Yesterday was a bad day: a very bad day. The kind of day on which the depths of my disorder are somehow visible to the general public; the kind of day on which sensitive people ask me if I’m ill. The kind of day on which, for whatever reason, bipolar reveals itself in enormous dark circles under my eyes.

It was the kind of day on which the thought of talking to people is nearly unbearable — at once repugnant and frightening, since I can’t trust myself to speak in a way that doesn’t reveal the magnitude of my debility; on which I feel the fear the injured alpha wolf must feel — that my weakness will be revealed and I will be torn apart.

The kind of day on which I am wildly paranoid in an inchoate kind of way, but still rational enough to know that I am paranoid.

Yesterday’s venture deeper into to the dark and tempestuous waters of mixed mania was almost certainly precipitated by the use of a sleep aid the previous night. It’s a counter-intuitive outcome, but one I’ve experienced regularly. For some reason, antihistamines do things to my mood.

When I’m fairly euthymic, they render me a little groggy and down the next day; when I’m in my current state — skating desperately along the knife’s-edge of mixed mania — they’re a potentially-disastrous crap shoot.

The sleep-inducing medication in question is an antihistamine.

I seem particularly prone to the adverse effects of antihistamines, anticonvulsants, and other sedation-inducing medications — in short, depressants. Alcohol can also induce deeply unpleasant and even dangerous mood-states after its pleasant effects have worn off.

I would conjecture that I’m also unusually prone — relative to non-bipolar people — to the effects of stimulants, but I rarely experience those with the immense dysphoria typical of my reactions to sedatives.

Sedatives combined with stimulants, meanwhile, are a recipe for a day in Hell (whereby I probably should’ve skipped the iced coffee I had with lunch yesterday).

Yet, there comes a point at which one must decide whether the risks of a sleeping pill-induced bad day are worse than those of continued insomnia.

The after-effects of the sleeping pill, presumably as my brain attempts to re-regulate itself, wear off in a day or so if I don’t take another one. It is possible to get through one very bad day with a little help.

The effects of insomnia, on the other hand, will continue to accumulate and self-amplify indefinitely, until the current manic episode passes — and it is difficult to predict when they’ll jump the track and become manifestly dangerous. Worse, manic insomnia tends to beget manic insomnia — the less I sleep, the less I sleep — which induces further mania.

This is, perhaps, the heart of the problem with bipolar disorder: beyond its often-disabling nature, beyond the fact that non-bipolar people seem literally (and, perhaps, understandably) unable to comprehend what it’s like, it carries with it an immense sensitivity to all the factors that influence brain chemistry — including the very medications we use to treat it.

Worse still, perhaps, it is associated with great creative gifts — but also with the inability to utilize those gifts.

Bipolar disorder disrupts the ability to do sustained, concentrated creative work (or uncreative work; it may be even worse — the “worstest” — for that!).

The medications we take to counter the destructive aspects of bipolar, meanwhile, are equally capable of destroying both the creative faculties and the ability, physical and/or mental, to exercise them.

Lithium alone is associated with micrographia, Parkinsonian movement disruptions, and disturbances in balance and equilibrium, to name just a few of its adverse effects. For visual artists, dancers, and musicians, it can be devastating. Worse, these effects do not always ease up (as is often the case with other medications) as the brain and body acclimate: instead, they are often cumulative and even progressive.

In some cases (the tardive dyskinesia and akathesia associated with antipsychotics; the thyroid disruption associated with lithium), they become permanent: they will remain, perhaps treatable but generally incurable, even if the medication is stopped.

Artists living with bipolar find themselves trapped between hammer and tongs. The immense sensitivity that informs our work is at once fed, imprisoned, and subjected to danger of execution by the firestorms that rage in our brains and minds; when we bring in the fire crews, however, the ensuing flood too often downs all but the mere ability to keep body and soul together. Too often, the ability of the soul to soar is not preserved, nor even the ability of the body the function as it once did.

I have no useful advice to offer, here — just frustration to vent.

The question that all of us who live with bipolar disorder always face is this: are the costs of this treatment worth the benefits?

For many, the answer is a resounding yes — for many more, a qualified yes. For others, though, the answer is no, or not really, or I feel trapped; there is no right answer, here.

Too often, practitioners and caregivers still treat those of us for whom the existing medical therapies are not acceptable bargains as recalcitrant children who do not know what is best for us.

Sometimes, of course, they’re right — bipolar is a disease that does not want to be medicated, and sometimes it’s the disease talking; likewise, in our most florid moments, we bipolar types aren’t always rational.

However, I don’t believe that should be the first response. When an apparently-rational patient says, “I have tried these medications, and the side-effects were untenable — what now?” a practitioner would do well to listen, to consider alternatives, and — if need arises — to make a referral to someone else who may know if another strategy.

And always, always — even when we are manifestly mad, with all the attendant indignity of madness — patients should be handled with dignity and tact.

By way of illustration, there can be no doubt that lithium, in particular, saves lives.

So, however, does penicillin — and we find other ways to treat people who respond adversely to penicillin. We don’t criticise them or treat them as bad patients.

We who are or who hope to become practitioners would do well to keep that very simple example in mind.

When we express contempt towards mental illness patients who can’t tolerate the usual medical therapies, when we treat them as misbehaving children or miscreants, we are really expressing deep-seated cultural prejudices. Also frustration, of course, but that alone really doesn’t explain it; a doctor, PA, or NP may be frustrated by a patient’s inability to take penicillin, but that frustration isn’t generally expressed as contempt.

Instead, penicillin sensitivity (especially when severe) is generally met with compassion — It’s too bad the simple and inexpensive option doesn’t work, let’s see what we can find that will.

I know this because I, in fact, can’t take penicillin. I’m deathly allergic to it.

I am not, in fact, likely to die from lithium use, and I’m willing to use it as a short-term intervention should things get really, really out of hand. I am not, however, able to tolerate is effects over long-term treatment. The same can be said for antipsychotics.

I do the best I can to manage without — and I continue to research and seek and hope for an alternative. I also realize that, for me, a medical alternative may never appear.

I continue to understand that my current strategy may not always be tenable, either — that sometimes bipolar disorder gets worse with age, and that a day may come when I am no longer able to manage as I currently do.

Right now, the lesser of the two evils is bipolar: someday, that may not be the case.

If that day arrives, I may have to strike a different bargain. Bipolar, in the end, is the mother of many bargains.

Until then, I will struggle to make the most of my creative gifts, knowing that someday I may not be able to use them.

Until then — and indeed, thereafter, should that day come — I will continue to be immensely grateful for the fact that I have health and mental-health practitioners in my life who do not regard my decision to eschew long-term medical therapy with contempt, as the foolish decision of an irrational child, but rather with compassion, as the careful decision of a rational and intelligent adult.

That is an immense privilege; a great gift.

It is also a reflection of privilege: I am white, male, of “normal” size, well-bred, well-educated, and well-spoken. I am married to a medical professional.

Doubtless, all of these things factor in the quality of care that I receive — when none of them should. All that should matter is that I am a human being, and thus deserving of respect even when I’m irrational, stubborn, and wrong.

This, ultimately, is what every single person with mental illness deserves — even when we are irrational: respect. The essential respect of one human being for another.

This is basic human dignity in action.

It should be neither a privilege, nor something we stumble upon by luck.