“The Ups and Downs, but Mostly the Downs” by Aimie McAllester
It all starts with the pills.
The blue ones, the creamy yellow ones, the off-white pills that I place on my tongue. Some leave a bitter taste, some none at all. I pour them down my throat like candy, like water, like a life-giving element. I do this trick every morning, every evening. Watch how many I can take. Watch how much I can take.
It all starts with the yellow pill, the one that gets me moving in the morning. This is the pill that changed my life, that settled me into a semblance of a normal person. Turns out my inability to pay attention to everything around wasn’t just a result of my swirling internal mind, but a disorder with a name. It was a revelation.
The next pill targets the swirling of emotions in my mind, lifts them up and grants me energy. I take this one eagerly, even as it leaves a bitter taste. I’m not sure whether it’s working at this point, or if I’d be worse off without it.
Without a doubt, I would be better off without the next pill. An SSRI—selective serotonin reuptake inhibitor—meant to lift me up like the other pill, instead sends me into chaos. I hesitate to take it, because surely, I’d be better off without it. But I listen to my doctor, for after all, he knows best, and later that night I am wide awake, my thoughts spinning and I am everything and nothing at once and I hate this feeling I love this feeling I fall down and rise up-
Enough of that. It’s time to get moving along, time to take the pills that control the various physical disorders that plague my body. How dare it rebel against me, how dare it tire so easily.
The morning passes so quickly, it seems, as I line up the pretty colors one by one.
—
Nighttime is much the same except. Sometimes I go crazy. Sometimes I take my car and drive hours into the night to drink wine and flirt with a near-stranger, arrive home when the morning light touches my window. Sometimes I sit in the dark and think wild, dangerous thoughts. And sometimes I do nothing at all.
But whatever I do. I take the pills.
The pills will make me sane.
Until they don’t.
—
Bipolar snuck up behind me and charmed me, luring me, a monster incarnate. I am not the only one. Oftentimes, when people are diagnosed with atypical depression, like I was, and then treated with antidepressants, a monster emerges from what was a simpler illness, and speaks in a soft voice, promising a life full of fun and adventure, a life very different from before.
Of course, once I was seduced by the bipolar monster, I was chucked headfirst into a nightmare.
The very first antidepressant that I tried was an SSRI. I didn’t have an instant hypomanic reaction to it, which is what it is called when people with bipolar start swinging up into a euphoric mood, so everyone assumed I was in the clear. I had warned my doctor about the dangers of my genetics (the girls in my family have a reputation for being a little crazy, a little “melodramatic”), so we kept a loose eye on my moods. At least for a couple of weeks. But less than a month later I was constantly in a state of agitation. It wasn’t hypomanic, not the way I’ve had it described to me. I couldn’t technically call it depression, because I still had some happy moments that weren’t there before the pill, but I had a tendency of hurting myself to release the agitation inside of me. I would go from throwing glitter at people during a party to viciously insulting myself in a few hours. And, while sometimes the hurting turned physical, most of the time it was mental. I had mastered an art-form of calling myself every name in the book, tearing into my worst traits.
The thing is, bipolar depression can often be hidden by atypical depression, such as my case. Bipolar is a complex and convoluted disease. It is defined by contradictions and polar opposites. It is tamed by a mixture of chemistry, acceptance, and willpower. But most importantly, it can hide for years, lying in wait.
The definition of atypical depression arose in the late 1950s. Psychiatrists had patients who had several characteristics in common such as responding to MAOIS (a type of antidepressant) but not tricyclic antidepressants (the antidepressant most similar to SSRIs at the time)(Singh and Williams, 2006). Other characteristics include cheering up temporarily, oversleeping, overeating, and having a pattern of extreme sensitivity to personal rejection. The bad thing is that a person can have a depressive episode that could be classified as atypical one time, and then have another depressive episode that is more typical the next. As a result, you can’t get officially diagnosed with atypical depression because you could always slip into a ‘typical’ depression the next time. This diagnostic limbo doesn’t help patients like me, who would shift from agitation to an eerie calm from episode to episode. And atypical depression can also masquerade as bipolar depression, which makes the diagnostic limbo even fuzzier.
The term aptly fit what I was going through at the time. I started oversleeping and overeating, combined with sporadic mood changes that nobody identified as rapid-cycling—which is what happens when someone with bipolar begins to flip moods rapidly. Eventually, my doctor switched me to another antidepressant because I begged him to do whatever he could. The constant agitation was driving me mad. This new antidepressant was supposedly stronger than the one I was on before. Had my doctor known about how similar atypical depression is to bipolar depression, instead of thinking I had ‘merely’ depression, I would have been given the correct medication. But I wasn’t. Instead, the medication acted as a switch, flipping me from what was atypical depression into full-blown bipolar.
Adding a mood stabilizer as an adjunct to those with atypical depression may help them more than an antidepressant by itself. Adding a mood stabilizer not only does the obvious (stabilizes moods), but it can also alleviate the depression that targets those on the ‘softer’ end of the spectrum. By smoothing out the highs and lows, the depression naturally has a shallower grip on a person, and this in turn allows a person to use other techniques to target the depression. Other techniques can include cognitive-behavior therapy and the like, but also include other remedies that can help with depression, such as sunlight, exercise, and eating healthy. Finding the right medicine sets a person on the right path to lead a better life. By viewing atypical depression as a form of bipolar, many more options for treatment open up.
This is why it is important to restate that atypical depression can often be thought of as ‘soft’ bipolar if we think of bipolar as a spectrum rather than a sharp dividing line. But this does not help the people who have already been diagnosed with bipolar. Bipolar, once you have one episode, has a tendency of reoccurring, and the more episodes you have, the more lay in your future. To prevent the disease from taking hold in your life, it’s optimal if you never have an episode in the first place. The ones who have suffered from an antidepressant-induced manic episode, however, have no choice. They must face the disease head-on and try to rid themselves of its hold, no matter how seductive at times it gets. And it was too late for me.
I began staying up later and later, my thoughts whirling around in my head pleasantly. Life was vivid, the colors were bright, and I was completely confident that I could change the world. I wanted this feeling to last forever and forever. When I mentioned this at my next doctor’s appointment, he was concerned, but I persuaded him to leave the antidepressant (what would I give for that wonderful feeling to last forever? Everything) and he did, but not before adding a medication that was supposed to help “stabilize my mood.” I didn’t believe that I needed stabilizing, but it might have been nice to sleep a little.
But bipolar already had its hold on me. The new medication didn’t stabilize my mood; in fact, it sent me up higher than I’ve ever been before. I started rapid-cycling again, my thoughts pinging back and forth inside my brain. I felt uncomfortable in my own skin, irritation climbing, I started snapping at everyone around me. I was sleeping/not-sleeping, excited/annoyed, charming/morose. I was everything at once.
—
I do remember a moment. Just one simple moment when I was sitting on a swing and looking up at the sky and thought for a second that everything will be alright. But it wasn’t enough. It’s never enough.
—
Adding an adjunct medication is easier when a patient has had a partial response than changing the medication altogether (as was my case). However, the problem can only be addressed if the doctor knows that there is a problem, and it is difficult to figure out the exact cause if the people are only seen as a series of neurotransmitters going haywire. Sometimes, even if a person presents what seems like standard depressive symptoms, there’s more going underneath the surface.
However, sometimes atypical depression is simply just that. I do know of at least one person who has atypical depression and didn’t slip into a hypomanic state like I did. Her genes were arranged in a way that did not predispose her to bipolar. While antidepressants destroyed my life, they saved hers, and for that, I cannot argue against the use of them in common practice. Rather, I just want to keep the activation of bipolar to a minimum, because once it is activated, it can’t be turned off—only controlled. More research is needed into the various biomarkers and sociocultural factors that predispose a person to a certain disease, particularly mental disorders which cause immense suffering but oftentimes are stigmatized by society.
—
I am armed with an arsenal of weapons. These pills, I line them up, I stack them, I deliberate the virtues of taking them versus not taking them.
I pop them one by one into my mouth, know their names like a prayer.
References
Singh, Tanvir & Williams, Kristi. (2006). Atypical Depression. Psychiatry (Edgmont (Pa.: Township)). 3. 33-9.
Biographical Note: Aimie McAllester is a young writer from the depths of the Piney Woods of East Texas. She is currently finishing up a bachelor’s degree in psychology with a minor in English Studies at UT Tyler and plans on obtaining a master’s degree in Clinical Psychology. In her free time, she goes on walks with her dog, Honey, and helps her family take care of her severely disabled brother, as well as engages in various ways of expressing herself creatively, often through music or writing.