Joel Breving

Yes, I am a doctor, specializing in psychiatry. And yes, I have been diagnosed with bipolar affective disorder.

As a psychiatrist, many of my patients are bipolar and I can't help but wonder: Would they still want me as a doctor if they knew I was bipolar? Would they feel relieved if they knew? How would it affect the doctor-patient relationship? Since I am a psychiatrist there are fairly clear guidelines. My personal life stays personal. But I question whether this rule was meant to be broken under certain circumstances. Could I help my patient or other doctors if they knew the truth? Or would I be branded, as many of my patients are labeled and stigmatized?

A psychiatrist learns early on that bipolar affective disorder is a devastating disease. It has a strong link to a family history of mental disorders (especially bipolar itself) and usually presents at age 19. Bipolar is characterized by episodes of depression where patients are sad, down and "blue" and exhibit sleep difficulties, decreased energy levels and decreased interest in activities. However, bipolar patients also exhibit mania or a manic episode, which is the opposite of depression. The patient feels too good, even euphoric. Their thoughts come quickly; they often need little sleep and feel they can do anything. During manic episodes, the patient will often get themselves into serious problems: spending sprees, sexual promiscuity, outlandish behaviors that are out of character. Manic episodes are rarer than depressive episodes, but they can be quite striking.

In my first year of medical school, under the pressure of all the work, I experienced my first mood episode. It was a mixture of both depression and mania, called a mixed episode. It became so severe that I started losing touch with reality. I didn't know where to turn, so a friend of the family who is a psychiatrist prescribed Prozac for depression at a low dose. It was the wrong treatment, but somehow I was able to persevere. The anti-depressant was just effective enough to channel my energy into a light mania that allowed me to be very productive and pull myself back from the ledge. Yet the balance was precarious and the disease lay dormant.

I remained on a low dose of Prozac for the next three years and was able to hold it together through medical school. My graduation from medical school was a crowning achievement in my life. The joy I felt was unbelievable. I also married my longtime girlfriend. My life was good.

After finishing medical school, I decided to go into psychiatry. I thought that I had just a little touch of depression, which is why the low-dose Prozac was working so well. I never thought I was bipolar. I started a residency in psychiatry at the University of Cincinnati and quickly my world came crashing down. Residency was the most difficult thing I ever had to do in my life: long days of tiring work and sleepless nights on-call. Being on call every fourth night started altering my sleep schedule and then I started getting depressed. I thought my anti-depressant wasn't working so I switched to another anti-depressant and still the depression worsened. I was seeing a general practitioner who was prescribing my medication. I should have been seeing a psychiatrist but I was in a psychiatric residency and felt ashamed that anyone would find out.

There is a 15 percent lifetime risk of completed suicide in patients with untreated bipolar disorder, an utterly striking figure as the average person has a less than 1 percent chance of completed suicide. More than a quarter of bipolar patients go untreated because it is so difficult to diagnose. One difficulty in treating bipolar is that patients quite often convince themselves they do not have an illness. They will look at me square in the face and tell me they are "fine" even after they went on a $20,000 shopping spree during a manic episode. They quite often do not take their medications and repeatedly decompensate. It is a vicious cycle. The disease can be frustrating for a psychiatrist but obviously more frustrating and even deadly for the patient.

My general practitioner kept on increasing the Paxil, but the disease kept on progressing. I started losing touch with reality again. And then a switch was flicked. My mind started racing a thousand thoughts per second and I only needed two hours of sleep a night and yet felt perfectly rested. I was starting to get ideas of grandeur. I was too good for medicine. I was going to transcend and become an author, an inventor; I never thought for a moment there was anything wrong. As I found out later, using anti-depressants in patients with bipolar disorder can be quite dangerous. The medication that was once helping me was now fueling a switch from depression to a full-blown manic episode.

I quit my residency on a whim after getting into a verbal altercation with one of my attendings. I stormed out of the hospital telling myself they had made the biggest mistake of their lives. I was going to transcend and become great. And no one could stop me.

My head in the clouds, I began writing a novel and working on a new type of video game system for which I was going to apply for a patent. I did not realize that my increase in goal-directed activity were hallmarks of the illness, either. Insight is so easy to apply to the outside world and other people but was all but lacking when it came to my internal world. But then money started becoming tight as my wife was in medical school and we had just bought a house with mounting bills to pay. My wife was reasonably enough worried about me but did not grasp the severity of the warning signs; somehow I had convinced her that I was "OK." When my "greatness" didn't translate into a steady paycheck, I started getting desperate and gambling on the stock market.

My dabbling in the market coincided with the tech crash of 2001. I placed all of our life savings into a stock that tanked after the crash. I had traded on the margin, 2 to 1, so we were $50,000 in debt. My wife stuck with me, but I had plans to fix that. I contacted an old ex-girlfriend. I was convinced all my problems would be solved if I left my wife and started over again with my ex-girlfriend. The wheels were coming off the bus.

I met up with my ex-girlfriend in New York and earnestly asked her to leave her fiancée and come live with me in Cincinnati, which prompted her to leave quickly, visibly disturbed. My wife found out about my ruse and I returned to Cincinnati where an intervention of friends and family were waiting for me. They pleaded with me to get professional help but I just laughed it off. Almost mercifully, my wife finally left me and all I had left to do was "crash," because what goes up inevitably must come down. I went into a deep, dark depression and when I awoke from it, I started waiting tables at a local Mexican restaurant to pay back my debts, my burden, my cross, alone.

It is painful just relaying that story to the outside world. When I put it down on paper, it seems surreal. The hurt that I caused so many people in my life, especially my ex-wife – it was truly unfair of me. But then another part of me says, "Don't be so hard on yourself. It was bad, but it was part of the illness and you paid a dear price yourself."

For the first time in my life, I went to see a psychiatrist, who was somewhat helpful. I was placed on a low-dose anti-depressant, Celexa, which again was the wrong treatment for bipolar but allowed me to stabilize. I consolidated all my debt. I kept waiting tables and with my life back on track, somehow got back into a psychiatry residency two years later at the University of Virginia. This time around I survived residency but still did not see a psychiatrist, just a general practitioner. In 2007, I graduated from residency and moved to New York City where I met the love of my life and married her. I have my own private practice. I am now properly diagnosed as bipolar and stable on medications. By most accounts, I am successful. But sometimes my ghosts still haunt me.

It took a lot of time for me to come to the realization that I am bipolar. I was ashamed and my mind was playing little tricks on me, convincing myself that I was just depressed. For years, I battled acceptance. And I don't think there was a particular day when a lightning bolt came down from the sky, but just a slowly growing accord.

I have been living with this secret for far too long: one that brought me to my hands and knees. It was overdue, but I really wanted to feel like I had conquered bipolar. But unfortunately, we don't conquer mental illness. We live with it. ¦