An Unquiet Mind: A Memoir of Moods and Madness (23 page)

With the usual sense of profound uneasiness that for me accompanies having to look through official hospital appointment forms, I stared at the packet of papers in front of me. In imposing capital letters
THE JOHNS HOPKINS HOSPITAL
was written across the top of the page. Scanning downward, I saw that it was, as I had expected, an application for clinical privileges. Hoping
for the best, but expecting the worst, I decided to tackle all of the straightforward questions first; I quickly checked “no” to a long series of questions about professional liability, malpractice insurance, and professional sanctions: During the previous application period, had I been involved in any litigation involving malpractice or professional liability? Were there any restrictions or limitations in my malpractice coverage? Had my license to practice ever been limited, suspended, subject to any conditions, terms of probation, formal or informal reprimand, not renewed, or revoked? Had I ever been subject to disciplinary action in any medical organization? Were there any disciplinary actions pending against me?

These questions, thank God, were easy to answer, having managed thus far, in a ridiculously litigious age, to avoid being sued for malpractice. It was the next section, “Personal Information,” that made my heart race; and, sure enough, before too long I found the question that was going to require something more than just a checkmark in the “no” column:

Five lines down was the hangman’s clause:

I read back over the “Are you currently suffering from” question, thought about it for a long time, and finally wrote next to it “Per discussion with the chairman of the Department of Psychiatry.” Then with a sinking feeling in my stomach, I telephoned my chairman at Hopkins and asked him if we could get together for lunch.

A week or so later, we met at the hospital restaurant. He was as talkative and funny as ever, so we spent several pleasant minutes catching up on departmental activities, teaching, research grants, and psychiatric politics. With my hands clenched in my lap and my heart in my throat, I told him about the clinical privileges form, my manic-depressive illness, and the treatment I was receiving for it. My closest colleague at Hopkins already knew about my illness, as I had always told those physicians with whom I most closely practiced. At UCLA, for example, I had discussed my illness in detail with the physicians who, with me, had set up the UCLA Affective Disorders Clinic and then, subsequently, with the doctor who had been the medical director of the clinic during virtually all of the years I was its director. My chairman at UCLA also knew that I was being treated for manic-depressive illness. I felt then, as I do now, that there should be safeguards in place in the event that my clinical judgment became impaired due to mania or severe depression. If I did not tell them, not only would the care of patients be jeopardized, but I would be placing my colleagues in an untenable position of professional and legal risk as well.

I made it clear to each of the doctors I worked closely with that I was under the care of an excellent psychiatrist, taking medication, and had no alcohol or
drug abuse problem. I also asked them to feel free to ask my psychiatrist whatever questions they felt they needed to about my illness and my competence to practice (my psychiatrist, in turn, was asked to communicate both to me, and to whomever else he thought necessary, if he had any concerns about my clinical judgment). My colleagues agreed that if they had any doubts whatsoever about my clinical judgment they would tell me directly, immediately remove me from any patient care responsibilities, and alert my psychiatrist. I think that all of them have, at one time or another, spoken with my psychiatrist in order to obtain information about my illness and treatment; fortunately, none have ever had to contact him because of concerns about my clinical performance. Nor have I ever had to give up my clinical privileges, although I have, on my own, canceled or rescheduled appointments when I felt it would be in the best interests of patients.

I have been both fortunate and careful. The possibility always exists that my illness, or the illness of any clinician, for that matter, might interfere with clinical judgment. Questions about hospital privileges are neither unfair nor irrelevant. I don’t like having to answer them, but they are completely reasonable. The privilege to practice is exactly that, a privilege; it is not a right. The real dangers, of course, come about from those clinicians (or, indeed, from those politicians, pilots, businessmen, or other individuals responsible for the welfare and lives of others) who—because of the stigma or the fear of suspension of their privileges or expulsion from medical school, graduate school, or residency—are hesitant to seek out psychiatric treatment. Left untreated, or unsupervised, many become ill, endangering
not only their own lives but the lives of others; often, in an attempt to medicate their own moods, many doctors will also become alcoholics or drug abusers. It is not uncommon for depressed physicians to prescribe antidepressant medications for themselves; the results can be disastrous.

Hospitals and professional organizations need to acknowledge the extent to which untreated doctors, nurses, and psychologists present risks to the patients they treat. But they also need to encourage effective and compassionate treatment and work out guidelines for safeguards and intelligent, nonpaternalistic supervision. Untreated mood disorders result in risks not only to patients, but to the doctors themselves. Far too many doctors—many of them excellent physicians—commit suicide each year; one recent study concluded that, until quite recently, the United States lost annually the equivalent of a medium-sized medical school class from suicide alone. Most physician suicides are due to depression or manic-depressive illness, both of which are eminently treatable. Physicians, unfortunately, not only suffer from a higher rate of mood disorders than the general population, they also have a greater access to very effective means of suicide.

Doctors, of course, need first to heal themselves; but they also need accessible, competent treatment that allows them to heal. The medical and administrative system that harbors them must be one that encourages treatment, provides reasonable guidelines for supervised practice, but also one that does not tolerate incompetence or jeopardize patient care. Doctors, as my chairman is fond of pointing out, are there to treat patients; patients never should have to pay—either literally or
medically—for the problems and sufferings of their doctors. I strongly agree with him about this; so it was not without a sense of dread that I waited for his response to my telling him that I was being treated for manic-depressive illness, and that I needed to discuss the issue of my hospital privileges with him. I watched his face for some indication of how he felt. Suddenly, he reached across the table, put his hand on mine, and smiled. “Kay, dear,” he said, “I
know
you have manic-depressive illness.” He paused, and then laughed. “If we got rid of all of the manic-depressives on the medical school faculty, not only would we have a much smaller faculty, it would also be a far more boring one.”

W
e are all, as Byron put it, differently organized. We each move within the restraints of our temperament and live up only partially to its possibilities. Thirty years of living with manic-depressive illness has made me increasingly aware of both the restraints and possibilities that come with it. The ominous, dark, and deathful quality that I felt as a young child watching the high clear skies fill with smoke and flames
is
always there, somehow laced into the beauty and vitality of life. That darkness is an integral part of who I am, and it takes no effort of imagination on my part to remember the months of relentless blackness and exhaustion, or the terrible efforts it took in order to teach, read, write, see patients, and keep relationships alive. More deeply layered over but all too readily summoned up with the first trace of depression are the unforgettable images of violence, utter madness, mortifying behavior, and moods savage to experience, and even more disturbingly brutal in their effects upon others.

Yet however genuinely dreadful these moods and memories have been, they have always been offset by the elation and vitality of others; and whenever a mild and gentlish wave of brilliant and bubbling manic enthusiasm comes over me, I am transported by its exuberance—as surely as one is transported by a pungent scent into a world of profound recollection—to earlier, more intense and passionate times. The vividness that mania infuses into one’s experiences of life creates strong, keenly recollected states, much as war must, and love and early memories surely do. Because of this, there is now, for me, a rather bittersweet exchange of a comfortable and settled present existence for a troubled but intensely lived past.

There are still occasional sirens to this past, and there remains a seductive, if increasingly rare, desire to re-create the furor and fever of earlier times. I look back over my shoulder and feel the presence of an intense young girl and then a volatile and disturbed young woman, both with high dreams and restless, romantic aspirations: How could one, should one, recapture that intensity or reexperience the glorious moods of dancing all night and into the morning, the gliding through starfields and dancing along the rings of Saturn, the zany manic enthusiasms? How can one ever bring back the long summer days of passion, the remembrance of lilacs, ecstasy, and gin fizzes that spilled down over a garden wall, and the peals of riotous laughter that lasted until the sun came up or the police arrived?

There is, for me, a mixture of longings for an earlier age; this is inevitable, perhaps, in any life, but there is an extra twist of almost painful nostalgia brought about by having lived a life particularly intense in moods. This
makes it even harder to leave the past behind, and life, on occasion, becomes a kind of elegy for lost moods. I miss the lost intensities, and I find myself unconsciously reaching out for them, as I still now and again reach back with my hand for the fall and heaviness of my now-gone, long, thick hair; like the trace of moods, only a phantom weight remains. These current longings are, for the most part, only longings, and I do not feel compelled to re-create the intensities: the consequences are too awful, too final, and too damaging.

Still, the seductiveness of these unbridled and intense moods is powerful; and the ancient dialogue between reason and the senses is almost always more interestingly and passionately resolved in favor of the senses. The milder manias have a way of promising—and, for a very brief while, delivering—springs in the winter and epochal vitalities. In the cold light of day, however, the reality and destructiveness of rekindled illness tend to dampen the evocativeness of such selectively remembered, wistful, intense, and gentle moments. Any temptation that I now may have to recapture such moods by altering my medication is quickly hosed down by the cold knowledge that a gentle intensity soon becomes first a frenetic one and then, finally, an uncontrolled insanity. I am too frightened that I will again become morbidly depressed or virulently manic—either of which would, in turn, rip apart every aspect of my life, relationships, and work that I find most meaningful—to seriously consider any change in my medical treatment.

Although I am basically optimistic about remaining well, I know my illness from enough different vantage points to remain rather fatalistic about the future. As a result, I know that I listen to lectures about new treatments
for manic-depressive illness with far more than just a professional interest. I also know that when I am doing Grand Rounds at other hospitals, I often visit their psychiatric wards, look at their seclusion rooms and ECT suites, wander their hospital grounds, and do my own internal ratings of where I would choose to go if I had to be hospitalized. There is always a part of my mind that is preparing for the worst, and another part of my mind that believes if I prepare enough for it, the worst won’t happen.

Many years of living with the cyclic upheavals of manic-depressive illness has made me more philosophical, better armed, and more able to handle the inevitable swings of mood and energy that I have opted for by taking a lower level of lithium. I agree absolutely with Eliot’s Ecclesiastian belief that there is a season for everything, a time for building, and “a time for the wind to break the loosened pane.” Therefore, I now move more easily with the fluctuating tides of energy, ideas, and enthusiasms that I remain so subject to. My mind still, now and again, becomes a carnival of lights, laughter, and sounds and possibilities. The laughter and exuberance and ease will, filling me, spill out and over and into others. These glinting, glorious moments will last for a while, a short season, and then move on. My high moods and hopes, having ridden briefly in the top car of the Ferris wheel will, as suddenly as they came, plummet into a black and gray and tired heap. Time will pass; these moods will pass; and I will, eventually, be myself again. But then, at some unknown time, the electrifying carnival will come back into my mind.