This title should really come with a long caveat: I’ve taken meds for both ADHD and bipolar in the past, so what I’m talking about here, in part, is why my treatment approach prioritizes the medical management of ADHD over the medical management of bipolar.

I initially meant to just write a post about my treatment protocol; about what I’ve chosen to do (for now) and why. When I started writing, I realized that this is going to have to be a series.

It seems like a good idea to begin with an explanation of what, exactly, I am doing treatment-wise.

I believe deeply in the power of complementary medicine: that is, harnessing both medical (including evidence-based naturopathics) and non-medical treatments.

The difficulty with complementary medicine is that it’s not easy — or, rather, it involves the investment of research and time.

By its nature, a sound complementary approach must be carefully designed to suit the needs and circumstances of any individual patient. Many doctors and patients are hard-pressed to find the time to do that; moreover, not all of us are in positions that allow us to.

It also really helps, as a patient, to have (or to be able to acquire) the background in scientifically-sound research practices that makes it possible to tell a sound study (and, thus, pretty reliable data) from an unsound one.

This, by the way, is one area in which I am eternally impressed with the overall community of mental health patients — perhaps because our conditions are still stigmatized and still, in many cases, under-researched and under-publicized, we tend to be very proactive about doing our homework. Likewise, those of us with solid academic research backgrounds tend to act as advocates and guides for those of us who don’t have as much experience, and I think that’s awesome.

In that same vein, though, complementary medicine tends to require a lot of participation from each individual patient.

It’s not a great solution for someone who just wants or needs to take a pill (or a few pills) and forget about it.

Historically, I’ve been kind of judgmental about that — but the reality is that, for a lot of people, being able to just take a pill (or even a handful of pills) is what is most workable.

Each of us has the right to do what’s most workable, and it isn’t fair for me to make judgments about what makes things workable or not workable for other people (unless they ask me to, and give me information from which to make sound inferences, and so forth!). Ultimately, it’s all about quality of life. If the medication-first approach is less onerous and provides better quality of life, that’s absolutely the right way to go!

What works best for me — that is, what strikes the best balance between usability, disease-management, and quality of life — isn’t going to be the same as what works best for someone else. That’s okay.

That’s one of the cool things about human beings: we’re all different. Sure, sometimes it makes life complicated, but it also makes life interesting.

Likewise, especially where bipolar is concerned, mood-stabilizing meds are an essential first-line therapy for a great, great many people.

Moreover, as with some antipsychotics in the treatment of schizophrenia, mood-stabilizing drugs (a class in which I’m including, for this discussion, both classic mood-stabilizers and also atypical antipsychotics) can prevent some of the brain changes associated with the disease and decrease the long-term likelihood of dementia.

This is something that Denis and I discussed very seriously when we were deciding how to manage things from a medical angle. The research that could determine whether other therapeutic approaches prevent this stuff hasn’t really been done yet. That’s a risk that, for now, I’m going to have to take (to be fair, it’s a reasonable one: there is absolutely no history of dementia in my family, even in the folks who had bipolar or bipolar-like symptoms).

I have had very serious problems with mood-stabilizing drugs in the past, which I’ll outline in my next post — problems which make taking them more debilitating than not taking them.

For me, mood-stabilizing drugs amount to a non-cure that’s worse than the disease, though if it ever gets back to a point at which it’s use them or die, I have given Denis the power to make that call for me (since, by that point, I wouldn’t be in any position to make that kind of decision for myself).

Moreover, they haven’t worked very well for me, and the side-effects (loss of equilibrium, loss of dexterity, tremors, and mental fog, in particular) kept me from doing the things that do work.

Thus, for me, the goal is to avoid mood stabilizers for as long as possible, which means (if I want to keep my brain in one piece) doing a metric crap-ton of research and using every other tool I can lay hands (or toes) on to keep it together … and still accepting that a day may well come on which I will have to go back to taking mood stabilizers anyway.

Each approach comes with benefits and challenges: more medication-focused approaches tend to bring more side-effects into the picture, while a less-medication intensive complementary approach involves a lot of effort, a lot of management, and no small amount of risk. For me, the drawbacks of the more medication-focused approach (debilitating side-effects) outweigh those of the less-medication-intensive approach (a heightened risk level; reduced day-to-day stability).

As an adult in a stable, mostly financially-secure relationship with no children, the risk is something I can afford.

I might feel differently about it if there were kids — especially small children — in the picture.

I grew up with a father whose volatile mood swings were so terrifying to me that, at one point, I opted not to participate in overnight visits for several years. To be fair, his alcoholism greatly exacerbated the problem. After he stopped drinking (and started using mindfulness and other tools to manage his moods), my Dad became someone I enjoyed being around — but little kids, especially, need predictable worlds to live in, worlds in which actions and consequences are linked in ways that make sense as frequently as possible.

I know that, even with my relatively-successful treatment model, there are still moments that the chain of reasonable reactions breaks. I may not be inclined to become abusive towards people or anything, but it’s still scary to be a kid and have no idea why your parent is foaming at the mouth in the general direction of the refrigerator. Likewise, it’s scary to be a kid whose parent goes from cucumber-cool to stark-raving-furious with no apparent transition time. That’s a thing I’m working on, but some of it’s the result of brain chemistry. Mood-stabilizing drugs could combat that tendency.

I might also feel differently about it if I had to be the primary breadwinner: if, tomorrow, Denis developed some kind of illness that prevented him from practicing, I wouldn’t be able to be as selective about the work I do and so forth, which would in turn expose me to many more destabilizing forces and stressors that I currently avoid through lifestyle management. Mood stabilizers might become pretty important in that sort of situation.

So what, you might wonder, does my particular complementary approach look like?

First, I do take fish oil as a mild mood stabilizer, an approach that has seen empirical support in academic research settings. It does seem to help in my case. It’s not perfect, but it’s a good compromise.

Second, I take the generic form of Adderall IR (the immediate-release version), which both helps to manage the executive-function function problems that come with my ADHD and actually, very much to my surprise, helps keep my moods on a much more even keel.

…So much so, in fact, that I’d really like to do some research into the question of whether other people with both rapid-cycling Bipolar I and the “predominantly-hyperactive type” subset of ADHD experience similar effects (I’m also curious about the biochemical differences between those of us with predominantly-hyperactive ADHD and those with the predominantly-attentive flavor).

I really didn’t expect that effect. Adderall is a psychostimulant, and psychostimulants are absolutely capable of precipitating mania in people with bipolar disorder (I have certainly experienced that effect with caffeine). When I started taking it, I was entirely prepared to have to stop for exactly that reason; likewise, my doctor started me out on a pretty low dose to avoid that eventuality.

However, for me, Adderall’s IR formulation behaves in a really interesting way: it both keeps my mood more level (in short, prevents emotional perseveration) during its effective period and makes me freaking tired as all heck when it wears off.

I have a literally lifelong history of insomnia — I slept little as an infant; in preschool, my pediatrician decided that I should be prevented from napping (not that I was sleeping during nap time anyway) in hopes that I would sleep at night; all through childhood and adolescence, I rarely fell asleep before 2 AM; etc. I still find the notion that my 7-year-old nephew just turns off like a light at bedtime absolutely incomprehensible.

The only reliable solution to my insomnia, historically, has been sheer physical exhaustion — which is pretty hard for me to achieve (and was essentially impossible to achieve when I had a desk job). It’s also a diminishing goal post: the more you exercise, the more exercise it takes to achieve exhaustion.

Adderall, bizarrely enough, does the job nicely. It wears off, and I feel tired — often, tired enough to get to sleep at an hour that resembles the hour preferred by the vast majority of my fellow humans. Considering that my brain, left to its own devices, wants to sleep from 2 AM – 10 AM or from 3 AM to 11 AM, that’s no small accomplishment.

Sleep, in turn, is critical to preventing mania for me (this is why any of the extended-release ADHD meds are off the table for me, as far as I’m concerned: fortunately, the generic form of Adderall IR is about the cheapest option going).

For me, sleep deprivation tends to lead very quickly into mania (this is true for most people with bipolar disorder). The less I sleep, the more hyperactive and manic I become, until suddenly I’ve been awake for nine days (yes, seriously, that’s my record) and I think I can conquer the universe, or whatever.

Thus, something that keeps my moods a bit more level during the day and actually allows me to sleep goes a long, long way towards preventing the largest peaks and valleys.

Denis says he does still notice fluctuations in my mood, but their amplitude is significantly smaller. I tend not to notice my upswings (except for the really black ones; dysphoric, agitated mania is very, very hard to miss), so I can’t really speak to that, but I do find that my depressions are less severe and less persistent: my brain just plain doesn’t get “stuck” in low spots as easily.

Likewise, the ability to get more done in the day and just keep my crap together a bit better (the ultimate goal of ADHD meds for most of us who take them) reduces stress, which in turn reduces emotional instability. Stress is huge destabilizing factor for me.

Third, I exercise. A lot.

“A lot,” for me, doesn’t generally mean thirty minutes a day, five days a week. I’m talking about hours every week — a typical Wednesday morning involves a thirty minute bike ride, a ninety minute ballet class, and another sixty-minute bike ride. I also spend much of my time on my feet, doing stuff, when I’m at home. I do all this stuff because I like doing it. I am happiest when I’m moving.

“Exercising a lot” used to mean just riding the bike a lot (like, upwards of two hours a day, in addition to the time I spent running errands and commuting), but I learned a couple of summers back that too much “just riding the bike a lot” can lead to waaaaaay too much sun exposure, which can lead to dizzying manias followed by really, really black depressions.

Now I dance. Getting back into ballet has been immensely helpful. I still get a ton of exercise, but the amount of sun exposure is controllable.

I don’t think ballet by itself would manage my mood, but I think it is, to an extent, the key piece in the whole puzzle — or, if you will, the lubricant in the machine.

Without dancing, the system doesn’t exactly break down right away. For a while, it chugs (and then creaks) along — and then, eventually, it fails.

Fourth, and perhaps most importantly: I am in a position that lets me make choices that in turn allow me to avoid stressors which precipitate episodes of mood destabilization.

This is a privilege. I am absolutely aware of that. It shouldn’t be one, but it is.

I wish every single person living with serious mental illness had the same privilege, because it makes a world of difference for me.

There are entire career paths that I look at and just say, “Nope, that flavor of stress is a huge trigger; not worth it.” Likewise, I’m in a position to consider the relative flexibility of various career paths.

Almost as importantly, I can say no to social invitations when I’m in a spot where the excess stimulation might send me up-spiraling, and I don’t feel obligated to take on social obligations that might get in the way of taking care of myself during difficult periods.

Likewise, it is, ultimately, the real crux of my whole system. It’s the reason that I hesitate to tell anyone else, “You should try what I’m doing!”

I am only able to do this because I’m lucky.

I get that.

Fifth, I pay attention to how things I put in my body affect my mood, and I try to respond accordingly.

Bipolar disorder is a disease of emotional regulation in the brain. The brain has trouble sticking with a nice, stable, basic mood; meanwhile, it all too easily gets stuck in low or high spots. When it’s going up, it doesn’t know how to stop until it hits some critical threshold; then it tends to crash all the way back to the abyssal depths.

The things we eat and drink can help or hinder the brain’s efforts to regulate itself.

Alcohol, for example, is a central nervous system (CNS) depressant. It may make you feel giddy and happy when you’re using it (then again, it may not), but from a biochemical perspective, it’s the opposite of a stimulant.

Under normal conditions, I can have a drink or two without worrying too much about it — but that’s it. Any more upsets the balance of my biochemical apple cart — and it can take days or weeks for my brain to recover its equilibrium; days or weeks in which I experience hellish depression. For me, it’s not worth it.

Caffeine, meanwhile, is a CNS stimulant.

It’s one I seem to have a beastly time processing, as well: an Adderall IR tablet taken between noon and 2 PM will wear off and leave me ready to sleep by 10 or 11 PM; not so much a Diet Coke or a cup of coffee.

Between sleep disruption and stimulant effects, more than a little caffeine quickly begets mania — and it seems that there’s a threshold beyond which there’s no backing down, for me. Up to a point, the conflagration can still be prevented; beyond that point, the flames are going to engulf the entire house before they die back.

Needless to say, I try to manage my intake of both caffeine and alcohol pretty carefully. The alcohol part isn’t hard — Denis and I are barely even social drinkers. Most of the things I do socially (ballet, cycling, creative stuff) don’t usually involve alcohol.

I say “usually” because our longest bike rides often end with a celebratory beer, and some of the more casual ones begin with a celebratory beer — but on rides that begin with a beer, more than one or two isn’t an option anyway. I wouldn’t be able to ride after that.

The caffeine part, historically, has been harder, because caffeine is so ubiquitous.

If you’re out for lunch, for example, and you want a drink that has flavor but not sugar, your options are generally iced tea or diet cola, both of which come with a fairly sizeable caffeine hit. Likewise, for me, the impact of one delicious cup of coffee is disproportionately strong relative to that of one delicious post-ride beer.

When possible, at restaurants, I order plain soda water with a twist of lime or lemon (at home, we drink mostly decaffeinated tea, plain soda water, or just plain water).

There are some foods with which I like plain, still water; beyond that, though, I simply accept that sometimes I’m going to drink some unsweetened iced tea or diet coke, and I try to plan accordingly. (Sugared beverages — including 100% juices, which are still basically liquid sugar — tend to screw with my blood sugar levels, so I avoid them almost all the time. The exception is the rare bottle of Mexican Coke during a lunch break on a long — like 50 miles or longer — bike ride.)

Beyond that, I just eat what I like — so a lot of fresh vegetables, raw spinach, raw cabbage, carrots, quinoa, all the tomatoes, eggs, and so forth, but also smoked white turkey hot dogs (which I prefer to regular ones), chorizo, pizza, and a little ice cream here and there. When I get a rare chocolate craving, I go for it; likewise, when I’m craving salt, I go find something salty — my body wastes salt, so in my case I’m usually craving it because I actually do need it.

For some people, certain foods screw with brain chemistry; beyond the blood-sugar issues that lead me to mostly avoid high-GI foods, I’m fairly lucky in that department. I do count calories, but more often than not it’s to make sure I’m eating enough.

Sixth, my half-baked mindfulness practice.

Like most people with ADHD, I am not a master of meditation. I am pretty good, though, at living in the present moment (this may be the sole benefit of living in Golden Retriever Time: while I’m capable of worrying about the future and obsessing about the past, I can’t while I’m doing anything else, especially anything physical), and the ability to think about my thinking that Adderall has afforded me has allowed me to reflect on what I’m thinking and feeling in ways that I haven’t been able to until now.

That’s a pretty cool development.

Adderall allows me to monitor my moods in ways I haven’t been able to in the past, which lets me check in with Denis about them when I think things are getting out of whack. That, in turn, means we can take action to try to mitigate any manic fires before they get out of control and to use whatever means are necessary to haul me out of a depression before it gets too deep.

Adderall also facilitates both those processes.

Initially, I felt weird about this “Adderall-as-mindfulness-tool” thing: specifically, it kind of felt like cheating. Then I realized that it basically boils down to the fact that, for most people, learning mindfulness is kind of like seeing over a fence that’s just at eye-height; it isn’t automatic, but it can be done with a bit of effort (and a little releve!). Me? I’m standing in a hole. Sometimes I can jump and get a glimpse over the fence, but that’s it. Adderall gets me to ground level. I still have to make the effort once I’m there.

I can’t claim any formal daily meditation practice, but I use mindfulness techniques frequently in daily life, and they help.

Seventh, I try not to be too obsessive about rules.

There are a few that I know don’t offer much leeway: sleep, for example. I really do have to be pretty rigid about sleep.

Beyond that: if I screw up, if things go off the rails … well, that’s part of life. I grew up riding horses, and we accepted falling off sometimes as part of the deal. That didn’t mean that we didn’t work to become the best riders we could, and to hone our abilities to reduce the likelihood of falling off — but it’s a thing that happens.

I build wiggle room into my diet.

I accept that sometimes I’m going to forget to take my Adderall.

I recognize that once in a while I’ll bang my toe coming off the lyra and have to take a few days off from ballet and cycling.

I understand that sometimes I’m going to overdo it being a social butterfly and sometimes I’m going to avoid the entire human race for far too long when I shouldn’t.

I accept that I really actually like diet cola and sometimes I’m going to drink it; I accept that I really actually like beer (hello, Koshihikari Echigo Rice Lager), and sometimes I’m going to drink that, too. I accept that I like the occasional glass of wine with dinner (though not at home; we don’t drink enough to make buying bottles worthwhile).

I accept that my current treatment modality may be only for now; that somewhere down the road, mood-stabilizing drugs may become necessary.

I’m not sure what I’ll do if that happens: like I said before, I don’t take them now because my quality of life with them was worse than it is without. I hope that I could adapt; that I could learn to live with them, but I don’t honestly know.

I accept that, too. It’s uncomfortable, but being upset about it isn’t going to change anything. Sometimes reality is uncomfortable, and while often we can do something about that, sometimes we can’t.

I accept that this current equanimity is a result of the fact that I’m experiencing the longest period of relative (though still bumpy) euthymia I’ve ever experienced, and that I will feel differently at times.

One Last Note

I realize this probably all sounds like a lot of effort. If it was a program that was being prescribed to me, at least, I would think that it did!

In truth, though, this approach mostly takes advantage of my own basic nature; the rest has been implemented a little at a time.

It’s kind of like counting calories: it sounds onerous, but that’s not how I experience it at all. It’s just a habit, a thing that I do. If you’d told me, five years ago, “You’re going to try to note down every single calorie you eat for the next five years,” I would almost certainly have mentally kicked you in the shins. Taken as a whole, that task sounds impossibly huge. Taken in itty-bitty pieces, though, it’s amazingly doable: “Present doughnut, only doughnut.”

Likewise, sometimes I forget, but the fact that I can see that as no big deal and just get back to it when I think of it really helps.

In some ways, the fact that my system of treatment has a number of different parts is a good thing for someone like me. It’s more flexible: when, inevitably, I forget to do one piece on a given day, the rest keeps on going pretty smoothly. I have to either forget one piece for several days in a row or forget several pieces all at once for things to fall apart completely.

Excepting exercise, no one part of this system really requires sustained effort — and exercise is a kind of effort I enjoy. If “sitting behind a desk for 8 continuous hours per day” was part of the system, it probably wouldn’t work as well for me.

Now that I’m pretty familiar with my own individual stress tolerances, stress-related decisions are fairly momentary. My last few semesters in school, I made a lot of decisions based on that premise: can I handle these three classes together? What if I add this one? What if I also do this other thing? The consequences of those decisions may have taken months to unfold, but the decisions themselves were momentary.

If you told me, “YOU CAN NEVER HAVE CAFFEINE AGAIN!” I might actually cry. Well, probably not, but I’d definitely give you a swift mental kick in the shins, and then I’d sulk. Not so much because I love caffeine so much (I can take it or leave it), but because never is a difficult word (and also because you’re not the boss of me, nyah, and you’re not so big :P). On the other hand, on any given day, at any given present moment, choosing not to drink coffee or cola or whatever is no big deal.

I don’t think about not drinking Diet Coke forever; I just think about what I’m drinking right now.

Obviously, that sort of thing is harder where actual physiological addictions are concerned (which is another reason I’m careful with caffeine — I have had to wrestle a serious caffeine addiction a couple of times already; not looking forward to doing that again). For me, in that department, an ounce of Keep That Stuff Away From Me is worth a pound of Betty Ford. It just helps not to think of it as, “I’m not doing this ever.” Because “ever” is a really freaking long time.

Anyway, so that’s the basics. Sorry this is so ridiculously long. I have a lot more thoughts about this topic, and I could keep on writing for hours (growing less and less coherent with each keystroke), but I think this about gets it down.

Next time (whenever that is, because Golden Retriever Time), I’ll write more specifically about my choices with regard to meds.

Future Installments:
Drugs
My experiences with mood-stabilizing drugs have been, in a word, awful. There are a lot of ways in which they interfere with critical parts of my well-being; likewise, there are ways in which they interfere with critical parts of my treatment plan — and they don’t work terribly well for me.

Behavioral Neuroscience
Some thoughts about why things might work for me; maybe also some thoughts about why the things that work for me might not actually work for everyone.