Regular readers of Philip Dawdy’s excellent Furious Seasons web site will be familiar with his opinion of the DSM’s bipolar II diagnosis. In keeping with his idea of “a free market of ideas in the mental health world” I would like to contribute my opinions on this topic.

First, let me be clear: I admire Phillip’s work on Furious Seasons, have supported his fundraisers, and hope he keeps at it.

The opinion that causes some controversy is succinctly put in his interview with Christopher Lane in Psychology Today.

Here’s the quote in full:

I may be the only writer in America who thinks BP2 is controversial and I can hardly think of any doctors who do. For me, it’s a questionable classification and something of a cop-out by the DSM writers for a couple of reasons: One, BP2 isn’t bipolar disorder, properly understood. There’s no mania, there’s no hospitalization for mania, and there’s no one running naked down the street. The most prominent features of BP2 are depression (and that covers the vast majority of a person’s time who is diagnosed with BP2) and bursts of energy, broadly understood. To me, that sounds a whole lot more like depression and agitation than it does manic-depression.

Two, the minute someone gets hit with a bipolar disorder diagnosis of any subtype, then they are faced with a profoundly bad set of social assumptions; they get stigmatized by friends and family; and they lose their jobs. I know of multiple cases along these lines, including one of a sheriff’s deputy in King County, Washington who was fired from her job as soon as the brass learned she had BP2, even though she had a stellar track record as a cop and had done nothing wrong on the job. That hardly seems fair when we’re talking about a disorder that doesn’t involve hallucinations or psychosis and has none of the off-the-charts impulsivity of true manic-depression. While it’s nice of researchers and mental-health advocates to claim that we’ve got to end this kind of stigma, in the real world that would take generations and by then people with BP2 today will have reached the ends of their natural lives.

Why BP2 wasn’t called something else is beyond me, but the diagnosis has sure caused a lot of unfair social damage.

I have a BP2 diagnosis, the comical history of which you can read here, and Phillip’s description in the first paragraph doesn’t characterize my experience at all well. The reason I have a BP2 dx rather than BP is that I haven’t suffered “marked functional impairment” in any of my “hypomanic episodes”. If I had then DSM 4’s criteria would have me as BP.

Hospitalization is not a required criterion for diagnosis of mania or BP. Nor is running naked down the street. What I experienced included delusions (e.g. I once began planning to become Prime Minister), paranoia, demented spending (thankfully I had no lines of credit when the behavior was worst when I was younger or it would have been ruinous), crazy creativity with loss of my self-critical faculty, no sleep, ludicrous self-esteem and embarrassing incidents the memory of which make me wince decades hence. This is a bit more than a “burst of energy, broadly understood”. And there is suspicion of genetic evidence: my father’s odd behavior and suicide smacks of manic depression. I rather agree with my shrink that the criteria of mania and BP are met rather closely except that, because I never lost a job, got kicked out of school, got arrested or was hospitalized, it lacks “marked functional impairment”. In other words, I got away with it. Apparently that makes it BP2.

Nor is this behavior agitated depression. I have a lot of experience with that and it is entirely different. In agitated depression my mood is dysphoric, pessimistic and cynical but I can’t sleep, relax or let up with the negativity whereas in hypomania I am euphoric, self-confident, optimistic and at one with the world. There’s no way to confuse these states, in my experience.

On Philip’s second point, I don’t really disagree but the statement sounds a little sweeping. I’m sure some people have suffered negative and unfair social consequences but I’m not aware of any affecting me, at least not so far and certainly not within the first minute of diagnosis.

Whether or not a different name for this disorder would, on the whole, have been better for patients, I really don’t know. Would the social consequences for something called, say, Major Depression with Hypomania (with, as most new psychiatric disorders have, a three letter abbreviation, say MDH) be any better? I don’t find that very convincing but I honestly don’t know.

Moreover, I imagine there may be benefit to patients from the BP2 name. It seems clear from the reading I’ve done that it’s important to treat BP2 in basically the same way as bipolar, especially in regard to the dangers of antidepressants. I imagine that many (most?) physicians are aware of these concerns in bipolar. My own GP refused to prescribe an antidepressant because of his suspicion of bipolar. He sent me to a psychiatrist who refused to prescribe an antidepressant without first a robust mood stabilizer. It took two years to get that right before I was given the antidepressant. According to, for example, Husseini Manji, this is the safest approach. (He even prefers in cases of MDD that are familial.)

If BP2 had instead a name that failed to make the association with bipolar, I wonder if some physicians, especially those who aren’t psychiatrists, might be less likely to recognize these risks. Given that most BP2 patients present with depression, the association with the bipolar word may spare them some risk.

Recovering from lithium

March 25, 2009

In late August 2008 I consulted my GP about the Lithium, frequent urination, dehydration and associated symptoms. He knew a lot about lithium-related diabetes insipidus (which means watery pee) and has several patients on lithium with the side effect.

He considered my theory that lithium was responsible for loss of athletic performance plausible given that the symptoms began when I started taking the drug and that dehydration can produce these symptoms. His view was that putting up with these urinary problems as an active 44 year old man was not a good choice. For an old person who mostly sits at home, perhaps the decision would be different but for a person with decades of active life ahead it’s not a good way to live.

I took a few other factors into consideration. The effects of lithium on the kidneys may get worse with duration of treatment. The effects may be only partially reversible or not at all with the chances of recovery worsening with treatment duration. Moreover, cycling is beneficial to my mental health: the flow, the accomplishments, the fun. And it’s the closest thing to meditation that I’ve experienced – it changes my mental state.

My GP advised that I try another mood stabilizer but warned me not to stop the lithium without consulting with my shrink.

So I stopped taking lithium immediately without consulting my shrink. I’m like that sometimes. It was a mistake. I don’t recommend it. I became really depressed very quickly and ended up back at my shrink in a couple of weeks with my tail between my legs.

She offered either valproate or trilptal. Valproate appears to be more effective but has worse side effects. Trileptal doesn’t look all that impressive from the trials data but it doesn’t have the threat of serious weight gain. I chose Trileptal.

At low dose made me irritable, anxious, jumpy, easily angered and sometimes confused. So we decided to try a higher dose which made these side effects even worse and made thinking quite hard at times. Then we switched to valproate.

The trileptal side effects went away and I started to feel myself again. Depressed. Mild to moderate depression was my baseline condition by now. It had been like that for about three years. But I wanted to give it time to see if the valproate was working as a mood stabilizer before adding an antidepressant. What’s happened mood-wise since then is a story for another blog entry.

But the main point for this story is that about 6 weeks after quitting lithium, I noticed that my cycling performance was improving. Then it improved quickly over the next two or three weeks, after which I had a couple of rides that confirmed that I was back on form. I was pretty much back to my former condition. Since I’d never quit training, my legs and cardio system were still strong and it seems that all I needed was for my kidneys to recover so I could get my hydration back to normal.

That was back in October and was very encouraging. I’ve kept the training up over the winter and I’m planning to start racing in a couple of weeks and have plans to ride the Saratoga 24-hour time trial in July.

Since I published my fairly optimistic May 27 2008 post on this topic, I’ve a few observations and thoughts to add.

1. It takes considerable discipline to keep up with my drinking, especially now the hot weather is here. (I don’t like to use the central AC if i don’t need to. I just strip to my shorts when it’s hot.) For a couple of days I attached a 45 min timer to a pint bottle, and that worked, but…

2. It seems to be quite easy in hot weather to wake up dehydrated. I have a pint every time I pee at night but I guess you can evaporate quite a lot during 8 hours in bed. Don’t really want to

3. I’ve had several long rides and it seems quite feasible to maintain hydration. If I drink at least 1.5 oz/mi or 2+ in hot weather then I don’t seem to be dehydrated at the end. I have the impression that the kidneys take a break on their polyuria craze while exercising.

4. I’ve had some very good rides and no really bad ones since I upped the drinking. But there have been several on which it seemed as though I was staring at the end…

If a well rested and prepared cyclist goes out for a ride, she or he can ride very hard for a couple of hours. After that, things slow down and effort level (as monitored by heart rate) diminishes as though approaching a steady state of roughly 65-70% of max heart rate as the limit of what can be sustained. After many hours riding, huffing and puffing up a hill and enduring considerable muscle pain, you can get it a little bit higher than that. But that compares with taking a similar hill at the start of the ride much faster and with ease at 90-95% max HR.

The difference, as I understand it, very roughly, is that at the beginning you have the glycogen reserves available which can be metabolized quickly and anaerobically. At the end you have to rely on metabolizing fat aerobically. Some of your muscle cells are the type that burns glycogen, other fibers burn fat, and some others can do a bit of both. So at the beginning of the ride you can use all your leg muscle as both fuels are available, at the end only the fat burners are working.

Sustainable HR depending on ride durationI figure effort level using heart rate. There’s a lot you can read about on the web about why that’s reasonable. The graph shows my best guess, based on experience, how my sustainable heart rate depends on ride duration, which is on a log time scale from 10 seconds to 100 hours (assuming I’m well warmed up for the short rides).

I’ve had several rides recently when I felt like I was starting at the end of a ride. The heart rate I could sustain at the beginning of the ride was around 145 to 155. There were no other issues. I recently rode, for the fifth time overall, the Boston Brevet Series 300 km in 12:24, 16 minutes faster than my previous best. So I’m riding fairly well but it’s definitely different.

It feels and seems as though I’m starting my rides with depleted glycogen reserve. And I think this may be the case. My suspicion is that lithium produces chronic dehydration which, among other things, cripples the glycogen recovery between rides.

Fatigue and muscle weakness are commonly listed as possible side effects of lithium. But as far as I can tell, that’s as far as anyone takes the subject. The causal mechanisms aren’t discussed. Nor are possible management strategies. I had those side effects bad enough to be almost ready to quit lithium when I figured out what was going on. I was then able to eliminate the side effects with a very simple remedy. I am not making suggestions for anyone but this is my story and it may be interesting to those on lithium, their family and friends, and those with patients on lithium.

I began medial treatment for BPDII Dec 2006 with Lamictal, presumably because I was presenting with depression. The Lamictal modified the depression by making me irritable and agitated all the time. Whether this change of mood was due to the drug or the disease wasn’t clear initially. But by summer I’d had enough of agitation and irritability (despite a attempt to mitigate it with Seroquel) and wanted a change.

So I started lithium. We monitored side effects, plasma Li level and kidney function during the ramp up. I had the thirst at first but that went away. Otherwise, all OK.

But when I got to 900mg sustained release daily dose I started to feel fatigued, weak, lethargic, and sluggish. I was sleeping more: 9-10 hours at night plus naps in the day. I had no energy and continuously faced a strong urge to lie down on the couch. My mood was affected: I was unhappy, irritable, and mean. And my athletic performance was dismal. This was very disturbing.

I am a male, early 40’s, and a cyclist. I do long distance cycling and a little bit of racing. I am relatively good; I finished Boston-Montreal-Boston 2006 in 70hr 34min, around the top 25% in an event that attracts cyclists from all over. I finished the 2006 400km Boston Brevet in 15hr 37min first out of 54 riders, 5 min faster than the next finisher. So before I started BPD treatment, I was a decent athlete. And please trust me that I have a good idea of what kind of baseline performance I can expect.

My performance on the bike in Nov and Dec was bad. I felt tired, my legs ached, I was having no fun and I was slow. My performance was off by 30-40% in terms of power*. I was embarrassed when I went out with the buddies. I didn’t enjoy cycling. My ambitions for 2008 seemed questionable.

It seemed like I was facing a choice between lithium and cycling. If so, it was fairly clear that lithium would lose since cycling has done more for my heath and mental wellbeing than any psychodrug.

Then in early Jan 2008 it started to get better. I was thrilled. I was not back to my previous performance but I was not far off. I had some good fast rides with the troop and things looked well. My shrink, who had no idea what had been causing the fatigue, agreed with me when I said: perhaps it was an initial thing and my body had adapted. But then in Feb the fatigue returned.

In Mar, while I was still feeling bad, I stopped taking lithium for one week to see what would happen. By the end of that week I was significantly improved, not fully recovered but noticeably better. When I started the lithium again I was back where I was.

I make a note of my weight regularly and the sheet is on the bathroom wall. So it was obvious when my body weight jumped up by 2.5% when I stopped lithium, stayed there for the week and then jumped back down where it was when I resumed taking lithium.

But it was a couple of weeks before a likely explanation dawned on me. My hypothesis was that lithium was causing dehydration and that dehydration was causing my symptoms of fatigue and weakness.

So I started drinking more. I was already drinking a lot relative to typical civilians but I stepped it up. I now drink 4-5liter H2O a day (roughly a pint every 90min) when not exercising. When cycling this goes up to about 0.75 – 1liter/hr depending on temperature and effort. When I get up at night to pee, I drink some more. I felt better already the day after I started drinking like this. The symptoms were gone.

Well, almost. Occasionally I have a day when I feel the side effects again. I attribute it to falling behind on my drinking.

I’ve discussed this with my shrink, who accepts the dehydration theory, and at length with my GP. He has several patients on lithium and explained to me how it affects the kidneys.

Lithium encourages the kidneys to drain clean water out of the blood. Technically, they say that it inhibits the kidneys’ ability to concentrate urine. That’s true but that doesn’t explain the dehydration. Better started: lithium inhibits the kidneys’ ability to concentrate urine AND boosts urination. So, for example, if you are dehydrated and on lithium, you can still pee plenty of pale or clear urine. For an athlete, this is tremendously important to understand.

Like many endurance sportspeople, I was in the habit of estimating hydration by monitoring urine color, volume and frequency. But on lithium this is misleading. As my GP explained, the only thing to go on is the sense of thirst. I make an effort to pay close attention to this. It’s a new habit and not so easy to learn but I think it works.

So that’s the end of my story. However, I’m still rather disappointed that I had to figure this out on my own. My shrink didn’t suspect dehydration as the cause of my symptoms. I found no clue despite hours of searching and reading online. I found mention of fatigue and muscle weakness and I found mention of the kidney effects and the need to drink enough but nothing that connected these – nothing to warn that lithium can cause dehydration that in turn can cause fatigue, muscle weakness, irritability and lethargy.

After I resolved the issue, I searched again armed with better queries and again found no sign that this is an understood problem. My shrink accepted the theory but it seemed new to her. Considering that one of the documented effects of dehydration (2% is enough) is mood disturbance (irritability is often recorded), this seems unreasonable. Aside from the physical symptoms, lithium is causing mood problems in some patients — needlessly.

* This was estimated from heart rate. Properly prepared (rest, feeding, etc.), I can expect to be able to ride at average 165bpm for an hour. This was down to 130bpm. Taking my sitting heart rate as 55bpm, this indicates about 40% power loss.

Mania is a narcotic: speed and cocaine together. It’s a high, for sure, a powerful one. Work is easy and you get a lot of it done. Ideas flow freely, new concepts arise without effort. Creative output is voluminous. You don’t tire, don’t sleep, you keep at it, whatever it is. You have confidence and, in particular, self-confidence, enough to tackle audacious projects and dissolve social inhibition. Productivity and imagination is immense, be it prose, poetry, music, philosophy, mathematics, computer programs or whatever.

But one utterly crucial characteristic of mania is loss of critical judgment. You are convinced of the originality of your ideas, the beauty of your art, the power of your music and the life-changing significance of the concepts you have understood. You are essential, inspired, brilliant, shining like a sun, superhuman — the evidence is everywhere but you don’t have the critical sense to know if it is real or an illusion.

When sobriety returns it does so with embarrassment. Even if there is no depression in the aftermath there is the evidence of your creative bender. Bad poetry, unfinished texts full of confused ideas, art that is after all neither original nor good. The philosophical theories you thought would change the world turn out to be incoherent.

It’s trite, worn-out and banal to mention it but what they say about the 90% perspiration is true. Inspiration is involved but seldom is it sufficient. Great works require a great amount of work. And they require the critical editorial eye. You didn’t produce a masterpiece throwing paints around all night in a hypomanic flight of virtuoso inspiration before going at dawn for coffee and deciding instead to write an opera. To your sober self what is on the canvas is a worthless embarrassment. Mania can’t make you superhuman — nothing can make you capable of producing works of genius with ease. It may give you inspiration but it robs you of the sense to judge which inspirations are worth anything.

Mania is a narcotic — your work is garbage but it makes you feel like god.

Mania is a fraud.

In her book, “An Unquiet Mind”, Kay Jamison avoids exploring this aspect of manic depression. And that’s very strange. It would be one thing if she were just talking about herself, if she were just a bipolar sufferer who refuses to discuss the evidence that the upside of mania is fake. But she’s a practicing clinical psychologist treating manic depressive patients and a scholar specializing in mood disorders with status as a world-class authority on the topic.

So she must have encountered this aspect and dealt with many patients who were dubious of the value of their manias. I spoke to my own therapist about this and she said that there are some patients she’s had who cherish their manic experiences, associate them with creativity and would fear loss of that part of their lives but that there are many others who, like me, are skeptical and fearful of mania and the intoxicated trash it generates.

Towards the end of her book she writes nostalgically of her earlier manic episodes. In the epilog where she says she would rather have the disease than not, she avoids making claims that anything of value came from the manic episodes but elsewhere in the book she does not. For example, she speculates about the possibility of eradicating the disease from the world and what a loss to society that would be: “The disease appears to convey its advantages [to the individual and society] not only through its relationship to the artistic temperament and imagination, but through its influence on many eminent scientists, as well as business, religious, military, and political leaders.” The astonishing thing here is the bald presumption that the disease confers any benefits at all. To Dr. Jamison this appears to go without saying. But many of us with intimate experience of the disease (I’ve had it for 25 years) disagree. I prefer my artistic temperament and imagination sober — the productivity may be lower but at least the product sometimes has value.

This book is not just a personal memoir. Dr. Jamison uses her platform as respected expert in the field to offer also an objective layman’s introduction to the disease. As such I consider it irresponsible to omit mentioning that it is nothing more than her personal opinion (and indeed a controversial one) that the disease has benefits and can, in balance, be a good thing.

Mania and hypomania obliterate critical judgment and reliable self-appraisal. Recognizing this, as Dr. Jamison does in her account of her manias, how could one fail to be suspicious of the accuracy of the memory of the experience or of the work products? One would have to have a motive to ignore this blindingly obvious line of thought.

I can understand that it may be hard to accept that what one recalls as the most creative moments of ones life were perhaps hollow or that which has distinguished ones life from the ordinary was possibly nugatory. I can see why people would avoid exploring these possibilities. But I cannot accept that this, of all books, should seek to avoid their mention. With her books such as this, Dr. Jamison seeks, among other things, respect and acclaim as a professional and an expert. I accord her that. But I consequently expect corresponding standards to apply. By those standards, I regard this obvious omission as irresponsible.

This being my history with the medical treatment of BPDII.

In summer 2003 I had been unemployed for more than a year. In October 2001, my employer, a high-tech equipment maker, went bankrupt after the investors lost their nerve the previous month. Every employee was laid off at a meeting in the cafeteria. This wasn’t a surprise but it was a new experience, as was unemployment. One has a lot more time when unemployed. With a full time job its hard to squeeze in all the things that are so much more interesting and relevant than either work or being at the office: reading books, practicing guitar, going to movies, clubs, concerts and gigs, playing games and sports, writing, collecting music, improving ones German, and maybe learning Spanish. But instead of thus deploying my unemployed time I just spent it being depressed.

In the second half of 2002, the absurd build-up to an outlaw violent US attack on Iraq was underway. I felt complicit in this war crime having subsidized it as a US tax payer and having failed to do anything much to stop it. A couple of friends managed to talk themselves into supporting the war — willful acceptance of a lie, as I saw it (still do). This was a betrayal I could not accept — a crushing blow. Then the war happened.

The next four months or so did not exist. Human memory is selective; it remembers only what is worth remembering, what’s new, not routine and literally memorable. I believe I managed to get out of bed every day, eat and wash myself. And I remember pain and self-hate from reliably failing at any of the tasks I set myself, no matter how simple and small. I’ve long known that ambitious goals when depressed are pointless but that getting something done, anything, no matter how small, was about the only thing that feels any better than really bad. But nothing happened.

In the summer I started to recover. It had been the worst depressed episode of my life. I had been through depressions often before, usually twice a year since mid-adolescence, but the evidence was that it was getting worse. I had wasted too much of my allotted time here being depressed. I went for help.

I consulted a private independent psychotherapist known to me for quick, effective results. I had a preconception that I wanted cognitive therapy to remedy the false cyclical logic of self-defeat and loathing in the depressed mind. I wanted to learn how to stop putting obstacles in the path of my own life.

After ruling out early life trauma or other subconscious motives for my illness and interviewing me about my symptoms he said he thinks I have manic depression should see a physician about drug therapy. Saying that he’s not a psychiatrist so he got out his copy of DSM-IV so we could read the diagnostic criteria of bipolar disorder together. We checked a few other conditions as differential and it seemed fairly clear that I was bipolar II, i.e. manic-depressive with mania that doesn’t reach the level of dysfunction.

Surprisingly, I was surprised. I had known that my behavior and moods were of a manic and depressive nature since I was an undergraduate student. I knew that there was a regular pattern of mania roughly every February and August followed by gradual onset of depression of increasing intensity until it flipped suddenly back to mania. I had learned to fear and prepare for the Manias. I could accurately and objectively characterize both the manias and the depressions. I also knew that these were the characteristic symptoms of manic-depressive illness and that it is also known as bipolar disorder. And I knew that manic-depressive people took lithium to control the symptoms; they used mood stabilizers. I had known all this for over twenty years but not made the connection that I was myself a manic-depressive, that is, I am a person with manic-depressive illness, bipolar disorder, and that needed psychiatric treatment.

So I sat in that psychotherapist’s chair (do any of them still use a chaise longue?) quite surprised, a little alarmed, trying to take the idea in. He encouraged me to take the view that the problem has a biological cause, that I shouldn’t feel responsible for my moods, and that I don’t need to tackle them alone. I roughly remember his words, “You don’t have to strap your balls on and go to fight this.” He suggested I think of myself as someone with congenital hypertension that no lifestyle adjustment can remedy. A blood-pressure-reducing drug may not be the most desirable solution but it’s better than nothing and it helps.

So I went to see a psychiatrist at the same hospital where my GP works. The meeting was farcical. She became obviously irritated with me when I said that I had taken myself to a psychotherapist privately. I became irritated at that and defended the therapist, a man I greatly respect, and my decision to see him. She became very angry that the therapist had offered a psychiatric diagnosis and she immediately disagreed. She decided that my depressions had not met the diagnostic criteria for major depression and therefore I wasn’t bipolar II. That I had managed to never lose my job as a consequence of depression was the key — if I had managed to hold down a job then I must be functioning. She really did nothing to hide her contempt for me and my friend the therapist or that she was professionally insulted that either of us, both equally unqualified, should have been so bold as to wield the DSM-IV or had the temerity to deploy technical terminology such as “bipolar II disorder” that we do not fully understand. But she offered me a consolation prize. She could, with more examination and after due consideration, perhaps offer me a diagnosis of cyclothymia. But why bother? All she could do with that diagnosis is offer a mood stabilizer like valporate, something I didn’t really want and that a mild disease like cyclothymia didn’t really need. I decided not to waste any more of her important time with my malingering or return to insult her professionalism again.

That absurd and pointless interview set my treatment back about three years.

I made an appointment to see a social worker for talk therapy. But by the time of the appointment I had found a job (a fairly good one, surprisingly enough, after two full years unemployed), I was hypomanic (a bit off schedule) and consequently arrogant enough to regard the therapy as unnecessary. So I stopped after only one or two visits.

But the cycles of the disease continued and when depressed I would fear for my job. My productivity was so poor that I could go for weeks without any real progress on any project. I managed to hide this, somehow I always have, but it’s really not a swell feeling to have to do so.

In early spring 2005 my mother, who lived in Scotland, was diagnosed with AILD, a bizarre and rare lymphoma. Her treatment with steroids caused psychosis and acute confusional episodes severe enough for hospitalization, once for two weeks against her will. (She was “sectioned”, as they say in the UK, which is when the police arrive with the ambulance.) Her subsequent treatment with antipsyhotics and thalidomide caused depression. It seemed like a cruel way to treat a woman in her late 60s.

I became tense, irritable and unhappy. It was a dramatically new. I clearly remember when I first noticed it, sitting with my legs wound tight around the office chair at my desk, back arched, leaning over the keyboard with a frown and restless fingers. It was perfectly persistent. It didn’t go away for over two years and after my mother’s death in August 2007.

During 2005 and 2006 my moods were still episodic but different. I did not experience euphoric hypomania, only dysphoric. I also learned what agitated depression was like. I was perpetually tense and irritable. It was exhausting.

In summer 2006 I returned apologetically to the social worker I had disdained the fall of 2003. I was in a tense, irritable remission when we met and for quite a while we didn’t have that much to talk about but I wanted to maintain regular contact in case something happened with my mood, which at some point was sure to happen. When in December it did, she suggested my GP prescribe an antidepressant (unlike the psychaitrist in 2003, the social worker didn’t regard my depression as subsyndromal, but then that psychaitrist would surly regard this social worker as unqualified to judge) but he refused saying I should see a psychiatrist and citing the risk that if I am indeed bipolar then an antidepressant could be dangerous.

I got an appointment very quickly and bipolar II diagnosis within half an hour. I was cagey about the somewhat paranoid and delusional thoughts featured in some of my youthful manic episodes. Seeing as the treatments are no different, I’d rather live without bipolar I on my medical records. I’ve never been ravingly psychotic but I’ve definitely walked on the perimeter of neurotic.

I was given lamotrigine and quickly developed a persistent low-level dysphoric hypomania: reduced sleep, fast thoughts, energy, ideas, arrogance, spending, irritability, cynicism, pessimism and I was unable to relax. I was given Seroquel as well and that helped me relax and sleep better. Eventually in the summer I asked to be taken off lamotrigine to see if the tension and irritability would go away. The doctor strongly resisted taking me off a mood stabilizer. We compromised on a lower dose, which didn’t help. In September, after my mother’s death, I switched to taking lithium and sertroline. The nine-month-old dysphoric hypomania dissipated but I was left with persistent fatigue and muscle weakness. Those side effects, and how I handled them, are the subject of another post in this blog