MH referral refused for the third time

[FullFiveFathom]

I went to my GP today. The local mental health services have refused a referral for the third time. My GP won’t change my meds (Effexor and mirtazapine).
The last time I saw a psychiatrist about three years ago they diagnosed me with Persistent Depressive Disorder. I have suffered from depression and anxiety all my life.
When I was seventeen I was diagnosed with unipolar disorder. None of the treatments I had helped much. After a while they told me I had treatment resistant depression.
The meds get me to the point where life is just about bearable but I have to avoid things that make me anxious, stick to a very limited routine and if anything stressful happens, I’m right back at the bottom of a black hole.
I put all my energy into looking after my kid, I have no energy, no motivation, don’t look after myself and don’t care.
I have no desire to do anything but lie down when I get the opportunity. Since I’ve been back on medication, I get some enjoyment out of things I used to like (reading, writing, music, tv) but it’s not much and when I’m stressed or tired or sometimes just randomly, I don’t want to do those things at all or I just can’t concentrate enough to focus on them.
I don’t work, have no hobbies or friends but none of that really bothers me although I suppose it’s not healthy.
I sleep at night but wake up exhausted from nightmares.
i have tried counselling, it just stressed me out more.
All I get from doctors etc is that basically this is as good as it gets for me. I don’t self harm, never did. I’m withdrawn but I get up and do what I have to do for my daughters sake and because I’m not a danger to myself or anyone and my dd is well looked after, nobody really listens to me. They think well, you’re managing, what else do you want? But I feel awful inside. At best I feel numb, at worst it’s very very bad.
I just wondered if anyone has any advice, and wanted to get some opinions if possible.
Am I unreasonable to expect doctors to do anything more for me? Maybe I am. Maybe my brain just doesn’t work properly and there’s nothing anyone can do about it. It seems that way.
Whenever I try to tell doctors how I feel it’s so frustrating. It’s like they’re telling me I’m fine but I don’t feel fine, I feel wretched.
What can I do?
Sometimes it’s like there’s someone else inside me who hates me and won’t let me be happy.

I'm sorry you feel like this. I don't think doctors are telling you that you are fine. It's not that they think you are fine and not that they are not listening. It's more that they are saying there is nothing medically they can do. Not everything can be fixed. Would you work with a social prescriber if you could get a referral to one?

Thank you for your reply @Nevertrustacop
I had never heard of social prescribing before. I just looked it up but I can’t really understand how it works.

Could something else be going on with you and the depression / anxiety are symptoms rather than the cause? Have you ever been assessed for autism/ adhd?

It’s possible but I don’t really think so. The GP included that in one of the letters they wrote to the mh clinic but they just wrote back and said if I want to get assessed for that I’d have to pay to do it privately and that just isn’t an option for me anyway.

@Nevertrustacop
I don’t think that sounds like something that would help but thanks for the suggestion.

I know you say you don't think so, but I wouldn't write it off entirely. Some of the things you included in your post could be described as autistic burn out. You can do free online tests which would give you a clearer picture and it's interesting that your gp noted it as a possible in your referral letter. If the online tests did indicate some type of nd it would be a starting point for you to discuss further with your Dr.

I would ask the GPs for a rationale as to why your referrals are being rejected. Every MH team has their inclusion and exclusion criteria. There will be a reason.

Hi! I'm really sorry you're having this experience. There is a ridiculous situation in mental health care, where a specific patient group fall between two services. I.e: people whose difficulties are 'too complex' to be managed within primary care / GP services / standard talking therapies, but 'not complex enough' to be accepted by psychiatry / CMHT / CTT. Its infuriating.

You said psychiatry have declined your case, but you haven't mentioned psychology services so I'm not sure if you've had that already? If you haven't, it's definitely worth looking into. Its a much higher level of input than standard NHS talking therapies.

In order to access it, you probably need to self refer to the standard talking therapies provider (GP should be able to provide their details), who will then assess. Talking therapies will take on patients with low-moderate needs (which comprise the majority of referrals) for step 1-3 IAPT / CBT eyc. But they refer the minority of patients with more complex patients to clinical psychologists.It sounds like maybe you could possibly fit into the psychology group? Could be worth looking into?

A PP suggested autistic burnout. Psychology service can't assess or diagnose autism, but if they they'll refer you for assessment if they think it's appropriate, so you shouldn't miss out on that if it's needed. But the psychology service itself has a much broader remit, which is really important in terms of not missing other possibilities, and they provide intensive psychological therapy - So maybe worth looking at whether you can access it, if you haven't already?

Many GPs can now refer you to other services for assessment, there's something called right to choose. So it doesn't have to go through the adult cmht if you want assessment for neurodivergence.

My adhd was diagnosed through cmht referral but my autism diagnosis was outsourced, as were my kids. My brother and sil went through right to choose.

what are your iron, b12, D levels?

personally I’d request blood tests and a move surgeries for a second opinion.

It's seriously worth knowing. Because I spent over 3 decades worried I was bipolar or something, because of regular 'breakdowns' and those often led to experiencing borderline psychosis at their worst.

Now I know I experience autistic shutdowns and autistic burnout, and that my outbursts are autistic meltdowns and understanding so much more about myself has meant I'm able to help myself self regulate better and explain things to people so I'm not wound up the way I was before.

Many women particularly are misdiagnosed with personality disorders and/or bipolar when they're actually neurodivergent. And living for so long with it undiagnosed can traumatise many of us, causing real incidences of bipolar, ptsd etc.

I'm depressed af but I understand it. And I also know much of mine is situational, I just also can't change the situations causing it (permanent physical disability, still getting used to the loss of everything which kept me ticking before my accident)

In most trusts, needs thresholds are incredibly high for psychiatry at the moment. Inclusion / exclusion criteria are almost always related to severe mental illness such as schizophrenia, bipolar disorder, psychosis - or people who are at high risk to themselves or others. You'd be wise to check inclusion criteria, but in most trusts if there's nothing in your GP referral to suggest the possibility of those issues / risks, that's the rationale for declining. They used to accept a much broader range of needs but things have changed a lot over past 15 years. I previously worked for mental health charity and we had people with long term complex significant needs offrolled from CMHT en masse in 2015. Its appalling.

Mental health nurse here ....

The evidence based treatment for chronic depression is antidepressants with talking therapy alongside.

I know you have tried counselling but i do wonder whether psychodynamic therapy might be more helpful for you. If you do a search some organisations will offer it free .

If there isn't anywhere you can get something other than counselling which you have tried, i would become more assertive and ask for another referral or a referral to the specialist depression service if you have one .

There really are more options that GP ought to be supporting you with- whether that's him augmenting your medication with some else or he needs to ask the mental health team if they are refusing the referrals what do they suggest. x

I would be thinking of trying ECT in your position.

My last suggestion if it at all possible is to look for a private psychodynamic therapist.

I don't think medication is going to be the answer for you but that some therapy is needed

@Bodybutterblusher ECT is not indicated.

But definitely some psychotherapy.

Thanks so much to everyone for your replies.
I was really down about this yesterday as the GP was very impatient with me and I’m just so tired of feeling this way so I really appreciate the advice.

@TheEightBall
I have read up a bit about autism and adhd and some of it does seem very familiar. When I spoke to the GP about it (a different one to the one I saw yesterday), she said it does sound like it’s possible but that unfortunately it would be near impossible for an adult in my position to get an assessment.
I have tried over the last few years to just accept some of the things about myself that I can’t seem to change. It has helped to a degree. I think something is different about the way I experience the world because everything stresses me out and when I look at other people it feels almost like they live in the same space but in a different reality somehow.
I first started to think maybe I’m just different when I did CBT a number of years back. I literally can’t do relaxation/ meditation because my mind just races with loads of thoughts and I don’t want to be alone with them. And I did Mundane Task Refocusing where you have to practice mindfulness when you’re doing daily tasks for example washing the dishes but all I could think of was how horrible all the sensations were and my mind just kept trying to escape. Having to drag it back is like torture. I thought it was meant to be horrible at first and eventually it would get better but it didn’t. It wasn’t until much later I figured out that mindfulness isn’t meant to be like that.

@scoobysnaxx
the reason they gave is that as @PeasPud said, they are overstretched and only seeing severe cases. They pushed me back to the GP in 2016 and are just standing firm on not taking me back. They scaled right back at around that time.

@PeasPud
I was referred to a clinical psychologist in my late twenties. (Im nearly forty now). I did CBT but it didn’t help much tbh. Unfortunately there seems to be this kind of attitude because waiting lists are so long that I already “had my turn” at that (and didn’t even find it helpful) so they won’t even consider referring me again.

@glittercunt
I will ask if there is anything like that available at my next appointment. Thank you so much for the suggestion. I will probably try a different GP next time.
Sorry to hear you have depression too. It’s just an awful thing to have to live with.

@WhateverEh
I have had bloods done fairly regularly over the last few years. I actually asked for it to rule out any deficiencies etc but the levels all came back okay. I should probably go back and get them done again though.

@Lifeissodifficult
I will look into psychodynamic therapy, thank you. There is a university near me where they do some types of therapy at a reduced cost because they’re students. I might try there.
The main difficulty I have with any kind of therapy is that having to be with a stranger, making eye contact and talking about difficult things just makes my stress go through the roof. Afterwards I can’t relax or sleep properly for days and I can’t help going over and over it in my head til it’s nearly all I can think about. That was when I was off meds but it probably wouldn’t be much better with them.
When I was a kid I used to keep a journal of all the things I did/ said “right” and “wrong” during the day so I could do better the next day. I made myself stop but I still sort of do it in my head even now 😬 I can’t help it. It gets out of control after a therapy session.

@Bodybutterblusher
My psychiatrist actually suggested ECT when I was younger. I was an in-patient at the time. I would possibly consider it if I went back into a major depression, but I wouldn’t need it now.

The meds seem to work to get me from severe depression to moderate/ mild. The problem is that I just get stuck there. I’m tired and worn out from being down all the time and it’s very frustrating and disheartening that there doesn’t seem to be much help available once I get out of the severe stage. It has affected every single aspect of my life, I have poor quality of life overall I would say and it’s definitely affecting my physical health at this stage.

Sorry for the really long post. I just wanted to reply to everyone. Thanks for taking the time to reply. I will definitely look into your suggestions xx

@PeasPud yes agreed I work as psychotherapist within mental health services and have daily battles pushing referrals through and also rejecting accepting my own.

OP if you are wanting a med change or to consider this as the GP refer you for a medication review. Sometimes they will push you through to a psychiatrist for a one off medication review at least.

Hi op, I really feel for you and can empathise as I'm in a similar -ish position. I think the problem with mental health provision is for those of us who don't fit ' perfectly ' into a box what can they do with us?. In ' normal ' cases of depression/ anxiety the patient is given an ssri, responds well to treatment ( give or take a few different doses/ different type of ssri) and is sent on their way. Job done. When you don't respond in this way and the antidepressant doesn't hit the mark, but your also not presenting with typical signs of bipolar or psychosis or schizophrenia etc, then there seems to be so little help available. One thing I have learnt over time is to try and give the gp as MUCH info as possible about how your symptoms present - so all the description you have in your post, down to the smallest details, even if you feel daft about mentioning your thoughts doing the washing up ' mindfully ' or the fact you used to write down your ' right' and ' wrong 'actions when you were a kid. So if you're very lucky you may meet a gp who puts all the little pieces together, gets a real understanding of how difficult life is for you, and perhaps starts to consider an alternative diagnosis and can push your referral through on this basis. I'm sorry if I'm just going over old ground and you're already doing all this in your appointments, but I know personally that I often minimise my problems with the gp as I'm embarrassed and I get overly stressed talking so tend to give the bare basics in an attempt to get out of there as quickly as possible! Some pp have given you some great advice about the right to choose pathway for nd assessment so perhaps you could ask about this too?. Good luck, and don't give up - you deserve a quality of life, you're entitled to one just as much as the next person.

I will keep trying @scoobysnaxx thanks.

@TheEightBall I’ll try to do that. I have written down what my actual problems are day to day for next time because I do find that when I’m in front of a doctor my mind just goes blank. Especially when it’s like yesterday and the doctor is impatient. I suppose it makes sense that you wouldn’t want to discuss things that make you feel vulnerable in that situation.
I think they think I’m just wasting their time (or looking for sedatives). It’s hard to keep going back like this.