Tag Archives: psychiatry

Dr Shyam K Bhat MD is a
Psychiatrist and Integrative
Medicine specialist.

He is board certified in
Psychiatry, Internal
Medicine, and
Psychosomatic Medicine,
with additional certification
in clinical hypnosis


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Flat World Psychiatry

Earlier this year, I was in Bangalore on a brief vacation, eager to see India’s recent economic progress first hand. I was not disappointed—new flyovers, crowded shopping malls, gleaming glass buildings—the city was almost unrecognizable. One pleasant evening, I was sipping a particularly tart Mojito at one of Bangalore’s many new nightspots.

The place was packed—confident and hip young things milled around the place, laughing, flirting, dancing, drinking, as a DJ in the far corner mixed house music. It was about 9 o’clock on a Friday. I had paid 1000

rupees—about $25—as cover charge; a cocktail was $8, and food started at $20 an entrée. People sat on low-lying beds arranged around a pool in the center, reminiscent of lounges in South Beach.

“Bangalore’s changed a lot, man,” I remarked. “This is more like Miami than Miami itself.”

Anand, an old school friend of mine, now a successful architect, nodded, waved his hand around, “Yeah, but don’t let it fool you. These guys aren’t really happy. Everyone’s stressed out of their minds. I mean, did you ever hear of divorces in India before? Now almost everyone I know is divorced!” With a start I realized that 3 out of the 5 at our table had been through a divorce.

“How’re things at work?” I asked Mahesh, a high school classmate who was now the marketing head of an American company with opera-tions in India.

“Busy, man. Very busy. Next week I’m off to Singapore, then to London, and DC in August. It’s crazy.” He grinned. “But the real stress is not work but my love life.”

I had attended his wedding almost 10 years previously, when he married his high school girlfriend against his parents’ wishes. They had divorced recently, and he was now dating again.

“I thought you were seeing that journalist?”

He shook his head. “I almost miss my ex, it’s that bad. They’re too independent these days. This girl, she doesn’t want to have kids, she doesn’t want to get married. She doesn’t want any kind of commitment, man. Get this. She tells me, ‘We both have busy lives. When we are free, we’ll hook up. Just don’t get sentimental on me.’ ”

He shook his head and smiled, managing to look regretful and proud at the same time.

A few days later, I was driving my father-in-law’s new sedan through peak Bangalore traffic. My wife was sitting next to me, trying to stifle her gasps as I edged past the cars and bikes, buses, and autorickshaws.

My son sat in the car seat at the back, blissfully unaware of the drama outside. The distance from my in-laws’ to my parents’ was only 10 miles, but it had already taken us more than an hour.

“Almost there,” I said to Ashwini.

One more traffic light, a last stretch, and we would be home. A space about 4 feet wide opened up, but as I tried to squeeze past a small Suzuki on the left, we heard a scraping sound over the din of traffic. The other driver, a big swarthy man with a large moustache, began to scream obscenities, threatening dismemberment because I had scratched his car.

I reacted in the time-honored way, shouting back a few obscenities of my own. He gesticulated wildly, indicating that I should pull over, but I couldn’t do that with the traffic coursing all around us, and besides, his demeanor wasn’t exactly reassuring. I motioned for him to follow us and continued through the traffic. It was a sign of progress, I thought, that no one had taken the slightest notice of our skirmish. This was vastly different from the India of the past, where the slightest altercation on the road would draw, within minutes, a large enough crowd to fill a small concert arena.

The Suzuki followed us through the traffic, and I could see the man in the car, still shouting and shaking his fist, agitated and sweating, while his wife and children sat in silence. Maybe I’d been away too long, or maybe I’d spent too much time practicing psychiatry, but I found myself thinking: Why is the man so angry? What was it exactly that this man was so angry about?

I stopped the car at the side of the road, and he screeched to a halt, a good 50 feet ahead. “You bloody fellow!” he shouted. “You buy big-big car and you don’t even know how to drive. Come here and look what you did.”

“Before I do that, please calm down. What’s the problem? Why are you so angry?” I said, as if in some surreal clinical encounter, where I was ineffectually trying to calm an agitated patient.

He blinked for a moment, his rhythm thrown, then recovered enough to shout, “Problem? You are the problem. Rich fellows driving without looking.”

I felt a sudden anger in the pit of my stomach. Therapeutic approach be damned—he wasn’t my patient. “You better learn some decency—”

“Decency?!” He charged toward me. “I will show you decency.” He pushed me hard, and I staggered a step back.

His son, who was sitting in the car, shouted, “Appa!”

I reacted instinctively. Furious, I made a motion to push him back, when the absurdity of the encounter struck me, and I stopped myself.

We stared at each other for a few seconds, and then I broke the silence. “Look,” I said in my less-than-fluent Kannada. “This is not worth fighting over. I will take care of the damages.”

“It’s your fault. You should have looked where you were going,” he said belligerently.

“That’s right; it’s my fault.”

That seemed to deflate him, and by the time we exchanged insurance information, the mask of anger had dropped and I saw him for what he was—a family man, on his way home, burdened by the stress of living in a city where a new wave of young software engineers and entrepreneurs flaunted their money, trivialized his values, and diminished his self-worth.

The following week, I called a friend at a local hospital. She’s a psychiatrist, one of only about 50 in Bangalore, a city of 6 million people. “Lots of depression and anxiety, but people still don’t like to go to psychiatrists,” she told me.

“So who treats them?”

“If they go to a doctor at all, it’s usually to a general practitioner, who will often prescribe some Valium.”

Now that I was looking for it, I could see portentous signs everywhere: hardworking corporate couples who spent very little time together, tales of rampant affairs at the workplace, reports of suicide in the newspaper almost every day, road rage, escalating violent crime.

I looked up the statistics online. They were appalling. India has the highest suicide rate among young people— more than 10 times the average suicide rate in the Western world.1

On our flight back, I looked out of the window at the sparkling lights of Bangalore that extended in every direction, announcing India’s arrival as a major economic force. It is a flat world now, as Tom Friedman writes2 globalization is here to stay. But on this visit, I realized that globalization extends not just to the economy and business, but to social change, and therefore to psychopathology as well. Two-fifths of the world’s population are facing an unprecedented challenge to their sanity, as everything that defines them—social norms, institutions, values, modest aspirations—is dismantled by the flat world. Unfortunately, the flat world analogy does not extend to access to psychiatric services, or to awareness about mental illness, and those suffering have to manage largely without the help of mental health professionals— India has only 3000 psychiatrists for a billion people.3

This is the flat world of psychiatry. Across the globe, people are richer, but unhappier. They carry an iPod in one pocket, and a Valium in another.



1. Aaron R, Joseph A, Abraham S, et al. Suicides in young people in rural southern India. Lancet 2004;363:1117–1118

2. Thomas Friedman. The World Is Flat: A Brief History of the Twenty-First Century. New York, NY: Farrar, Straus and Giroux; 2005

3. Das M, Gupta N, Dutta K. Psychiatric training in India. Psychiatr Bull 2002;26:70–72

My First Day

Dr. Venkatesh, Professor of Psychiatry and Head of the Department, had a thick mustache and a permanently disgruntled attitude.

“What is schizophrenia, I say?” he asked by way of greeting, as we stood in his small office, sweating in the Bangalore summer.

“Sir,” I ventured, “it’s a psychotic disorder in which there are delusions, hallucina-tions, and decreased functioning.” I’d read a few pages from the abridged version of Kaplan and Sadock—bought the book, in fact—and since this was the only subject where my interest exceeded that of my peers, I hoped this was my turn to shine.

Dr. Venkatesh looked at me as if I was unclean. “You fellows don’t study, only come here to enjoy,” he said, which was a bit unfair because, frankly, there was not much to do at Victoria Hospital by way of enjoyment. “Get out, all of you,” he said, with disgust. “Go and learn something, I say.”

We shuffled out of his office, our heads bowed. In those days, in most medical schools in India, humility and subservience were the preferred modes of relating to one’s teachers and seniors. Confidence was often interpreted as arrogance, an unforgiv-able sin, and could result in failing the rotation. The safe approach was to replace any trace of confidence with a profound, almost theatrical meekness—head down, voice high pitched and soft, and minimal eye contact.

The less one knew about the subject, the more humble one had to appear. Ignorance was permissible, as long as one was sufficiently humble. Years later, while working in the U.S., I would be surprised by the unabashed self-assurance of medical students in the West, who would wax eloquent even on occasions they did not know the answer to a question. “Well, I think the data is not clear on that. In my experience. . . .”

I would never have passed medical school with that attitude. As medical students, it was essential for us to understand the dynamics of each department—who to keep happy, who to avoid, and so on. In psychiatry, the word was that Dr. Venkatesh was only the ceremonial head. The man who was really in charge was Dr. Sreenivas, a PG in psychiatry. PG was short for postgraduate, the term used in India for resident physician.

Dr. Sreenivas met us in a dark classroom next door, which was also used as a conference room of sorts, and on occasion, an interview room.

We would have to sit here, he said, until we got some patients.

I was surprised that we would have to wait for patients. This was the government hospital—free health care for the poor—and consequently, clinics and wards were overflowing with patients. In the medicine clinic, for example, a physician would rou-tinely see more than 200 patients a day. Obviously, business was slower in the psychiatry department.

I sat on the edge of the front bench from where I could see the Skin and Venereal Disease Clinic, which was adjacent to the psychiatry clinic. I am not sure why exactly sexually transmitted diseases were clubbed together with dermatology, but there it was.

I passed time by trying to assign patients waiting in line to one or the other. Skin or VD?

There was a man with white patches on his face—leukoderma, probably. Skin. Behind him, in the queue, a woman with the obvious lesions of leprosy. Definitely, Skin.

Then a man without any obvious abnormalities. I noticed his hand straying towards his groin. VD, I decided.

Almost half an hour passed in this manner. Two of my classmates were playing makeshift cricket at the back of the room, using a rubber ball and a heavy book for a bat. From another corner of the room, I could hear the sound of loud snoring.

Finally, Dr. Sreenivas came back. “No, no, don’t get up,” he said, as a few of us scrambled to our feet. “We have an interesting case. Only one of you can come.”

It wasn’t as if there was a huge rush to the door. I vaguely remember 2 of us standing up, and then the other person volunteered to sit this one out.

She was in her mid-30s, I estimated, and like many of the patients who came here, she was from a nearby village. She sat on the chair and looked straight through us. The man sitting next to her—the husband—stood up when we entered the room.

“What to do, Sir? Please. You have to help,” he said, speaking in Tamil.

I could understand Tamil, but spoke very little of it. Luckily for me, Dr. Sreenivas only expected me to observe the interview. He proceeded to piece together the story from the husband.

The wife did not say much, other than, “I cannot see,” after which she began to mutter unintelligibly, staring into space.

They’d been married for about a year, the husband said, and their life had been perfectly ordinary until a few weeks before. One night, he came back from the arrack shop, where he’d had his customary 3 sachets of the country-made liquor. What was that? Yes, he did drink every day, but what of it?

When he came back that night, and sat down for dinner, the rice was cold. He hit his wife because she should know better. Yes, yes, he should not have done that, but he did not hit her very hard. “Anyway, I don’t hit her every day, but once in a while only.”

When he slapped her this time, instead of heating up the food as she would usually do, she closed her eyes and began to chant some slokas from the Gita. He was about to raise his hand again when she looked at him, held out her palm, and blessed him. God promise, he could smell some jasmine even though there were no flowers in the room. What was going on? And then, he realized that a devi had come inside her—she had become a goddess.

So, for the next 5 days, he treated her as the goddess she was. He cooked for her, he performed poojas every morning, worshipping this divine being who graced his house, and as for the arrack shop, why, he had forgotten the way only.

His story was interrupted by a mewling sound from her. He jumped, but Dr. Sreenivas patted his hand. “Don’t worry,” he said. She lapsed into silence, and the man continued.

So, everyday he cooked for her and became an exemplary husband. “After all, a devi has to be treated like a devi.” On the fifth or sixth day, he could not remember which, he went out to the arrack shop again. “Just one packet I had, Doctor.” When he came back and went to pay her homage, she suddenly shrieked and slapped him on his face. Hard. She then began to use words that only he and his friends would use, especially when the cricket team was not playing well. “She does not know such bad words, Doctor.” He was stunned. Then he realized that he had been tricked. It was not a devi that had entered her being, but a pishachi, a she-devil. She was possessed by an evil spirit.

He touched a small cut on his face and showed us the blood on his hands in classic Bollywood fashion. “Look at my face; see what the pishachi did. Anyway, I brought her here because my neighbor, who is being a teacher, said this might be mental problems.”

“This is not her problem, but yours,” Dr. Sreenivas said gravely.

“Why, Sir? Why you are saying that?” “See here, Mister,” Dr. Sreenivas replied. “There is a saying in Kannada, ‘When you treat a woman well, she is an angel. Treat her badly, she is a devil.’ ”

Later, as a nurse helped the lady out of the room, Dr. Sreenivas explained the case to me. “Classic possession case with hysterical blindness. She has a conversion disorder. Now what I will do is give her some diazepam, then suggest to her that the devil will leave her and that she will be able to see again.”

I was impressed that she could be cured so easily, but Dr. Sreenivas misinterpreted the expression on my face. “Yes, yes, I know the books say this needs psychotherapy and all that, but we don’t have the resources. Not to worry, she will be alright, and more importantly, it will cure the husband also. Hopefully, the fellow will be scared enough so he will behave himself.”

A few hours later, I saw the patient leaving the hospital with her husband. He trailed behind her, slightly bent, as if he were cowering before a devil, or perhaps, bowing before a goddess.

Where Experts Are Many

Conversation 1

The resident handed me the phone. “The psych charge nurse thinks the patient should stay in the ICU,” he said.

I glanced at my watch. My outpatient clinic was in 15 minutes. We had had a hard time convincing the family and the patient about the need for psychiatric admission, and now this. I took a deep breath.

“Linda, how are you?” I said, in that cloyingly pleasant tone my voice takes on when I am trying to suppress irritation.

“Dr. Bhat, what an unfortunate case. We have to do whatever we can to take care of this young man. We have to do what’s right for him.” I didn’t say anything, and after a pause, she continued, “I am just concerned about him being transferred to psych.”


“You know, with that catheter in his chest.”

“He needs the catheter for dialysis, and he’s going to need it at least for the next 3 weeks. He’s medically stable, though, and obviously needs a psych admission. Are you concerned about nursing care for the cath

“No, we’ve taken care of Ash caths before. It’s just that. . . . What if he pulls it out while he’s here? I am not sure what we would do.”

“Look, he’s not actively suicidal right now, and he can’t stay on the medical ward or in the ICU for the next 3 weeks when what he needs is treatment for his depression. I don’t think there’s a danger of his pulling out the cath, but if he did, you could always call the rapid response team.

They’ll be there in less than 2 minutes.”

“It’s just that we haven’t had suicidal patients with Ash caths here before—”

“And in your opinion, this patient is actively suicidal?”

“No, well, I haven’t laid eyes on him, and of course, I am not questioning your clinical judgment—”

“I don’t mean to minimize your concerns, but as you said, you haven’t even seen the patient and I just spent an hour with him. I’m telling you that in my clinical opinion, he is better off being treated on the psych floor. Now, obviously, no one can guarantee that he won’t pull out the cath, but all things considered, the benefits far outweigh any risks.”

“I’m not so sure, but I guess if that’s what you want—”

“It’s what’s best for him.”

“Well, OK, but we are going to want to keep him on continuous observation.”

“That sounds reasonable. I’ll let the inpatient psychiatrist know.


Conversation 2

“I don’t think he has a bipolar disorder; I think it’s more like anxiety,”

Dr. Ahmed, the resident, said.

“Well, it’s true that sometimes anxiety can be misdiagnosed as hypomania, but tell me more. Why do you think it isn’t hypomania? What did you see on the mental status exam?”

“Oh, nothing that would make me think of bipolar.”

“What did you think of his speech?”

“Yes, it was a bit fast—”

“Was it pressured?”

“Maybe, a little bit pressured.”

“Dr. Ahmed, pressured speech is like pregnancy.

Either it is pressured or not. It can’t be a ‘little bit’ pressured.”

“In that case, yes. His speech was pressured.”

“What did you think of his thought process?”

“It was a bit tangential.” He saw the look on my face.

“OK, it was tangential.”

“Was he grandiose?”

“No, I don’t think he was grandiose.”

“What did he say about his academic abilities?”

“I don’t remember.”

“He said, ‘I was the smartest kid in school. I am very smart.’ Do you think that’s true?”

“Maybe; I am not sure.”

I sighed. “From the mental status exam, did you get a sense about his intelligence—did he seem average, below average, or unusually bright?”

“He was average, I think.”

“So, he’s overstating his abilities, which means that we are seeing an elevation in his self-esteem, consistent with hypomania, or narcissism. Anything else you noticed about him?”

“He said that his mood is anxious.”

“Well, what did he say exactly, Dr. Ahmed? He didn’t use the word ‘anxious’ did he?” I felt like a lawyer cross examining a particularly slippery witness.

“I think he said he was feeling some kind of ‘internal pressure,’ and in my experience, that sounds like anxiety.”

“It takes about 20 years of experience to say, ‘in my experience,’ Dr. Ahmed. Maybe this case will give you a different perspective. Now, the patient said, ‘I feel an internal pressure, like something in my body that wants to come out.’ That might be anxiety, but it’s also consistent with hypomania. What is his sleep like, did he say?”

“He said it was not good; he does not sleep well.”

“Correct. He said, ‘I can go days without sleep and still feel pretty good.’ So, although anxiety can explain some of his symptoms in isolation, if you put everything together—the decreased need for sleep and irritability, his pressured speech, the tangential thoughts, maybe some grandiosity—I would say the patient does have a bipolar disorder.”

“OK,” Dr. Ahmed said, then added, “But it could also be anxiety.”

Conversation 3

“I don’t think I’m depressed; my moods go up and down every day. I was reading up on it on the Internet, and I think I have bipolar with ADD.”

“Susan, you don’t have bipolar. Your mood does go up and down, but that’s because of your depression, anxiety, and your personality. You don’t have ADHD. Your concentration is off because of your mood. ADHD begins in childhood and—”

“I seen on TV that you can get ADD as an adult,” she interrupted.

“Adults who have ADHD have had it since they were kids. So, you cannot have ADHD as an adult, if you didn’t have it as a kid.”

“You don’t think I got ADD or bipolar then?”

“No, what you have is mainly anxiety and depression, and—”

“Well, you’re the doctor, but it sure sounds like bipolar to me.”

It had been a frustrating day, and I tried to relax for a few minutes in the doctors’ lounge with a cup of orange and spice tea, the kind that I usually associate with less strenuous times back  during my psychiatry residency in England. Dr. Fernandez, with his trademark scrubs and surgical cap, was eating a ham sandwich, and leafing through a newspaper.

 “Hey, how’s it going, Hector?”

 “Bueo. All good,” he replied, with a broad smile.

 I closed my eyes and wondered what it would be like if his specialty was more like mine. What would his day be like, if surgery were more like psychiatry?

Conversation 4

“Dr. Fernandez, are you the surgeon who operated on

Mr. Jones?”

“Si, yes, and you are?”

“I’m the nurse taking care of him. I notice that you made a horizontal incision and chose a retroperitoneal approach. I think you might want to consider a vertical incision, and avoid retroperitoneal dissections.”

Conversation 5

Dr. Fernandez examines the patient, looks at the CT scan, then pronounces, “As you can see, Ms. Wilson has acute appendicitis and needs an appendectomy.

The resident interjects, “In my experience, his symptoms are more like gastroenteritis, and I think the patient will be fine with some fluids.”

Conversation 6

“It looks like you have a direct inguinal hernia, Mr. Smith,” Dr. Fernandez says.

The patient replies, “Are you sure I don’t have an indirect inguinal hernia?”

“Where facts are few, experts are many.”

—Donald R. Gannon

Days Like This

I feel terrible,” she said. “I can’t sleep, I cry all the time, and I don’t want to do anything around the house.”

Her symptoms seemed mind-numbingly mundane. I’d heard a dozen similar stories in the past week alone, probably thousands over the years, and I had to remind myself that for her, this was a singular experience.

She’d never felt anything like it.

I dictated my note in a practiced monotone. Hers might be a story of despair, or even of hope and healing, but the words were generic: depressed affect, speech soft, thought processes logical and goal directed. . . .

I asked myself: what happened to that sense of wonder and privilege I felt when I first started out in psychiatry? I questioned whether my colleagues ever had days like this. I looked at them as they worked: one was at her desk efficiently taking care of paperwork, and my other more senior colleague, with more than 20 patients to see that afternoon and onerous ad-ministrative responsibilities, sighed heavily as his pager went off again.

Even his legendary patience looked like it was wearing thin.

Outside, the sky was gray and overcast, a depressingly obvious meta-phor for my mood. Why, I asked myself, did I choose to become a psychiatrist?

Of course I’d been asked that question before—most of us have—

but I hadn’t thought about it for a while. It’s interesting how we rarely ex-amine the very choices that define us.

When I was in residency, in a combined internal medicine and psychiatry program, everybody approved of the internal medicine part of my training—that was acceptable, even commendable. But my friends and family thought psychiatry an unfortunate choice, although interesting in a morbid sort of way. To them, psychiatrists were like members of a secret society that dabbled in dark and unholy deeds. Psychiatry was a place everyone had heard of, but nobody wanted to visit.

In my final year of medical school, in Bangalore, I met a psychiatrist, my father’s acquaintance and occasional golf buddy, at a party.

“Think carefully before you do psychiatry,” my mother said, pointing discreetly at Dr. Muralidhar, who was standing by the buffet table serving himself pulao and chicken. “He has no social life because people don’t want to acknowledge that they know a psychiatrist. Only a few other doc-tors are his friends, but most people run away when they see him.”

My mother was given to hyperbole when she was trying to make a point, but this story of ostracism only increased my desire to become a psychiatrist. I watched Dr. M standing alone in a corner; to me, he was a noble figure, a Galileo, a Socrates, a Gandhi, a pioneer who pursued the truth despite formidable opposition. Later that evening, my fantasy was sullied a bit by the sight of Dr. M talking happily to a group of his friends, laughing and chatting, with no signs of the stigma that my mother had re-ferred to earlier.

When I joined medical school, a friend of my father’s, a prosperous businessman from Bombay, asked me, “So, what do you want to specialize in?”

“Psychiatry,” I replied.

He looked at me, his eyes widened, then he leaned back and laughed out loud. “Psychiatry!” he exclaimed, with a mixture of hilarity and disbelief, as if I’d just told him I wanted to become a Bollywood star. The conversation ended there. I didn’t ask him why he reacted that way. But I’d grown up in that milieu; I’d seen the movies, and read the books, and I knew what he was thinking—that a psychiatrist is someone who walks the halls of a dank, decrepit building, a large rusty ring with keys in one hand and a flickering candle in the other, as crazed inmates scream wretchedly inside their barred cells.

For many people of his generation, there was no such thing as a normal person with an illness of the mind. You could, for example, be an average person who just happens to have a bad heart, or an ordinary woman who just happens to have arthritis. But the moment you were afflicted by mental illness, your very core changed; it was as if a person who was psychotic was transformed into another species altogether, a species that was considered better left uncared for, unheeded, and unmentioned. And I fancied myself the protector, shielding this underdog from the derision of people like the businessman from Bombay.

I remember other incidents that might have sparked my interest in psychiatry.

A classmate in college, on the eve of his exams, was found dead, hanging from the stairs, a paper bag over his eyes, and a rag in his mouth.

“Why did he do that?” I asked a friend of his.

He shrugged. “He thought he was going to fail the exams.”

His death was ascribed to academic pressures, and his parents were blamed for pushing their son too hard. No one ever suggested that a mental illness may have been responsible for his death. The family left the city a few years later, never to be heard from again.

Then, there was a distant relative of mine, my mother’s uncle’s cousin or something like that. (His proximity to the family was always minimized.) The family secret was that the man would sometimes take his clothes off and run around naked in the village, much to the embarrassment of his family.

I was curious. “Why does he do this?”

My cousin shrugged. “He’s just like that,” she said. “Crazy.”

And then, there was the boy in my seventh grade class who was clearly unwell. Even as 12-year-olds, we knew that he was different from the rest of us. Jasdeep ate pieces of chalk with seeming relish, and then often, when the teacher looked away, he took a piece of glass and casually ran it across his forearm, taking pleasure in the reactions he got from us: amazement, disgust, fear, and fascination. None of us thought of telling the teacher. To us, Jasdeep was just being Jasdeep. Later in the school year he was caught cutting himself, and his parents were summoned for a meeting. I remember Jasdeep coming back to school the following day, subdued and sullen. His father had beaten him, he said. A week later, he started eating chalk again and cutting himself with a vengeance.

But my first vivid memory of anything psychiatric is from one summer evening in the late 1970s, when my parents inadvertently took me to see the famous movie about a girl with mental illness, I Never Promised You a Rose Garden. They thought the title was fairly innocuous.

I was 6 years old at the time, and the movie’s images burned into my consciousness like a primordial dream: a girl taken to a hospital by her concerned parents; savage men brandishing spears and riding unbridled horses across barren lands; and flashes of the girl cutting her wrist and periodically extinguishing cigarettes on her forearm.

After I asked my mother for the third time, “Why is she doing that?” my parents and I left the theater.

I spent the rest of the week wondering why the girl had seemed so upset, why she’d cried and why she’d hurt herself. In retrospect, those must have been difficult questions for my parents to answer. How does one explain mental illness to a child who is still coming to terms with the concept of normalcy?

As I thought about these incidents, I realized that although I was not exposed to more than one’s usual share of psychopathology, I always wanted an explanation for what I saw; psychiatry was a method of inquiry into the questions I’d always had. I realized that for me, as for many of us, psychiatry was not a dispassionate career choice, but a vocation.

I think we become psychiatrists because all our lives we have observed things on the periphery of our consciousness, things that we could not describe, or comprehend, or change, until we learned the language of psychiatry.

We did not choose our passion as much as it chose us. On days like this, when my work seems dull and exhausting, thankless or frustrating, when even someone’s misery seems commonplace and tiresome, I find it useful to remember why I am a psychiatrist. Remembering why comforts me, inspires me, and renews me.

I went in to see my next patient. There was nothing else I’d rather be doing.