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I suspect that I'm having a depressive relapse after a month or two of genuine euthymia. No surprise that coincides with a return to work and exam grind. My workload is probably 3-10 times what it was on my first rotation. I used to get bored during my shifts. Now I barely have a moment to park my ass, and the other doctors and I have to draw straws to decide who gets to have lunch first. I used to have the time to (at least in theory) revise my notes during working hours or browse the internet. Right now my phone is helpfully noting that I've reduced my screen time by a remarkable margin.
Is this going to get better? Hah. Haha. Hahahaha. This is going to be my life for the next 5 months, no relief from the pain. I am under-medicated for my ADHD. I have worsening migraines. I leave work wanting nothing more than to crawl into bed and stay there.
What clinched the self-diagnosis was sighing. Literal, audible sighing. The last time I was properly depressed, a junior colleague clocked this tell before I did, which surprised me, since I thought I was hiding things well. The literature, predictably, confirms a correlation. (The body keeps the score and occasionally narrates it out loud.) I caught myself doing it yesterday. Then an intern asked me why I was sighing.
@ToaKraka was kind enough to link to the PHQ-9 screening questionnaire lower in the thread. One glance at it made me wince, I didn't have to add up the numbers to know it didn't look good for me.
The good news is that Paper B pressure lifts next week, possibly forever if I pass. I have never failed an exam in my life. That fact is a load-bearing pillar of my self-esteem, and I am aware of how that sentence sounds coming from a psychiatry resident. I'm willing to risk the burnout. The exam has to be cleared eventually, deferring wouldn't buy me study time anyway, and a pass earns me twelve to eighteen months of academic reprieve. The workload stays the same. This is the only consideration keeping me from filing the current monomaniacal focus under "obviously irrational."
Apparently, around 20% of psychiatry residents experience burnout or depression. Lovely. Glad to have good company. I know the pharmacological management of depression like the back of my hand.
Before anyone panics, I'm going to talk to my GP, and warn her that I might need to see a psychiatrist. The last time I did this was slightly awkward, given that I knew precisely what she would suggest before she said it, and she was kind enough to treat me like a fellow professional and go off my self-assessment. I know precisely what to do if it gets too bad to bear.
Let's hope it's just exam stress. Being fully honest, that's not likely to be the case. But it'll help, on the margin. But tripling my stimulant dose?* Proper migraine prophylaxis? More optimism on that front. And I know the NICE referral pathways well enough to demand that I get something more immediate and robust than another course of Standard Antidepressant.
*What a fucking joke. The ADHD assessment and treatment pathway is designed to weed out 90% of people with ADHD before they see an actual psychiatrist. At least if you don't spend a third of a month's wages on a private assessment and consultation. I fell off that wagon because of... depression and ADHD. Getting back on it will be either time consuming or expensive, and I'll take the latter any day of the week.
Oh well. At least I'm not a gynecologist. Gotta look at the bright side of things.
In my experience with ADHD medicine/stimulants (both adderall and lisdexamfetamine) there was a terrifying drop off in efficacy / tolerance level increase after a very short time.
This was around Covid and there was some kind of shortage, so I got prescribed 40s of Elvanse (lisdex) and told to halve them. That was incredible for like 2 weeks. Then I had to take the whole pill. After another 3 weeks, even that stated to fade. That’s around when I quit. From time to time when I need to do long, uninterrupted, boring work I take one, and it works well, but I never do it more than three days in a row for the reason above.
Do they really work for you daily, years on end?
For 90% of my life, I never had to take them daily. Back in India, I'd normally use my methylphenidate SR infrequently, and take a sustained course only before my exams or when I had to study. I'll do anything but open a textbook when not on medication, and even then, it takes a lot of willpower to not end up procrastinating. It's not a coincidence that my Motte-posting goes up drastically around then.
That changed in the UK. I thought I could work unmedicated and save it for my professional exams. No luck. I need something like 20mg of methylphenidate SR just to keep myself going through a 9-5. Then I might need 20-50mg to get studying done on days when I'm not working. I find it borderline impossible to study at all after a full day's work.
When I'm taking methylphenidate at a stretch, over 4-6 months almost daily (as I have done for serious exams in the past)? I think there's an escalation from 20mg a day to 40mg a day over that period, which isn't that significant. And when the exam is over, I get a long drug holiday which resets any tolerance.
I was switched to dextroamphetamine (IR) last year, which is much, much easier to tolerate for me. I was being titrated up, and I was only on my second month and 5mg twice daily when I fell off the train and stopped seeing my psychiatrist. Because I was depressed. Because that's the sensible thing to do when you're getting depressed, of course. Stupidity induced by sickness aside, 10mg a day is a modest dose, and I expect that I'd have gotten up to something much higher by now.
So tolerance hasn't been a serious issue for me, or at least I never seem to get to the point where it's inadvisable to increase doses. The methylphenidate fucking sucked, so I didn't even want to increase the dose.
You probably know the usual advice: drug holidays. If you have a more experimental psych, they might be willing to swap you around between different drugs so that you never become entirely tolerant (I don't remember the degree of cross-tolerance, but methylphenidate and amphetamines have somewhat different mechanisms of action).
There's personal idiosyncracy involved, but in general, most adults on ADHD meds settle down to a steady-state and can keep it that way. It sounds like you're unlucky in having unusually fast tolerance buildup.
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In retrospect you ever think you’d have chosen a different career path entirely? The front lines of health and medicine always had zero appeal to me. I definitely have my preferred path I would’ve chosen, except for the fact that the industry hadn’t matured and established such that there was a viable and well defined path at the time I’d have come of age to first begin pursuing it in higher education.
When I was in the later years of grade school and throughout junior high and early high school, I was in gifted and AP programs and high achieving courses for a time and I’d always been administered tests that I had no doubt were designed to have you fail; they were enormously difficult. Comprehensible and I could and did do them but the amount of work was enormous. I think perhaps like you albeit at a younger age I just wasn’t mentally prepared for it; and having the right attitude and perspective is a huge part in being able to make it in various disciplines and when you’re up against challenges. Back then I just wanted to go play with my toys and video games by myself and be left alone. By the time I was in high school I deliberately underplayed things to coast by so I didn’t have to get recognized by everyone else. If blowhards want to excel and look good by performing better than you, let them. The brightest stars burn out the quickest and have the shortest lives. If you looked at my report card around that time I had everything. A’s, B’s, F’s and D’s; just enough to squeeze by. My mental health was better because of it but those who knew me didn’t like what I was doing at all.
Is it possible for you to pivot to a psychiatric modality that’s less straining on you mentally? When I read the DSM-IV several years ago, that alone was enough to give me a mental illness. How do you feel about the people who say psychiatry is a fraudulent, applied science in the first place?
Not really. I entered med school because that was the default expectation, and I couldn't think of better alternatives (I was nudged, not forced into it). I discovered I genuinely like psychiatry as a subject, whereas I genuinely loathe most other branches, particularly internal medicine or surgery. Not for me.
In hindsight, I discovered I do like programming a little. But I found this out too late, and I wouldn't have been brave enough to choose that after high school. It possibly would have been a bad choice for me.
I don't know about mental fortitude on my end dawg. My ADHD diagnosis is not fake. It just didn't exist then, nor did I receive any medication. It's not like I manifested a work-ethic and appreciation for higher education of my own volition, I just found out that the drugs solved problems that nothing else could.
Yes, but you need to remember that I'm a psychiatry resident. I don't get to choose what I do or where I go for the next 2 or 3 years. This placement is unusually awful, and I can't just tell them they need to send me elsewhere. I am optimistic that after 5 months, I'll be somewhere much, much quieter.
I expect that if/when I'm more senior, and as @Throwaway05 suggests, more experienced, it won't be so bad. I have a decent idea of what I'd like to do (General Adult psychiatry, probably). That is a long time away. The British system is retarded.
I've only read the V. And the ICD-10 and 11. Sorry for being a poser. Don't worry, memorizing them gave me mental illnesses too, or at least made my existing ones worse.
I diagnose them with moderate to severe intellectual disability. Or I would, if I could. Instead, I ignore them, and feel glad about the fact that 99% of people don't have such awful takes. There's plenty of room for critique of psychiatry, which I have done myself, but it's not a fraud. I treat sensible criticism with respect.
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Rotations get better. By the end you'll look back at your level of knowledge and efficiency and be horrified. Remember this part.
Also - I think you said you are on consults, consults in any specialty are highly variable. Some seasons, weeks, months are harder than others. Sometimes jack shit will happen because the hospital is stuffed and another specialty is suffering. The tide goes in an and out, but it does GO.
When I was in residency I had a senior who made the claim that people are fast or slow, and that that never changes. I've learned that's true, but only for some personalities. You do not have that personality.
You can get faster and more efficient if you want to. So want to. And figure out how to do that.
Thank you. But I don't think this rotation is likely to get much better, and I say this while fully acknowledging the possibility that depression and fatigue is coloring my judgement.
You have to understand that I'm surrounded by other, competent doctors. Some of them scarily so. They don't get the breaks very often either, barring the "mandatory" lunch break half of them eat at their desk.
I hope I get faster and more efficient. I'm touched by your faith in me. The workload still seems daunting. Oh well, it's 5 months. I've done a full year of about-as-bad, and that only made me so depressed I seriously contemplated quitting medicine. Right now, I'm older, wiser, and better acquainted with antidepressant guidelines. Getting better medicated is my best bet for making this bearable. I am pursuing it like my career depends on it, which it may well do.
It's impossible to have a good version of this talk in this setting, but I will try - usually (but not always, I'm not there, I don't know what you are struggling with) the problem for early phase trainees is excess cognitive load associated with stuff that should be "free." Writing notes shouldn't usually require thinking, it should only require time. Basic interviews will be effortless. Physical exam (oh wait psych lol)...
Later the difficulty will be true medical decision making in complicated cases, advanced level exam and interview, and leadership and administrative tasks. These have higher ceilings.
For now you are probably finding it painful to do basic things. I mean yeah, that is what training is for. Most of the work is those basic things though, and as you do them more often you will find them easier, they will be automatic. Even sitting at your desk working is less exhausting if dictating or typing your note is automatic and not an onerous process as you remember how to accurately describe such and such thing.
Example - as you start getting more experience you'll notice how remembering everything for the patient encounter gets easier. This is not because you are gaining memory kung-fu, it is because your brain is automatically knowing what is important and pertinent and what is default.
This process will happen as time goes on, but with some mindfulness you can accelerate it - or if that's hard you can just ride the wave and know it will happen.
It's happened before for every trainee and it will happen to you.
One of my favorite processes in medical education is watching textbook driven people go "you aren't teaching me" and then gradually realizing that the work is the teaching and that they learned the textbook without needing to sit down and do that bullshit.
It comes. It's hard and you have to do it, but the knowledge and skills come.
Then things get easier.
*Above advice not valid for procedural skills.
Thank you. There is a lot of context I haven't shared, and probably won't share, even in private (with anyone, not you, you'd be more likely to know than most).
That's not the biggest problem I have. I'm happy to write proper psychiatric notes. I write essays on the internet for fun, and that's more intellectually taxing.
You'd be unpleasantly surprised. I definitely was. Psychiatry works very differently here. As a trainee at my level, I do a lot of medical management of physical illness, and I don't like it one bit. This will only change when I become a registrar. I'm not sure what the threshold for "call medicine and ask them to manage this" is in the US, but it's much higher here. That's what's really killed me in the past. [More highly relevant information that I am studiously omitting.]
An early trainee is a glorified ward donkey. All I can do is bray and scratch my ass.
I agree that things will get better later, with time and experience. You know why my last placement sucked. This one sucks for entirely different reasons. Mostly the drastically higher workload. It should get better, once I push through the next 5 months, which I intend to. I worked very hard to get here, I have nowhere better to go, and I do sincerely believe things will get better eventually. I still appreciate the support.
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Wishing you luck brother!
Thanks. Glad to be depressed together, and hoping we can get well together. At least you know my advice comes from a place of unusual professional and personal familiarity.
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