Despite all of these hundreds of hours of talk therapy, I can’t say that I have ever experienced much in the way of a change of either outlook or behavior.
And then, one day, on my way home from giving a depressingly poorly attended reading in bucolic and beautiful Marin County,*2 I found myself considering the possibility of steering my wheel hard to the right and hurtling off the Richmond Bridge. The thought was more than idle, less than concrete, and though I managed to make it across safely, I was so shaken by the experience that I called a psychiatrist.
That psychiatrist diagnosed me with bipolar II disorder, a less serious variant of bipolar I, which was once known as manic depression. Though this diagnosis was a shock, it wasn’t a surprise. Bipolar disorder runs in families, and my father and other members of my family have it. I suppose in the back of my mind I always feared that my shifting moods might be an expression of the disease.
Bipolar disorder is characterized by changes in mood, energy, and activity levels. Most people experience these different emotional states, but in bipolar people they are intense, sometimes drastic and disturbing. Like “Maybe I’ll spontaneously drive my car off this bridge!” disturbing. They can have a profound impact on daily functioning and relationships. Up to one in five people with bipolar disorder will commit suicide, and rates may even, paradoxically, be higher for those suffering from bipolar II. Psychiatrists posit that individuals with bipolar I, though their suffering is more intense, are less able either to formulate a desire to commit suicide, or to carry it out. People with bipolar II possess the competence necessary to end their suffering.
Though these statistics scared me, having a diagnosis was also in many ways a profound relief. It explained so much! Like my tendency to overshare at dinner parties and on the Internet. Or the day I stood, trembling with rage, as the dry cleaner shrugged his shoulders at the ruin he’d made of my expensive new shirt. The purchase itself was made in a period of overspending typical of bipolar disorder, and my reaction to the dry cleaner’s perfunctory apology was a symptom of what’s known as “irritability.” Irritability, or “irritable mood,” is a clinical term, a piece of jargon, defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as “a mood state in which apparently minimal stimulus or irritant produces excessive reaction, usually characterized by anger, aggressiveness or belligerence.” It seems kind of an anodyne way to describe shrieking at one’s local dry cleaner.
My diagnosis gave me the language to understand the more positive aspects of what was happening to me as well. It shed light on experiences like the time I wrote three novels in six months, with a clarity of focus and attention to detail that I had never before experienced. This type of sublime creative energy is characteristic of the elevated and productive mood state known as hypomania. So exhilarating and fruitful were these periods that I sometimes thought they were sufficient compensation for the other, dark side of the disease.
After my diagnosis, I embarked on seven years of psychotropic medications, suspended only for a brief period in the early stages of one of my pregnancies. The list of meds I’ve tried and rejected is so long that my friends use me as a kind of walking Physicians’ Desk Reference, able to recite symptoms and side effects for anything their shrinks might prescribe, like the soothing voice-over at the end of a drug commercial: “Abilify is not for everyone. Call your doctor if you have high fever, stiff muscles, or confusion.” Off the top of my head, I have over the long course of this journey in mental illness and mood alteration been prescribed the following medications: selective serotonin reuptake inhibitors (SSRIs) including: citalopram (Celexa), its nongeneric and thus more costly fraternal twin sister escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft); the serotonin-norepinephrine reuptake inhibitors duloxetine (Cymbalta), venlafaxine (Effexor), and venlafaxine XR (Effexor XR); the atypical antidepressant bupropion (Wellbutrin); the mood stabilizers lamotrigine (Lamictal) and topiramate (Topamax); amphetamine (Adderall, Adderall XR), methylphenidate (Ritalin and Concerta), and atomoxetine (Strattera); the benzodiazepines alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan); the atypical antipsychotic quetiapine (Seroquel) (a particularly bizarre prescription since I have never been remotely psychotic); the sleep aids zolpidem (Ambien) and eszopiclone (Lunesta). I’m sure I’m forgetting some. That can happen when you take a shit-ton of drugs.
Some of these medications worked for a little while—sometimes a few days, sometimes a few months. But with every new pill there were new side effects. Since SSRIs made me gain weight and deadened my libido, standard practice dictated that we add new meds to combat the weight gain and to pump up my sex drive. Those drugs made me irritable, so the doctor prescribed something else to calm me down; round and round in a seemingly futile cycle.
Unfortunately, this kind of trial-and-error experience is quite prevalent in mental health treatment. These drugs act on people in different and unexpected ways, and it is often difficult to concoct the precise cocktail to address an individual’s array of issues. Furthermore, practitioners, even the best ones, still lack a complete understanding of the complexity and nuance both of the many psychological and mood disorders and of the many pharmaceuticals available to treat them. Were mental health research more adequately funded, perhaps there might be more clarity. Certainly, misdiagnosis might be less common.
Years after my initial diagnosis, while tumbling down an Internet rabbit hole the genesis of which I can’t remember, I stumbled across an abstract of a clinical study on PMS that made me question whether my diagnosis of bipolar disorder was correct. My bipolar disorder did not comply with the requirements written in the DSM-5. My hypomania rarely lasted the requisite four days, and never toppled into mania, and, though I regularly fell into black moods, I had never had a major depressive episode. My moods were not as extreme as my father’s, nor had I ever suffered any real professional or personal damage as a result of them.*3 Was I really bipolar?