"Maybe you're just feeling better," my psychiatrist said, "because something good has happened in your life." He was the only psychiatrist who was open on a Saturday and covered by my insurance plan, provided by a job I couldn't stand.
I pondered this as I stared out the window on a dull, gray February afternoon in Queens. The monotony of my desk job hadn't changed in the nearly two years I'd been there, except that I was barely making deadlines because I couldn't focus. My personal life was the same—still solid with my long-term boyfriend, but nothing particularly life-changing going on. I saw my friends regularly, and my family was good. Which is to say: Things were fine, but nothing that great was happening—at least, nothing to elicit days' worth of feeling euphoric, barely sleeping, being hyper-creative, and starting a million projects I knew in the back of my mind were never going to get done. I would later find out that this was a form of mania. My psychiatrist at the time, however, didn't believe me when I explained the symptoms.
"Why don't I keep you on the same dosage of Wellbutrin, and you come back in a month to see how you feel?" I took the paper prescription and headed out of the office, knowing the "crazy-sexy-skinny pill" wasn't going to be the answer to my problems. I would eventually be diagnosed with bipolar II—a milder yet more confusing form of bipolar disorder. But it would take some frustrating trial-and-error to get there.
"Bipolar I is anyone who's had a full-blown mania, and you only need one [manic phase] to meet those criteria. Bipolar II is the people who've never had a full mania, but have had mild manias called hypomanias," psychiatrist Michael Gitlin, professor of clinical psychiatry at the UCLA School of Medicine, explains. People with full-blown mania experience what he calls significant functional impairment. "They've done damage to their life because of the mania: getting arrested, getting fired, ruining a long-term relationship, pissing away life savings, getting hospitalized, being psychotic. Any one of those will make you manic, not hypomanic." Hypomania, on the other hand, isn't as life destructive, but is still accompanied by racing thoughts, an increase in energy, and feelings of grandiosity.
While the manic phases in bipolar I and bipolar II are different, the depression is equally severe. People with bipolar disorder are depressed most of the time. Some people have manic phases frequently, while others only have a few in a lifetime and may not experience mania until later in life. This is why it's so often overlooked and misdiagnosed.
I was first diagnosed with depression during my freshman year of high school. I went from being a straight-A honor student to barely pulling in Cs and Ds. When I wasn't in school, I was in my room sleeping, ignoring my homework. I would pack my lunch, only to toss it in the trash once I got to the cafeteria. I lost 20 pounds. There was nothing to be depressed about, which was the most frustrating part: I had the typical privileged white upper-middle class upbringing, with a loving family and vacations and a nice home on a golf course. The more I reflected on this, the worse I felt; it would have been easier to pin my depression on childhood trauma. People who say things like "happiness is a choice" have never known what it's like to be trapped in the prison of your own mind, ashamed of simply existing and believing you don't deserve to live to see another day.
When my parents scolded me one day for not focusing on my schoolwork, I finally broke down into uncontrollable sobs. "I don't see the point of doing homework," I choked out through tears, "because I don't see the point in living. Every day, I want to die." It sounds like something any melodramatic teenage girl would say, but I meant it. I spent each day trudging through a dark fog, thinking about how I could hang myself from the second-story banister in our foyer without traumatizing my parents. Luckily, they believed me and made an appointment with the nearby children's hospital. I would spend the next few months visiting a rotation of a psychologist, adolescent physician, and registered dietitian trying to treat my various mental illnesses with Zoloft—which increased in dosage every few weeks—and a meal plan.
With psychotherapy, medication, and a healthy diet, I seemed to be doing well. So well that I took myself off the medication and therapy cold turkey before my senior year. That's the funny thing about antidepressants: When they're doing their job and making you feel better, it tricks your brain into thinking you don't need them anymore.
Over the next ten years, I naively thought I could treat my "mood swings" with good old-fashioned diet and exercise, no matter how bad they got. Despite my years trying to ignore it, my depression and its dear friend, suicidal ideation, started hounding me worse than ever after I moved to New York. Instead of a rope and a noose, New York brought its own set of suicide opportunities: I could wait until the subway came barreling through a station and toss myself off the platform like a used tissue flung towards a wastebasket. Or, in a landscape of towering skyscrapers, ride an elevator to the top floor, seek an open roof deck, and jump.
Every once in awhile, through my dark depression, I would emerge to find myself light, happy, and extra motivated. As a creative person, I welcomed these surges of energy. I would be flooded with dozens of brilliant new ideas: an outline for a book, a new blog I must launch, or an article that would be just perfect for a magazine feature. I would ride this wave of creativity, typing diligently away on my laptop for hours, trying to jot down the words as fast as they came to my brain. I could survive on little sleep, and would wake up feeling excited to take on the day, despite my racing thoughts. It was a welcome reprieve from the heavy cloud I was normally under. This is what a hypomanic episode looked like for me.
"Hypomanic people by definition are not causing major damage in their life," Gitlin says. "In fact, they usually feel terrific. They're more productive than usual, they sleep a little less, they have more energy. They and lots of people around them would say, 'Gee, they're doing great. There's nothing wrong with them.' It's only later in retrospect that we realize that they actually have hypomanias."
Under Wellbutrin's influence, I stayed up until 4 AM one night completing projects for my apartment. I DIY'd a chalkboard frame, painted a new tray for our coffee table, backed up all the files from my laptop to an external hard drive, and organized all the shoes in my closet, carefully labeled with washi tape and a Sharpie marker. It was the most productive I had been in ages.
I was also more emotional than ever. As someone who has struggled with anxiety since her first depression diagnosis, I found myself routinely overcome with unexplained feelings of nervousness, sometimes with my heart beating so fast I thought I was having a heart attack. Other times, I would be so angry and irritable, I would lash out at my live-in boyfriend. "Why would you throw those ripe bananas away when you know I like to freeze them for my smoothies?" I screamed one evening, my blood boiling in my veins and surging to my head. For someone who used to be so laid-back and even-keeled, this felt like an out-of-body experience. Turns out, manic stages can also manifest themselves as feelings of irritability instead of grandiosity.
So I found another psychologist covered under my insurance and snuck away to his office on the Upper West Side during my lunch break. After explaining my symptoms of both depression and what I thought was mania (thanks to Dr. Google) during the patient intake, he asked what the most irrational thing I had done was. I knew my form of mania was more subdued (i.e. typing on my laptop all hours of the night instead of, say, draining my bank account and going on a shopping spree), and my previous psychiatrist didn't take me seriously, so I took some creative liberties.
"Umm, sometimes I spend a lot of money I don't have." True, I haven't always been the most financially-savvy person, but it was a gross exaggeration. I don't think spending $100 at Target counts as a mania-fueled shopping bender. Regardless, he bought it. He prescribed me Equetro, an anticonvulsant used to treat seizures and bipolar disorder. When treating bipolar patients, Equetro is usually paired with something else, such as an antidepressant. My doctor said to come back in a couple weeks to see how I was doing on the medication and if we needed to combine it with another prescription.
We never got that far. He didn't have a receptionist, so there was no one to take my calls to schedule a follow-up appointment, and he wasn't returning my voicemails. Meanwhile, taking Equetro felt like I was shot with a horse tranquilizer (or, what I imagine being shot with a horse tranquilizer feels like). I was constantly tired, and my depression was worse. Every morning when I woke up, I felt like I had been hit by a truck. I had to literally peel myself out of bed, barely making it through brushing my teeth and dry shampooing my hair before slogging towards the subway. It's not safe to take yourself off medication without a doctor's permission, but I couldn't spend one more day of feeling like a zombie.
It took seeing yet another psychiatrist, whose office was filled with woodland fairy-inspired trinkets and signs emblazoned with phrases like Life isn't about waiting for the storm to pass; it's about learning to dance in the rain to arrive at the diagnosis of a milder form of bipolar disorder. She seemed to believe me when I explained my hypomanic symptoms and prescribed me Latuda. Latuda is used to treat bipolar depression, which is different than unipolar depression, or what people normally think of as standard depression.
"If you have either one manic or one hypomanic episode in your life and you have depression, then you have bipolar depression," Gitlin explains. "You can have a bipolar I depression and you can have a bipolar II depression."
Although I was doing all right on Latuda, I wasn't taking anything to address the mania and irritability. I was able to focus at work and get up in the morning after a good night's sleep feeling refreshed, but the side effects weren't great. My doctor instructed me to take Latuda at night with at least 350 calories, so I popped one in with dinner; eating another heavy snack before bed wasn't ideal for someone who has always struggled with her weight and had to count calories diligently.
Within an hour of taking it, I would get a weird sense of foreboding and dread, like I couldn't even fathom brushing my teeth or washing my face. This isn't that uncommon of a symptom, according to drug forums I read. Then, it would knock me out. I felt all right during the day, but my bedtime routine felt like torture, and I couldn't take my medication if I knew I had plans during the evening. (Hint: When prescribed medication for mental illness, don't skip doses).
About a year and a half after my first Wellbutrin experience, I finally visited the last remaining psychiatrist on Zocdoc who was covered under my insurance and had manageable office hours. He believed me when I described the depression, the random bouts of energy, and the irritability. He kept the Latuda but coupled it with another mood stabilizer. I would take one of each before bed. After a few weeks, I was starting to notice a major difference. I hate to say I was feeling like "myself" because in my life before depression I was still a kid, but it was the closest I had ever felt to normal.
My journey to a proper diagnosis is not at all uncommon. Aside from the lack of access to proper care, even under insurance coverage (which is a whole other issue), bipolar disorder itself is still widely misunderstood and murky to diagnose.
"Most people with bipolar disorder have depression before they have a first hypomania or mania. In that case, you can say, 'Well, they were misdiagnosed,' but there was no reason to know that they have bipolar disorder. They haven't had their first episode yet," Gitlin explains. "Hypomania is very easy to miss and since people tend to have a first depression before they have a first mania or hypomania, a lot of those people will emerge into bipolar disorder, but in fact, at the time that happened there was no reason to know that."
Bipolar disorder may not present itself until later in life—after all, it only takes one manic phase to technically be diagnosed—and is usually brought on by a major life change: the loss of a loved one, the end of a relationship, a new baby, and subsequent lack of sleep. For me, that was moving from a small town in Southern Illinois to the biggest city in the US, jobless, and with no money. And it shouldn't be all that surprising; mental illness runs in my family and can be traced back to at least my great-grandparents on my mom's side.
I've reconciled the notion that mental illness is a chronic condition that needs a constant course of treatment, including lifestyle changes, to stay healthy. For me, that means the proper combination of medications, a healthy diet, regular exercise, and sleep. If I slack on my workouts, or get less than six hours of sleep a night, extreme irritability or a slippery slope into a dark depression are sure to follow. Although psychotherapy is also highly recommended, I'm still trying to find a therapist under my insurance who keeps atypical office hours. (Note: Bipolar disorder is covered under the Americans with Disabilities Act, but explaining to your employer that you need at least an hour off every week for therapy still feels embarrassing and self-indulgent).
People with bipolar disorder are also warned to stay away from heavy alcohol use, which is difficult for someone like me, whose entire social life revolves around drinking on the weekends.
"I don't care if people have a drink, but excessive alcohol use is going to be problematic on a variety of levels for people with mood disorders," Gitlin says. "It [makes] you disinhibited, so whatever you're doing, you're going to do more of and unwisely. Secondly, high dose alcohol is a depressant." Trust me, I'm working on cutting back.
Accepting the label of bipolar II is more difficult than depression was, but it's a relief to pinpoint an explanation for my weird hodgepodge of symptoms. Treatment also doesn't mean the symptoms of your illness go away completely. I still have days where I'm depressed, or can't focus, or irritable for no reason. And there's always the fear that I'll never be as creative as I was during my hypomanic phases, although I'd gladly trade being uninspired for feeling like an out-of-control crazy person.
My current combination of prescriptions also may not work for me forever. Gitlin says it's common for patients to change medications and dosages several times throughout treatment. But for now, it's working, and that's something to be thankful for.
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