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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 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.
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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