"Sligo Mental Health services"

About: Sligo Adult Community Mental Health Services Sligo General Hospital / Psychiatry

(as the patient),

About, almost two years ago to the day, I was living abroad and suffered a nervous breakdown as a result of long standing psychological issues that were left untreated.

I was flown back to Ireland, and initially applied for admission to a hospital in Dublin. However, due to insurance complications, admission was refused.

They referred me to services locally here in Sligo.

I was given an initial assessment, and prescribed a low dose of anti-psychotic medication, to assist with the intense anxiety and distress I was experiencing at the time. I was also referred for CBT. This was in April of 2014. It would be about 6 months before I received a phone call for an initial CBT consultation.

Upon that meeting, I was told CBT was not the correct form of therapy for my issues, and was immediately discharged. I had another consultation with the local consultant, who saw me for, about 2 to 3 minutes.

I was prescribed a high dose of another different anti-psychotic drug, and the anti-depressant drug, which I had been also administered previously, and showed no effect on my symptoms - them being - constant and intense distress, anxiety, social withdrawal, hourly crying spells (persisting for months), chronic fatigue, IBS, inability to eat, and general lack of functionality.

My parents became so disillusioned with the lack of success of treatment, they stood in on my behalf, due to my inability to function and therefore implement these changes myself, and arranged an outpatient consultation for me with a private facility in Dublin.

Upon seeing the doctor there, he told me that I had been misdiagnosed with a terminal mental health illness, thus the high doses of anti-psychotics I was being prescribed. Bear in mind, this diagnosis was made during the 2 to 3 minutes meeting I had had previously.

He took me off the one of the drugs, and due to my complaints of ineffectiveness of the other at a high dose, also removed that from my regiment.

He then scheduled a hospital admission, to conduct further assessments and treatment.

Administration at the private facility I attended was in my experience woefully lacking, so it took about, 3 months, under constant daily duress from myself, for them to finally get back to me telling me again, that insurance complications would not allow my hospital admission, and I was to be again discharged to the care of HSE Sligo mental health services. During the time, I also made a trip to the ER in Sligo General Hospital, for an overwhelming onset of suicidal ideation.

The team was dispatched from the mental health sector to meet with me, upon which time I was told that, due to being, "under the care" of Dublin services, whilst waiting for results of my admission application there, they, in effect, could not treat me or deal with my case in any capacity. Two months on from this, I would get a letter confirming my discharge from the private facility , and return to the HSE.

I went in personally to the HSE administration building in Sligo, to insist on a meeting with the consultant. My time previously with them, I had been seen by an intern GP, doing his mandatory 6 months in the mental health sector - who seemed to me, to have an almost non-existent understanding of in depth mental health issues. I found him extremely brief and dismissive.

I must confess though, for someone such as myself in that position - which was very much teetering on the edge, not to be dramatic about it - this was not sufficient care.

The clinical nurse manager in Sligo's HSE, arranged an appointment for me with the consultant psychiatrist, which came up in about a week of being re-referred to their service. At that meeting, I was told that I would be referred to their clinical psychologist for assessments. This was made available to me on this occasion, where it was not available previously -due to staff not being available. To be totally clear about that situation; it is my understanding that Sligo's HSE and some patients under its umbrella, had no psychological treatment available for a one period year.

4 months from that point, I would begin treatment with their psychologist.

We are now in April of 2015, one year on from my initial crises.

Treatment began with a series of written assessments, to allow the psychologist to gain insight into my situation. They pointedly noted that, the results of the tests, were markedly different from my, "personal presentation" - in that, I did not present/look like as either being either mentally ill, anxious, or depressed.

Yet the results clearly showed severity in each of those areas.

This would be a definite criticism I have to the nature of psychiatry - in that, a psychiatrist will make an assessment in a 10 to 15 (in my initial case, 2 to 3) minute period, based purely on what they see i.e. the patient "presentation". And then they will administer power medications based on what is in my view, a paltry evaluation.

After the initial few weeks of written assessments, the psychologist I was attending began treatment. Progress was hugely inhibited by my lack of personal functionality, translating into the therapy sessions themselves - to a large degree, I was unable to interact sufficiently with the therapist, and constant and relentless presentation of distress.

At this time, through personal research and suggestion from those close to me, I became aware that, I should make notes outside of the therapy, on issues I felt were prevalent, that may be contributing to my situation. The notes consisting of, events in the past, the nature of my interaction with those around me, my inhibitions, fears, traumatic events, personal ideals etc. I would then bring these written notes into therapy, and use them to assist the therapist in my treatment. The therapy improved tenfold when this approach was incorporated. At this time, I was completely unmedicated. Despite the improvement in therapy, I was experiencing intensely all my previous symptoms, most notably overwhelming suicidal ideation.

I began to research thoroughly into various suicidal methods, and organised various ways to end my own life, as quickly, painlessly and efficiently as possible.

Previous to committing to the implementation of one of these methods, I personally resolved to have my case examined from every possible point of view, and empty my bank account attempting to resolve my issues, before I went past the point of no return.

I had thorough health screenings with leading consultants around the country.

My physical health was revealed as being pristine.

During one particularly severe bout, I contemplated the idea of turning myself into a medicated vegetable - simply to alleviate the distress. On this note, I scheduled another appointment with a HSE doctor, who saw me on short notice, and requested to be put on a new or different anti-depressant. On the third day of this medication, the suicidal ideation lifted. This was the first glimpse of success I had, since my initial crises and referral to mental health services. For the next 6 months, I would continue to be seen by the clinical psychologist with Sligo's HSE.

I will say, I found the psychologist to exhibit an outstanding level of professionalism. I will also say that, during the 6 months of treatment, where I received 45 to 50 minutes of therapy a week.  

I resolved, throughout this time that, despite the relief I found in attending therapy, it did not seem to be having an actual impact on my symptoms.

I was not eating better, nor sleeping better. It did not improve my functionality, and it did not serve to reintegrate me socially, as severe social withdrawal and a resentment and hatred for people in general, seemed to be a very prevalent symptom of my condition.

As a result of the slight improvement with the trial of a different anti-depressant medication, and research revealing that oftentimes patients may go through several of these medications before experiencing full remission, I began the process of augmenting and varying my intake of medications.

Another meeting with the psychiatrist, which was much improved from previous meetings, due to my improved functionality as a result of the medication I was on, and thus my ability to speak and convey myself much more clearly and coherently, the psychiatrist augmented my regiment with a starter dose of another drug

This served to induce somnolence at this starter dose. It had been about 8 years since I was able to sleep properly, and had been chronic for the past 4, so taking this felt like a miracle.

Despite objections, I scheduled another appointment with the good doctor about 6 weeks later, and insisted on a dose increase. Following this, I would begin to return to physical activity and exercise, for the first time in years, for short periods in the evening.

In terms of attending therapy, the psychologist informed me that, our time was drawing to a close, due to the fact that they would be off work for an extended period of time. I was informed that they were not to be replaced whilst they were off. Again, my understanding is that this resulted in the entire area of Sligo/Leitrim and that area covered by the HSE, being without psychological treatment available to its patients. Moreover, upon discussions with members of the team there I was informed that, even when they did have an active psychologist, the waiting period to see them, was normally about 12 months from time of referral. I had been seen in 4 months previously, as I had been actually admitted to the HSE a significant time previous to that, and due to the fact that the doctor from the private facility had contacted Sligo services, stressing the importance of opening my case in the immediate future, due to the severity he felt my case comprised of. As I understand it at the moment, there is still no replacement psychologist with Sligo's HSE, nor is their plans to introduce one. I believe it will be another 6 to 8 months before the return of their own psychologist.

For me personally, my dose of mirtazipine was again increased to the maximum licensed dose, and again, another leap of improvement occurred. Unfortunately, in terms of cycling through these different medications to find a point where I have achieved full remission and can return to my work etc., I have met significant resistance, as it seems to be a policy within the field of psychiatry, whether improvements are observed or not, to keep a patient on a sole medication for 6 months to a year. What's the reason for this? Your guess is as good as mine.

I have an acquaintance whom I met through an occupational therapy group, who told me he had spent 5 years, highly sedated on anti-psychotics, which were notorious also for inducing weight gain.

The doctors refused a medication modification, until he changed services.

Under extreme duress, I obtained a script from my doctor for, from what I have researched, could potentially be a more potent and efficacious anti-depressant medication, which I will be beginning shortly, when I taper off my current drugs which, despite alleviating my initial distress, proved not to be nearly as efficacious in terms of restoring my functionality. I believe a large part of the difficulty I encountered in terms of in terms of obtaining this medication adjustment, stemmed from what I mentioned earlier, regarding the nature of psychiatric assessment. The doctor told me outright, that I didn’t present as being depressed. For that reason, they could not administer this more potent anti-depressant.

This is despite the psychologist’s report that, a plethora of the most in depth and comprehensive written psychological examinations, revealed my anxiety and depression as lying on the highly severe end of the scale.

It effectively took the 20-minute consultation of persistent arguing, for the doctor to eventually to write the script and dismiss my presence, out of what seemed in my opinion to be frustration and exasperation. I was informed that, if I returned the next meeting, 3 months from now, requesting further augmentation, that I would be discharged as a patient.

All that being said, I am no longer in the hopeless black hole I was in for so long.

I am still in the receipt of disability allowance, which is infinitely appreciated and a credit in one way to the running of this country.

I have achieved significant improvement of my situation, and still live in hope that, with the implementation of a functional combination of medications for myself, that I can obtain 100% remission, and return to my life.

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Responses

Response from Martin Jones, Team Coordinator - Sligo Community Mental Health Team, Sligo Leitrim Mental Health Services, Health Service Executive

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Dear James,

Thank you for taking the time to post your feedback about the health care services.

I am sorry to hear about your negative experiences and would really like the opportunity to meet with you to discuss this further. Please contact me directly at martin.jones@hse.ie or 071 91 55120.

You may like to take a look at www.healthcomplaints.ie a website which provides information on how to make a complaint or give feedback about health and social care services (public or private). This website has been developed for people who use health and social care services in Ireland, as well as for their families, care-givers and advocates. You could also access information on how to make a formal complaint on the HSE website (http://www.hse.ie/eng/services/yourhealthservice/feedback/). This will direct you to how you can make a formal complaint should you wish to do so. The HSE and Healthcomplaints website also provides information of a number of advocacy supports/agencies which may interest you.

Please accept my assurance that we take feedback regarding our services very seriously.

It provides our service an opportunity for us to continually improve the care and service we provide.

It would be good to be able to meet with you in person to discuss your experience. If you do not wish to do so, I wish you well in your continued journey to recovery.

Best wishes,

Martin

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Response from Tòmas Murphy, Area Director of Nursing, Mental Health Service Manager, Sligo Leitrim Mental Health Services

James,

You tell a very powerful story and have shown great resolve, resilence and ambition to recovery from this current bout of illness which you are expierencing. You deserve great credit.

In relation to our services, our ambitions are to support as many people as possible in the shortest waiting time as possible. We do this by aiming to have all referrals contacted by a member of the community mental health team within 12 weeks of receipt of referral to our services. For the majority of cases this is being achieved, however at times this is not always attainable for numerous reasons.

It is regrettable that some areas were less than satisfactory for you, and I apologise for same. The services place great pride on providing the best possible care in the least restrictive environments as possible. We aim to always improve what we are doing and thus we take the opinions of those who use our services, very seriously.

I extend my invitation to meet and would be happy to explore some of the critisms and positives which you experienced, any time. My email address is tomasp.Murphy@hse.ie.

Regards for now,

Tomas

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Update posted by James (the patient)

The team co-ordinators had contacted me requesting feedback on any changes I felt had been made since the time of logging this initial story.

My own personal situation has again, markedly improved.

That being said, the reason as to why this has come about, is manifold.

Firstly - allow me to say that, I have found the service the HSE sligo services has provided, overall, to be phenomenal.

One thing I would not question, is the work ethic of those involved. The nursing staff, the team co-ordinators, the psychological and psychiatric staff.

The multiple opportunities the HSE provides, all locally, to assist in dealing with mental health issues, be it occupational therapy, psychological therapy, medical administration, support groups - in terms of the Eolas program - family assistance in terms of aiding and reassuring family members of those afflicted.

I have partaken in everything available that I felt, or those whose care I was under, felt would be of benefit to my recovery, and like I said - the effort and passion of those involved at assisting patients to recovery, is unquestionable.

So just so there are no misconceptions, that everything the HSE has done and provided for me - is appreciated and valued, absolutely.

That being said - unfortunately - there has been, and to some degree, remains to be, one terrible hindrance in terms of the nature of treatment administered, and resultingly, the potential outcome of that treatment.

And to be perfectly honest - given what I've outlined, the dedication of those involved, and their commitment to providing the best possible service - I have reservations about even commenting, criticizing.

But the reality is, from a very general, service users point of view, I feel there are some improvements that could be so very easily applied, that could, and should, make the difference of night and day to the treatment outcome; at least, there is no question that that would be the case relative to my own situation.

And very simply, the main hindrance, roadblock, that I have experienced - and this opinion was profoundly shared by other service users whom I met through the Eolas program - that the conflicting opinions of the medical consultants/doctors, and that of the patients, can often lead, ultimately, to the administration of medicine, medication, to an almost counter productive outcome.

Now initially I had considered this to be an issue, purely with the psychiatric staff.

The consultant doctors, the medical professionals who make the decisions regarding diagnosis, and thus, the course treatment would take.

But given consideration of the situation, and a more in depth look at - and pardon me if this sounds a little much coming from a meager service user - but a more in depth look at what transpires behind the scenes in terms of communication and liaison between all members of staff, that insight given to me by the application to view my medical record and files through the freedom of information act, it is clear that, it is, exactly that, communication and liaison - where the service falls down, and thus, the treatment administered, the administration of medication, lacks - pertaining to myself, and my situation.

As I feel I made abundantly clear in the initial story logged here, my "clinical presentation", does not correlate to that which, perhaps even requires medicinal treatment.

I'm in shape, I present well, dressed and groomed, energetic upon consultations - "euthymic", I believe is the psychiatric definition, or that's what doctors have been writing on my file at least.

Now, in terms of a clinical presentation that meets the diagnostic criteria for depression, by example?

Is there a requisite for the doctor to incorporate the phrase, "reeks of urine", on his evaluation sheet, to meet the criteria for such a diagnosis?

The point being - I feel, even with the most outstanding, boarding on a divine, sense of intuition, it would be extraordinary to have the ability glean a life time behavioral breakdown, years and years worth of information, on a two to three minute observation and handful of general questions.

Yet this seems to remain to be the means by which "clinical presentations" are evaluated - and the basis for the administrations of these potentially life altering, life restoring, or potentially life crippling side-effect inducing, medications.

The doctor must make his decision based on this presentation.

And, the information he reads in the patients file, outlined by the other team members.

The psychologists, the occupational therapists, the family therapists, and so on.

Yet - using myself as a means to evaluate the degree to which this is being done?

Well, apparently there remains to be a lacking.

Perhaps not just a lacking; more, I would say, a deficit.

My file in no way seemed to reflect my genuine symptomolgy.

The symptomology consistent with depression; a severe, functionality purging depression.

I had spent session after session, hour after hour, with an occupational therapist.

One on one meetings, where I could not walk, could barely talk, complained terribly of crippling lethargy, distress, weakness from not having eaten.

And I have to question why there wasn't material in my file, with large bold print stating, "this guy can't finish one slow-paced-stroll lap of the park. When I leave him, he's hunched over on a park bench, and he's so uncommunicative, that the meeting itself is terribly awkward for me as a fully functioning person who's used to regular verbal communication"??

But upon examination of my file - there was some information mentioned about how, "he seems to have a slight slowing of motor function......".

I mean - if I'm a doctor, and I read that, in addition to a "clinical presentation" of a "euthymic" young man - well, I can see how it may be difficult to arrive at a diagnosis of endogenous refracted depression.

The psychologist I attended; we did a number of written examinations. Lengthy examinations.

I think four or five in total.

Each one demonstrating a severity of anxiety, and severity of depression, a severity of energy loss and distress.

Yet upon reviewing the psychological report compiled and submitted to my file, there was a well written outline of the course of therapy, the interpersonal issues that I experienced, the possibility of some kind of personality disorder, but nothing definite, and a note that a follow up evaluation may be in line at some point in the future - as ultimately, they didn't feel talk therapy really offered any benefit or relief -something which myself and the psychologist had discussed and agreed upon.

Again, in terms of assisting a medical doctor to evaluate symptomology, which is tasked to those who have extended periods of personal interaction with myself, as oppose to the 5 minute psychiatrist interaction - I would fail to see how such a report or articulation of my condition would assist that doctor of arriving at a conclusive diagnosis of some kind.

Coupled with the fact that the written examination result charts - compiled in graph format, which had very acute spike at the denominators for "anxiety" and "depression" - were not included in the report, nor submitted to my file - thus, available to the medical doctor?

Apparently not.

The overall point I'm making, is very simply - the real issue I experience with the service, on the surface, is the administration of psychiatric medication; which, given that I have a psychiatric condition, an endogenous condition, responsive solely to medication, not to therapy - is rather important to my recovery.

But, as I said, upon further consideration and examination of the root cause of this issue in the system - I wouldn't even say it's with the evaluation process, or if that is the case, I would say it's only minor tweaks that that requires.

I had been thoroughly evaluated, from multiple points of view - as I clearly outlined above.

It appears the real issue, is the degree, the thoroughness, the professionalism that is shown in terms of the liaison of the various system support networks, to reach a multi-model, well informed end product, upon which the consulting medical doctor can make a diagnosis - on the strength of which he can incorporate something additional to a "clinical presentation", a five minutes visual observation a handful of general questions, in terms of deciding what medication, and perhaps the degree of medication, a patient requires.

I understand this is the public system, and of course they're inundated with patients, dealing with such a vast number in any capacity deserves acclaim.

But having dealt also, albeit briefly, with the private system - the degree to which that consultant emphasized inter staff liaison, was extremely noticeable.

His go-to approach seemed to be, to send this patient (me), to every evaluatory possibility; CBT, psychotherapy, constant (more than one; several), medical registrar evaluations - as well as a minimum of a half an hour private and personal evaluation with myself, before deciding a course of treatment.

His liaison consisted not only a viewing of the medical reports delivered, but also telephone conversations with the therapists delivering them, and then intercommunication between those therapists - and ultimately all that information then relaid back to him.

Given the numbers, would it be possible to do this on the public system?

Are the resources there?

Given the recent budget cuts, it would appear unfortunately, that perhaps - attaining that level of evaluation and care provided by paying patients in private hospitals, may be a stretch for the HSE.

And again, I'm very aware it may sound a little much, a little rich perhaps, for a mere service user to present with such profound criticisms.

But resources aside, there are multiple very straight forward an inexpensive means to improve this situation.

One example was raised by the mental health pharmacist during a talk delivered during one Eolas program meeting.

Fill in a tick-box-box series of surveys and questionnaires, online, previous to each psychiatric consultation, or consultation of any kind, where evaluation is necessary.

And I must point out that, having lived in the Netherlands for an extended period and having dipped in an out of mental health services during my time there - this particular approach, questionnaires, very simple to complete, and scored by computer, is absolutely the norm, across the board, for both psychological and psychiatric staff.

And in terms of financial support to put such a system in place; honestly, having studied computer science, it would be very much a fractional impact on their resources to instate such a system; more than quite trivial.

And to organize staff briefings where the level of liaison and comprehensiveness of reports submitted for the information of the medical doctors, is stressed, outlined, and a taught how to be performed in the most functional and efficient manner, to yield the best and necessary insightful outcome.

Apart from some time and thought, I fail to see how that has a financial impact at all.

That appears to me to be solely a task of modifying/improving the approach that's currently in place - and given the nature of the modification that's necessary, I can't say it's exactly a tremendous intellectual burden on those involved either.

There was mention of medical information meetings to be established, chaired perhaps by a pharmacologist, for service users, to assist with understanding their medication regiment, the effects of their medications, and to raise their awareness of the actual pharmacology/kinetics/dynamics of specific medication categories and subtypes within those categories etc.

Thus far, six months on - the outlook appears bleak for the fruition of this.

I had been invited to attend meetings known as "connecting for life", which basically appeared to be a gathering of various mental health staff member from the Sligo/Leitrim area, in an attempt to establish an "action plan" to deal with the rates of suicide in Ireland.

There were some positive ideas raised there in.

One in particular that jumped out at me was the creation of an Irish based mental health community forum, website, a chat forum, for all intents and purposes.

Now - these are in place on the internet of course, but mostly opperrating from US based servers.

The creation of such a website specific to Ireland, I feel would be a tremendous addition for service users, and, indeed in terms of my own recovery, I have made significant use of the US based forums as a means of attaining information links, literature resources, the study of neuropharmacology, the medications specific to my condition etc.

In fact - I suppose, I mentioned at the top of this (more length than expected) reply, I had alluded further significant improvement for myself.

This - I must point out, came about solely on the basis of self research, self education, effectively self diagnosis - the determination specifically of what my condition entails and, on the basis of medical research performed and documented, and clinical trial data, what has proven effective at dealing with my own specific symptomolgy - what medications I should take, in short.

Upon compiling case studies of this data and presenting it to my GP (not affiliated with HSE mental health services), he agreed to prescribe me off license medications, medications not approved for treatment of depressive conditions in Ireland (though approved and widely used in other countries; the US, Canada etc).

And as medical research and clinical trial data found and thus predicted, significant impact was made, and thus significant improvement in my condition.

At the present moment, I have reached somewhat of a happy medium with the consultant I am attending (to whom I recently switched to, given the lack of progress with the former, as a result of the difference of diagnostic opinion, as previously outlined), where he will make recommendations, but in terms of actually prescribing, given our difference of opinion, based on "clinical presentation" and that outlined above, he will write to my GP outlining his points of view and recommendations, but the responsibility of the prescribing itself, will be in the hands of my GP.

Back to the point of an Irish based mental health and mental illness support discussions internet forum, as I alluded to, there were several good ideas put forth.

Though, it seemed that the administrator self appointed to instigate the website, felt it would be a "long and expensive" task.

Again - assuming as it may sound, having studied the basics of web design, the reality is, under the supervision of the most reasonably competent programmer, and with the input of medical staff to influence the layout, such a website could and should be up and running in less than a fortnight - with the potential for further customization of course - at minimal expense, given there are multiple online templates available offered through businesses who specialize in providing such a service, and on which several very well known and highly successful and popular Irish and British websites are based.

However - that falls into the category of what may happen.

Along with what may happen regarding the improvement of in house communication and liaison and file documenting, along with the instigation of medical exchange support groups.

To conclude, regarding my own situation; I will say, that when I determined a base medication which incited gradual reform of my cognitive impairment, self study regarding my own condition and its potential treatment has been invaluable and absolutely instrumental in my further recovery.

As I made clear, it's on the basis of this, that I'm effectively being treated - which I am perfectly fine with, as it stands.

I would just hope that perhaps in time the above points gradually improve as, in terms of the administration of certain medications, which are again off license in Ireland, they are on occasion provided, but done so solely upon the consent of a consultant, a doctor of such rank, and not a GP.

So there is a bridge that has yet to be crossed, it's not yet quite clear how that may be done but, for this moment, I will continue to work on it, and work with what's available.

I've come a long way, but I still have a long way to go.

And the day I reach a point where I can apply for even a part time job, to know that I have the functional stability to do so, will be a tremendous success, and although I'm optimistic, I am also tentative.

Response from Martin Jones, Team Coordinator - Sligo Community Mental Health Team, Sligo Leitrim Mental Health Services, Health Service Executive

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James,

Thank you for comments about the Sligo/ Leitrim Mental Health Service - I will remind the team that they are doing a good job and their efforts are appreciated.

As always your feedback as a user of the service is greatly valued as it can help us improve and know what we are getting right.

As you mention medication you might find our choice and medication website helpful which is run by the Sligo Leitrim Mental Health Pharmacy Services...

http://www.choiceandmedication.org/sligo/

I wish you every success on your continued recovery, James.

All the best

-Martin

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