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Part of my stubbornness can be put down to human nature. It is hard for anyone with an illness, chronic or acute, to take medications absolutely as prescribed. Once the symptoms of an illness improve or go away, it becomes even more difficult. In my case, once I felt well again I had neither the desire nor incentive to continue taking my medication. I didn’t want to take it to begin with; the side effects were hard for me to adjust to; I missed my highs; and, once I felt normal again, it was very easy for me to deny that I had an illness that would come back. Somehow I was convinced that I was an exception to the extensive research literature, which clearly showed not only that manic-depressive illness comes back, but that it often comes back in a more severe and frequent form.

It was not that I ever thought lithium was an ineffective drug. Far from it. The evidence for its efficacy and safety was compelling. Not only that, I knew it worked for me. It certainly was not that I had any moral arguments against psychiatric medications. On the contrary. I had, and have, no tolerance for those individuals—especially psychiatrists and psychologists—who oppose using medications for psychiatric illnesses; those clinicians who somehow draw a distinction between the suffering and treatability of “medical illnesses” such as Hodgkin’s disease or breast cancer, and psychiatric illnesses such as depression, manic-depression, or schizophrenia. I believe, without doubt, that manic-depressive illness is a medical illness; I also believe that, with rare exception, it is malpractice to treat it without medication. All of these beliefs aside, however, I still somehow thought that I ought to be able to carry on without drugs, that I ought to be able to continue to do things my own way.

My psychiatrist, who took all of these complaints very seriously—existential qualms, side effects, matters of value from my upbringing—never wavered in his conviction that I needed to take lithium. He refused, thank God, to get drawn into my convoluted and impassioned web of reasoning about why I should try, just one more time, to survive without taking medication. He always kept the basic choice in perspective: The issue was not whether lithium was a problematic drug; it was not whether I missed my highs; it was not whether taking medication was consistent with some idealized notion of my family background. The underlying issue was whether or not I would choose to use lithium only intermittently, and thereby ensure a return of my manias and depressions. The choice, as he saw it—and as is now painfully clear to me—was between madness and sanity, and between life and death. My manias were occurring more frequently and, increasingly, were becoming more “mixed” in nature (that is, my predominantly euphoric episodes, those I thought of as my “white manias,” were becoming more and more overlaid with agitated depressions); my depressions were getting worse and far more suicidal. Few medical treatments, as he pointed out, are free of side effects, and, all things considered, lithium causes fewer adverse reactions than most. Certainly, it was a vast improvement on the brutal and ineffectual treatments that preceded it—chains, bloodletting, wet packs, asylums, and ice picks through the lobes—and although the anticonvulsant medications now work very effectively, and often with fewer side effects, for many people who have manic-depressive illness, lithium remains an extremely effective drug. I knew all of this, although it was with less conviction than I have now.

In fact, underneath it all, I was actually secretly terrified that lithium might not work: What if I took it, and I still got sick? If, on the other hand, I didn’t take it, I wouldn’t have to see my worst fears realized. My psychiatrist very early on saw this terror in my soul, and there is one brief observation in his medical notes that captured this paralyzing fear completely: Patient sees medication as a promise of a cure, and a means of suicide if it doesn’t work.