The following is my doctor's report in London:
Please find attached discharge report from our team. I hope that you are settling back in okay in Mongolia.
With best wishes for the future,
Dr Dominic Glover
Chartered Clinical Psychologist
Area 3 CMHT
37 Claybrook Road
London W6 8LN
Wednesday 28 January 2009
Private and confidential
North End Medical Centre
211 North End Road
London W14 9NP
Dear Dr Clubb,
Re: Mr Jadamba Nyambayar DOB: 04.12.1980
3 Lambrook Terrace, London SW6 6TF
I am writing to update you on Mr Jadamba Nyambayar’s contact with Area 3 CMHT, following his referral to us by Dr Muraro (Reader and Honorary Consultant in Neurology) on 8 May 2008. He has been seen for three psychiatric outpatient appointments, six psychology appointments, and was offered a vocational assessment. At his last appointment with myself last week he informed me that he was returning to his native Mongolia on 18 January on a permanent basis. We are therefore discharging him from the CMHT.
Reason for referral to the CMHT
The reason for Mr Nyambayar’s referral in May 2008 was because depression was thought to be a major component of his difficulties. Dr Muraro asked for an opinion on Mr Nyambayar’s likely mood disorder and advice on his treatment. Mr Nyambayar’s had presented with a primary complaint of memory disturbance, which he attributed to a head injury sustained in his early teenage years.
Psychiatric outpatient contact within Area 3 CMHT
Mr Nyambayar was assessed on 18 July 2008 by Dr Pardis Mostajabi (St1 to Dr Dale) and was commenced on a low dose of Citalopram (10mg). He was also referred to myself for a psychological assessment. Dr Mostajabi’s letter of 22 July summarises her initial assessment. He has been seen in psychiatric outpatients on two further occasions (5 September & 31 October). On 5 September, Mr Nyambayar reported feeling quite low and his Citalopram was increased to 20mg (please see letter dated 12 September). At his appointment on 31 October, he reported that he had been doing quite well and his mood was much more stable. He was to continue taking Citalopram 20mg (please see letter dated 4 November). He was due to be seen for a follow-up appointment shortly, but given that he was now returned to Mongolia, this will no longer be happening.
Psychology contact within Area 3 CMHT
I met with Mr Nyambayar for two assessment sessions on 3 September and 3 October 2008. We discussed his belief that he had a poor memory and where this idea came from; we also discussed his mood difficulties, including poor motivation and suicidality. At that time, he was enrolled on an English course at a local college, had a part-time job as a kitchen assistant, and reported that he was drinking 4-5 bottles of beer 2-3 nights per week. He also reported that he had pushed his girlfriend and had also hit a friend whilst under the influence of alcohol. He planned to stop drinking.
We have subsequently met for four treatment sessions (13.11.08, 27.11.08, 11.12.08 & 15.01.09). We developed a formulation highlighting the role of behaviour in the maintenance of his low mood and carried out a behavioural activation intervention. This has involved Mr Nyanbayar completing weekly activity schedules, noting the link between activity and mood, identifying avoidance patterns and implementing alternative coping responses, and scheduling in more activities that have a positive effect on his mood. He was able to observe that rumination, drinking and comparing himself to others had a negative effect on his mood, whereas seeing friends and going to the cinema had a positive effect. He has tried to do fewer of the former activities and to do more of the latter.
We have also discussed his memory in terms of two alternative possibilities, one being that there is an organic memory problem, and the other being that there is no organic problem but that his worry about there being a problem is causing him to selectively attend to anything he forgets and may in fact be interfering with his memory. We have discussed findings from his brain scans and a recent cognitive assessment in relation to these alternatives, and Mr Nyambayar’s conviction in his belief of there being an organic problem has decreased.
Occupational Therapy contact with Area 3 CMHT
I referred Mr Nyambayar for a vocational assessment within the team on 6 November 2008, as at that time he was looking for work that would give him more enjoyment. However, he did not respond to the Occupational Therapist’s phone calls and was closed.
Other contact with services
Mr Nyambayar has also been seen by Dr Muraro and Dr Perry, who are neurologists at the Charing Cross Hospital. Dr Perry runs a specialist memory clinic. I understand that the results of an MRI brain scan carried out in October 2008 were normal. He has also been seen for a neuropsychological assessment by Dr Stephen Gunning (clinical psychologist), whose report states that Mr Nyambayar’s memory performance suggests no impairments.
As reported earlier Mr Nyambayar decided recently to return to Mongolia and was returning there on 18 January. He has had a number of memory investigations carried out whilst he has been in the UK, which are consistent in finding no memory impairment.
In terms of the behavioural activation treatment for depression that I have carried out, Mr Nyambayar has engaged well with the treatment and has completed homework tasks that he has been asked to. His scores on the PHQ-9 have decreased from 16 (moderate-severe range) at the start of our sessions to 2 (normal range) at our last session and his scores on the GAD-7 have reduced from 14 (moderate range) to 0 at our last session.
We are now closing his case at Area 3 CMHT. Please feel free to contact us should you have any questions.
Dr Dominic Glover
Chartered Clinical Psychologist
Cc: Dr Hina Rauf, ST1, Area 3 CMHT
Mr Jadamba Nyambayar (to be emailed to email@example.com)