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Notes -
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 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.
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.
I know what residency is, I’m just loosely thinking about your career trajectory more broadly. Residency can’t be pretty brutal, sorry to hear what you’re going through.
I haven’t read the ICD-10. My mother was a homemaker all her life but her small library was filled to the brim with a lot of medical literature that she liked to read and study about (for some reason). Occasionally I picked things up here and there.
But don’t be down on yourself to think you didn’t have the bravery to go into programming when you entered fucking medical school. Passion is what allows you to endure and if you’re going through that, you’re a very capable guy. My like of healthcare as a subject matter rests at the floor. I couldn’t do what you’re doing.
Hahahahaha.
There’s actually quite a sizable minority of people in the US that truly believe that. Maybe it’s the case that psychiatrists over-diagnose people(?); don’t know. I’ve never seen one. A lot of people seem to think psychiatrists are just glorified counselors that deal drugs. I don’t know if it’s still a common practice to think you can establish a working hypothesis on someone in 15 minutes. That seems completely absurd to me. But I’d take your word on the matter as a psychiatrist over mine any day of the week.
Really hope you do well.
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.
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.
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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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