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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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