Our team decided to examine the exact statistics based on reports from the Substance Abuse and Mental Health Services Administration(SAMHSA). The resulting insights concerning those diagnosed with a co-occurring mental health disorder and substance use disorder are staggering, and you can see a compilation of our findings below.

Of those who were diagnosed with each of these mental health disorders, a large percentage were also diagnosed with substance use disorder. Only 2% of the overall population without a mental health disorder suffer from SUD. In contrast, over a third of the people diagnosed with a personality disorder were also diagnosed with SUD. For example, those diagnosed with personality disorder were 18 times more likely to have SUD than those without a mental health disorder.

This trend repeats itself with all of the major mental health disorders. Those diagnosed with bipolar disorder and schizophrenia are both 11 times more likely than the general population to suffer from SUD. Anxiety, adjustment, and depressive disorders all have a rate 8 times that of the general population for SUD. Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) had the lowest rate of co-occurring SUD, but even those disorders increase people’s risk of SUD by 5 times.

Those suffering from mental health disorders, in general, are at higher risk of homelessness, imprisonment, or being admitted to a psychiatric institution. Those struggling with both substance abuse and mental health disorders are often 2 or 3 times more likely than people diagnosed with only a mental health disorder to wind up homeless. Similarly, those suffering from a co-occurring mental health disorder and SUD were far more likely than those with just a mental health disorder to spend time in a psychiatric institution or in the justice system. Those with a personality disorder combined with SUD are at the greatest risk of spending time in the justice system, and those with schizophrenia or a psychotic disorder are most likely to be sent to a psychiatric institution.

Substance use disorder has become more prevalent in the U.S. over the past decade, with an average of 3% of the population experiencing SUD in 2013 and 2014. That percentage fell to 2% in 2015 and 2016.

The average percentage of people with SUD is higher in those aged 25 and over. Nearly 5% of the U.S. population in 2014 in that age group had SUD, although that number fell in 2015 and stayed steady at 3% in 2016. That age group still has the highest rate of SUD overall.

Overall, alcohol was the most common substance to be abused by those with mental health disorders. However, in the case of anxiety disorders, opioids were the most commonly abused substance, and in the case of ADD/ADHD, marijuana was the most common substance to be abused. Those with depression had the highest rates of substance abuse overall, followed closely by bipolar disorder and schizophrenia and psychotic disorders.

Those suffering from mental health disorders and substance use disorder are fighting battles on multiple fronts. Mental health and management of addiction go hand in hand, and it’s crucial that those diagnosed with co-occurring mental health and substance use disorders get additional support. If you’re looking for more information on treatment options for those with co-occurring disorders here.

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Infographic provided by americanaddictioncenters.org

Find out more about the effects of Substance Abuse and Self Harm here.

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Both depression and mania can be master manipulators—playing tricks on our mind, convincing us to believe things that just aren’t true. Whether it’s challenging the negative thought loops or recognizing the patterns of fabrications in how we perceive the world around us, simply being aware of the fact that we can’t always believe everything we think can help keep us on track.

Lie #1: “I’m not deserving of love”

When we are in an unstable period and grappling with extreme mood shifts, our thoughts have a habit of turning on us. The nature of bipolar can contribute to bouts of unworthiness and low self-esteem, with a constant refrain of thinking we aren’t deserving of love. When we accept the diagnosis and make caring for ourselves a priority, we can learn to love ourselves and not buy into this common misbelief.

Lie #2: “I’ll never have a healthy, fulfilling relationship”

Some of us may have experienced a painful break-up, or more than one, which was then followed by us believing—thanks to bipolar’s manipulation—that we’ll never have a loving commitment again. This is not true. The first and most important step is to come to terms with the diagnosis, then realize that with a proper management and treatment plan, a regular and stable life (and relationship!) is possible.

Lie #3: “I am flawed”

First of all, bipolar is not a defect or a sign of emotional instability. It is a brain-based mood disorder that can be managed with proper treatment. Scan through the myriad articles and first-person accounts on bphope and you’ll readily find others who have identified their own benefits of bipolar. Yes, benefits. Being creative, empathetic, and sensitive, embracing a natural go-getter mind-set, and having a zest for life are all great attributes.

Lie #4: “I’m better, so I don’t need my medication”

We often believe this when we don’t entirely accept or understand our diagnosis. It may feel easier to deny the bipolar than to come to terms with living with a mood disorder, especially if self-stigma is an issue. The truth is that any life trigger can risk our stability, so adhering to a prescribed medication or treatment plan is a crucial part of managing bipolar and maintaining that “better” feeling.

Lie #5: “I’ll never feel happy again”

It’s common to believe that the pain we feel while in a depressive episode is permanent. At that time, it can be difficult to imagine that the dark veil will ever lift. But, as we know, the illusion of permanence is just that: an illusion. While finding the lightness that comes with stability after a depressive episode may take longer than we had hoped, realizing that bipolar depression is a temporary state can make it more bearable to endure.

Lie #6: “I don’t need sleep”

This is misbelief is especially common when we’re in a hypomanic or manic state. We fall for the falsehood that when we’re feeling productive, getting sleep is a waste of valuable time. In fact, during these times, it’s critical to remember that a regular sleep schedule can regulate our wellness. One of the best rules is to go to bed at the same time each night and get up at the same time each morning—seven days a week.

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Anxiety disorders are the most prevalent coexisting condition with bipolar. In fact, recent studies indicate that more than half of those with bipolar also have a diagnosis of anxiety. The overlap is so striking, medical researchers are questioning whether or not it could be a precursor to bipolar. Either way, chronic worry, stress, and tension play such an influential role in how we respond to treatment that assessing for these symptoms is a crucial first step. Understanding how both health conditions intersect is key to effective care.

Anxiety Two Ways

It’s important to determine how these puzzle pieces fit together; anxiety can be either a symptom of bipolar or a separate comorbid condition. Making a distinction requires monitoring both mood and anxiety, noting the duration of disturbances in each. If your anxiety alleviates when you achieve mood stability, then it is likely a symptom of bipolar. However, if your mood is stable but your tension and nervousness persist, then you likely have a coexisting condition that should be treated as such by a health professional.

Greater Impact

Obtaining accurate and early diagnoses can have a big influence on well-being because anxiety exacerbates the course of bipolar in a number of ways. Specifically, research shows that it results in bipolar symptoms that are more severe and more frequent; it is linked to decreased medication adherence; and it is associated with greater “residual symptoms” when a mood episode resolves.

Mistaken Identity

Whether a symptom of bipolar or its own diagnosis, anxiety can often be mistaken for acute, or temporary, stress—or vice versa. This generally occurs during troubling life circumstances, such as going through a negative experience or dealing with a traumatic event. Yet sometimes anxiety can come out of nowhere, remaining a concern even in the absence of an identifiable cause or trigger. Part of the challenge for diagnosis and treatment is the fact that these two conditions interact in varied ways for different individuals.

Know the Symptoms

Because it’s not always easy to distinguish between where anxiety falls in relation to bipolar (as a separate condition or a symptom), health professionals point to the following as an indication of a coexisting diagnosis: panic and dread; poor sleeping due to anxiety; ongoing anxiety while bipolar symptoms are stable; not showing response to anxiety treatment; and difficulty finding appropriate medication dosing. In contrast, when it is a bipolar symptom, it generally presents as irritability or agitation; physical restlessness and racing thoughts; and improved treatment along with other symptoms of bipolar.

Setting the Scene

Although more research needs to be done, some studies have found that anxiety diagnosis typically precedes the onset of bipolar symptoms and may even represent risk markers for a subsequent bipolar diagnosis. This is especially true with generalized anxiety disorder (GAD) and panic disorder. In fact, according to one study, individuals with GAD were “12 times more likely than the general population to receive a bipolar disorder diagnosis,” and those with panic disorder were “10 times more likely to have comorbid bipolar disorder.”

What to Do?

Because a coexisting anxiety condition tends to worsen the course of bipolar, getting an accurate diagnosis as early as possible is essential. In addition to a tailored medication and psychotherapy treatment protocol, there are other ways to help manage anxiety symptoms: physical activity, mindfulness meditation, adequate sleep, joining a support group, avoiding caffeine, and learning to reshape negative thoughts and behaviors, perhaps with the assistance of talk therapy.

Sources:
“Treatment of Anxiety Disorders in Patients with Comorbid Bipolar Disorder,” Mental Health Clinician 8, no. 6 (Nov. 2018): 256–­63
J. Phelps, MD, “Two Ways to Have Anxiety with Bipolar Disorder,” PsychEducation (June 2019)
L. LaBouff, “Two Anxiety Disorders Tied to Bipolar,” Bipolar Laid Bare (June 2016)
“Specific Anxiety Disorders and Subsequent Risk for Bipolar Disorder: A Nationwide Study,” World Psychiatry 15, no. 2 (June 2016): 187–88

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Research shows that physical exercise can benefit one’s mental health. But there are other advantages to challenging oneself in this manner.

You’re probably thinking, “Oh, here we go again. Another post that is going to tell me to exercise.” Well, you’re right, a bit. You see, research has proven that exercise improves one’s mental health and is a good adjunct to traditional therapies. I don’t think that there is much disagreement with this. But what I’m talking about is actual physical fitness.

To further explain, I want to make the connection between physical activity and bipolar disorder in a more metaphorical sense.

For the last roughly 20 years I’ve engaged in endurance sports like long-distance running and cycling. I’ve successfully completed two full marathons, three half-marathons, and countless shorter-distance races like 5Ks and 10Ks. In the last few years, I had to drop the running due to lower back issues; however, I’ve replaced it with cycling. I typically ride anywhere between 20 and 40 miles, and even longer distances when in training. Last summer, I participated in a 102-mile fundraising ride, which was as much a “bucket list” thing to do as anything else.

I don’t share these accomplishments to brag. If anything, I’m just expressing how much my life has revolved around these types of activities.

The thing to keep in mind is that there have been times in my life when I literally couldn’t get out of bed. If you’ve ever had this experience, then you know what I’m talking about. But this is where the connection between physical fitness and bipolar comes in.

With our condition, when we’re in the midst of mania, anything is possible. The energy we experience is virtually unlimited. If only it were possible to bottle this energy and be able to take a sip every once in a while to keep us going then everything would be great. Unfortunately, this isn’t possible.

On the other end of the spectrum, when one is having a depressive episode, it is horribly challenging even to get dressed.

What I have learned over the course of my 37 years of living with bipolar is that our condition is fatiguing. Not just in the sense of the depression that it is associated with it, but the simple idea that we have to endure the ups, downs, and in-betweens of the condition. And this is where the metaphor comes in.

You see, life is a marathon, not a sprint. It is so important to recognize that despite how hard things can get, recovery is possible, and we have to hold on to this hope one day at a time.

It was 1999, and I was running in the Marine Corps Marathon in Washington, DC. I was able to participate in this legendary event as a result of raising funds for the Leukemia and Lymphoma Society. It was a cold October day, perfect to run 26.2 miles. Ever since my days running cross-country in high school, I had dreamed of completing a marathon.

1999 is a long time ago, and many of the memories are tucked in the corners of my subconscious. But there are some images that stand out: the throngs of people lining the streets in Georgetown, the Marines in full gear running the distance, and those individuals who carried our nation’s flag while, at the same time, running as I was.

But one memory that sticks out is that of the 14th Street Bridge. This is approximately 20–21 miles into the race. I recall running up the bridge and beginning to struggle. Then I looked to my right and saw a person walking, and I literally said to myself, “That looks like a good idea.” So, I did just that.

Knowing that I was only 6 or so miles from the finish was enough to keep me moving. I ran with intermittent walking breaks. HOWEVER … I didn’t quit. I kept my focus on the goal: to finish, one way or another.

As I made my way to the finish line at the Marine Corps Memorial, I had an incredible sense of accomplishment. Runners actually complete the race by running up a steep embankment. Once you cross the line, a Marine puts the finisher’s medal on you.

The comparison I would make between the challenge of running one of the most storied endurance events of all time and having bipolar is that no matter what, we have to remain focused on our goals, whatever they may be. Whether it’s returning to work, getting out of the house to go shopping, or simply taking a shower, being able to tap into the reserve that lies within is crucial. By doing so, we give a much-need boost to our self-esteem.

In 1981, when I emerged from the first of the many manic episodes that followed, I never in my wildest dreams imagined that I’d be able to accomplish many of the things I have in the years since. One thing I do know, though, is that it takes equal measures of work, hope, and belief to make it all come together.

So, challenge yourself. What is your goal, and how can you make it a reality? Feel free to leave a comment on something you’ve done or would like to do.

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Even though I am stable, I feel that bipolar depression has permanently changed all aspects of my brain: my memory, ability to focus, and self-confidence.

Having lived with Bipolar I for over a decade, I have been through my share of depressions. However, there was one from the winter of 2011 until the fall of 2012 that I wasn’t sure I would make it out of. This was my Great Depression. A depression so severe I could not get out of bed. When I did I collapsed on the couch. At first, I felt so much pain I couldn’t stop crying. Then the pain became so deep I grew numb. I couldn’t cry. I couldn’t experience any emotions except despair. The time I spent awake I was either crippled with anxiety or desperately planning to take my own life.  Eventually, I was put on antidepressants. At that point, I had not yet been diagnosed with bipolar disorder. A manic episode followed and lasted about five months, landing me in the hospital with a bipolar diagnosis.

After my hospital stay, I experienced yet another depression that lasted nearly two and a half years.

These two depressions were my absolute worst, and I have noticed a mental fallout ever since. The lingering effects of these depressions  have left me with a poor memory, difficulty concentrating, slower cognitive functioning, and a social anxiety that has never quite dissipated.

When I was depressed, I believed that I was worthless, that I was a loser, and that people thought the worst of me. This led to a deep rift between myself and the rest of society. I suddenly felt as if I could no longer connect with people. And the worst part is that this feeling still lingers. Most of the time when I try to interact with people, the voice of the old depression says, “You’re not good enough, don’t even try to make a joke because you’re not funny anymore, you’re a pathetic loser.”

Even though I am stable and have been for quite awhile, I feel like my brain has permanently changed. I’d much rather stay at home than do anything else. I’m content to be practically alone. And when I do have to go out into the world, I’m always afraid my cognitive deficits will be noticed, whether it’s my poor memory or my difficulty focusing.

Not willing to accept defeat, I have been looking for studies on brain changes after depression. I wanted to make sure I’m not the only one who has experienced these lingering effects. Scientists have found that depression can in fact damage the brain, and that the hippocampus in particular can actually decrease in size by ten percent after a depressive episode. The hippocampus is responsible for memory and stress functions. It is also part of the limbic system which contains the amygdala. Together, it is our emotional center. And a loss of memory isn’t just about being forgetful. One scientist explains, “Your whole sense of self depends on continuously understanding who you are in the world – your state of memory is not about just knowing how to do Sudoku or remembering your password – it’s the whole concept we hold of ourselves.”

So how can you overcome the mental fallout after depression and improve everything from your memory to your emotional, mental, and physical health?

The answer is exercise.

There are some promising studies being done on how exercise affects our brains. Researchers at UC Davis Health System in Sacramento, CA, found that intense exercise lasting between eight and twenty minutes increased certain neurotransmitters in the brain. Particularly they found that levels of glutamate and gamma-aminobutyric acid, or GABA, were positively affected by exercise. These two neurotransmitters are often depleted in people with major depression. Levels of glutamate and GABA were found to improve not only immediately after exercise, but into the following week as well. This means that certain cognitive functions, emotions, and visual processing were all positively influenced with lasting effects.

Admittedly, I still struggle to find the time or desire to exercise. Even knowing how it immediately improves my mood (having experienced it firsthand), I tend to lack the motivation. And my excuses find even more traction in winter. It’s too cold! I’m too tired! It’s too dark!

So to combat this I bought a mini trampoline to use in my apartment. It’s about 33″ and all I do is jump up and down on it, but even five to ten minutes while listening to music is a great mood booster. And besides the physical benefits, it also has a way of dislodging my stuck thoughts and interrupting the circuitry of obsessive thinking. Furthermore, bouncing on a trampoline provides just the right amount of exercise for me. Too much exercise can trigger a manic episode in some people. On the other hand, that isn’t an excuse to be entirely sedentary. If you’ve been struggling to find the right type of exercise, I encourage you to try the trampoline.

If you don’t want to bounce, that’s ok too. But find an exercise and stick with it. The emotional, physical, and mental benefits are too good to pass up.

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The sheer convenience of eating processed foods makes them highly attractive, especially when you’re depressed. But what’s the effect inside your body?

“We are what we eat” may be a cliché, but it’s true! According to the Centers for Disease Control and Prevention, more than 68 percent of all Americans are considered overweight or obese. People with bipolar disorder are not alone in their tendency to reach for fast foods, simple “carbs,” and caffeinated energy drinks. Eating better could help you feel better!

How does eating processed foods affect my body?

Several large studies have shown that dietary patterns high in processed foods and simple sugars are associated with increased incidence of depression, whereas diets high in whole foods like vegetables, whole grains, and fatty fish are associated with reduced incidence. Research indicates that the unfavorable nutrient ratio in processed foods contributes to the body perceiving that it is in a chronic state of inflammation; in other words, you feel lousy.

Inflammation is a normal immune response, and it’s usually a good thing: acute inflammation after injury or infection is the body’s attempt to heal itself. Chronic inflammation, on the other hand, is when your body no longer has the ability to turn off the inflammatory response and it starts damaging healthy tissue in your body and sending signals to your brain that can influence neuronal circuits to depress your mood; some studies have shown that inflammation can actually lead to depression. Chronic inflammation also has been linked to a higher risk for so-called lifestyle diseases like diabetes and heart disease.

Can you explain “good” vs. “bad” fats?

The benefits of omega-3 fatty acids, a polyunsatured fat found most abundantly in some kinds of seafood, nuts, and seeds, are well publicized. These “good fats” have been shown to combat inflammation. Less talked about is the ratio of omega-3 and omega-6 fatty acids in the modern diet. Although omega-6 is also a polyunsatured fat, excessive levels may contribute to inflammation in the absence of adequate omega-3s. Vegetable oils used to manufacture processed foods, including safflower, corn and, soybean, are a common dietary source of omega-6.

The evidence that diets of individuals with bipolar disorder are of lower quality overall comes from research in which participants were asked to maintain a food diary; subsequently, dietary elements in the blood were measured. Analyses found a lower intake of polyunsatured fatty acids and a greater amount of saturated fatty acids—the “bad fats” found in whole-fat dairy foods, fatty meats, and palm and coconut oils. Furthermore, omega-3 was disproportionately reduced compared to omega-6. High levels of omega-6 relative to omega-3 are associated with inflammatory states and have been shown to be unfavorable for mood disorders and other health conditions.

How can I improve my diet?

Here are some tips for better eating:

Avoid mindless snacking. Practice mindful awareness of each bite. Think about why you are eating right now as well as what. Bored? Restless? Maybe a walk around the block is what you really need.

Plan ahead. Many people with bipolar are prone to impulse buying, so thinking ahead about meals and making a shopping list is very helpful. Keep fruit handy on the counter, carrot sticks prepped and ready in the fridge. Carry healthy snacks with you to cut down on fast-food stops.

Shop smart. When shopping for groceries at a large store, shop around the outer sections first—that is where the healthier foods are typically found. Be selective on items in the middle of the store, and read labels. Locate a farmers’ market and explore it and ask questions.

Keep a food diary. As an exercise in mindful eating, write down everything you eat or drink for a few days (there are several freely available smart phone apps to make this easier). Often just the simple action of being aware of what you are putting in your mouth is enough to spur you to make wiser choices.

Bon appétit!

Printed as “Ask the Doctor: Eat Better, Feel Better,” Winter 2017

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Managing our negative thoughts is absolutely essential. Here’s how to stop them before they spiral into full-blown depression.

#1 Distinguish between what you feel and what is real

Our moods can easily blur our vision. Feeling depressed often means feeling life is hopeless, but it’s important to realize these views are symptoms of bipolar and do not reflect reality. “In other words, it’s the depression talking, not an objective picture of your situation,” psychologist Elizabeth Saenger, PhD, explains. She suggests we think back to a time when we were optimistic about the future, and tell ourselves that what we thought then about our life was more accurate.

#2 Shift your focus

When we disregard the positive and instead concentrate on the unfortunate aspects of a situation—dwelling on soccer games lost, and forgetting our victories—we do ourselves a tremendous disservice, asserts Saenger. Instead of focusing on our limitations, we can think about what a friend would say to us to contradict this negative line of thinking.

#3 Ban overgeneralizations

How many times have you concluded, on the basis of a single failure, that you will always fail? Don’t fall prey to overgeneralized thoughts such as “No one cares about me” and “I’m never going to be able to get a job.” Instead, let the words always, everybody, never, and nobody serve as red flags that you’re probably overgeneralizing.

#4 Create alternatives to mind-reading

When we’re depressed, we may be apt to misread or try to “mind-read” how people feel about us. If we automatically conclude someone does not like us because they didn’t say “hello,” rather than considering whether it was because they didn’t see us, this is mind-reading. Saenger says it can help to fold a piece of paper into three columns, then write down the behavior that discouraged us in the first column; our automatic interpretation of it in the second; and multiple alternative explanations in the third.

#5 Create a gray continuum when you have black-or-white thinking

Black-or-white, or all-or-nothing, thinking involves inappropriately categorizing objects, situations, or people into one extreme or another. When we are depressed, it is easy to think of ourselves as a total failure, or as completely worthless. Remind yourself that the world is made of shades of gray, and people who are all good or all bad are rare.

#6 Break up catastrophizing

Catastrophizing involves noticing one unfavorable fact or unfortunate situation and making it mushroom in our minds into a chain of hypothetical circumstances that end in disaster. Observed symptoms of a cold lead to an imagined death from pneumonia; a minor mistake at work results in nightmarish visions of getting fired. When we predict calamities, we can ask ourselves: How probable is each event in the chain that leads to disaster? And how likely it is they could all occur together?

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Every winter, like clockwork, I struggle with depression. One of the best pieces of advice I’ve gotten from a therapist is to practice “self-soothing,” which can do wonders when combined with medication and therapy. Whether I meditate or listen to calming music, self-soothing helps me take care of myself in a gentle, compassionate way, much like I’d heal a wounded animal.

I recently discovered the concept of Hygge (pronounced “hyoo-guh”). It’s the Norwegian term for a mood of coziness and feelings of wellness and contentment. Hygge came from one of the coldest regions of the planet, where the sun disappears for months in winter. And yet the Scandinavian countries are some of the happiest in the world. You don’t have to visit Norway to enjoy Hygge. I’ve found some simple ways to self-soothe with it, and they’ve helped me alleviate winter depression.

Relax by a fire (or candle).

There’s something calming about the golden glow of a crackling fireplace. Maybe it’s because our ancestors used fires to cook, warm themselves, and to gather around. Fireplaces make me feel relaxed and secure. If you don’t have a fireplace, light a candle. I love candles because they give off mood-brightening light and a tranquil scent.

Curl up and snuggle with yourself—or someone else!

I have a fuzzy throw blanket on my sofa at all times. I feel snug and cozy when I’m bundled up, especially in winter. I love lying on the sofa with my boyfriend and snuggling up with him under the blanket. I recently knitted blankets for friends and family so I could share the joy of Hygge with handmade, meaningful holiday presents. The experience brought me closer to my loved ones, and it gave me the gift of pride and accomplishment.

Lounge around.

There’s no point in embracing Hygge if you aren’t wearing comfortable clothes that bring you joy. Lounging in my fleece robe and fuzzy socks gives me a feeling of comfort. Whatever your lounge clothes are, appreciate them and what they do for you. Hygge isn’t about looking sharp; it’s about feeling happy by wearing what feels good.

Enjoy a calming concoction.

When the temperature drops, sipping a cup of hot tea instantly relaxes and soothes me. I also love drinking dark hot chocolate, because it tastes delicious and lifts my mood. I never drink coffee or black tea when I’m unwinding. Caffeine just makes me jittery, and that can amp up, rather than mute, anxiety and depression.

Lighten your mood with natural light.

Light is one of the best ways to beat depression. Lots of people who struggle with seasonal depression use daylight lamps, but I opt for natural light. During wintertime, I open all the curtains in my house to let in as much sunlight as possible. The natural light boosts my mood and reminds me to appreciate the world around me in all its glory.

Unplug and get lost in a good book.

Constant dings from alerts on my phone can add to my stress and anxiety levels. Social media can make my depression worse by compounding my feelings of insecurity and worthlessness. When I want to take a break and envelop myself in Hygge, I unplug everything and curl up with a good book. Losing myself in a good story engages my mind with what I consider a very healthy form of escapism.

Connect with others.

Remember that your home is a respite for you, but it can also be a welcoming space for friends to gather in. Hygge is about embracing yourself and sharing your love and compassion with others. What you give you can often get back tenfold. Bake some cookies and invite a few good friends over to enjoy them with you. Host a board game afternoon or start a book club. Whatever you do, make sure it involves real connection and conversation. That’s one of the best medicines I’ve found for coping with the isolation that comes with winter depression. Opening up to others gets me out of my own head. It reminds me that I’m not alone, and that helps improve my mood.

Since I’ve incorporated Hygge in my life, my seasonal depressions haven’t been as hard on me. Hygge soothes my body and mind. By engaging my senses, being present and thankful, appreciating my surroundings, and connecting with others, I’m able to better handle my moods and survive the dreaded winter months. Bringing the spirit of Hygge back from my trip to Scandinavia was the best souvenir I found.

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Bipolar disorder adds an extra layer of complexity to whatever emotions we experience. It can be hard to tell the difference between a fleeting feeling and an impending episode.

Sometimes, I am sad. And when I am sad, I start to think, “Am I too sad, or is this normal?” Other questions follow: “Will I be able to stop feeling sad? If not, what then? What if this is the beginning of that long, slow slide into the darkness?”

Because I have bipolar disorder, there is always this extra layer of something entangled with whatever emotions I am experiencing.

I have struggled with mood swings, manias, and unforgiving depressions my entire adult life. In my experience, feelings can’t always be trusted.

Getting through the days too often reminds me of an old-time fun house. Without warning, what I thought was a solid foothold swings into motion. What I thought was forward is now slipping backward. Stairs bob up and down, floors tip from side to side. The challenge is simply to get from one end of the room to the other without losing your balance.

After many years in the fun house, I have come to realize that navigating the challenge has mostly to do with remaining light on your feet and avoiding judgment. Instead of “this is wrong” or “this is making me look foolish,” accept that the ground is moving in random, unpredictable ways. “Think of it like skating,” someone once told me. “Glide forward. Don’t get stuck to one spot.”

There will always be some element of second-guessing my feelings and emotions, but I have worked hard to learn how to separate “chemistry” from “context.” Say a dinner I made isn’t appreciated the way I think it should be. Rather than vowing never to cook again, I take a step back and listen to my self-talk.

It helps to name my emotional state: “I am angry.” (Hmm, that’s interesting. What else are you?) “I am anxious.” (Hmm, and this, too, will pass.) “I am irritated.” (Hmm, please be more specific.)

There are other useful tools: taking a centering breath, writing thoughts in a journal rather than expressing them aloud and considering gratitude.

Sometimes when I’m upset, friends ask me if I’m taking my meds. Considering my history, this is a reasonable question—but annoying all the same. Should I now include that individual in my irritation?

I cannot control whether my emotions—irritability, anger, sadness, mirth, anxiety—will be regarded as symptoms. But I can choose to take a breath, feel what I am feeling, and glide forward without getting stuck to the fun house floor. I can choose to be thankful there are people in my life who can ask the difficult questions.

Often, I need to ask myself the same questions—to dig into the issue of chemistry vs. context. I remember one Friday afternoon when I sat weeping in my car, alone in an empty parking lot. I had been to see a medical professional who tossed off an insensitive comment about living with bipolar, and that set me off.

What he said exactly isn’t important. We have all heard comments that make us feel as if our diagnosis is somehow a character flaw instead of a legitimate medical illness.

Was I overreacting? A single comment, made in ignorance, can and should be ignored. But, over a lifetime, comments like that add up. Occasionally, one takes us by surprise, reopens old wounds, reminds us of the price we have paid because of that kind of ignorance.

Even when it is managed well, there is an aspect of bipolar illness that never goes away—a profound grief for what might have been. Would things have turned out differently for me in a more empathetic environment? Is it possible to create a more understanding, educated world?

That is my goal. Still, I hear the demeaning comments. And sometimes I get sad. And sometimes I weep. But that’s okay. I have learned that being sad can also be a symptom of being well; of finding our footing, of moving ahead.

Printed as “On My Mind: Emotional Intelligence,” Summer 2015

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Recently, I received a phone call from someone who wanted to check-in on the state of my thoughts. I was having a trying mental health day, and I had phoned this person earlier requesting some words of encouragement. We spoke for awhile and then I carried on about my business to the best of my abilities.

I was both surprised and touched by the follow up call. I don’t think I’ve received one like it before, unless you count the one from the nurse after a medical procedure. I don’t know if there is another person in my life who understands me or bipolar well enough to recognize that it was necessary.

I’m not sure how many people in my life realize I live with a serious illness. It’s also a treatable and treated illness, but that doesn’t make it less serious. And if people who care about me don’t realize bipolar is serious, I am partly to blame for minimizing its impact on my life in our conversations.

This is a memo to the ones who care but aren’t nearby enough to see the impact of bipolar on my life as it is unfolding:

If you haven’t heard from me in weeks or months, it doesn’t mean I’m busy crushing it, clicking my heels together and chasing rainbows—unless crushing it is code for showering twice a week.

I am the CEO of a mental illness. I have been for two decades. I’m at the helm of this ship during good times and bad. The main component of success is not jumping overboard, and the the rest is taking the life preserver extended to me when I do.

It would be nice to report that after this much time I have fully mastered the art of having bipolar disorder and have moved on to more interesting hobbies like fencing or tennis. It would be nice if I could say recovery requires the standard ten thousand hours of practice and after that you’re a genius past the point of relapse. That’s not my experience.

My experience is that with the right tools and a strong support network, you can get better as things grow worse, and by that I mean you get better at coping with worse things and that you get better by coping with those things.

Certain aspects of managing this disorder have become easier for me, like identifying triggers and setting boundaries around my needs, but there is one thing I find increasingly difficult as time passes: telling you when I’m struggling.

My desire to be perceived as someone living successfully with bipolar disorder often prevents me from reaching out to the people who matter most when I need it most. When I’ve enjoyed a long period of stability, it’s tough to admit that I’m not in a good place anymore.

I forget that a relapse doesn’t mean I’ve lost all the progress I’ve made. I withdraw during these times so I won’t have to report the truth, which is I’m ashamed and that I feel like a failure.

I put off making phone calls for weeks that turn into months because I’m waiting to have good news to share with you. I want to be able to reply to the question how are you with something better than “Recently showered and using everything I learned from Aristotle’s rhetoric to talk myself into pants and breakfast.”

I want you to hear from a woman who is thriving in spite of bipolar disorder, not one who has quit a job or started yet another, not one who is picking stupid fights with her husband, keeping a house fit for racoons, struggling to get published and otherwise choking on her own potential. I want to be a daughter, sister, aunt, and friend you can be proud of.

I know you aren’t waiting for good news and that you just want to hear my voice, but it feels great to get a reminder now and then.

When you aren’t living under the same roof as someone or seeing them on a daily basis for school or work, it can be difficult to tell how they’re doing, especially if you only have brief conversations and text messages to go by. There are many physical manifestations of a change in mood, but they aren’t particularly helpful if you aren’t there to witness them. Sometimes the biggest clue that I’m struggling sounds like nothing—withdrawal doesn’t make noise.

There is a small group of core people that I talk bipolar with, and if you aren’t in that group, I’m asking you and myself, why aren’t we talking about it? I’m afraid to disappoint you, and I’m afraid to lose you. What are you afraid of?

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