He never said: You will not get better. He would never say that. My psychiatrist was, and always will be, a saint. It was no coincidence that his first name was Angel.

But the prognosis was the same. What I have—Ultra Rapid Cycle Bipolar 1—doesn’t improve with time. Actually, it’s a progressive illness, and it continues to ravage its sufferers as they get older, leading to hospitalizations, hallucinations, and in many cases, death. My case, with early onset and early diagnosis, along with the classical presentation of mania followed by depression, was associated with a worse outcome.

I wasn’t going to get better. It could be, with management, livable. But I would always have symptoms, and I would always be disabled in some way.

I felt like I was staring down the barrel of a gun. An unstable, frankly shitty life, full of chaos and confusion, mental illness, and depression, or the alternative—I could kill myself. No one let me believe that was an option, but technically, it was my trump card. It was in my back pocket, just in case. If things ever got too hard, I could always opt out. Just in case.

Telling your friends and family that you’re going to kill yourself if things get too hard doesn’t go over well.

Some people were understanding. They knew how deeply and painfully I struggled, and they knew that my outlook was bleak. “It’s shitty,” my friend D— said, when I confessed my diagnosis to her. “That’s all I can say. It’s shitty. There’s really nothing else to say.”

Explaining that my doctor had essentially explained that I wasn’t going to improve tended to make people get quiet. My partner, who suffers from epilepsy, was sympathetic. He understands what it means to be permanently disabled. Sometimes, it’s not livable. Sometimes, you feel like there’s no hope.

Some people were less understanding. “I don’t think that’s such a great plan,” my friend A— said. “I love you. I want you to stay alive.”

“Of course,” I said. “But if I’m in and out of the hospital every six months, well, I’m not doing that. I’m peacing out.”

My partner said I didn’t have the guts to do it. He said I wouldn’t be able to pull the trigger. I thought maybe he was right. But when desperate, people do desperate things. This didn’t feel like the suicidal I had felt at the depths of Bipolar depression, that pull to sink under the surface, to disappear into a hole that suddenly appears in the ground. This felt purely rational, the precisely intelligent choice I was making because my situation was unlivable. I wasn’t about to resign myself to a life of disability, mental illness, and trauma. I was going to simply fade away into darkness.

***

I had tried every Bipolar drug on the market by early 2020, except for some of the stronger, first generation antipsychotics, which are generally considered to be the last line of defense because of their high tendency for side effects. But I tried all the mood stabilizers, lithium, and a variety of antipsychotics, and had to quit taking all of them for a variety of reasons, mostly because I couldn’t tolerate the side effects. High anxiety, vertigo, weight gain, weight loss, suicidal ideation, shaky hands, IBS-like symptoms, nausea and vomiting; I went through all of this and more before I finally found a cocktail that kept me even somewhat together. My doctor kept upping my dose as Bipolar symptoms continued to break through, until he couldn’t up it anymore. There was nothing he could do. We had exhausted  what medication could do for me.

“We could put you back on lithium,” he suggested, during the grips of a new episode. I was depressed, feeling sick and horrible.

“Please don’t do that,” I said. I wanted to feel better and lithium would only make me feel worse. It gave me serious stomach issues and had led to more than one bathroom emergency over the nine months I had taken it in 2019, along with a thirty-pound weight gain. “I really don’t want to go back on lithium.”

“We don’t have very many other options.”

“I know. I know. Okay, I’ll try the lithium.”

“The other option is to increase your Rexulti, but you’re already on such a high dose.”

Rexulti, a second-generation antipsychotic, has been the medication that saved my life. But lately it’s been less and less effective, and I’ve had to take more and more of it, which puts me in direct risk of serious side effects.

“Let’s do that.”

“It’s just temporary solution.”

The Rexulti increase worked for about a week, and then had to be increased again. I now take 4.5mg, which is over the maximum recommended dose, and will likely be adjusted again and again in the coming weeks as my mood shifts. “I can’t do this,” I said to my psychiatrist at our last meeting, tears running down my cheeks.

“But you have to,” he said quietly.

Right now, as I write this, I feel okay. But small changes, like a one hour time difference or a planned vacation, can throw me out of whack easily, sending me spinning out of orbit.

“I can’t live my life in fear,” I repeated to several of my loved ones when they expressed concern about my upcoming three week trip to Nashville, TN, to visit my partner. The trip had been planned for a month. “I can’t just not travel because I’m afraid of having episodes.”

Sitting at my desk in Nashville, my brain has finally reached equilibrium. I’m not manic, and I’m not depressed. I’m working, getting through the freelance editing work that I’ve contracted to do slowly and painfully. I’m seeing my partner and my friends. I’m going and sitting by the pool when I feel too overwhelmed, taking the vacation I truly deserve after over a year of pounding the pavement.

I’ll probably never hold a full-time job. I’ll always have to take time off to manage this illness. I may be hospitalized again. I won’t ever have children, even though right now I don’t want them, and I feel grief that this choice has been taken from me. The meds I’m on cause birth defects, and I can’t be unmedicated for nine months; I would be a danger to myself and my child. I can’t travel long distances because I have to be close to a hospital with modern meds, and I’m particularly sensitive to jet lag.

This is the hand that I was dealt. I have to live with it. I have to play my cards, and hope that I play them well. I have to hope.

***

Bipolar is a progressive, degenerative brain disease—it literally eats your gray matter—and the more episodes you have, the more brain tissue you lose. I can feel my brain degrading, my memories lost to the ether, things I used to know suddenly not where I left them. If you can arrest the progress and stop the sufferer from having episodes, you can save them from worse function. That’s what my doctor is trying to do—stop me from a worse outcome, regain as much functionality as possible.

Most days, you wouldn’t know I have a mental illness. I work from home. I get dressed. I go out and see my friends. I see my parents. I call my mom. But then suddenly, I become nonfunctional. The disease takes over. I’m manic, zippy, energetic, too buzzed out to focus on anything, literally vibrating at my desk. Or else I’m depressed, unable to eat, unable to talk, thinking of nothing but death.

In these states, I just want it all to stop. I understand why people kill themselves—just to make the thoughts stop. About half of all U.S. suicides can be attributed to Bipolar; it has the highest suicide rate of any psychiatric illness. Between 8-20% of Bipolar sufferers will eventually make a successful attempt.

I don’t want to die. But I understand why someone would. I’m not looking at a good prognosis. Someday, some way, I might make a difficult choice.

***

You’re like a grandma,” my partner says, upon coming into my bathroom and seeing the pill bottles lined up on the sink. I throw them back—the antipsychotic, the mood stabilizer, the antidepressant—all without water. The pills are supposed to keep me from going crazy. They’re supposed to keep me alive. They do a pretty good job. And for that, I am grateful.

Bipolar has taken a lot from me. Memories, relationships, opportunities. But it has also made me into the person that I am. I can’t imagine my life without it—who I would be, how I would change. Mental illness will always be a part of my life, whether I like it or not.

So I live. For now, I live.

Joanna Acevedo is a writer, educator, and editor from New York City. She was nominated for a Pushcart in 2021 for her poem “self portrait if the girl is on fire” and is the author of three books and chapbooks, including Unsaid Things (Flexible Press, 2021) and List of Demands (Bottlecap Press, 2022). Her work can be found across the web and in print, including or forthcoming in Litro, Hobart, and the Rumpus. She is a Guest Editor at Frontier Poetry and The Masters Review, Associate Poetry Editor at West Trade Review, and a member of the Review Team at Gasher Journal, in addition to running interviews at Fauxmoir and The Great Lakes Review. As well as being a Goldwater Fellow at NYU, she was a Hospitalfield 2020 Interdisciplinary Resident. She received her MFA in Fiction from New York University in 2021 and is supported by Creatives Rebuild New York: Guaranteed Income For Artists.