The Off-Label Request and the Prescriber
You are a psychologist in an integrated primary care clinic. A 58-year-old client, Ms. T, has treatment-resistant depression. Her psychiatrist (a colleague in the same clinic) has tried two SSRIs without adequate response and is considering adding low-dose aripiprazole, an evidence-supported augmentation strategy. Ms. T, who has read about it online, asks you to 'tell the doctor to put me on it.' Separately, you notice in the shared record that the psychiatrist recently started Ms. T on a benzodiazepine for sleep, and that she has been on it for six weeks - longer than the clinic's guidelines recommend. Ms. T has a history of a fall and lives alone. You are not a prescriber.
1. How do you respond to Ms. T's request while staying within your role and supporting her autonomy?
Read the worked answer
First, clarify role boundaries: you do not prescribe and should not promise to 'tell the doctor' what to do. What you can do is help Ms. T advocate for herself and ensure her preferences are communicated to the prescriber. Second, support autonomy and informed choice: ask what she has read, what appeals to her about aripiprazole, and what her concerns are. Correct misconceptions gently and note that augmentation decisions involve weighing evidence, side-effect burden (e.g., metabolic effects, akathisia), and her individual risk profile. Third, facilitate communication: offer to help her prepare questions for the psychiatrist, or (with her consent and per clinic workflow) share your observations about her depression severity and treatment response in the shared record so the prescriber has your input. Fourth, respect the prescriber's clinical judgment - the decision is theirs, made with the client. Your contribution is your assessment data and the client's expressed preferences, not a directive. Document the discussion and the referral back to the prescriber. This is collaborative care: you are not a passive conduit, but you are also not the decision-maker on pharmacotherapy.
2. What, if anything, do you do about the benzodiazepine concern, and how do you raise it without overstepping?
Read the worked answer
This is a patient safety issue that falls within your role as a member of the care team, even though you do not prescribe. Six weeks of benzodiazepine use for sleep in a 58-year-old who lives alone and has a fall history raises real concerns: dependence, cognitive effects, falls, and the difficulty of discontinuation. Clinic guidelines recommend short-term use.
Steps: (1) Assess clinically - ask Ms. T about her sleep, daytime sedation, any falls or near-falls, and how she feels about the medication. You may learn she wants to stop or is worried. (2) Communicate with the prescriber directly - a brief, collegial, patient-centered message ('I wanted to flag that Ms. T mentioned X; sharing in case it's useful for your medication review') is appropriate and expected in integrated care. Frame it as information sharing, not criticism or a demand. (3) Support the client's voice - encourage her to raise sleep and the medication at her next psychiatry visit; help her prepare. (4) Do not unilaterally advise her to stop the medication - abrupt discontinuation of a benzodiazepine can be dangerous; that is the prescriber's call. (5) Document your observations and the communication. (6) If the prescriber does not respond and you believe there is ongoing risk, escalate through the clinic's usual channels (e.g., medical director) - but exhaust collegial routes first. The guiding principle is collaboration and nonmaleficence, not territoriality.