WHO AM I?
Professor Marshall walked out to the reception area in his private rooms, smiled at Martin, shook his hand and offered his invitation. ‘Would you like to come in?’
Martin rose to his feet, returned the smile and said, ‘No.’
Marshall hesitated briefly, before walking with Martin to his office and suggesting which chair he should take.
‘No?’
Martin’s eyes twinkled. ‘You use the same invitation that I give to patients. I’ve been waiting for someone to turn it down and wondering how I would handle it.’
Marshall smiled. ‘Simply mischief then? Suggests that the depression has not come back.’
‘No. The mood has been reasonably stable.’
‘So no depression and no highs?’
‘Nothing distinct that I can detect.’
‘And the tricyclic withdrawal side-effects?’
‘They’ve gone completely.’
‘Any other side-effects?’
‘Well I’ve got a huge appetite. Snacking a lot and I’ve put on five kilos in the last week.’
‘Almost certainly the olanzapine packed it on but perhaps a contribution from the lithium. But you’ve ceased the olanzapine, haven’t you?’
‘A couple of days ago. What should I do about the TCA?’
‘Well we know you have melancholia and you are going to need an antidepressant for a period to prevent any recurrence. It had to be stopped when you were high as it was either driving it or contributing to it. The amount you are on now settled the withdrawal side-effects but the dose is too low to prevent a recurrence.’
‘How about another antidepressant?’
‘It’s an option. But, despite what the pharmaceutical companies say, not all antidepressant drugs are equally effective. The tricyclics are oldies but they’re also goodies for melancholia. So, if you don’t get any significant side-effects, I’d suggest we keep you on it, but I’ll give you a written schedule for increasing the dose. If the depression comes back there are a couple of other antidepressant options I favour.’
‘And the lithium?’
‘I suggest we keep you on it for another six weeks or so while we’re increasing the tricyclic, and then slowly taper it to see whether you do have a bipolar pattern or not, as I suspect. I’ll get you to do another twelve-hour lithium level at the end of this week and we’ll check a few other things, like your creatinine.’
‘So you’re optimistic?’
‘Absolutely. If it’s a unipolar melancholia then management should be quite straightforward. If it’s bipolar, we’ll work out whether it’s bipolar one or two, and as I mentioned, I favour quite differing medication strategies for each. But again, it’s relatively straightforward.’
‘That’s a huge relief.’
‘And how are things going otherwise?’
‘Well I’ve reported myself to the Board and they’ll have a hearing to determine if I’m an impaired practitioner. They’ll be seeking a report from you…’
‘That’s fine.’
‘And they’ll appoint an independent psychiatrist to write another report.’
‘Standard practice.’ Marshall spoke more gently. ‘I don’t think you need to be apprehensive about the Board. It goes out of its way to assist doctors with such problems and those with a mood disorder rarely run into any significant difficulties.’
‘Even those with a bipolar disorder?’
‘As long as they take their required medication and their mood is under complete or relatively complete control. I’ve seen numerous GPs and many specialists practising at the highest levels with a bipolar disorder. Six British prime ministers had a bipolar disorder. None lost office as a consequence – although such a diagnosis wasn’t known to the public or to them – and all were viewed as better than the self-doubting anxious British PMs.’
‘Reassuring. My practice colleagues don’t appear to be so sanguine.’
Marshall frowned. ‘Problems?’
‘Some of them are apprehensive about me returning to the practice.’
‘Why?’
Martin was now accustomed to Marshall’s staccato questioning. He returned the ball. ‘Unclear. Certainly the diagnosis of a mood problem is at the heart of it. Especially as they think I have a bipolar condition.’
‘So, stigma. It sorts people out.’
‘Should I be open with them?’
‘That’s a difficult one to answer. I think you are only obliged to tell key family members if they are likely to be supportive. We’ve de-stigmatised depression well in this country but bipolar is an additional step. Some employers can be very apprehensive. Yet, of my patients who talk openly about it, they report very little kickback and they generally become incredibly resilient. Seemingly become untouchable, and intriguingly, the course of their condition usually improves. It’s your call, Martin.’
‘Have you another ten minutes?’
‘Five.’
‘The mania was wonderful up to a certain level. And then I became arrogant, self-indulgent and entitled. Rabelaisian. I engaged in things that were morally wrong and I did things that I had always judged and now judge again as behaviourally unacceptable. I don’t understand that process. I don’t understand how I lost my moral compass, even my own personality.’
‘It goes with the condition, Martin. For those who have had years of bipolar disorder, one of their biggest problems when their mood has been brought under control is that they don’t know who they really are – having been defined for years by highs and lows. It can create a real existential crisis, and needs to be worked through.’
‘And it’s impacting on my marital relationship.’
Marshall went to his library and handed Martin a book. ‘I suggest you read this. Captures a lot of narratives of people with bipolar disorder. Do that first. Later, if the problems with your wife can’t be reconciled, we’ll get you both to see a psychologist who works a lot with my bipolar patients.’ Marshall looked at his watch. ‘Let’s meet again in a month unless there is a problem. OK?’
HIGH FIDELITY ISSUES
Tuesday evening echoed the tones of the previous nights. Martin welcomed Sarah home with a guarded smile.
‘I’ve nearly got dinner ready. How was your day?’
‘Fine. I’ll do the salad.’
She joined him in the kitchen, setting up preparations where her back faced him. Martin smiled wryly to himself and poured her a glass of wine. She let him put it down without turning to thank or even smile at him. At least a minute passed before she spoke.
‘And how was your day?’
‘Well I saw Marshall and it all went very positively. He’s quite optimistic about things.’
‘That’s excellent,’ Sarah said without turning around. ‘Could you put the news on?’ She took their plates to the lounge and the two ate, watching television, without commentary and without conversation. After finishing her meal ahead of Martin, Sarah put her plate in the dishwashing machine.
‘I need to do some work on the computer.’
Martin asked quietly, ‘Sar, please stay.’ Sarah turned around and hesitated, her face lacking any emotion. Martin decided not to touch her, to respect her space. ‘Sar. We have to talk. We have to talk this through.’
Sarah bristled. ‘We have to?’
‘We should. We need to. I know I have put our marriage in jeopardy by my own actions. I can’t risk the possibility of losing you. I love you too much.’
Sarah sat back down and Martin turned to look directly at her, inviting a response.
‘When we married, Martin, you swore at the wedding ceremony that you would always be faithful. I’ve always viewed you as a man of integrity. You having an affair and with such a dangerous bimbo shows a lack of judgment. That and the deceit have shattered me. It’s left me numb.’
Martin said nothing for a few seconds. ‘I feel exactly the same about myself. Nothing but shame.’
Her voice rose and her face show
ed an anger that Martin had never before seen in her. ‘And yet you want to talk about it. For me to simply forgive you? Like some ever-accepting lotus-eating Griselda? To excuse you?’
‘I certainly don’t seek to excuse but I would like to try to explain.’
‘You can explain it? Don’t make me laugh!’ She slammed the TV guide booklet onto the lounge.
‘Please let me make an attempt. I’ve been reading a book Marshall gave me on people’s experiences during manic states.’ Martin started to flick over pages marked with stickers as Sarah stared ahead. ‘Descriptors of feeling entitled and invulnerable are so common. One woman noted that riding the high of bipolar she could argue persuasively, and passionately rationalise every decision and action. That’s what I felt at the time.’
Sarah spoke more softly. But solemnly. ‘Which is what you might be doing now.’
‘I certainly hope not. One man beautifully described how mania can’t be harnessed.’ Martin read from the book, his finger tracing selected phrases. ‘That when charging in mania’s ferocious vortex, there is no place for strategy. That when on fire to be told just say no doesn’t work. That you don’t manage it when its swooping, screeching talons tear every good instinct from you. You find yourself in Boston because you wanted to see the Sox play. A sense of invincibility was common. One wrote I am hell: all thunderbolt and lightning for those around me. Listen to this Sarah. I have only loved one man with all my heart. Receiving a phone call from him on his mobile in first class, informing me that he is Neo from the Matrix and that I am to arrange a Porsche to collect him from Heathrow Airport is not a call I wanted to receive.’
Sarah held up her hand. ‘I get all that, Martin. And I get you intellectualising the process. I’ve also been reading about bipolar disorder. But why did you have that affair?’ While her question was infused with anger, there were tears in her eyes. Briefly only before anger again surfaced. ‘No. Affair gives it some status. Why did your humping of this woman commence the very day after I flew overseas and cease the day I returned? That suggests a level of sane judgment to me.’
‘Sar. What you say is absolutely logical. But, during the high, logic went out the window.’
‘You say your libido was out of control. Let’s say you had had a particularly attractive female patient at that time. Feeling entitled and whatever other descriptors you choose, would you not have groped her in that state?’
‘Sarah. You know I’ve always been firm about boundaries between doctors and patients. That would never have happened.’
Sarah responded icily. ‘Then Martin, my logic tells me that your logic doesn’t exactly go out the window during a high. You try to tell me that the state is uncontrollable and then you accept that it is controllable in certain circumstances. The two statements are mutually exclusive. I hear a clear capacity to make a choice. Is it simply the weight of the consequences that determines whether you keep your genie in the bottle? If it’s the latter, then we have a problem in that you presume that being unfaithful to me is without distinct consequences. How do you think I feel about that?’
‘Sar, I’m mortified.’ His head dropped.
Sarah put her hand out and pushed Martin’s head up so that he was forced to look directly at her. ‘As you should be but you said you wished to explain. I’m not hearing an explanation that works for me.’
Martin now felt able to look her comfortably in the eyes. She had vented some retributive anger. They may be arguing but at last they were communicating. He tried to remain non-provocatively rational. And he wanted to be honest.
‘At the milder stages of the high, I retained my capacity to care about others. In fact, I think I was even more empathic than usual. That went when I became more manic. I then felt completely entitled. I went past an inflection point. Everything had to fit into my world.’
‘It was then all about you.’
‘Yes. And the same thing happened when I got to the worst of the depression and I wanted to die. During that period I didn’t…couldn’t…factor you in. You, everyone in my life, were all irrelevant. I was so absorbed in myself, in the pain. And yet, when you rang me, when I was with you, even at that worst time, you did pierce that self-absorption.’
Sarah pressed on. ‘But returning to the mania. Is it not like taking alcohol to excess? That both are simply disinhibiting? In essence, that you had some want, some urge to have sex with another woman and the mania simply activated that wish?’
‘I don’t believe so.’
‘But of course you would say that.’
‘I have never entertained the idea of having an affair. Never.’
‘Perhaps you simply put a mantle over such urges as they don’t fit with your view of yourself?’
‘You’re drawing a very long bow.’
‘But what if it’s true?’
‘Then, as you suggest, my self-judgment about being a moral person risks being a sham. I can’t bear to think along that track. As I said, a similar thing happened when I was at the worst of the melancholia and I went past an inflection point and wanted to die. I don’t think I have ever held an unconscious death wish. I think something categorical happened at both poles. I was no longer me.’
Sarah smiled wryly and then spoke seriously, no anger in her voice. ‘I still love the man I married. I just don’t know whether you are truly that man. That’s my difficulty. It goes beyond simply trying to re-establish trust.’
‘But you said you believed in redemption, Sar?’
‘Theoretically.’ Sarah decided not to discuss her other concern. One that was not settling. He had gone manic – outrageously manic and psychotic. Why might this not happen again? She could only armour herself against that possibility by maintaining a protective barrier.
A TIME OF DOUBT
Martin had slept better on the Tuesday night, again in the separate bedroom, as Sarah had gone to bed early after their discussion and closed the door quite loudly. Her views were clear. And they were talking.
His task for the day was to address the medical practice staff at lunch. Over the morning he reviewed optional strategies. He could state that he been diagnosed with a bipolar disorder but there was some doubt about the diagnosis and that it was more likely a unipolar depression. He could say he had had a lengthy episode of melancholia but that it was now under control with medication. He could tell them he had depression and that he was seeing someone about it. Should he mention medication? And how might he best reveal that he had self-reported as an impaired practitioner?
He arrived early for the lunch and, as the doctors drifted in, he chatted with each one. Not one asked How are you? He interpreted this as reflecting respect rather than insensitivity. They were going to leave it to him to tell his story. Most appeared pleased to see him and he responded by trying to josh with as many as possible. Dave stood in the background, watching the interactions but judging there was no need to intercede.
Dave chaired a presentation by a pharmaceutical company representative and then invited Martin to speak. Martin stepped forward incisively. His smile elicited smiles from most of the other doctors.
‘Thanks, Dave. I understand that most of you have heard that I’ve been very depressed. I have to tell you that the way the Wallabies have been playing this year – and their disastrous performance a couple of weeks back – was extremely depressing for me. Their win last weekend has, however, allowed me to believe in redemption and I’m now sufficiently cheered to return to work.’
Martin noted that, while several of the doctors were grinning, smiles had left the faces of several others. Clearly they viewed him as flippant. At one level they were being quite unfair. If he had broken his leg there would be no need for him to stand up and give an account of himself. Some presumably wanted to hear his account. And some needed to know more.
Martin became solemn. ‘More seriously, it seems as though clinical depression runs through my family and I certainly got hit heavily with it some weeks back. I don’t thin
k it distinctly affected my medical capacities in the early phases. Later I believe it did and I took time away from the practice.’ Martin wondered whether he should say any more. ‘And even later I needed to go to hospital for a week.’ Frowns crossed the faces of a couple of the doctors, while the others remained impassive or appeared concerned. ‘I ended up with an excellent specialist there. He’s reviewed me since I left hospital and is optimistic about things. I feel quite back to normal now and that’s why I believe it’s also fine for me to return to the practice.’
He observed the group settling, apart from one doctor, Brett ‘Eeyore’ Tompson. Tompson had a reputation for being difficult and had little tolerance for those with psychological problems. Tompson clearly wanted more information and he could be predicted to pose abrasive if not offensive questions. Why would someone put manic depressive graffiti against your name? Are you not a danger to the practice? Are you on medication? Martin had no wish to address such issues. The last would simply reflect stigma.
Dave cut in, spanning the group. ‘As you would all know, we doctors are not immune to mood disorders.’
In Two Minds Page 22
