(Please note: Contains profanity and graphic discussion of suicide.)
I think the breakthrough for me was when I discovered that not all mania looks crazy. You don’t necessarily stay up for four days writing on the walls. Sometimes it just looks to neutral observers as if you’re … you know, kind of awesome. You’re interested in things, super productive, socially engaged, confident, and, here’s the kicker: it’s legit. That’s right, you sort of just become a mild superman for a week or even sometimes much longer. Because your ideas aren’t nuts – they might not change the world, but they’re perfectly decent ideas. And then you execute! Yes, it would be better to move the office to the basement and the gym to the garage and no, it will not take longer than two hours if you remain focused, which you most definitely fucking will. The wife will be impressed. “Good idea! Were you working on that yesterday? Oh, really!? You did all that after lunch? That’s awesome hun!”
This subdued mania is formally known to the clinician as “hypomania.” I.e., you’re just a little manic. It’s a lot like, no, it’s exactly like, being high. You have energy. And that feels so good when the flip side is a bleak, barren wasteland of malaise, apathy, and anhedonia.
One thing they don’t tell you about treating mental illness is that just doesn’t always work that well. In fact, there are some guidelines that list non-medical treatments as “first-line” options for treating depression. That’s right, it’s such a crapshoot giving someone a pill for head troubles sometimes that a lot of doctors are hoping that if you just exercise frequently and keep a regular schedule, you’ll stop obsessing over killing yourself when you’re in a down cycle.
I say “obsessing,” but I think the way one’s mind is so violated with, so invaded by the idea of suicide when depression skids to the canyon floor, it’s really more like the patient is possessed. I have spent days on end thinking of nothing all day other than that “I should just kill myself.” If this sounds like a special kind of torture, then I am communicating the situation to you effectively. Occasionally, the thought of suicide will strike me as a revelation: “Oh, that’s it! I’ve got it! I’ll kill myself! That’ll do the trick.” And then a glorious, orgasmic wave of relief washes over me. Finally, I’ve figured something out to put an end to all this misery.
The first time I ever talked at all about this to a medical professional, I went through an intake nurse, an eval nurse, and finally arrived at a psychiatrist. Each asked me in turn, “do you have a plan?” I told them I had thought about where to do it so I would be discovered by a stranger and avoid traumatizing anyone I cared about. I told them I figured I would get things in order first. That I would dispose of all my extraneous personal possessions so my family wouldn’t be forced to spend an inordinate amount of time sorting through my personal belongings, agonizing over what to throw out and what to keep. I told them I would leave a relatively detailed note to help them also avoid coming into conflict with each other over which of my things went to which family member. Through all this sensitivity, though, there shined a ray of psychosis. I had the idea that I would slice my right jugular vein open. I mean wrists are so cliche, don’t you agree? I hadn’t conceived of all of this forethought as a “plan,” but it seemed from the way they fast-tracked me up the treatment chain that it did indeed amount to such.
Many bipolar patients only ask for help when they’re down and that is what I had done up to this point, but on this particular occasion, I opened up about my ups as well. I had cycled through Celexa, Lexapro, and Effexor over the years without much success and now discovered that these types of medications – Selective Serotonin Reuptake Inhibitors – could actually induce mania in the bipolar population and were rarely therapeutically effective. I hadn’t had much success with any of them, of course, so the psychiatrist wrote me for Wellbutrin instead. It was, by far, the most efficacious antidepressant I’d ever tried. It got me up off the floor (Wellbutrin turns out to be chemically similar to plain old speed) and all but eliminated the burning, clawing urge to kill myself. When I continued to experience rapid shifts in mood, periods of extreme irritability, and recurrent episodes of hypomania, however, it was deemed appropriate that I begin administration of a mood stabilizing drug as well. That is when I entered the hellish prison of Lithium.