The Wednesday Wellness threads are meant to encourage users to ask for and provide advice and motivation to improve their lives. It isn't intended as a 'containment thread' and any content which could go here could instead be posted in its own thread. You could post:
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Requests for advice and / or encouragement. On basically any topic and for any scale of problem.
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Updates to let us know how you are doing. This provides valuable feedback on past advice / encouragement and will hopefully make people feel a little more motivated to follow through. If you want to be reminded to post your update, see the post titled 'update reminders', below.
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Advice. This can be in response to a request for advice or just something that you think could be generally useful for many people here.
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Encouragement. Probably best directed at specific users, but if you feel like just encouraging people in general I don't think anyone is going to object. I don't think I really need to say this, but just to be clear; encouragement should have a generally positive tone and not shame people (if people feel that shame might be an effective tool for motivating people, please discuss this so we can form a group consensus on how to use it rather than just trying it).
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Notes -
Thank you. Yeah, it can be an uphill struggle. But when I feel like crying myself to sleep, I remind myself I didn't become an OBGYN resident and the smiles sort themselves out. Psychiatry is probably the least taxing? I don't know, maybe the Public Health or Occupational Medicine people sleep at their cubicle all day.
Very kind of you to say. I will note that being a programmer in India is not a good time. The opposite even. If I'd grown up in the States, maybe I'd have been more open to the idea, but life is what it is. I even seriously considered a career pivot and was grinding MIT OCW and Leetcode (I did one medium successfully!) before I matched into psych, but I desisted when I realized that GPT-4 was better than me and would stay that way. Good call. I'd be so screwed right now.
Goodness. I only read that stuff because I'm paid to. Tell her it's not too late to become a shrink, I've seen junior doctors in their late 40s in the UK. Why do all of that for free?
Psychiatrists both overdiagnose and underdiagnose people. We misdiagnose people too. We're only human. Some of us are better than others (for example, I'm worse). It depends on a lot of considerations, and most importantly, we don't really have blood tests for depression or a brain scan we can do to declare schizophrenia. You have to consider all kinds of nitty-gritty details like the tradeoff between sensitivity and specificity, ROCs, cost-benefit analyses etc, inter-rater validity for diagnoses etc. But there is no obvious rampant abuse where I can see it.
Thank you! So do I :(
It’s an attitude that certainly helps. I won’t say I was ever strongly interested in psychiatry per se, but one thing I always paid attention to in my intellectual development was publishing houses and the topics they often target. I was obsessed several years ago by reading a lot of what came out of Guilford Press and read a concise copy of the DSM-IV that was really popular. I loved it and it caused me to go into a real deep dive into that world for a few weeks before I moved onto other topics.
Any reason why?
Indeed. The tech sector is getting crushed quite badly from what my friends are experiencing right now. And they are ‘not’ fans of the whole AI thing at all. I know how to code here and there but as far as large-scale enterprise projects, yeah; no. I don’t want that on my shoulders. I’m content being a fully middle of the road kind of guy. Mentally I could handle that kind of pressure. I’ve always had the grit to face down stress and pain, but it doesn’t mean I enjoy it. I hate it as much as anyone else does.
I think she just had a passion for that stuff, the same one that I’m lacking to go into a field like that. She’s deceased now but when I was a kid all throughout life she’d be keeping up with that stuff. I only read a fraction of it in broad strokes.
Now this is my shit right here. How do psychiatrists gauge whether they’re more or less on path to following a proper diagnosis? I still imagine there’s a rigorous process in place that’s more than just professional guesswork (although I’m sure sometimes it seems that way, it’s multidimensional).
Do you think it’s possible to have something like blood tests for depression in the future? I’ve read quite a lot on Behavioral Genetics (not trying to get far away from psychiatry) but is it possible there will ever be a cross-disciplinary convergence where psychiatry may be subsumed into some greater branch of genetics? When I read studies about how divorce is heritable (or rather it shares a strong genetic link) or just how strongly our biology determines personality and behavior, it’s startling at times. Especially if parenting really doesn’t matter all that much, then maybe fields like psychiatry and pharmacotherapy or pharmacogenomics may dominate the healthcare of the future. Fascinating to me.
You got this, 😤 ❤️ 👊.
Oh boy. This is a long and tough topic. So Medicine is hard. Some people get that some people don't but it needs to be carefully examined.
Some questions are harder than you think, and we don't realize it because we take so much for granted.
So like what is a disease anyway? What is sepsis?
The later is a question still under investigation even though treating sepsis is a core hospital task.
What about a run of the mill bacteria infection? Well turns out usually we are just pattern matching or guessing based off of what died to the antibiotic. An actual culture is useless or impossible most of the time. Spirochetes took forever to identify because splashing shit with these colors we usually use didn't work (yes that's what we do! Random dye!).
A lot of stuff might be an infection and we just don't know yet because who knows what caused it. It's a miracle we figure out prions existed for instance.
So sewing and cutting and surgery is great and all but the noodly thinking bits are an important and interesting part of medicine. Cue nosology.
But you asked about psychiatry though.
That's a further complicated question. The brain is like the most complicated thing in existence, and mental health is the most complicated and multifactorial aspect of medicine.
The specifics become specific, it is why doctors have jobs after all. Some diseases have neuro-chemical markers, brain imaging findings, genetic components and other "hard stuff." This is evolving and of unclear clinical significance.
Sometimes we go off what facilitates communication - depression is hard to define. If everyone including the patients agrees what depression is then you've found it. Sometimes this becomes a cultural negotiation.
Sometimes clinical response is king - if it looks like a duck and quacks like a duck and gets slaughtered by medication like a duck then you got it.
To TLDR it - explaining the specifics of a diagnosis in a thorough way is easy to convey to people in the field who have a shared assumption base, but to people outside of it a lot will be lost in translation and it can look like some stupid questionnaire defines everything.
The rigor isn't what we want but it's more than you fear.
Thanks for showing up. I suppose you can still sympathize with an early-career sod like me, and I'm grateful for that. Now all we need is @reo for the senior psychiatrist take. Don't let the team down dawg!
there are so many replies that i got confused as to where to place this. so i just wrote about the philosophy of medicine, as i understand.
Medicine is the only field where the tool and the patient are the same kind of things - one complex human system meeting another complex human system. That is not a limitation, which needs to be overcome. It is precisely the practice.
Medicine is basically a field where no single model is complete, and the models are always being revised.
By model, i mean it is a simplified picture of how something is or how it works. And it is useful exactly because it leaves things out. Doctors are a special kind of cartographers trying to build up better and better maps to different types of territories.
How do we build those? We started with dissecting the human body, of a cadaver precisely not alive human. Some of us had experience with dissecting a frog or cockroaches (plenty a dime at my place). if you have never seen an open frog, you would be very surprised how much empty it really is. so we cut open a cadaver slowly, methodically, and matched with the photographs in an accompanying manual. we did what it asked us to do, and we continued to match and understand the specific naming systems. the naming systems and particular language are a new language which we learnt so that we can read and talk through that new language with other doctors and nurses and be sure what we are trying to convey is correctly and unambiguously understood by them. and we use it to read books, articles, journals, all life.
Over time, we got comfortable building those new language and mental models of how some particular structure in body is seen and how it is expected to be at a certain place only and not at some other place. Then we shifted to not normal stuff aka pathology. Those normal structures - how can they go wrong. so that knowledge was built upon multiple such cuttings of not-normal structures. We built branches over our normal mental models. eg. the stomach model has this normal model and these abnormal models (which can be of a huge variety).
We also pattern matched these newer not-normal models to find patterns across multiple structures and systems. So, we found Infection Models work reasonably well across the Stomach model, Liver model, Kidney model, etc. This all works pretty well for most of the structures.
Except the brain system. The system is completely different from all other systems. For example, it has a different way of blood supply. Which we named blood-brain-barrier (just a model to say that there is some kind of barrier to normal passage of stuff between the brain tissue and blood).
Over time, more correctly in only last few decades, we have started to see the brain in exquisite detail live and we have been able to have some understanding of which side and which parts of it do what (or get active doing some particular activity).
So for brain things, the models are relatively new and they have to be assessed in terms of what the patient says about his problems, how we are able to see what is happening, what we give (by trial and error) and how it affects the patients. we keep on doing it, write the entire process and revise it more and more. since it is a relatively new field, there are lot of competing what-to-do models, including non-medicinal models and medicine-models. we have done lot of experimental stuff to name all the various little parts of all these models (namely the little chemicals which go to and fro), but they are mostly arbitrary. imo, we are a long way from deep understanding.
The brain has a different problem too. The structure of brain and the function of brain are very disjointed categories. like if you are reading this line, a combination of light pattern goes from this LED to your eyeball, to a functioning wire connecting the back of the eyeball to back of your brain, and then it lights up a particular set of other wires, which are criss-crossed across lot of other brain parts. This is just this little reading line. add the memory of this particular style of light pattern with what it means. now build upon this layer of complexity to what things are normal (the normal model). what things are out of normal (huge number of other not-normal models). and what-to-do models about all those.
When someone thinks of DSM as some sort of fixed written well defined set of maps, i think it is a wrong idea - it is like confusing the map with the territory. IMO, it is a good (at present) way to have a comprehensive set of loose maps. and it will be revised as our understanding gets better, sometimes worse before getting better. sometimes, there will be paradigm shifts.
Same with the genetics parts: yes, those are some newer models, in which we pattern-matched some particular sequences with some disease patterns, because we found few which were absolutely always associated with one particular way of the patient's model of behavior (we call them sure-shot way to label a model). and at other times, it was just found to be more common (we call them more or less probable ways of having a particular set of problem model).
But my base understanding is: Medicine is an interactive playing of what patient shows up, what lenses the doctors have, what models are used to try to change the course of patient's behavior and how it can help in changing the course. At times, it is as simple to sit and listen to the patient and the doctor needs to lend the ear and hold the hand. And at other times, it is a full fledged active working of doctor, a nurse, and 3 attendants to tie the patient and give a sleeping medicine.
So, given how much of this is model-stacking on model-stacking, where does the irreducible human encounter fit? I don't think it as a failure of science, but as the thing which makes medicine medicine and not engineering.
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Well differential diagnosis is always a struggle to deal with because symptoms may be compatible with a handful of underlying conditions. Common symptoms are also more often than not precursors to more narrowly defined symptoms that can be isolated to a diagnosis. Medicine is a hugely multifactorial discipline and it’s understandable why seemingly simple things involve a complex decision making process. Seems like it’s still messy enough that a lot of it is educated guesswork. How much would you say the average person takes for granted that particular matters are “settled” as far as concepts like “health,” and “disease,” go and that these debates don’t exist behind closed doors between doctors? In other words do these disagreements and debates only belong to relative edge cases or is it pretty widespread across ailments?
Do physicians generally “know” or feel with a high degree of confidence when they’ve correctly zeroed in on what the problem is? I’m just imagining the mental flowchart-like references to chasing a problem down isn’t actually that much different from a mechanic who chases down the chain of failure in a car, or a technician who’s chasing down a motherboard failure on a laptop. By what clinical standard do absurd ideas like Drapetomania, or genetic feeblemindedness, or pathological altruism fail to pass scrutiny? Is it simply because our culture doesn’t legitimize such assumptions?
One book I loved reading years ago was Atul Gawande’s Checklist Manifesto, and it was striking how it effective it’s been proven in medical settings. It’s a great thing to have in a discipline that involves some of the most complex pattern matching capabilities needed that are known to man.
Also, why was it a miracle prions were discovered?
It depends on the thing, but it is important to keep in mind that for many problems diagnosis is not important (especially in psychiatry). Fixing a problem is important, but a clear diagnosis? Nah. In psychiatry most problems are fixed by an SSRI or an antipsychotic - who cares if they have schizophrenia, schizoaffective, or bipolar disorder if the solution is the same. Who cares what the cause of the hypertension is? Rule out some important things to rule out, and then move on.
Also because the level of specificity - sick, infection, bacterial infection, anaerobic bacterial infection, a specific organism, the specific genetic profile of the specific strain of that organism, all of these are accurate diagnosis, but you can stop early and often should.
So it's hard to answer some of these questions without being reductive or ponderous.
Our tools aren't magic - for a long time the start of the art for identifying bacteria was dumping dye on it. Identifying something as weird as your own bits during slightly weird shit is hard as hell.
You're giving me exam PTSD, and I haven't even given the exam. SSRIs are not just what you'd rely on for BPAD, there's a ton of context for when they're actively harmful, or when you need antipsychotics and mood stabilizers. Good to know that the exam prep prepares me for discussions on this underwater basket weaving forum.
All granny with a UTI needs is Prozac and Zyprexa!
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But diagnosis is about defining what the problem is, right? Scope, range, severity, etc. In psychiatry I’d imagine it’s even more difficult than a standard internal medicine practice or surgery for instance. Last I’d read, some reports have indicated that most SSRI’s probably don’t work, which I assume demonstrates how robust the placebo effect can be. A bandaid doesn’t cure a cut. A bandaid creates a space for the wound to heal on its own. And for some injuries that’s all that’s necessary from a medical perspective. Suppose the medical efficacy for SSRI’s were 100% though. The treatment takes the form of a bandaid more than it does a fix if you ask me. The latter isn’t exactly what I’m asking a psychiatrist to do, that’s a near impossible task; I’m only saying that’s more what I’d liken it to.
Should the average person be surprised about the fragility and active debate over active cases? I don’t think there should be concern or worry over it TBF, what other alternative is there to trust when you’re in agonizing pain?
I mean lifestyle interventions are always the first recommendation for everything - lose weight and your BP improves. Socialize and exercise more and your depression improves. People don't do these things so we hit the second line interventions of actual medicine that are a band-aid not a solution.
In the case of SSRIs, if one doesn't work....you just switch to the next thing. Psych has more viable first and second line agents than most disciplines. Even if hit rates are lower it isn't a big deal.
Additionally, depression is more of a syndrome than a disease - shit life syndrome, major depression due to a cardiac problems, classic melancholic depression, all of these things manifest slightly differently but more or less the same and zero percent chance we have a full understanding of the underlying pathophysiology. Shit life syndrome likely responds poorly to medication, but how are you going to define that and separate it for the purposes of research?
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There are millions of them. The median salary is shit. Hundreds of thousands are desperate to move abroad.
If you think getting out of India as a doctor is hard, oh boy...
I'm really sorry, but a proper answer here would take more time than I can reasonably spare. I really shouldn't be here in the first place :(
TLDR:
We mostly use blood tests to exclude other physical causes for depression, like hypothyroidism, anemia etc.
Technically? You can use low 5-HIAA levels, but nobody does, probably for good reasons I don't have time to Google. Maybe @reo or @Throwaway05 can show up and do the dirty work for me. Help a brother out, ya know.
Neuroimaging isn't entirely useless either, in the sense that there are things in the brain we can observe changing in the depressed. But it's not very reliable. Same with OCD, autism or schizophrenia.
So I hope. So I hope. Thank you.
Is this due to over saturation? Other countries having first mover advantage? Corruption / nepotism? Etc. What are the high paying careers and positions over there, or is more of a problem of economic mobility?
Over saturation? Definitely. Anyone can get a CS degree, and it's not even strictly necessary. Medicine, on the other hand, is strictly regulated and there's a limit on the number of doctors entering the workforce.
The best paid programmers in India usually work for FAANG or adjacent companies, at the Indian branches. Some freelance, earning Western wages while at home. The majority just get by working shitty jobs for long hours with average pay (which means pitiful pay by Western standards). The worst off are TCS code monkeys, who really have nothing going for them.
Keep in mind that this isn't necessarily worse than many other professional careers. Engineers in India aren't enjoying themselves either.
The easiest way to get career or income mobility is to get hired by a foreign company, establish a reputation, and apply for a transfer to a foreign branch. I have a cousin in ML who makes big bucks (by Indian standards, which means close to my UK salary). He's been offered roles in the US, but only on a temporary "put out fires" basis, and not at comparable wages to what someone living and working there would make. I've encouraged him to take it, or simply apply directly at American companies for local full-time roles (H1B route, probably). He entered ML well before it was cool or over saturated, even if he wasn't involved in LLM work. That means he's extremely lucky/forward thinking, probably the latter. I remember him installing weird vision models on my gaming PC when he used to visit, back in 2017. Good for him, I want him to get out while he still can.
And yes, the quota system for H1Bs only worsens things. Everyone is desperate to get one of those.
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