Speaking to a psychiatrist and preparing to change medication

Near the beginning of the year (it’s now June), I asked my new GP to refer me to the NHS mental health services in Scotland. I had largely given up on NHS mental health services when I lived in England, but given how ill I am, (and how much money I’m spending on private therapy), I thought I would try again now that I live in Scotland. The wait for a mental health assessment ended up being 4 or 5 months after I spoke to the GP, though to be fair to them the original date I was offered was 3 or 4 months from when I spoke to the GP – I had to rearrange due to a work commitment. For any readers not familiar with NHS mental health services, this length of wait is what I’d consider relatively short.

Interestingly, I was referred to a team who work with people with serious/chronic mental illness instead of a team who work with less severe or long-term conditions. This was different to what happened in England in 2016/17 – in that case I was referred to what I believe was the higher of the two intensity levels for CBT (available through IAPT). As I’ve described elsewhere that level of treatment wasn’t appropriate for me, as I had complex, chronic OCD, as well as a lot of previous experience with different CBT-based treatments. The psychiatrist I saw this month in Scotland recognised that, based on my history, the level of psychological support I needed was the level provided by a clinical psychologist (clinical psychologists have a minimum of 3 years of training). Unfortunately the waiting list to see a clinical psychologist is about a year, so she thought my best option would be to continue seeing my private therapist. My private therapist is excellent, but it makes me wonder what other people in my situation who don’t have the luxury of being able to afford private therapy are supposed to do. When it comes to mental illness, those of us with the more serious conditions seem to wait the longest.

Medication options

I got the impression that the psychiatrist knew what she was doing, in part because she acknowledged that I have a lot of knowledge about my own mental health through the way she spoke to me. (In fact, it’s a good job I could remember the various antidepressants I’ve taken over the years, as my NHS records still haven’t got up to Scotland, more than 6 months since I asked for them to be moved.) We discussed what options might be available in terms of changing my medication. One option was adding an antipsychotic to the SSRI (sertraline) that I was already taking. Another was coming off sertraline and moving onto clomipramine. Clomipramine is one of the old class of antidepressants, which were used before the advent of SSRIs. There is some research to suggest it could help with OCD.

In terms of my medication, I started my first antidepressant, fluoxetine (Prozac) when I was 17. At the time I remember feeling that it was quite cool to be taking a medication that wasn’t licenced for under 18s, but unfortunately it didn’t do anything for my OCD. During the following years I moved between SSRIs (and one SNRI, venlafaxine), eventually ending up on sertraline for about 7 years. I felt that sertraline may have backed me up a bit when I had successful CBT in 2012, but other than that I have never noticed a definite benefit of taking it. Despite this I had struggled to come off it on my own (I did try once but my bad thoughts got stronger, so I only managed to get down to 175mg from 200mg – 200mg being the maximum dose that is typically prescribed). For some time I have suspected that this worsening of OCD may have been a placebo effect – i.e. I knew I was reducing the medication so my OCD got worse in response to this knowledge, rather than OCD worsening because of a biochemical change.

My experience has been that GPs are reluctant to do much to alter psychoactive medication. I mentioned clomipramine to a GP earlier this year, as I’d read it could help OCD, and her reaction was “oh, you’d need a psychiatrist for that!”* But because I haven’t seen a psychiatrist since about 2013, I’ve essentially been languishing on a high dose of sertraline that I suspect wasn’t doing anything useful. The psychiatrist I spoke to the other day seemed a bit surprised that no one in the NHS had directed me towards a change in medication, given that I am seriously ill and the medication I am taking hasn’t altered that fact.

The psychiatrist and I decided that I’d try to switch to clomipramine. She recommended coming off sertraline quite fast – faster than I had assumed was ok in terms of side effects – but as I say, I trusted her judgement. I asked her to write down what dates I should reduce the dose by each increment, and also asked what the rationale was for reducing it quickly. She said it was to minimise the amount of time that I am without any therapeutic-level medicine, which makes sense. In the past, when switching between SSRIs, I have always increased the new SSRI at the same time as decreasing the old SSRI, so there hasn’t been a time when I’ve come off completely. However, it isn’t safe to be on sertraline and clomipramine at the same time, so I have to come off sertraline first. This will be the first time in 13 years I haven’t been on a daily SSRI/SNRI.

The psychiatrist also prescribed propranolol (anti-anxiety medicine) and temazepam (sleeping medicine) to help me through the process. I was especially grateful for the temazepam – I’ve always had insomnia but nowadays the more important the event I need to get up for, the more my brain will refuse to sleep. I’ve asked GPs to prescribe temazepam as it helped me in the past but they wouldn’t do so, I think because it’s addictive. As a result I’ve had to do many important things (exams, long drives etc.) on barely any sleep. But that’s a digression!

I’m actually writing this on the last day of sertraline before I’m fully off it, so I know how it’s turned out, but this post has already gone on too long so I’ll let you know how it went in the next post! One last thing to add regarding the psychiatrist appointment – she said she would prescribe the anti anxiety and sleep medication on Wednesday, and on Thursday I got a call from my GP telling me I had a new prescription to collect. I was a little overwhelmed that someone was actively looking after my mental health without me having to fight for it. Counter-intuitively I actually found myself feeling a bit angry – I’ve just coped with severe OCD for so many years without stopping to fully acknowledge that the NHS should be caring for me – that’s its purpose. Now that someone within the NHS is proactively helping me, it’s given me room to feel other emotions in relation to that care. Nevertheless, it is excellent to experience high quality pro-active care, let’s hope it continues!

*Full disclosure (because I have OCD and worry about being 100% accurate) – there’s a chance I said “clozapine” instead of “clomipramine”, in which case the GP’s reaction makes more sense, as from what I can tell clozapine is a particularly heavy duty medication. But having done a quick search online I’m assuming I did say “clomipramine” as that seems to be the medication that has been linked to improvements in OCD.

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