depression, it is not clear that medication was the proper treatment.
Ms. F could have suggested counseling or a combination of medication and counseling. Prescribing a medication that is known to cause suicidal thoughts in some young people — ithout further dialogue with a parent and without a referral to a mental-health professional — was an error in judgment.
Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.