A Primer on Depression and Bipolar Disorder

Dimitri Mihalas (1999)

B. Qualifications

At this point, it is logical to establish what my "credentials" are for writing this pamphlet. First, I should say that I am not a doctor, psychiatrist, psychologist, or social worker. Likewise I am not qualified as a research worker in this field. Therefore, you should not take what I write as medical advice; always consult with your physician before you undertake any new treatment regimen or alter an old one. I am only a layman in the field. Nevertheless, I am an "expert" because I have suffered with bipolar disorder for 43 years. I have also gotten to know a large number of other CMI people, mostly with bipolar disorder. We all know the illness "inside-out". And we all have had experiences we can share with others to guide them in their own struggles with mental illness, whether first-hand, or in helping a friend or relative.

So allow me to sketch here the course of my own illness. It has been a long journey since its first recognizable manifestation when I was 16, to its ultimate definitive diagnosis as bipolar disorder when I was 47 in 1986. From the ages of 16 through 20, I was an undergraduate at UCLA. During those four years I experienced the tremendous energy of very mild mania (hypomania), and was able to do things like take a triple major (astronomy, mathematics, physics) while getting all A's. At the time, I thought that that was just my "normal" state; but in retrospect, I can see all of the hallmarks of mania.

In graduate school, at Caltech, I had my first episode of depression when I was 21. I felt unhappy, discouraged, helpless, hopeless. Compared to my more recent experiences, it was a mild-to-moderate episode, but at the time it seemed awful. The treatment I was offered was ineffective (really very little was known about treating depression then!); eventually the depression faded away. From the age of 24, when I completed graduate school, to 46, I had many ups and downs, sometimes hypomanic for a year or two, sometimes depressed for a similar period. During this entire time, I had no idea of what the nature of my "problem" was. Nonetheless I was able to have an active and successful research and teaching career at Princeton University, University of Chicago, University of Colorado, and the National Center for Atmospheric Research.

In the Fall of 1985, we moved to the University of Illinois. That was the trigger for a rapid (!) descent into the worst depression I have ever experienced. It was extreme misery: I was unable to think or concentrate (I was literally unable to read a newspaper); I felt utterly worthless, incompetent, and a failure; I would have nightmares of being sentenced to death; then I would lie awake for most of the night in extreme anxiety; I got out of bed in the morning only with the greatest of difficulty; I enjoyed nothing; I was in deep despair. I consulted a psychiatrist, who prescribed an antidepressant. Unfortunately it didn't work.

In early December 1985, I crashed yet farther down and became suicidal: a quiet little voice in my mind started telling me that my condition was hopeless, and would not, could not, change; that there was only one way out, death; and that the time to take that exit was now. This went on relentlessly, over-and-over, hundreds of times per day. During the first week of January 1986, I returned home early one afternoon to take my gun and kill myself. But I couldn't find the gun (I found out later that my wife had removed it from the house on the psychiatrist's advice), so I was thwarted; I was in such a poor mental condition at the time that I couldn't even think of another plan! A short time later, I had an experience which I will describe later, that convinced me that it is ethically indefensible to suicide, so I resolved to tough it out to the bitter end, whatever that might be, without taking the "back door" out.

I struggled onward with the same doctor and the same medication until the end of May 1986. Both I and my wife repeatedly complained to him that the medication was doing no good whatsoever; possibly it was making matters worse. He complacently assured us that it really was doing some good, that he could see the improvement "from the outside" even if I couldn't see it "from the inside". As I learned later, I was right and he was wrong. Indeed, had I known then what I know now, I would have insisted that he try another medication (and yet another if necessary) until we finally found one that actually did work. And if he had refused, I would have found another doctor, fast! But I didn't know the ropes yet, and I accepted his authority blindly. I hope that no one who reads this document will ever make that mistake; it is, after all, a matter of life or death; perhaps your life or death. In retrospect, I believe that this particular psychiatrist is incompetent with medication. He meant well, and he offered me a lot of support through "talk therapy"; but he didn't even try to do his job with the most critical part of the treatment -- the medication. To this day, I will never recommend him to anyone with a biogenic mental illness.

At the beginning of June 1986, I returned to Boulder for the coming academic year. I had taken leave without pay from my Illinois position so as to seek better medical help in Boulder. I had the good fortune to start working with Dr. Kay Grace. She could immediately see the acute nature of the crisis I was in, and as soon as was feasible she recommended I consult with Dr. Steven Dubovsky of the University of Colorado Department of Psychiatry; Dubovsky is at the cutting edge of research in psychopharmacology in the Rocky Mountain area. I was in such bad shape at that time that I refused even to go into Denver to see him, and chose instead to wait for a time in early August, when he would be in Boulder. He interviewed me for nearly two hours, and finally said something to the effect that I was a perfect textbook example of someone suffering from extreme biological depression (he even would have liked a videotape of the interview). He then said "I will predict, with a 95% confidence level, that it will be possible to obtain at least a 90% remission of your illness". I was too worn out to respond emotionally, and I only said "I don't believe you," to which he replied "O.K., don't believe me; just do what I tell you to do." He prescribed new medication, and I promised to take it.

And so I did. In the next three weeks, I began to experience an improvement in my physical state, but not in my mental state. Dr. Grace said this was typical, but she also stressed the danger: I still felt bad enough mentally to want to kill myself, but now I also had the physical energy to follow through. She wanted to hospitalize me, but I refused. I was afraid of being confined, and didn't want to be further stigmatized by having spent time in a mental hospital. Looking back, I realize that she was right and I was wrong. But she accepted my decision, and showed by example what she meant by the "theraputic alliance" between victim and doctor, an alliance that both of us believed in and worked hard for. Basically, she went to the wall with me in each of our sessions during that critical time, each time getting me to agree/promise/pledge that no matter what I would return for our next scheduled visit. She was buying time; and I could see that her strategy was working. I could also see the cost to her of buying that time for me. I am eternally grateful to her for being willing to pay that price; there is no way I can ever repay her.

In what still seems like a miracle to me, I went to bed on Saturday night, August 30, 1986 still suicidal, feeling absolutely at the end of my rope, and woke up Sunday morning, not only not depressed, but even mildly manic. The medication had finally worked! I immediately called Dr. Grace, who said "Fine! Now we can start you on lithium."

The depression had been broken! I was feeling good for the first time in nine months. My sojourn in hell was over. Perhaps it wasn't going to be necessary for me to die after all! Thus began a period of rehabilitation and reconstruction that continues to this day. I am not "cured"; the underlying causes of the illness are still there. In the following months, I had many "ups" and "downs", gradually decreasing in amplitude. But I was clearly in remission, and I had every reason to suppose I could stay there. In the following year, Dr. Grace and I worked intensively at straightening out many psychological problems that had built up over a lifetime of fighting bipolar disorder on my own. I will describe some aspects of that work later. Years later, Dr. Grace said of August 1986, "It was a close call. And, at the time, I wasn't at all sure we were going to make it." But we did; and as Shakespeare said, all's well that ends well.

Unfortunately, as mentioned above there are no "cures" for the affective disorders. All the doctors can promise is a remission. I went along quite well from 1987 until the beginning of 1996, when the pendulum swung the other way, and I became severely manic. This time I had the full scale disease; full mania is to hypomania as a tiger is to a house cat. I had stopped seeing my psychiatrist frequently because I believed that the medical regimen I was on would continue to work as it "always" had in the past. And as I became more manic, I felt "better and better", and more convinced that there was nothing wrong. In reality, lithium was failing to be an effective antimanic medication for me, and I was making disasterous decisions in my life: spending money wildly, having an affair, jeopardizing my profession.

Fortunately, in the beginning of 1997, I had a serious automobile accident (which I attribute directly to the mania) which landed me into the hospital. I had a significant, but not life-threatening brain injury. I was eventually moved to a rehabilitation hospital. While there, my lithium got severely out of balance, and I went into a deep coma induced by lithium toxicity. At the time, I was in what my daughter later described as a "floridly psychotic" state, eyes closed, and screaming constantly in terror from the psychotic "dreams" or "visions" I was having. I barely survived.

Once the reason for my psychotic manic state was recognized, it was brought under control with a new, superior, medication. So I have been cut with both edges of the "sword", and I have learned to respect this slippery illness even more than before. Even then, by the end of 1997 my brain chemistry had been so altered by the new anti-manic medication that my anti-depressant failed, and I again became suicidal (though not as bad as in 1986). This time, I had the wisdom to put myself in the hospital (stigma notwithstanding!) in order to make a safe transition from my old antidepressant to the new one. That worked out beautifully.

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