A duty to listen . . . you don't violate confidentiality if you keep your mouth shut

My daughter’s father has recently (within the last week)begun taking an antidepressant for depression.  He and I had been getting along well with no fights or hostility depsite some disagreements during this time. We are divorced but are friends and are able to attend family functions and cooperate as to our child 95% of the time or more.  Since he began taking this medication he has become very moody. One moment he is iritable, suspicious, aggressive, angry, blaming and paranoid the next he is fine the next he is yelling the next he is paranoid. The two months leading up to this he was on a roll at work, socially and was very interested in sex. Then he said he just became lost (within the span of two weeks). A close friend of mine had a depression diagnosis change after she went on an antidepressant and tried to commit suicide so I consulted with a psychiatrist here who says he has been misdiagnosed and is likely bipolar.

I informed his GP who prescribed the meds as well as his psychologist. His GP’s position is that she can’t follow up on my information because of confidentiality. I don’t understand this. I didn’t ask for any information. I do understand that I am his ex-wife but I’m not asking them to tell me anything about him. I just want to make sure he gets follow up, if needed. (I am wary of armchair diagnoses even from docs I know and trust.)

What is a doctor’s duty to act on information about a patient’s reaction to a medication from a third party in this situation?

This is a difficult situation . . . but not uncommon.  Peripherally involved family members often have a better eye on the situation than either the patient or me.  Dealing with the patient one-on-one in a vacuum has severe limitations.  Especially when I get such a small slice of a person’s time (I’m sure the GP has only minutes to reassess how your ex is doing on any particular follow up.  For this reason, I LOVE when family is involved.  These situations often occur, however, when a family member reaches out to me to give me information when they are not part of the treatment (so far), but are fearful of something bad happening. This is often a parent of a twenty-something who is still involved with the child’s life but in a very peripheral way.  They, like you, are fearful that the patient may react to their attempts to help by getting angry or upset and pulling away, thus damaging the relationship and limiting the chance of giving help. Your situation is unique in that it is not typical for divorced people to have a “95% getting along” thing.  It points to your mutual maturity and dedication as parents.  It is vitally important that that attitude be maintained.  So . . . what do we do here.

A couple points stand out from your letter.  1)  you are “friends”,  2) you attend mutual family functions, and by extension, I assume that you remain friends with some of his blood relatives, 3) the pattern of symptoms you describe, and, 4) you know who his GP and his psychologist are.  

First, lets start with what I think is going on here.  If we don’t have a diagnosis . . . we can’t treat.  While we are not going to have a diagnosis here, there are some very clear pointers that will also give us some direction with what to do.  I agree with the armchair shrink who thinks your ex might be bipolar.  It has all the right features.  You describe him being “on a roll” at work with an increase in social ability, improvement at work and a heightened sex drive.  These are clear indicators of a hypomanic episode.  Nobody EVER goes to the doc to complain about that.  It feels G-R-E-A-T . . . which is part of the problem.  An intervention at those times is difficult.  You get a response such as . . . “what, you don’t want me to be happy???”  . . . or . . . “you are just jealous” . . . but rarely do you get insight.  The unfortunate truth of a hypomanic episode is that, like all good things, it must come to an end.  And when it does, it is not pretty.  Typically, the mood state that follows hypomania or full blown mania is depression.  And, as if being depressed is not bad enough, the difference in feeling between being hypomanic and being depressed is so great that it is doubly extra painful for the person.  Once you taste hypomania, your “set-point” for “normal” is different.  Being “just OK” can feel a little depressed.  Going from the heights of hypomania to the depths of depression feels just terrible.  And THAT is when people go to their doc for treatment.  The GP, having limited time and limited experience with complicated psychiatric issues, will see someone who was doing well but now has several weeks of classic symptoms of depression and will prescribe an antidepressant.  The response of a patient with Bipolar Disorder is classically what you describe above.  Moody, irritable, unpredictable, hostile, and potentially aggressive.  It can be persistent, or, as you describe above, can be co-mingled with times where he is his usual self.  Or, even worse, it can co-mingle with the return of hypomanic symptoms where the patient feels really, really, really gooooooood again.  And can think . . . “aaaaahhhhh . . . this medicine is really working!!!!”  The irritable moody episodes are often externally blamed by the patient.  For example, “I’m angry because I’m sick and tired of you acting like this . . . it’s not me . . . it’s you who has the problem . . . ”  Which is why dealing with this by yourself will be very difficult.

So, here is what I suggest . . . 

First, you need an ally.  My guess is that you are not the only family member who has seen this.  Or, If you are, there must be someone who will be willing to step up to the plate and help this guy out.  Doing it alone risks you being identified by him as the bitchy meddlesome ex-wife, a position you have avoided so far.  If no one will help, do it alone, but there is safety in numbers.  Once you have your ally, you can decide how you will approach this.  There is no one right or wrong way. It depends on the patient in question, and the nature of the relationships between him and those who are intervening.  It is imperative that it be done in a concerned and non-threatening manner.  The point is to get him help, not to harass him.  Somehow, this message must be conferred.  If it is the consensus of those who are willing to intervene that it should NOT be done face to face, then, we must use alternate means . . .  


I get these all the time.  The letter from the concerned family member, letting me know what is going on.  They invariable have a totally unhelpful ending such as . . . “don’t tell him I told you!”  What, you afraid of being a tattle-tail????  Docs HATE these because it puts them in the position of having information that should be acted on but “not” being able to say where the information came from.  Does it violate HIPAA (more on that in another blarticle).  NO.  HIPAA prohibits the release of protected health information without the patient’s consent.  It says NOTHING about receiving information from family members.  If someone calls me or writes me a letter, they know I am involved with the patient’s health care. They write or call me by name.  Its not like they started in the yellow-pages under “A” and finally got to “H”.  When I accept phone calls by family members, I will tell them that I am answering the phone call as a courtesy to the caller and I am neither confirming or denying that the person in question is or was under my care.  HIPAA does not allow me to talk.  It does allow me to listen.  I will then suggest that, if they think the patient is under my care, they can write me a letter or they can come in to the next session with their family member and we can deal with this as adults.  If they write me a letter, I will, most likely, be sharing it with the patient. But . . . I don’t always need to.

For the above example, the doc could simply say to your ex that it is not uncommon for patients who start antidepressants to feel irritable and be more easily angered . . . ” . . . anything like that happening with you?”  If he admits it . . . BINGO!!! Problem solved.  GP refers your ex to a psychiatrist because the situation is too complicated and potentially dangerous for the patient.  The same can be done with the psychologist.  He or she can query your ex more thoroughly about changes in mood and, if elicited, get him in with a psychiatrist.  Whenever possible, I do bring up the letter or the verbal communication from the family.  It keeps everything honest and above board.  If, I need to bring the communication up to get the patient to address what I feel are clinically important issues that he is ignoring, I do.  If I feel that the patient has enough insight into the situation and bringing up the letter or communication would be detrimental, I don’t bring it up.  Every case is different and must be handled in a clinically appropriate fashion.  But, from a doc’s perspective, having knowledge and not acting on it could potentially be a liability issue. 

You seem to be a caring and concerned friend to your ex.  He is lucky.  What you describe are very serious and concerning mental health symptoms consistent with a Bipolar Disorder.  If it is, his health, his career, his relationships, and maybe even his life is at risk.  Do what you need to do to get him help.  Even if it is initially upsetting for him, it would be my hope that, someday, he will look back on this and see what a good friend you are.

–Dan Hartman, MD

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